Difference between revisions of "Delayed Onset Muscle Soreness"

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Delayed Onset Muscle Soreness (DOMS) is a familiar experience to most people who exercise. It effects people who weight train and run particularly, and DOMS can produce anything from mild muscle soreness to debilitating pain and weakness.  
+
Delayed Onset Muscle Soreness (DOMS) is a familiar experience to most people who exercise. It affects people who weight train and run particularly, and DOMS can produce anything from mild muscle soreness to debilitating pain and weakness.  
−
= What is DOMS? =
+
=What is DOMS?=
−
DOMS generally occurs between 24 and 72 hours after unusual or severe exercise, such as racing a marathon. DOMS is particularly related to eccentric exercise, which is where the muscle works to resist becoming longer, rather than working to contract. When you muscles absorb the impact of running, this is eccentric. [[Downhill Running]] is much more eccentric than flat or uphill running.  
+
The soreness of DOMS generally peaks between 24 and 72 hours after unusual or severe exercise, though soreness may occur sooner after running<ref name="Vickers2001"/>. DOMS is particularly related to eccentric exercise, which is where the muscle works to resist becoming longer, rather than working to contract. When you muscles absorb the impact of running, this is eccentric exercise, and [[Downhill Running]] is more 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=200px caption="Muscle damage from eccentric exercise (downhill running)">
 
<gallery widths=300px heights=200px caption="Muscle damage from eccentric exercise (downhill running)">
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File:EccentricA.JPG|Muscle before downhill running<ref name="images"/>
+
File:EccentricA.JPG|Muscle before downhill running
−
File:EccentricC.JPG|Immediately after downhill running<ref name="images"/>. Notice the disruption to the dark bands (z-bands) that are part of the muscle structure showing there is immediate damage.  
+
File:EccentricC.JPG|Immediately after downhill running. Notice the disruption to the dark bands (z-bands) that are part of the muscle structure showing there is immediate damage.  
−
File:EccentricD.JPG|One day later<ref name="images"/>, the damage and disruption is worse, indicated some continued breakdown.  
+
File:EccentricD.JPG|One day later, the damage and disruption is worse, indicated some continued breakdown.  
−
File:EccentricB.JPG|Muscle 14 days later<ref name="images"/>, structurally recovered (other metrics do not return to pre-exercise levels at 14 days).
+
File:EccentricB.JPG|Muscle 14 days later, structurally recovered (other metrics do not return to pre-exercise levels at 14 days).
 
</gallery>
 
</gallery>
−
 
+
<gallery widths=300px heights=200px caption="Muscle damage after running a marathon" >
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= What are the symptoms of DOMS? =
+
File:MarathonFiberDamage.jpg|The selective pattern of damage, showing the normal upper fiber adjacent to the 'moth eaten' appearance of the damaged lower fiber.
−
The soreness of DOMS is different to a 'pulled' muscle. With DOMS, large areas of the muscle are very tender to the touch, and the pain is very unpleasant. With a pulled muscle, 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. This is often described as 'loosening' up.  
+
File:MarathonFiberDamage2.jpg|Here you can see extreme damage, with only the Z band of the fiber remaining (marked Z). Adjacent fibers show far less damage.
−
   
+
</gallery>
−
= Why is DOMS important? =
+
=What are the symptoms of DOMS?=
−
DOMS can prevent continued running, due to weakness and soreness. However, the biggest issue for long distance runners is that although the pain occurs 24-72 hours after exercise, the weakness peaks after 30 minutes <ref name="Z1"/>. If you've ever run a long, steep decent (the latter part of Iron Mountain or Mount Mitchell Challenge spring to mind), you'll know the strange feeling 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 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.
+
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.  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"/>.)
−
= What does DOMS mean to you? =
+
* 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.  
−
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. It is 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.
+
* 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.
−
= How to treat DOMS? =
+
* A reduction in the Range of Motion<ref name="Saxton-1995"/><ref name="domsiso"/><ref name="Gulick-1996"/>.
−
Do if you do get DOMS, what can you do?
+
* 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.  
−
* [[Caffeine]] has shown to be effective in reducing the pain of DOMS, as well as reducing the weakness<ref name="X1"/>.  
+
* Decreased [[Running Economy]]<ref name="Smith-1992"/><ref name="Braun-2003"/>.  
−
* [[NSAIDs and Running|NSAIDS]] (Ibuprofen, Acetaminophen/Paracetamol, etc.) have been shown to increase the pain of DOMS, though they may delay its onset<ref name="DomsNsaids"/>, and NSAIDS may also impair healing<ref name="um"/>.
+
* 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"/>.
−
* The evidence for anti-oxidants is scant, but Vitamin C, D and E might help.
+
* 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"/>.
−
* The evidenced for massage, stretching and ice is ambiguous<ref name="X2"/>. In fact, short periods of [[Cryotherapy| icing]] can make DOMS worse<ref name="TsengLee2012"/>.
+
=Why is DOMS important?=
−
* Light exercise has been shown to relieve DOMS<ref name="X3"/>.  
+
Because running involves a lot of eccentric stress, DOMS is common in runners, especially after [[Downhill Running]]. The pain that occurs 24-72 hours after exercise can prevent continued training. However, the biggest issue for long distance runners is that although the pain occurs 24-72 hours after exercise, the weakness peaks after 30 minutes <ref name=<ref name="Marginson-2005"/>/>. If you've ever run a long, steep descent, 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 descents 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.
−
* Performing a [[Warmup]] before exercise does not appear to reduce the resulting DOMS<ref name="Evans-2002"/>.
+
=What does DOMS mean to you?=
−
* Some<ref name="DaviesThompson2009"/><ref name="DaviesThompson2009"/><ref name="Kraemer-2001"/><ref name="DomsComp"/>, but not all<ref name="KraemerFlanagan2010"/><ref name="Viguier-2010"/> studies show that [[Why compression clothes|Graduated Compression Clothing]] mitigates DOMS. A meta-analysis<ref name="MacRae-2011"/> of 14 studies that looked at post exercise muscle soreness, 9 showed a reduction in soreness and 5 showed no change. Looking at the various studies, it appears that compression clothing may have the greatest benefit after 48-72 hours.
+
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.
−
 
+
=How to prevent or treat DOMS?=
−
My personal experience is that a small amount of easy running, while painful, can speed up recovery. I have found no benefit to ice, massage, or Ibuprofen.
+
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 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.
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= Tangent - DOMS and Lactic acid =
+
{| class="wikitable"
−
DOMS is not caused by lactic acid; a full discussion will have to wait until I write an entry on 'the lactic acid myth', but suffice to say, lactic acid is your friend, not your enemy.
+
!Strategy!!Timing!!Soreness!!Weakness!!Downsides
−
 
+
|-
 +
|Repeated Bout Effect
 +
|Before (days to months)
 +
|Strong evidence of reduced weakness
 +
|Some evidence of reduced weakness
 +
|None
 +
|-
 +
|Carbohydrate and/or protein
 +
|After
 +
|Some evidence of reduced soreness
 +
|Strong evidence of reduced weakness
 +
|None
 +
|-
 +
|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
 +
|-
 +
|Massage
 +
|After
 +
|Some evidence of reduced soreness
 +
|No benefit
 +
|None
 +
|-
 +
|Warmup
 +
|Immediately before
 +
|Some evidence of reduced soreness
 +
|No benefit
 +
|None
 +
|-
 +
|Light Exercise
 +
|After
 +
|Transient pain reduction
 +
|No benefit
 +
|None
 +
|-
 +
|TENS
 +
|After
 +
|Transient pain reduction
 +
|No benefit
 +
|None
 +
|-
 +
|Icing
 +
|After
 +
|No benefit
 +
|No benefit
 +
|None
 +
|-
 +
|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
 +
|Before and/or After
 +
|Most evidence indicates no benefit
 +
|Most evidence indicates no benefit
 +
|Can impair recovery
 +
|}
 +
==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"/>, possibly as soon as 24 hours post exercise<ref name="Chen-2001"/>.
 +
==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<span style='color:#FF0000'><ref name="Wojcik-2001"/><ref name="Green-2008"/></span>. 
 +
* 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.)]]
 +
|}
 +
==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"/>. 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.
 +
==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"/>.  No studies were found that looked at the effect of wearing compression clothing during DOMS inducing exercise on the subsequent recovery.
 +
==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"/>.
 +
==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}}
 +
[[Cryotherapy| Icing]] does not help<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"/>
 +
==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"/>.
 +
{| class="wikitable"
 +
|-
 +
!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"/>.
 +
==NSAIDs==
 +
{{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. 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.
 +
{| class="wikitable"
 +
|-
 +
!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"/>
 +
|
 +
|}
 +
=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 Ca<sup>2</sup>+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.
 +
** '''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.  
 
=See Also=
 
=See Also=
 
* [[Downhill Running]]
 
* [[Downhill Running]]
 
* [[Downhill Intervals]]
 
* [[Downhill Intervals]]
−
 
+
=References=
−
= References =
 
 
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Revision as of 05:44, 18 January 2013

Delayed Onset Muscle Soreness (DOMS) is a familiar experience to most people who exercise. It affects people who weight train and run particularly, and DOMS can produce anything from mild muscle soreness to debilitating pain and weakness.

1 What is DOMS?

The soreness of DOMS generally peaks between 24 and 72 hours after unusual or severe exercise, though soreness may occur sooner after running[1]. DOMS is particularly related to eccentric exercise, which is where the muscle works to resist becoming longer, rather than working to contract. When you muscles absorb the impact of running, this is eccentric exercise, and Downhill Running is more eccentric than flat or uphill running. The images below show the damage that occurs from eccentric exercise[2] and marathon running[3]:

  • Muscle damage from eccentric exercise (downhill running)

  • Muscle before downhill running

  • Immediately after downhill running. Notice the disruption to the dark bands (z-bands) that are part of the muscle structure showing there is immediate damage.

  • One day later, the damage and disruption is worse, indicated some continued breakdown.

  • Muscle 14 days later, structurally recovered (other metrics do not return to pre-exercise levels at 14 days).

  • Muscle damage after running a marathon

  • The selective pattern of damage, showing the normal upper fiber adjacent to the 'moth eaten' appearance of the damaged lower fiber.

  • Here you can see extreme damage, with only the Z band of the fiber remaining (marked Z). Adjacent fibers show far less damage.

2 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. In addition, there are other symptoms, such as:

  • Reduction in strength[4][5][6][7], typically 30-60%[8]. (Note that the reduction in strength starts immediately following the damaging exercise and increases over the next 24-48 hours[9]. The initial reduction in strength can be as much as 40%[8].)
  • Increased passive muscle tension[10]. A muscle suffering from DOMS will often be hard to the touch, even when relaxed as much as possible.
  • Swelling of the muscle[10], which can be seen as a lack of muscle definition in lean individuals.
  • The perceptions of joint angle and force are impaired[4], which can result in reduced coordination and a sense of clumsiness.
  • A reduction in the Range of Motion[4][5][6].
  • Changes in running biomechanics, possibly as compensation for other changes[11]. For instance, the reduction in Range of Motion can result in a reduction in stride length.
  • Decreased Running Economy[12][13].
  • Impaired Glycogen repletion[12][13], though higher carbohydrate intake partly offsets the reduction[14]. There is some evidence that Glycogen levels continue to drop after DOMS inducing exercise[15][16], and the deficiency in glycogen lasts for over 72 hours[16].
  • There are some studies that indicate there are possible changes in muscle fiber recruitment patterns[17][18][19].

3 Why is DOMS important?

Because running involves a lot of eccentric stress, DOMS is common in runners, especially after Downhill Running. The pain that occurs 24-72 hours after exercise can prevent continued training. However, the biggest issue for long distance runners is that although the pain occurs 24-72 hours after exercise, the weakness peaks after 30 minutes [20]/>. If you've ever run a long, steep descent, 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 descents 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.

4 What does DOMS mean to you?

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 [21]. 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.

5 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 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.

Strategy Timing Soreness Weakness Downsides
Repeated Bout Effect Before (days to months) Strong evidence of reduced weakness Some evidence of reduced weakness None
Carbohydrate and/or protein After Some evidence of reduced soreness Strong evidence of reduced weakness None
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
Massage After Some evidence of reduced soreness No benefit None
Warmup Immediately before Some evidence of reduced soreness No benefit None
Light Exercise After Transient pain reduction No benefit None
TENS After Transient pain reduction No benefit None
Icing After No benefit No benefit None
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 Before and/or After Most evidence indicates no benefit Most evidence indicates no benefit Can impair recovery

5.1 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)[10][9]. The initial bout does not have to cause significant soreness or damage[22]. 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[23]. By contrast, eight weeks of training with 50% of the maximal eccentric load did not provide protection against a subsequent maximal bout[24]. 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[25]. 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[26]. Another study showed that 30 minutes of downhill running provides protection for between 6 and 9 weeks[27]. There is evidence that the RBE may rapidly start to provide protection from soreness and weakness[28], possibly as soon as 24 hours post exercise[29].

5.2 Carbohydrate and Protein

Main article: 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[30][31] [32][33], and may[33][31] or may not reduce weakness[34][35][34].
  • Most studies have shown that protein will reduce muscle weakness after DOMS inducing exercise[36][37] [38][39][40], with only two studies showing no improvement[41][42].
  • The effect of protein on soreness is more mixed with some studies showing improvement[43] [44][40], but others not[36][45][42].
  • Not surprisingly 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[39], as shown below.
  • In addition to reducing muscle soreness, protein supplementation in military recruits also reduced illness and injury[44].
  • Taking carbohydrate alone after DOMS inducing exercise does not appear to help[46][47].
The change in strength after DOMS inducing exercise. CON: control, PRE: protein before, POST: protein immediately after, TWENTY-FOUR: protein 24 horus after[39].

Protein helps with recovery from DOMS[40]. 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.

Peak force generated after DOMS inducing eccentric exercise. (*is significant change from baseline, double S marker indicates significant change from treatment.)
Peak power generated after DOMS inducing eccentric exercise.(*is significant change from baseline, double S marker indicates significant change from treatment.)

5.3 Caffeine

Main article: Caffeine

Caffeine has shown to be effective in reducing the pain of DOMS, as well as reducing the weakness[48]. (The reduction in weakness did not reach statistical significance in regular caffeine users[49].) 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.

5.4 Massage

Main article: Massage

Massage is widely used to prevent and treat injuries. Most meta-analysis suggest that post-exercise massage helps with the soreness of DOMS[50][51], though the mechanisms are unclear[52]. Studies that give massage 2-3 hours after DOMS inducing exercise showed reduced soreness[53][54][55], but not weakness[54][55]. One study that gave massage 2 days after exercise that resulted in reduced soreness and improved muscle function[56], but other studies that use massage 24 hours or more after exercise showed no benefit[57][58]. 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.

5.5 Compression Clothing

Main article: Why compression clothes

Studies show that wearing Graduated Compression Clothing during the days after DOMS inducing exercise mitigates the soreness[59][60][61][62][63][64][65] and weakness[60][62][63] of DOMS. Relatively few studies showed no benefit from compression clothing[66][67]. 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[68]. No studies were found that looked at the effect of wearing compression clothing during DOMS inducing exercise on the subsequent recovery.

5.6 Warmup

Main article: Warmup

Performing a Warmup before exercise may help reduce DOMS pain[69][70], but not all studies support this[71].

5.7 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[72][73][10][9].

5.8 TENS

TENS may reduce the soreness of DOMS[74], but the effect seems to be transient[75] and the effect is reduced if combined with icing[76]. Not all studies show any pain reduction[77] and none show a reduction in the weakness.

5.9 Icing

Main article: Cryotherapy

Icing does not help[78][79][80][7], and can make DOMS worse[81][82]. Ice reduces pain slightly, but does not restore strength[76]

5.10 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[83][84][85] or they do not[86][87] [88].

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[89]
3,000mg/day 3 days prior and 4 days post-exercise reduced soreness[90]
400mg/day 14 days prior to exercise reduced soreness[91]
3,000mg/day 3 days prior and 5 days post-exercise no effect[92]
1,000mg/day 2 hours prior and 4 days post-exercise no soreness change, but impaired strength recovery 7 and 14 days after exercise[93]
1,000mg 2 hours prior to exercise no effect[94]
400mg/day 12 days prior and 3 days post-exercise no change in soreness[95]
1,200 IU/day 30 days prior to exercise No effect[96]
500mg/day 1,200 IU/day 30 days prior and 7 days post-exercise improved muscle function but no change in soreness[97]
1,000mg/day 300 mg/d 6 weeks prior to exercise no change in function[98]

5.11 Stretching

Main article: Stretching

Stretching before[99][100] [101], after [100][102][103], or both before and after[104] exercise does not help with DOMS. In fact, stretching alone can induce DOMS[105].

5.12 NSAIDs

Main article: 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. 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[106]. 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.

NSAID Soreness Weakness
Ibuprofen 2xImproved[107][108]

7xNo Effect[109][110][70] [111][112][113][114]

1xMaybe[107]

8xNo Effect[109][110][70] [111][112][113][108][114]

Ibuprofen Gel 1xNo Effect[115]
Acetaminophen (Paracetamol) 2xNo Effect[116][117]
Aspirin 2xImproved[118][119]

2xNo Effect[116][117]

2xNo Effect[118][119]
Naproxen 4xImproved[120][121][122][123]

1xNo Effect[124]

3xImproved[120][121][122]

1xNo Effect[124]

Diclofenac Possible slight reduction[125]
Codeine 1xNo Effect[116]
Rofecoxib 1xNo Effect[126]
Ketoprofen 1xImproved[127] 1xImproved[127]
Bromelain 1xNo Effect[114]

6 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[9][10]:

  • 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[128].
  • 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.

6.1 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)[129][130]:

  • 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.
    • 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.

7 See Also

8 References

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  114. ↑ 114.0 114.1 114.2 Stone, MB.; Merrick, MA.; Ingersoll, CD.; Edwards, JE. (Nov 2002). "Preliminary comparison of bromelain and Ibuprofen for delayed onset muscle soreness management.". Clin J Sport Med 12 (6): 373-8. Template:citation/identifier.
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  116. ↑ 116.0 116.1 116.2 Barlas, P.; Craig, JA.; Robinson, J.; Walsh, DM.; Baxter, GD.; Allen, JM. (Jul 2000). "Managing delayed-onset muscle soreness: lack of effect of selected oral systemic analgesics.". Arch Phys Med Rehabil 81 (7): 966-72. Template:citation/identifier. Template:citation/identifier.
  117. ↑ 117.0 117.1 Template:cite journal
  118. ↑ 118.0 118.1 Riasati et al.: Aspirin and delayed onset muscle soreness ASPIRIN MAY BE AN EFFECTIVE TREATMENT FOR EXERCISE- INDUCED MUSCLE SORENESS | ResearchGate http://www.researchgate.net/publication/228091056_Riasati_et_al._Aspirin_and_delayed_onset_muscle_soreness_ASPIRIN_MAY_BE_AN_EFFECTIVE_TREATMENT_FOR_EXERCISE-_INDUCED_MUSCLE_SORENESS
  119. ↑ 119.0 119.1 Francis, KT.; Hoobler, T. (Sep 1987). "Effects of aspirin on delayed muscle soreness.". J Sports Med Phys Fitness 27 (3): 333-7. Template:citation/identifier.
  120. ↑ 120.0 120.1 Dudley, GA.; Czerkawski, J.; Meinrod, A.; Gillis, G.; Baldwin, A.; Scarpone, M. (Jan 1997). "Efficacy of naproxen sodium for exercise-induced dysfunction muscle injury and soreness.". Clin J Sport Med 7 (1): 3-10. Template:citation/identifier.
  121. ↑ 121.0 121.1 Baldwin, AC.; Stevenson, SW.; Dudley, GA. (Aug 2001). "Nonsteroidal anti-inflammatory therapy after eccentric exercise in healthy older individuals.". J Gerontol A Biol Sci Med Sci 56 (8): M510-3. Template:citation/identifier.
  122. ↑ 122.0 122.1 Lecomte, JM.; Lacroix, VJ.; Montgomery, DL. (Apr 1998). "A randomized controlled trial of the effect of naproxen on delayed onset muscle soreness and muscle strength.". Clin J Sport Med 8 (2): 82-7. Template:citation/identifier.
  123. ↑ "The Effect of Taking Naproxen Drug on the Level of Perceived Pain and Changes of CPK Serum after Eccentric Exercise - Harakat Volume: 37, Issue:". http://journals.ut.ac.ir/page/article-frame.html?langId=en&articleId=1003701. Retrieved 3 January 2013.
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  127. ↑ 127.0 127.1 Sayers, SP.; Knight, CA.; Clarkson, PM.; Van Wegen, EH.; Kamen, G. (May 2001). "Effect of ketoprofen on muscle function and sEMG activity after eccentric exercise.". Med Sci Sports Exerc 33 (5): 702-10. Template:citation/identifier.
  128. ↑ Schwane, J (Mar 1983). "Is lactic acid related to delayed-onset muscle soreness.". Physician & Sportsmedicin 11 (3): 124-127;130-131.
  129. ↑ McHugh, MP. (Apr 2003). "Recent advances in the understanding of the repeated bout effect: the protective effect against muscle damage from a single bout of eccentric exercise.". Scand J Med Sci Sports 13 (2): 88-97. Template:citation/identifier.
  130. ↑ McHugh, MP.; Connolly, DA.; Eston, RG.; Gleim, GW. (Mar 1999). "Exercise-induced muscle damage and potential mechanisms for the repeated bout effect.". Sports Med 27 (3): 157-70. Template:citation/identifier.
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