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eMedicine Specialties > Physical Medicine and Rehabilitation > Muscle Pain Syndromes

Postexercise Muscle Soreness

Divakara Kedlaya, MBBS, Clinical Associate Professor, Department of Physical Medicine and Rehabilitation, Loma Linda University School of Medicine
Timothy Kuang, MD, Pain Management Fellow, Department of Physical Medicine and Rehabilitation, Loma Linda University Medical Center

Updated: Jun 6, 2008

Introduction

Background

Hough gave the first detailed description of delayed-onset muscle soreness (DOMS) in 1902. DOMS is a widely recognized entity and is experienced by nearly everyone during his/her lifetime. It is defined as the sensation of discomfort or pain in the skeletal muscles following physical activity, usually eccentric, to which an individual is not accustomed. Although DOMS is experienced widely, there are still controversies regarding its origin, etiology, and treatment.

Related eMedicine topics:
Contusions
Exercise Physiology
Myofascial Pain in Athletes
Overuse Injury

Related Medscape topic:
Resource Center Exercise and Sports Medicine

Pathophysiology

Muscle pain mechanism

The sensation of pain in skeletal muscle is transmitted by myelinated group III (A-delta fiber) and unmyelinated group IV (C-fiber) afferent fibers. Group III and IV sensory neurons terminate in free nerve endings. The free nerve endings are distributed primarily in the muscle connective tissue between fibers (especially in the regions of arterioles and capillaries) and at the musculotendinous junctions. The larger myelinated group III fibers are believed to transmit sharp, localized pain. The group IV fibers carry dull, diffuse pain.

The sensation of DOMS is carried primarily by group IV afferent fibers. The free nerve endings of group IV afferent fibers in muscles are polymodal and respond to a variety of stimuli, including chemical, mechanical, and thermal. Chemical substances that elicit action potentials in muscle group IV fibers in order of effectiveness are bradykinin, 5-hydroxytryptamine (serotonin), histamine, and potassium.

Etiology and pathophysiology

DOMS results from overuse of the muscle. Any activity in which the muscle produces higher forces than usual or in which it produces forces over a longer time period than usual can cause DOMS. According to Tiidus and Ianuzzo, the degree of muscle soreness is related to the intensity of the muscle contractions and to the duration of the exercise.1 The intensity seems to be more important in the determination than is the duration.

Five hypotheses are used to explain the pathophysiology of DOMS.

  • Structural damage from high tension
    • This hypothesis originally was proposed by Hough and is the most scientifically accepted theory. The delayed pain is related directly to the development of peak forces and to the rate of force development in rhythmic contractions. DOMS is not related to the state of fatigue of the muscle.
    • The rhythmic and tetanic contractions that cause the greatest acute fatigue and discomfort in the muscles during exercise results in the least delayed pain following the exertion.
    • The structural damage is evident in muscles that are not trained for the particular exercise.
  • Metabolic waste product accumulation
    • One of the most popular concepts in the lay exercise community is that delayed soreness is a result of lactic acid accumulation in the muscles.
    • The degeneration and regeneration of muscle fibers observed after 2-3 hours of ischemia are similar temporally and quantitatively to the forces resulting from exercise-induced injury.
    • An apparent relationship exists between exercise intensity and the extent of soreness. Much evidence against the metabolic hypothesis also may be noted. The most convincing evidence is that the muscle contractions that cause the greatest degree of soreness require relatively low energy expenditure.
    • Exercise involving eccentric contractions requires lower oxygen consumption and produces less lactate than does exercise with concentric contractions at the same power output.
    • Energy use per unit area of active muscle appears to be less in eccentric exercise than in equivalent concentric exercise.
    • Schwane and colleagues tested the metabolic hypothesis. Their results indicated that downhill running requires significantly lower oxygen uptake (VO2) and produces less lactic acid than does level running but that it nonetheless results in greater DOMS.2
  • Increased temperature
    • Type III and IV nerve endings are sensitive to temperatures of 38-48°C.
    • Elevated temperature could conceivably damage the structural element in the muscle, resulting in necrosis of muscle fibers and breakdown of connective tissues. Eccentric muscle exercise may generate higher local temperatures than do concentric contractions. Rhabdomyolysis (extreme of DOMS) is more prevalent in untrained subjects during exercise in the heat.
  • Spastic contracture
    • Studies by Travell and co-investigators in 19423 and a later series of experiments by Cobb and colleagues4 demonstrated elevated electromyographic activity in sore muscles.5 Altered nerve control and vasoconstriction lead to decreased blood flow and ischemia, which in turn initiate a pain-spasm-pain cycle.6 The magnitude of pain depends on the number of motor units involved.
    • Other investigators have been unable to detect increased electrical activity in sore muscles.
  • Myofibrillar remodeling
    • The literature suggests that myofibrillar and cytoskeletal alterations are the hallmarks of DOMS and that they reflect adaptive remodeling of the myofibrils.
    • There are 4 main types of changes:
      • Amorphous widened Z-disks
      • Amorphous sarcomeres
      • Double Z-disks
      • Supernumerary sarcomeres

Frequency

United States

The incidence of DOMS is difficult to calculate, because most people with DOMS do not seek medical attention, instead accepting DOMS as a temporary discomfort. Every healthy adult most likely has experienced DOMS on countless occasions. DOMS occurs regardless of the person's general fitness level.

Mortality/Morbidity

  • Only temporary morbidity (pain, soreness, reduced muscle performance) is associated with DOMS. Diminished performance results from reduced voluntary effort due to the sensation of soreness and from the muscle's lowered inherent capacity to produce force.
  • No evidence exists to support the idea that DOMS is associated with long-term damage or reduced muscle function. Animal studies indicate that injured muscles regenerate during the period following exercise and that the process essentially is completed within 2 weeks.

Race

No race predilection is associated with DOMS.

Sex

  • Stupka and colleagues showed that muscle damage following unaccustomed eccentric exercise is similar in males and females; however, the inflammatory response is attenuated in women.7
  • MacIntyre and coauthors found that the patterns of DOMS and torque differed between males and females after eccentric exercise.8
  • In a study by Dannecker and colleagues, no sex differences were detected, except that higher affective ratios were reported by men than by women.9

Age

DOMS generally is not reported in children. Adults of all ages can experience DOMS.

Clinical

History

  • A history of heavy, unaccustomed exercise, particularly involving eccentric muscle contractions (eg, downhill exercise) is reported.
  • The patient complains of pain, soreness, swelling, and a stiff or tender muscle spasm.
  • The muscles are sensitive, especially upon palpation or movement.
  • Decreased range of motion and reduced strength is noted (especially 24-48 hours postexercise).
  • The patient has a sense of reduced mobility or flexibility.
  • DOMS begins 8-24 hours after exercise and peaks 24-72 hours postexercise; it then subsides over the next 5-7 days
  • Acute onset muscle soreness begins during exercise and continues for approximately 4-6 hours after exercise.

Physical

  • The tenderness often is described as localized in the distal portion of the muscle, in the region of the musculotendinous junction. According to one study, tenderness in this region could be due to the fact that muscle pain receptors are most concentrated in the region of the tendon and connective tissue in the muscle. The fibers' angles to the long axis of the muscle are greatest in the region of the musculotendinous junction, increasing the susceptibility of the fibers to mechanical trauma.
  • In severe DOMS, the pain is generalized throughout most of the muscle belly.
  • Swelling of the muscle belly can occur.
  • Muscle tenderness is present.
  • Decreased muscle strength and flexibility also are noted.

Causes

  • Heavy, unaccustomed exercises contribute to the development of DOMS.
  • Exercise involving eccentric muscle contractions results in greater disruption or injury to the muscle tissues than does concentric exercise. Thus, any form of exercise with eccentric muscle contractions causes more DOMS than does exercise with concentric muscle contractions. Ample evidence from histologic studies, electron microscopic examination, and serum enzymes of muscular origin supports this notion.
  • To produce a given muscle force, fewer motor units are activated in an eccentric contraction than in a concentric contraction. In eccentric contractions, the force is distributed over a smaller cross-sectional area of muscle. The increased tension per unit of area could cause mechanical disruption of structural elements in the muscle fibers themselves or in the connective tissue that is in series with the contractile elements; however, it has not been proven that injury to muscle cells or to connective tissue is the causative factor in DOMS.

Differential Diagnoses

Acute Poliomyelitis
Myofascial Pain
Postpolio Syndrome

Other Problems to Be Considered

Muscle strain or tear
Muscle cramps
Phosphorylase deficiency (muscle soreness after exercise)
Phosphofructokinase deficiency
Carnitine palmityl transferase deficiency
Other types of myopathies

Comparative features of pain during or immediately following exercise, delayed onset muscle soreness, and muscle cramps associated with exercise

Pain During or Immediately Following ExerciseDelayed Onset Muscle Soreness (DOMS)Muscle Cramps Associated with Exercise
EtiologyProbable buildup of metabolic by-products (include lactic acid, pyruvic acid)Unaccustomed eccentric exerciseHyperexcitability of lower motor neuron, possibly related to loss of fluid and electrolytes, and low magnesium level
OnsetDuring exercise12-48 hours postexerciseDuring or after the exercise
Duration/RecoveryDiminishes upon termination of exercise and return of normal blood flowRecovery within 7-10 daysLasts usually between a few seconds and several minutes
Type of nerve endingType IV free nerve endingPrimarily type IV free nerve ending
Type III is also involved.		Most likely type III free nerve ending
Type of muscle contraction associatedSustained or rhythmic concentric and isometric contractionsUnaccustomed eccentric muscle
exercise		Severe, involuntary, electrically active contraction
TreatmentTerminate exercise.Exercise the "sore muscle." No other proven effective treatmentGentle stretch of the affected muscle
Contraction of antagonistic muscle
PreventionNo proven effective preventive measureNo proven effective preventive measureStretching the affected muscles may be effective.


Workup

Laboratory Studies

  • Serum creatinine kinase level usually is elevated, but it is nonspecific.

Imaging Studies

  • In a study by Dierking and colleagues, diagnostic ultrasonography, when used in the diagnosis of DOMS, was not sensitive enough to detect changes in a cross-sectional muscle area.10
  • Magnetic resonance imaging (MRI) can detect muscle edema in DOMS but is not indicated clinically for the diagnosis. In a prospective evaluation of DOMS, abnormalities found in MRI persisted up to 3 weeks longer than did symptoms.

Histologic Findings

  • Immediately after exercise, free erythrocytes and mitochondria may be observed in the extracellular spaces.
  • Increase in the numbers of circulating neutrophils and interleukin-1 occurs within 24 hours after exercise. A prolonged increase in ultrastructural damage and muscle protein degradation occurs, as well as a depletion of muscle glycogen stores.
  • Friden and colleagues observed Z-line streaming within eccentrically exercised muscle fibers that occasionally led to total disruption of the Z-band area; this resulted in disorganization of surrounding myofilaments.11
  • From 1-3 days postexercise, the period of time when DOMS is most intense, phagocytes are present in the muscle fibers, and injury to the muscle usually is more apparent.

Treatment

Rehabilitation Program

Physical Therapy

Although it provides only temporary relief, exercise of the sore muscle probably is the best way to reduce DOMS. Muscular soreness diminishes acutely with exercise. With the cessation of exercise, however, the soreness returns, and this cycle continues until the muscle becomes conditioned sufficiently through training. Why exercise decreases DOMS is not clear, although several possibilities exist, including the following:

  • Breakup of adhesions from the injured, sore muscles takes place during exercise.
  • Increased blood flow or temperature in the muscle helps to decrease the accumulation of noxious waste products.
  • Endorphin release by neurons in the central nervous system increases during exercise.
  • Increased afferent input is noted from large, low-threshold sensory units in the muscles (muscle group-Ia, Ib, and II fibers [gate control theory]).
  • Subjects direct attention to the activity and away from the pain.
  • The training effect appears to be highly specific, not only for the particular muscles involved in the exercise, but also for the type of contractions performed. For example, Schwane and Armstrong found that in rats, the muscle damage that occurs during downhill running is prevented by downhill or level training but not by uphill training.2

Ice-water immersion and ice massage are frequently used, particularly among high-level athletes, to minimize the symptoms of DOMS. A randomized, controlled study by Sellwood and colleagues challenged the use of ice-water immersion  as a recovery strategy for athletes.12  In this investigation, ice-water immersion did not effectively minimize or prevent symptoms of muscle damage after eccentric exercise in young, relatively untrained individuals. Given that trained athletes are relatively well protected against DOMS, ice-water immersion is likely to offer them even less benefit for the minimal soreness they may experience after eccentric exercise.

Another study, by Isabell and coauthors, showed that the use of ice massage or ice massage with exercise did not significantly reduce the symptoms of DOMS.13

Medical Issues/Complications

No evidence supports the premise that DOMS is associated with long-term damage, reduced muscle function, or other complications.

Consultations

Consultation with the patient's athletic trainer and coach may be indicated.14,15

Other Treatment

  • A study by Barlas and colleagues indicated that acupuncture generally is not effective in the treatment of DOMS16 ; however, an unblinded study by Lin and Yang suggested that acupuncture is effective against DOMS.17
  • Mekjavic and co-investigators concluded that hyperbaric oxygen therapy does not affect recovery from delayed onset muscle soreness.18
  • Zhang and colleagues noted that a double layer of Farabloc, an electromagnetic shield, wrapped around the thigh has been shown to reduce DOMS.19
  • In a study by Craig and coauthors, combined low-intensity laser therapy was not shown to be effective against DOMS.20 However, a study by Douris and colleagues that used 8 J/cm2 of phototherapy did show a beneficial effect.21
  • In one small (6 subjects in each group), randomized, double-blind, placebo-controlled study by Hasson and coauthors, individuals treated with pulsed ultrasonographic therapy (PUS) showed significantly reduced soreness.22 However, in a larger (12 patients in each group) randomized, double-blind, placebo-controlled study by Craig and co-investigators, no significant benefit from PUS was demonstrated.23 In a study by Ciccone and coauthors, there was some suggestion that ultrasonography may enhance DOMS and that phonophoresis with salicylate may have therapeutic benefits.24
  • Tourville and colleagues showed that sensory-level, high-volt, pulsed electrical current was not effective in reducing the measured variables associated with DOMS.25
  • Transcutaneous electrical nerve stimulation (TENS), in an uncontrolled study by Denegar and Perrin, showed some benefit in relieving the soreness associated with DOMS26 ; however, in a randomized, placebo-controlled study by Craig and colleagues, the use of TENS did not show any significant benefit.27
  • In a small study by Hasson and coauthors, dexamethasone iontophoresis immediately after exercise was shown to decrease muscle soreness perception in DOMS.28

Medication

In many controlled studies, general analgesics and nonsteroidal anti-inflammatory medications have not been consistently effective against postexercise muscle soreness.29

In a randomized, placebo-controlled study, Cannavino and colleagues showed that transdermal 10% ketoprofen cream was effective in alleviating self-reported DOMS in isolated quadriceps muscles of patients following repetitive muscle contraction, particularly after 48 hours.30 This relief was apparently secondary to the effects of the medication, because no other medications or pain relief measures were used in the study.

Oral ascorbic acid (vitamin C) and other antioxidants also have been investigated as possible medications for DOMS, with mixed results. A study by Connolly and coauthors suggested that a vitamin-C supplementation protocol of 1000 mg taken 3 times a day for 8 days is ineffective in protecting against selected markers for DOMS.31

The homeopathic medicine Arnica 30x was studied in a randomized, double-blind, placebo-controlled study and was found to be ineffective in treating DOMS.

Bajaj and colleagues showed that the prophylactic intake of tolperisone hydrochloride provides no relief of postexercise muscle soreness but that it does result in a reduction in isometric force.32

In a randomized, placebo-controlled study, Connolly and co-investigators showed that tart cherry juice can decrease some of the symptoms of exercise-induced muscle damage.33 Most notably, strength loss averaged over the 4 days after eccentric exercise was 22% with the placebo but only 4% with the cherry juice.

Follow-up

Further Inpatient Care

  • No inpatient care is needed for individuals with DOMS.

Further Outpatient Care

  • Outpatient care is limited mainly to proper education on specific exercise programs.

Deterrence

  • Armstrong states in his review that there are no preventive measures for DOMS except for previous specific training of the involved muscle.34
  • No study has demonstrated that proper warm-up before and cool-down after exercise will help to prevent DOMS.
  • Johansson and colleagues discovered that preexercise static stretching has no preventive effect on the muscular soreness, tenderness, and force loss that follows heavy eccentric exercise.35
  • Nonsteroidal anti-inflammatory medications are not effective in preventing DOMS.
  • Thompson and coauthors note that oral contraceptive use attenuates soreness following exhaustive stepping activity in women, but no association can be drawn between estrogen ingestion and exercise-induced muscle damage.36
  • Boyle and co-investigators showed that yoga training and a single session of yoga appear to attenuate peak muscle soreness in women following a bout of eccentric exercise.37 These findings have significant implications for coaches, athletes, and the exercising public, who may want to implement yoga training as a preseason regimen or as a supplemental activity to lessen the symptoms associated with muscle soreness.

Prognosis

  • DOMS can temporarily reduce muscle performance. The diminished performance results from reduced voluntary effort due to the sensation of soreness and from the muscle's lowered inherent capacity to produce force.
  • No evidence supports the idea that DOMS is associated with long-term damage or reduced muscle function.
  • Animal studies indicate that injured muscles regenerate during the period following exercise and that the process essentially is completed within 2 weeks.

Patient Education

  • The patient needs to be educated on a specific progressive exercise training program before engaging in a heavy, unaccustomed exercise, particularly one that involves eccentric muscle contractions.
  • For excellent patient education resources, visit eMedicine's Back, Ribs, Neck, and Head Center and Sports Injury Center. Also, see eMedicine's patient education article Muscle Strain.

Miscellaneous

Medicolegal Pitfalls

  • Misdiagnosing DOMS as another pathologic condition of the muscles can have significant medicolegal consequences.

References

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Keywords

postexercise muscle soreness, delayed-onset muscle soreness, DOMS, post-exercise muscle soreness, muscle overuse, rhabdomyolysis, metabolic waste product accumulation, spastic contracture, myofibrillar alterations, cytoskeletal alterations

Contributor Information and Disclosures

Author

Divakara Kedlaya, MBBS, Clinical Associate Professor, Department of Physical Medicine and Rehabilitation, Loma Linda University School of Medicine
Divakara Kedlaya, MBBS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Paraplegia Society, and Colorado Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Timothy Kuang, MD, Pain Management Fellow, Department of Physical Medicine and Rehabilitation, Loma Linda University Medical Center
Timothy Kuang, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Curtis W Slipman, MD, Director, University of Pennsylvania Spine Center, Associate Professor, Department of Physical Medicine and Rehabilitation, University of Pennsylvania Medical Center
Curtis W Slipman, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, International Association for the Study of Pain, and North American Spine Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain (Tailbone Pain, Coccydynia) Service, University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Patrick M Foye, MD, FAAPMR, FAAEM is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Lourdes Regional Rehabilitation Center, Our Lady of Lourdes Medical Center
Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Alegent Health Care, Immanuel Rehabilitation Center
Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

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