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Delayed Onset Muscle Soreness

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== What is DOMS? =={{DISPLAYTITLE:Delayed Onset Muscle Soreness (DOMS) generally occurs between 24 and 72 hours after unusual or severe exercise, such as racing a marathon. for Runners}}DOMS is particularly related to eccentric of critical importance for runners. Unlike many other types of exercise, which is where the muscle works running requires your muscles to resist becoming longerextend under load, rather than working to contractabsorbing your weight as you land. When you muscles absorb the impact of runningThis extension under load, this is called eccentric. Downhill running , is much more a prime cause of DOMS, and while the soreness is delayed, the accompanying weakness is immediate. This eccentric than flat or uphill runningstress is why marathon runners are often hobbling around the day after a race. The soreness good news is that a bout of DOMS is different to a 'pulled' muscle. With inducing exercise provides protection against future DOMS, large areas and so it's a critical part of the muscle are very tender to the tough, and the pain training. This "Repeated Bout Effect" (RBE) is very unpleasant. With a pulled musclecore aspect of training, and by intentionally inducing DOMS you can prevent the area of tenderness soreness that occurs after long distance races. The less obvious, but more important benefit is usually more localized and that you also prevent some of the weakness that occurs towards the pain end of massage longer races. This is sometimes described as a 'good pain'key benefit to [[Downhill Running]] and especially the [[Treadmill Descent]]. I believe that incorporating Treadmill Descents into my training is the reason I've completed 100-mile races with little muscle soreness. == Why is DOMS important? =Introduction =Delayed Onset Muscle Soreness (DOMS can prevent continued running, due ) is a familiar experience to weakness most people who exercise. It affects people who weight train and run particularly, and DOMS can produce anything from mild [[Muscle| muscle]] sorenessto debilitating pain and weakness. HoweverDOMS is caused by eccentric stress, where the biggest issue for long distance runners is that although muscles working to resist lengthening, such as lowering a weight or absorbing the pain occurs 24-72 hours after exerciselanding forces of running. [[Downhill Running]] is a particular source of eccentric stress. DOMS not only produces delayed soreness, the but immediate weakness peaks after 30 minutes <ref name="Z1"/>that generally lasts a similar length of time. If you've ever run DOMS also produces swelling, tense muscles, reduced coordination and a limited range of motion. A key benefit of DOMS inducing exercise is that a longbout of DOMS can give protection against similar future exercise, steep decent and the protection lasts for months. This Repeated Bout Effect (the latter RBE) is a critical part of Iron Mountain or Mount Mitchell Challenge spring to mind)endurance training. Running with the correct [[Cadence]] can help prevent DOMS, you'll know the strange feeling and [[Nutrient Timing| taking protein after DOMS inducing exercise]] is one of weak numbness that pervades your quads as the effect of the downhill builds up. If you've felt a similar weakness in the latter stages of a marathon, this best treatments, though [[Why compression clothes| compression clothing]], [[caffeine]] and [[massage]] can also help. It seems that [[Vitamin C]] may not be glycogen depletion creating 'critical to the wall', but eccentric muscle damage that will later manifest itself as RBE. =What is DOMS?=The soreness of DOMSgenerally peaks between 24 and 72 hours after unusual or severe exercise, though soreness may occur sooner after running<ref name="Vickers2001"/>. It DOMS is suggested that this particularly related to eccentric exercise, which is where the reason muscle works to resist becoming longer, rather than working to contract. When your muscles absorb the Boston Marathon course impact of running, this is relatively sloweccentric exercise, even though it and [[Downhill Running]] is a net decentmore eccentric than flat or uphill running. The images below show the damage that occurs from eccentric exercise<ref name="FeassonStockholm2002"/> and marathon running<ref name="Warhol-1985"/>: <gallery widths=300px heights= What does DOMS mean to you? =200px caption=There is some good news in all of this. While excessive "Muscle damage from eccentric exercise can cause DOMS, doing some eccentric exercise causes the muscles to adapt and to be able to handle eccentric exercise without DOMS <ref name="Y1(downhill running)"/>File:EccentricA. There are two ways then of protecting your muscles from DOMS in running; running greater distances, or running downhillJPG|Muscle before downhill runningFile:EccentricC. It is JPG|Immediately after downhill running . Notice the disruption to the dark bands (z-bands) that are part of the muscle structure showing there is greatly underutilized in training regimesimmediate damage. Most hill training workouts focus on File:EccentricD.JPG|One day later, the uphill segmentdamage and disruption is worse, and relegate the downhill to recoveryindicated some continued breakdown. File:EccentricB. While uphill can produce some benefitsJPG|Muscle 14 days later, it is the downhill that can provide the greatest advantagestructurally recovered (other metrics do not return to pre-exercise levels at 14 days). Adding hills into your workout can make you </gallery><gallery widths=300px heights=200px caption="Muscle damage after running a much stronger runnermarathon" >File:MarathonFiberDamage.jpg|The selective pattern of damage, and have benefits even on flat race courses. Don't just use showing the downhill normal upper fiber adjacent to recover from the uphill'moth eaten' appearance of the damaged lower fiber.File:MarathonFiberDamage2.jpg|Here you can see extreme damage, but work on with only the Z band of the downhillfiber remaining (marked Z). Adjacent fibers show far less damage. </gallery>== How to treat Why is DOMSimportant? ==Do if you do get Because running involves a lot of eccentric stress, DOMSis common in runners, what especially after [[Downhill Running]]. The pain that occurs 24-72 hours after exercise can you do? Caffeine has shown to be effective in reducing prevent continued training. However, the biggest issue for long distance runners is that although the pain of DOMSoccurs 24-72 hours after exercise, as well as reducing the weaknesspeaks after 30 minutes <ref name="X1"/>. There is no evidence for the use of anti-inflammatory drugs (Ibuprofen), or anti-oxidants. The evidenced for massage, stretching and ice is ambiguous <ref name="X2Marginson-2005"/>. Light exercise has been shown to relieve DOMS <ref name="X3"/>.My personal experience is that If you've ever run a small amount of easy runninglong, while painfulsteep descent, can speed up recovery. I you'll know the strange feeling of weak numbness that pervades your quads as the effect of the downhill builds up. The Boston Marathon or the latter part of Mount Mitchell Challenge have found no benefit to ice, massage, or Ibuprofendescents that cause this type of weakness. If you've felt a similar weakness in the latter stages of a marathon, this may not be [[Glycogen]] depletion creating 'the wall', but eccentric muscle damage that will later manifest itself as DOMS. It is suggested that this is the reason the Boston Marathon course is relatively slow, even though it is a net decent.=What does DOMS mean to you?= Tangent There is some good news in all of this. While excessive eccentric exercise can cause DOMS, doing some eccentric exercise causes the muscles to adapt and to be able to handle eccentric exercise without DOMS <ref name="Y1"/>. There are two ways then of protecting your muscles from DOMS in running; running greater distances, or running downhill. I believe that downhill running that is greatly underutilized in training regimes. Most hill training workouts focus on the uphill segment, and relegate the downhill to recovery. While uphill can produce some benefits, it is the downhill that can provide the greatest advantage. Adding hills into your workout can make you a much stronger runner, and have benefits even on flat race courses. Don't just use the downhill to recover from the uphill, but work on the downhill.=Determining if you have DOMS=It's not always obvious if you have DOMS or some other problem. Here are some simple checks that can help guide you:* As the name suggests, DOMS normally occurs a day or two after the exercise, but this is not always the case. * The soreness of DOMS eases off with light exercise, so if the pain gets less then it's probably DOMS but if it gets worse it's probably not. The lessoning of the pain should occur after a few minutes of light exercise, such as walking or gentle running. * The soreness of DOMS is normally quite diffuse over a large area of the muscle and the soreness is close to the surface. Often the muscles are tender to the touch and [[Massage]] is too painful. That is different to something like a muscle tear which has a sharp, localized pain, or a [[Trigger Points| Trigger Point]] that has a painful lump in the muscle. * DOMS also reduces the strength of the effected muscles, and this can be quite dramatic in extreme cases. * Often a muscle with DOMS is hard to the touch, even when it's as relaxed as possible. A healthy muscle should only be firm when it's contracted. ==DOMS Scale==This is a simplistic scale that I use to evaluate how bad my DOMS symptoms are. This is focused on DOMS of the quads, the most common areas noticed in runners. {| class="wikitable" style="margin- DOMS and Lactic acid ==DOMS is not caused by lactic acid; a full discussion will have to wait until I blog on 'the lactic acid myth', but suffice to say, lactic acid is your friend, not your enemyleft: auto; margin-right: auto; border: none;"! DOMS Scale ! Stair Test |-| 0 | You can walk down stairs without discomfort. |-| 1 | You can walk down stairs with some pain, but there's no need to hold on to the handrail. |-| 2 | You can walk down stairs with some pain, but you only need to hold on to the handrail for balance. |-| 3 | You need to put some of your weight on the handrail to descend stairs. |-| 4 | You need to put nearly all of your weight on the handrail to descend stairs. |-| 5 | Your quads cannot lower any weight and descending stairs it tricky. Descending stairs involves standing opposite the handrail and locking the leg that is opposite the handrail. Your body is then tilted towards the handrail, using your arms to lower your weight. The leg nearest the handrail is locked straight and once your body is lowered, it takes the weight. Repeat for each step. (Or avoid stairs.) |}==Likert Scale Muscle Soreness==There is a more general scale of muscle soreness that applies to all muscles, but is not focused on DOMS<ref name="Vickers2001"/><ref name="Impellizzeri-2007"/>. {| class="wikitable" style="margin-left: auto; margin-right: auto; border: none;"! Scale! Description|-| 0 | An absence of soreness |-| 1 | A light pain felt only when touched / a vague ache |-| 2 | A moderate pain felt only when touched / a slight persistent pain |-| 3 | A light pain when walking up or down stairs |-| 4 | A light pain when walking on a flat surface / painful |-| 5 | A moderate pain, stiffness or weakness when walking / very painful |-| 6 | A severe pain that limits my ability to move |}=What are the symptoms of DOMS?=The soreness of DOMS is different to other forms of muscle soreness. With DOMS, large areas of the muscle are tender to the touch and painful when the muscle is used. With other forms of muscle soreness the area of tenderness is usually more localized and the pain of massage is sometimes described as a 'good pain'. The pain of DOMS will normally lessen with light exercise such as walking, which is often described as 'loosening' up. However, the soreness of DOMS is not the best indicator of the muscle damage, and similar levels of soreness can result from differing levels of muscle damage<ref name="NosakaNewton2002"/>. In addition, there are other symptoms, such as:* Reduction in strength<ref name="Saxton-1995"/><ref name="domsiso"/><ref name="Gulick-1996"/><ref name="Paddon-Jones-1997"/>, typically 30-60%<ref name="Baldwin Lanier-2003"/>. (Note that the reduction in strength starts immediately following the damaging exercise and increases over the next 24-48 hours<ref name="Cheung-2003"/>. The initial reduction in strength can be as much as 40%<ref name="Baldwin Lanier-2003"/>.)* Muscle tenderness. DOMS makes the muscles tender to the touch, and the pain associated with pressure differs between DOMS and normal muscle soreness. With DOMS, the pain is extremely unpleasant and can be nauseating, where normal muscle soreness can be painful, but the pain has a sense of relief and is sometimes call a "good pain." The muscle tenderness can be measured from the "Pressure-Pain Threshold", where pressure is increased until the subject feels pain rather than pressure<ref name="Pearcey-2015"/>. * Increased passive muscle tension<ref name="Howatson-2008"/>. A muscle suffering from DOMS will often be hard to the touch, even when relaxed as much as possible. * Swelling of the muscle<ref name="Howatson-2008"/>, which can be seen as a lack of muscle definition in lean individuals. * The perceptions of joint angle and force are impaired<ref name="Saxton-1995"/>, which can result in reduced coordination and a sense of clumsiness. * A reduction in the Range of Motion<ref name="Saxton-1995"/><ref name="domsiso"/><ref name="Gulick-1996"/>.* Changes in running biomechanics, possibly as compensation for other changes<ref name="domsbio"/>. For instance, the reduction in Range of Motion can result in a reduction in stride length. * Decreased [[Running Economy]]<ref name="Smith-1992"/><ref name="Braun-2003"/>. * Impaired [[Glycogen]] repletion<ref name="Smith-1992"/><ref name="Braun-2003"/>, though higher carbohydrate intake partly offsets the reduction<ref name="Costill-1990"/>. There is some evidence that Glycogen levels continue to drop after DOMS inducing exercise<ref name="Zehnder-2004"/><ref name="Widrick-1992"/>, and the deficiency in glycogen lasts for over 72 hours<ref name="Widrick-1992"/>.* There are some studies that indicate there are possible changes in muscle fiber recruitment patterns<ref name="Miles-1997"/><ref name="Zhou-1998"/><ref name="Zhou-1996"/>.=How long does DOMS last?=It seems likely that exercise characteristics (duration, intensity, etc.) will change the time to recovery<ref name="Vickers-2001"/><ref name="Paschalis-2005"/>. The soreness generally peaks between 24-72 hours after the damaging exercise, but will last at least 4 days<ref name="Paschalis-2005"/>. My personal experience is that DOMS can last for over a week, and I prefer to avoid [[Downhill Running]] in the two weeks before a race, though sometimes I will include it as close as 10 days beforehand. =The effect of steepness on DOMS=I have found that steeper descents produce disproportionately severe DOMS. This might be due to the angle of the knee, as most<ref name="Jones-1989"/><ref name="Child-1998"/> (but not all<ref name="Paschalis-2005"/>) studies indicate that the longer a muscle is when being stressed, the greater the DOMS. This effect is most noticeable when using a [[Treadmill]] for [[Downhill Running]], as small changes in angle can produce a big difference in DOMS. =How to prevent or treat DOMS?=There are various approaches to preventing or treating DOMS. The table below is a summary of the approaches showing how likely the strategy is to prevent or treat DOMS combined with the possible significant downsides. At the top are those that are likely to help and have no downsides, then those that have no effects or downsides, then those with little benefit and significant downsides. {| class="wikitable" style="margin-left: auto; margin-right: auto; border: none;"! '''Strategy '''! '''Timing '''! '''Soreness '''! '''Weakness '''! '''Downsides '''|-| Repeated Bout Effect | Before (days to months) | Strong evidence of reduced soreness | Some evidence of reduced weakness | None |-| [[Nutrient Timing| Carbohydrate and/or protein]]| After | Some evidence of reduced soreness | Strong evidence of reduced weakness | None |-| [[Cadence]]| During | Some evidence of reduced soreness | Some evidence of reduced soreness | None |-| [[Why compression clothes| Compression Clothing]]| After | Some evidence of reduced soreness | Some evidence of reduced weakness | None |-| [[Caffeine]]| After | Some evidence of reduced soreness | Some evidence of reduced weakness | None^a |-| [[Massage]]| After | Some evidence of reduced soreness | Some evidence of reduced weakness | None |-| [[Warmup]]| Immediately before | Some evidence of reduced soreness | No benefit | None |-| Light Exercise | After | Transient pain reduction | No benefit | None^c |-| TENS | After | Transient pain reduction | No benefit | None |-| [[Cryotherapy| Icing]]| After | No benefit | No benefit | None^b |-| Antioxidents | Before and/or After | Mixed evidence | Mixed evidence | Conflicting evidence of reduced [[Endurance Adaptations]]|-| [[Stretching]]| Before and/or After | No benefit | No benefit | # [[Stretching]]temporarily weakens muscles # Can induce DOMS # Can lead to injury |-| [[NSAIDs and Running| NSAIDs]]| Before and/or After | Most evidence indicates no benefit | Most evidence indicates no benefit | Can impair recovery |}Notes* ^aCaffeine can interfere with sleep* ^b Only ever use ice in a bag, never a frozen gel pack. Gel packs start too cold and can cause skin or nerve damage.* ^c Light exercise does not appear to speed up healing, but it does not hinder it either.==Repeated Bout Effect==The DOMS that follows an initial bout of eccentric exercise is much less on subsequent similar bouts. This is often called the Repeated Bout Effect (RBE)<ref name="Howatson-2008"/><ref name="Cheung-2003"/>. The initial bout does not have to cause significant soreness or damage<ref name="Clarkson-1987"/>. As few as 2-10 maximal eccentric repetitions can protect against a subsequent larger bout (24-50), but the initial bout must be close to maximal effort<ref name="Brown-1997"/>. By contrast, eight weeks of training with 50% of the maximal eccentric load did not provide protection against a subsequent maximal bout<ref name="Nosaka-2002"/>. There is some cross-over of protection between different forms of exercise. For instance, eccentric weight training protects against soreness and weakness in subsequent downhill running<ref name="Eston-1996"/>. The protection from the RBE is long lived. One study showed that while the initial weakness was not reduced by the RBE, the recovery of strength was much faster for up to 9 months, and soreness was less for up to 6 months<ref name="Nosaka-2001"/>. Another study showed that 30 minutes of downhill running provides protection for between 6 and 9 weeks<ref name="Byrnes-1985"/>. There is evidence that the RBE may rapidly start to provide protection from soreness and weakness<ref name="Mair-1995"/>, within 5 days<ref name="Ebbeling-1989"/>, and possibly within 24 hours<ref name="Chen-2001"/>. One study<ref name="Brockett-2001"/> demonstrated a change in the length-tension curve of DOMS trained muscles. As shown on the chart below, 7 days after a bout of DOMS inducing exercise the hamstring is able to generate more force and generate it at a greater angle. [[File:Length Tension Curve and DOMS.jpg|none|thumb|500px|A chart of a subject before and 7 days after DOMS inducing hamstring exercise. The chart shows the angle and the torque developed, indicating that after training the hamstrings are not only stronger, but are able to generate power at significantly longer length. This may be part of the underlying mechanism for the repeated bout effect.]]===Repeated Bout and Vitamin C===I found a single study that looked at how the repeated bout effect changes with [[Vitamin C]]<ref name="HeHockemeyer2015"/>. As described below, most studies have found a small reduction in DOMS with Vitamin C. This 2014 study found that for the first bout, Vitamin C reduced the muscle soreness for the hamstrings, Quads, and Tibialis Anterior (shin), but the soreness of the glutes and calves were similar. However, for the second bout, not only was the soreness was reduced for the placebo, but it was further reduced with the Vitamin C. While this is just one study, it is intriguing with some profound implications. If the protective benefits of the repeated bout effect are dependent on nutritional (or other) factors, some runners may not get the benefit from their training. Personally, I've been taking ~1g/day of Vitamin C for many years due to [[Epidermolysis Bullosa| skin condition]]. However, the evidence that Vitamin C impairs the adaptation to exercise caused me to take a break for about 15 months. During that break from Vitamin C, I found my ability to perform downhill running was quite impaired, and I didn't seem to be able to build up resistance from the repeated bout effect. [[File:Does Combined Antioxidant Vitamin Supplementation Blunt Repeated Bout Effect.jpg|center|thumb|500px|]]==Carbohydrate and Protein=={{Main| Nutrient Timing}}The damage of DOMS requires repair, so it's not surprising that taking [[Protein]] or amino acids, which are the building blocks of the muscle fibers, helps with recovery. * Most studies show that amino acids reduce muscle soreness<ref name="HowatsonHoad2012"/><ref name="Greer-2007"/> <ref name="Matsumoto-2009"/><ref name="Shimomura-2010"/>, and may<ref name="Shimomura-2010"/><ref name="Greer-2007"/> or may not reduce weakness<ref name="Jackman-2010"/><ref name="Nosaka-2006"/><ref name="Jackman-2010"/>. * Most studies have shown that protein will reduce muscle weakness after DOMS inducing exercise<ref name="CockburnHayes2008"/><ref name="Valentine-2008"/> <ref name="CookeRybalka2010"/><ref name="Cockburn-2010"/><ref name="Etheridge-2008"/>, with only two studies showing no improvement<ref name="Wojcik-2001"/><ref name="Green-2008"/>. * The effect of protein on soreness is more mixed with some studies showing improvement<ref name="Luden-2007"/> <ref name="Flakoll-2004"/><ref name="Etheridge-2008"/>, but others not<ref name="CockburnHayes2008"/><ref name="Samadi-2012"/><ref name="Green-2008"/>. * Not surprisingly [[Nutrient Timing| timing]] may be important, with CHO+PRO having an effect on muscle weakness directly after or 24 hours after, but not before DOMS inducing exercise<ref name="Cockburn-2010"/>, as shown below.* In addition to reducing muscle soreness, protein supplementation in military recruits also reduced illness and injury<ref name="Flakoll-2004"/>.* Taking carbohydrate alone after DOMS inducing exercise does not appear to help<ref name="Close2005"/><ref name="Nelson-2004"/>. [[File:Protein Timing.jpg|none|thumb|300px|The change in strength after DOMS inducing exercise. CON: control, PRE: protein before, POST: protein immediately after, TWENTY-FOUR: protein 24 horus after<ref name="Cockburn-2010"/>.]]Protein helps with recovery from DOMS<ref name="Etheridge-2008"/>. The graphs below show the impact of 100 grams of Protein taken immediately after 30 minutes of downhill running. Note that muscle soreness peaked at 72 hours, even though force and power had returned to baseline. {| class="wikitable" |- valign="top"|[[File:DOMS Protein Force.jpg|none|thumb|300px|Peak force generated after DOMS inducing eccentric exercise. (*is significant change from baseline, double S marker indicates significant change from treatment.)]]|[[File:DOMS Protein Power.jpg|none|thumb|300px|Peak power generated after DOMS inducing eccentric exercise.(*is significant change from baseline, double S marker indicates significant change from treatment.)]]|}==Cadence=={{Main|Cadence}}A study that looked at how changes in [[Cadence]] impacted the DOMS symptoms of downhill running showed that compared with a runner's preferred cadence, a higher cadence reduced subsequent weakness while a lower cadence increased soreness<ref name="RowlandsEston2001"/>. This change in DOMS is not surprising given that an increased cadence reduces the impact forces of running<ref name="Mercer-2003"/><ref name="Hamill-1995"/><ref name="Clarke-1985"/>. The impact forces from a lower cadence are mostly absorbed by the knee<ref name="Derrick-1998"/>, which would create greater eccentric loading of the quads. In addition, most<ref name="Jones-1989"/><ref name="Child-1998"/> (but not all<ref name="Paschalis-2005"/>) studies show that the more extended a muscle is when undergoing eccentric stress, the more likely it is to suffer from DOMS. This is likely to compound the effect of Cadence on DOMS. ==Compression Clothing =={{Main| Why compression clothes}}Studies show that wearing [[Why compression clothes| Graduated Compression Clothing]] during the days after DOMS inducing exercise mitigates the soreness<ref name="DaviesThompson2009"/><ref name="Kraemer-2001"/><ref name="Kraemer-2001b"/><ref name="KraemerFlanagan2010"/><ref name="Jakeman-2010"/><ref name="Davies-2009"/><ref name="DuffieldPortus2007"/> and weakness<ref name="Kraemer-2001"/><ref name="KraemerFlanagan2010"/><ref name="Jakeman-2010"/> of DOMS. Relatively few studies showed no benefit from compression clothing<ref name="CarlingFrancis1995"/><ref name="Pearce-2009"/>. However, the results of compression clothing are likely to vary with the particular garment, how well it fits and therefore the pressure that is provided<ref name="MacRae-2011"/>. I found one studies that looked at the effect of wearing compression clothing during DOMS inducing exercise on the subsequent recovery<ref name="McDonnellCooper2018"/>. This study used either or both graduated or uniform compression socks on hiking, a trail run, or calf exercise, with the socks also worn for the following four days. Graduated socks reduced DOMS pain on the hike compared with no compression, the only test with no compression as a control. The uniform compression reduced the pain compared with graduated on the run, and there was no difference between them on the calf exercise. This suggests to me that uniform compression might be better than graduated, or at least, it might not be worth paying extra for graduated compression. ==Caffeine=={{Main| Caffeine}}[[Caffeine]] has shown to be effective in reducing the pain of DOMS, as well as reducing the weakness<ref name="Maridakis-2007"/>. (The reduction in weakness did not reach statistical significance in regular caffeine users<ref name="Park-2008"/>.) While the evidence for caffeine reducing the weakness of DOMS, this is one of the few approaches that can help offset the weakness during the damaging exercise. ==Massage=={{Main| Massage}}[[Massage]] is widely used to prevent and treat injuries. Most meta-analysis suggest that post-exercise massage helps with the soreness of DOMS<ref name="Ernst-1998"/><ref name="Moraska-2005"/>, though the mechanisms are unclear<ref name="Tiidus-1997"/>. Studies that give massage 2-3 hours after DOMS inducing exercise showed reduced soreness<ref name="Smith-1994"/><ref name="Zainuddin-2005"/><ref name="Hilbert2003"/>, but not weakness<ref name="Zainuddin-2005"/><ref name="Hilbert2003"/>. One study that gave massage 2 days after exercise that resulted in reduced soreness and improved muscle function<ref name="MancinelliDavis2006"/>, but other studies that use massage 24 hours or more after exercise showed no benefit<ref name="Hart-"/><ref name="Dawson-2004"/>. A study that used 20 minutes of foam rolling immediately following the DOMS inducing exercise, then again at 24 and 48 hours showed a significant improvement in both pain and muscular performance<ref name="Pearcey-2015"/>. Therefore it seems likely that the timing of the massage is important, though other factors, such as the style of massage and the extent of the DOMS may also change the outcome. My personal experience suggests that massage immediately after the exercise is more effective than when the massage is delayed. (All too often, the muscles are too painful under pressure to allow any form of massage.) ==Warmup=={{Main| Warmup}}Performing a [[Warmup]] before exercise may help reduce DOMS pain<ref name="Law-2007"/><ref name="RahnamaRahmani-Nia2005"/>, but not all studies support this<ref name="Evans-2002"/>.==Light Exercise==Light training in the days following DOMS inducing exercise generally accepted to be one of the most effective ways of reducing muscle soreness, but unfortunately the reduction in pain is temporary<ref name="Armstrong-1984"/><ref name="Zainuddin-2006"/><ref name="Howatson-2008"/><ref name="Cheung-2003"/>. A study that looked at running 30 minutes/day after DOMS inducing downhill running shows that the extra exercise neither helped nor hindered with soreness, weakness or [[Running Economy]]<ref name="ChenNosaka2008"/>. (The study only looked at the 7 days following the downhill running, and it would be interesting to know if there are any longer-term differences.) One study used cycling at light (30%) or moderate (70%) immediately after DOMS inducing exercise<ref name="TufanoBrown2012"/>. The moderate intensity cycling prevented the loss of strength, and actually increased strength on days 3 and 4. There were no differences between the control and the light exercise, nor between any of the conditions for soreness. This is an interesting suggestion that higher intensity exercise might be beneficial, but the study has a number of flaws, including the use of predicted [[Maximum Heart Rate]] to set exercise intensity. ==TENS==TENS may reduce the soreness of DOMS<ref name="Denegar-1989"/>, but the effect seems to be transient<ref name="Denegar"/> and the effect is reduced if combined with icing<ref name="Denegar-1992"/>. Not all studies show any pain reduction<ref name="Bonacci-1997"/> and none show a reduction in the weakness. ==Icing=={{Main| Cryotherapy}}Sadly, [[Cryotherapy| Icing]] does not help with DOMS<ref name="Yackzan-"/><ref name="Shunsuke-2004"/><ref name="Gulick-17"/><ref name="Paddon-Jones-1997"/>, and can make DOMS worse<ref name="TsengLee2012"/><ref name="Isabell-1992"/>. Ice reduces pain slightly, but does not restore strength<ref name="Denegar-1992"/>. (In my experience, ice can be extremely effective at helping heal muscle tears and non-DOMS muscle injuries, but not DOMS.)==Protracted Heat==One study looked at applying heat for 8 hours, either directly after DOMS inducing exercise or 24 hours later<ref name="PetrofskyBerk2017"/>. The study used "ThermaCare" chemically generated heat wraps, and I suspect the study was sponsored by the company. The 60 subjects underwent 5 minutes of squats to induce DOMS, then 20 were controls, 20 had immediate heat for 8 hours and the remainder had heat applied 24 hours after exercise. The immediate heat subjects had little reduction in strength over the follow three days, where the 24-hour delayed heat was no different from the controls. The strength drop was about 24% in controls/delayed-heat, which is a meaningful improvement. There was some reduction in pain over the first two days, with the immediate heat doing better than the delayed heat, which was slightly better than the controls. ==Antioxidants - Vitamin C and E==The evidence for anti-oxidants is mixed, with some studies showing a benefit but not others. Note that one study below showed an impaired recovery with vitamin C supplementation. In addition, there is mixed evidence that vitamin C and/or vitamin E reduces [[Endurance Adaptations]] from exercise<ref name="Gomez-Cabrera-2008"/><ref name="RistowZarse2009"/><ref name="Strobel-2011"/> or they do not<ref name="Wadley-2010"/><ref name="Higashida-2011"/> <ref name="YfantiAkerstrom2009"/>. A 2019 systematic review of 50 studies covering 1,089 subjects concluded that there was moderate quality evidence that Vitamin C reduced DOMS at 48 and 96 hours, with lower quality evidence for 6 and 24 hours, but the reduction was quite small<ref name="RanchordasRogerson2018"/>.{| class="wikitable" style="margin-left: auto; margin-right: auto; border: none;"! Vitamin C! Vitamin E! Dose Period! Result|-| 3,000mg/day| | 14 days prior and 4 days post-exercise| Vitamin C reduces soreness in first 24 hours<ref name="Bryer-2006"/>|-| 3,000mg/day| | 3 days prior and 4 days post-exercise | reduced soreness<ref name="Kaminski-1992"/>|-| 400mg/day| | 14 days prior to exercise| reduced soreness<ref name="Thompson-2001"/>|-| 3,000mg/day| | 3 days prior and 5 days post-exercise | no effect<ref name="Connolly-2006"/>|-| 1,000mg/day| | 2 hours prior and 4 days post-exercise| no soreness change, but impaired strength recovery 7 and 14 days after exercise<ref name="CloseAshton2006"/>|-| 1,000mg| | 2 hours prior to exercise| no effect<ref name="Thompson-2001x"/>|-| 400mg/day| | 12 days prior and 3 days post-exercise| no change in soreness<ref name="Thompson-2004"/>|-| | 1,200 IU/day| 30 days prior to exercise| No effect<ref name="Beaton-2002"/>|-| 500mg/day| 1,200 IU/day| 30 days prior and 7 days post-exercise | improved muscle function but no change in soreness<ref name="Shafat-2004"/>|-| 1,000mg/day| 300 mg/d| 6 weeks prior to exercise| no change in function<ref name="Mastaloudis-2006"/>|}==Stretching=={{Main| Stretching}}[[Stretching]] before<ref name="High-1989"/><ref name="Johansson-1999"/> <ref name="Wessel-1994"/>, after <ref name="Johansson-1999"/><ref name="Buroker-1989"/><ref name="Herbert-2007"/>, or both before and after<ref name="Lund-1998"/> exercise does not help with DOMS. In fact, stretching alone can induce DOMS<ref name="Smith-1993"/>. Both static and dynamic stretching are ineffective<ref name="XieFeng2018"/>.==NSAIDs/Pain Relief=={{Main|NSAIDs and Running}}The most common NSAIDs (Ibuprofen, Acetaminophen/Paracetamol, and Aspirin) are unlikely to help with DOMS, but Naproxen may reduce the pain and weakness. (See below for notes on Aspirin and resolvins.) If an NSAID is taken, it should probably be immediately after the damaging exercise rather than waiting until the soreness develops. It seems likely that taking an NSAID for DOMS will reduce the muscular growth that would normally occur as part of the recovery. In one disturbing study, rabbits treated with an NSAID (flurbiprofen) after DOMS inducing exercise initially recovered their strength after 3-7 days, but between days 7 and 28 days the rabbits became weaker while the untreated controls became stronger<ref name="Mishra-1995"/>. I have not included other animal studies, but this is the only one that looks at how NSAIDs impact the longer term recovery from DOMS. There's an emerging belief that NSAIDs suppress inflammation, without actually resolving it<ref name="Markworth Maddipati Cameron-Smith 2016 pp. 110–134"/>. Studies of Turmeric, which acts as a selective COX-2 NSAID<ref name="RamsewakDeWitt2000"/>, are promising. Reduction in soreness is mixed, with some studies showing reduced soreness<ref name="Nicol-2015"/><ref name="Drobnic-2014"/> <ref name="NicolRowlands2015"/>, while others do not<ref name="McFarlinVenable2016"/><ref name="TanabeMaeda2015"/>. However, one study shoes reduced weakness and inflammation markers<ref name="TanabeMaeda2015"/> and an animal study showed less subsequent reduction in running performance in mice<ref name="Davis-2007"/>. Several studies showed reduced markers of damage<ref name="Kawanishi-2013"/><ref name="Davis-2007"/><ref name="TanabeMaeda2015"/><ref name="McFarlinVenable2016"/> <ref name="NicolRowlands2015"/>. However, Turmeric should be treated like any other medication as there are safety concerns; see [[NSAIDs_and_Running#Turmeric_as_an_NSAID| Turmeric as an NSAID]] for details. {| class="wikitable" style="margin-left: auto; margin-right: auto; border: none;"! NSAID! Soreness! Weakness|-| Ibuprofen| 2xImproved<ref name="Hasson-1993"/><ref name="pmid12580656"/>7xNo Effect<ref name="Grossman-1995"/><ref name="Pizza-1999"/><ref name="RahnamaRahmani-Nia2005"/> <ref name="KrentzQuest2008"/><ref name="Arendt-NielsenWeidner2007"/><ref name="Donnelly-1990"/><ref name="Stone-2002"/> | 1xMaybe<ref name="Hasson-1993"/>8xNo Effect<ref name="Grossman-1995"/><ref name="Pizza-1999"/><ref name="RahnamaRahmani-Nia2005"/> <ref name="KrentzQuest2008"/><ref name="Arendt-NielsenWeidner2007"/><ref name="Donnelly-1990"/><ref name="pmid12580656"/><ref name="Stone-2002"/> |-| Ibuprofen Gel| 1xNo Effect<ref name="HyldahlKeadle2010"/>| |-| Acetaminophen (Paracetamol)| 2xNo Effect<ref name="Barlas-2000"/><ref name="SmithGeorge1995"/>| |-| Aspirin| 2xImproved<ref name="Riasata-2010"/><ref name="Francis-1987"/>2xNo Effect<ref name="Barlas-2000"/><ref name="SmithGeorge1995"/>| 2xNo Effect<ref name="Riasata-2010"/><ref name="Francis-1987"/>|-| Naproxen | 4xImproved<ref name="Dudley-1997"/><ref name="Baldwin-2001"/><ref name="Lecomte-1998"/><ref name="journals.ut.ac.ir"/>1xNo Effect<ref name="Bourgeois-1999"/>| 3xImproved<ref name="Dudley-1997"/><ref name="Baldwin-2001"/><ref name="Lecomte-1998"/>1xNo Effect<ref name="Bourgeois-1999"/>|-| Diclofenac | Possible slight reduction<ref name="DonnellyMcCormick1988"/>| |-| Codeine| 1xNo Effect<ref name="Barlas-2000"/> | |-| Rofecoxib | 1xNo Effect<ref name="LoramMitchell2005"/> | |-| Ketoprofen | 1xImproved<ref name="Sayers-2001"/>| 1xImproved<ref name="Sayers-2001"/>|-| Bromelain | 1xNo Effect<ref name="Stone-2002"/>| |-| Turmeric| 2xImproved<ref name="Nicol-2015"/><ref name="Drobnic-2014"/>2xNo Effect<ref name="McFarlinVenable2016"/><ref name="TanabeMaeda2015"/>| 2xImproved<ref name="TanabeMaeda2015"/><ref name="Davis-2007"/>|}==HMB (β-hydroxy-β-methylbutyrate)==There's limited research on HMB and DOMS which suggests HMB might help reduce DOMS<ref name="van SomerenEdwardsHowatson2005"/><ref name="NunanHowatsonvanSomeren2010"/><ref name="KnitterPantonRathmacher2000"/>. The research isn't great, and the results aren't huge, but given the other benefits of [[HMB|HMB For Runners]], I think it's worthwhile. (As an aside, I was amazed to find one study on HMB and DOMS didn't actually use a product containing HMB<ref name="AbumradRathmacher2011"/><ref name="NunanHowatsonvanSomeren2011Ack"/>!)==CBD Oil==I have heard anecdotal suggestions that CBD oil may help with sleep after DOMS inducing exercise, but I've found no supporting research. Note that in 2018, World Anti-Doping Agency (WADA) removed CBD, from its 2018 prohibited substances list, but the legality of CBD is complex. ==Omega-3==There's some limited evidence that Omega-3 oils might help with DOMS<ref name="Anthony Macartney Peoples 2021 pp. 143–153"/>. The Omega-3 oils need to be long chain, such as fish oil, and include EPA and DHA. There's some evidence that athletes may need more Omega-3, with up to 5g/day of EPA/DHA being recommended<ref name="Thielecke Blannin 2020 p. 3712"/>. ==Omega-3, Aspirin, and Resolvins ==One interesting possibility is the combination of Omega-3 and low dose Aspirin, because Aspirin triggers the conversion of DHA to resolvins<ref name="Dalli Winkler Colas Arnardottir 2013 pp. 188–201"/>. As the name suggests, these resolvins cause the resolution of inflammation rather than simply suppressing inflammation. (Resolvins are not immunosuppressive<ref name="Gilligan Gartung Sulciner Norris 2019 pp. 6292–6297"/>.) While there's no studies on how resolvins interact with DOMS, there's a compelling hypothesis<ref name="Markworth Maddipati Cameron-Smith 2016 pp. 110–134"/> and some initial research into general muscle recovery from injury<ref name="Markworth Maddipati Cameron-Smith 2016 pp. 110–134"/>. The typical dose used to study aspirin triggered resolvins is 81mg after a study comparing 81/325/650mg doses found that 325mg had a negligible improvement over 81mg<ref name="Chiang Bermudez Ridker Hurwitz 2004 pp. 15178–15183"/>. It's unclear if less than 81mg might be effective, as I couldn't find any research into lower doses. (Anecdotally, a medical researcher suggested to me that much lower doses might be sufficient.)[[File:Resolvins .jpg|400px|thumb|center|The time course of inflammation.]]=Menstrual Cycle=A study has shown that DOMS does not vary with menstrual cycle<ref name="ChaffinBerg2011"/>.=Mechanisms of DOMS=The underlying mechanism of DOMS is thought to consist of phases; the initial damage that occurs during the exercise and then secondary damage that occurs subsequently<ref name="Cheung-2003"/><ref name="Howatson-2008"/>: * '''Primary damage'''. The initial damage is believed to be mechanical in nature, both on the contracting parts of the muscle (sarcomeres) and the supporting structures (primarily the z-bands). While there are some suggestions that the primary damage might be due to metabolic factors such as low blood flow, low oxygen saturation, impaired metabolite clearance, these causes are not well supported. The idea that DOMS is caused by lactic acid has been rejected<ref name="Schwane-1983"/>.* '''Secondary damage'''. The secondary damage appears to be initiated by the disruption of the intracellular Ca²+homeostatis, which leads to further myofibrillar damage including degradation of the cell membrane.==Mechanisms for the Repeated Bout Effect==For those interested in the details, there are several possible mechanisms that might be responsible for the Repeated Bout Effect (RBE)<ref name="McHugh-2003"/><ref name="McHugh-1999"/>:* '''Neural adaptation'''. The RBE may be due to changes in the way muscles are recruited. While there is some direct evidence that RBE occurs without neural adaptations, it is possible that this mechanism contributes to the protection. ** '''Increased recruitment of slow-twitch fibers'''. Fast-twitch fibers may be more susceptible to eccentric damage, so an adaptation to recruit more slow-twitch fibers might reduce DOMS. ** '''Activation of more muscle fibers'''. Recruiting a larger number of fibers may reduce the eccentric stress on each fiber, thus reducing the damage. * '''Mechanical adaptation'''. It is possible to consider muscle damage as similar to materials fatigue. These adaptations are in the non-contracting structures of the muscles. For instance, protection from damage could come from increased structural strength in the z-band of the muscles which get disturbed by eccentric exercise as seen above.** '''Increased dynamic muscle stiffness'''. Dynamic stiffness refers to how stiff the muscles are when contracted. ** '''Increased passive muscle stiffness'''. In contrast, passive stiffness is when the muscles are relaxed. It is unclear if increased passive stiffness protects against eccentric damage or actually exacerbates it. * '''Cellular adaptation. '''A number of changes at the cellular level may provide protection against eccentric damage. ** '''Increased sarcomeres. '''The sarcomeres are part of the contracting mechanism of the muscles. The contraction of a muscle comes from parts of the sarcomere sliding over each other. One adaptation to eccentric exercise may be that the overlap in these sliding areas becomes larger. A study in rats suggests that the adaptation may include more sarcomeres in series, which produces a greater Range Of Motion and greater force at longer muscle lengths<ref name="Lynn-1998"/>.** '''Changed inflammation response. '''The delay in soreness is probably due to a delayed inflammatory response, so changes in that response could reduce the soreness. However, this would not reduce the immediate loss of strength.** '''Maintenance of Excitation-Contraction coupling'''. One reason for the loss of strength following eccentric exercise is that the nerve impulses (excitation) may result in less contraction. The decoupling could be due to lack of neural drive (perhaps due to pain), physical disruption of the contracting structures of the muscle, or a failure to activate those contracting structures. =Limitations of the current scientific studies=While there are a large number of scientific studies available on DOMS, these studies have a number of limitations. * Most studies use a small number of subjects, limiting their ability to detect the effectiveness of treatments. * The studies are not consistent in the level of DOMS that is provoked, with some studies having relatively mild soreness. * Not all studies avoid the confounding effects of the Repeated Bout Effect. This can be where the study has not ensured that subjects have not performed any eccentric exercise in the recent past, or where subjects undergo multiple bouts in the study. * The studies generally do not establish any dose/response relationship.* Human studies are limited in their timeframe, so that the longer term effects of the treatments are unclear. * Studies often focus on how a treatment reduces the symptoms of DOMS without looking at how the treatment might also change the adaptation process. A DOMS treatment that effectively reduces soreness and/or weakness but also prevents any adaptation to the training has limited benefit. ==See Also==

* [[Downhill Running]]

* [[Downhill Intervals]]

 == References ==

<references>

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