Revision as of 04:49, 16 April 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. DOMS is caused by eccentric stress, where the muscles working to resist lengthening, such as lowering a weight or absorbing the landing forces of running. Downhill running is a particular source of eccentric stress. DOMS not only produces delayed soreness, but immediate weakness that generally lasts a similar length of time. DOMS also produces swelling, tense muscles, reduced coordination and a limited range of motion. A key benefit of DOMS inducing exercise is that a bout of DOMS can give protection against similar future exercise, and the protection lasts for months. Running with the correct Cadence can help prevent DOMS, and taking protein after DOMS inducing exercise is one of the best treatments, though compression clothing, caffeine and massage can also help.

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 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 ^[4]/>. 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.

3 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 ^[5]. 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.

4 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 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.

5 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^[6][7][8][9], typically 30-60%^[10]. (Note that the reduction in strength starts immediately following the damaging exercise and increases over the next 24-48 hours^[11]. The initial reduction in strength can be as much as 40%^[10].)
• Increased passive muscle tension^[12]. A muscle suffering from DOMS will often be hard to the touch, even when relaxed as much as possible.
• Swelling of the muscle^[12], which can be seen as a lack of muscle definition in lean individuals.
• The perceptions of joint angle and force are impaired^[6], which can result in reduced coordination and a sense of clumsiness.
• A reduction in the Range of Motion^[6][7][8].
• Changes in running biomechanics, possibly as compensation for other changes^[13]. For instance, the reduction in Range of Motion can result in a reduction in stride length.
• Decreased Running Economy^[14][15].
• Impaired Glycogen repletion^[14][15], though higher carbohydrate intake partly offsets the reduction^[16]. There is some evidence that Glycogen levels continue to drop after DOMS inducing exercise^[17][18], and the deficiency in glycogen lasts for over 72 hours^[18].
• There are some studies that indicate there are possible changes in muscle fiber recruitment patterns^[19][20][21].

6 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.

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.

6.1 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)^[12][11]. 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], within 5 days^[29], and possibly within 24 hours^[30].

6.2 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^{[31][32] [33][34]}, and may^[34][32] or may not reduce weakness^[35][36][35].
• Most studies have shown that protein will reduce muscle weakness after DOMS inducing exercise^{[37][38] [39][40][41]}, with only two studies showing no improvement^[42][43].
• The effect of protein on soreness is more mixed with some studies showing improvement^{[44] [45][41]}, but others not^[37][46][43].
• 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^[40], as shown below.
• In addition to reducing muscle soreness, protein supplementation in military recruits also reduced illness and injury^[45].
• Taking carbohydrate alone after DOMS inducing exercise does not appear to help^[47][48].

The change in strength after DOMS inducing exercise. CON: control, PRE: protein before, POST: protein immediately after, TWENTY-FOUR: protein 24 horus after^[40].

Protein helps with recovery from DOMS^[41]. 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.)

6.3 Cadence

Main article: 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^[49]. This change in DOMS is not surprising given that an increased cadence reduces the impact forces of running^[50][51][52]. The impact forces from a lower cadence are mostly absorbed by the knee^[53], which would create greater eccentric loading of the quads. In addition, most^[54][55] (but not all^[56]) 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.

6.4 Compression Clothing

Main article: Why compression clothes

Studies show that wearing Graduated Compression Clothing during the days after DOMS inducing exercise mitigates the soreness^{[57][58][59][60][61][62][63]} and weakness^[58][60][61] of DOMS. Relatively few studies showed no benefit from compression clothing^[64][65]. 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^[66]. No studies were found that looked at the effect of wearing compression clothing during DOMS inducing exercise on the subsequent recovery.

6.5 Caffeine

Main article: Caffeine

Caffeine has shown to be effective in reducing the pain of DOMS, as well as reducing the weakness^[67]. (The reduction in weakness did not reach statistical significance in regular caffeine users^[68].) 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.

6.6 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^[69][70], though the mechanisms are unclear^[71]. Studies that give massage 2-3 hours after DOMS inducing exercise showed reduced soreness^[72][73][74], but not weakness^[73][74]. One study that gave massage 2 days after exercise that resulted in reduced soreness and improved muscle function^[75], but other studies that use massage 24 hours or more after exercise showed no benefit^[76][77]. 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.

6.7 Warmup

Main article: Warmup

Performing a Warmup before exercise may help reduce DOMS pain^[78][79], but not all studies support this^[80].

6.8 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^{[81][82][12][11]}. 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^[83]. (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.)

6.9 TENS

TENS may reduce the soreness of DOMS^[84], but the effect seems to be transient^[85] and the effect is reduced if combined with icing^[86]. Not all studies show any pain reduction^[87] and none show a reduction in the weakness.

6.10 Icing

Main article: Cryotherapy

Icing does not help^{[88][89][90][9]}, and can make DOMS worse^[91][92]. Ice reduces pain slightly, but does not restore strength^[86]

6.11 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^[93][94][95] or they do not^{[96][97] [98]}.

6.12 Stretching

Main article: Stretching

Stretching before^{[109][110] [111]}, after ^{[110][112][113]}, or both before and after^[114] exercise does not help with DOMS. In fact, stretching alone can induce DOMS^[115].

6.13 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^[116]. 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.

7 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^[11][12]:

• 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^[138].
• 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.

7.1 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)^[139][140]:

• 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.

8 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.

9 See Also

• Downhill Running
• Downhill Intervals

10 References

1. ↑ Andrew J Vickers, BMC Musculoskeletal Disorders, volume 2, issue 1, 2001, pages 5, ISSN 14712474, doi 10.1186/1471-2474-2-5
2. ↑ L Feasson, D Stockholm, D Freyssenet, I Richard, S Duguez, J S Beckmann, C Denis, Molecular adaptations of neuromuscular disease-associated proteins in response to eccentric exercise in human skeletal muscle, The Journal of Physiology, volume 543, issue 1, 2002, pages 297–306, ISSN 0022-3751, doi 10.1113/jphysiol.2002.018689
3. ↑ MJ. Warhol, AJ. Siegel, WJ. Evans, LM. Silverman, Skeletal muscle injury and repair in marathon runners after competition., Am J Pathol, volume 118, issue 2, pages 331-9, Feb 1985, PMID 3970143
4. ↑ V. Marginson, AV. Rowlands, NP. Gleeson, RG. Eston, Comparison of the symptoms of exercise-induced muscle damage after an initial and repeated bout of plyometric exercise in men and boys., J Appl Physiol, volume 99, issue 3, pages 1174-81, Sep 2005, doi 10.1152/japplphysiol.01193.2004, PMID 15817716
5. ↑ Skeletal muscle damage and repair http://books.google.com/books?id=ueMh1x7kFjsC&lpg=PA195&ots=wwIhuoi0Nt&dq=Tiidus%201997&pg=PA69#v=onepage&q=Tiidus%201997&f=true
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7. ↑ ^{7.0 7.1} Delayed Onset Muscle Soreness and Decreased Isokinetic Stren... : The Journal of Strength & Conditioning Research http://journals.lww.com/nsca-jscr/abstract/1988/05000/delayed_onset_muscle_soreness_and_decreased.1.aspx
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13. ↑ Muscle Soreness During Running: Biomechanical and Physiological Considerations http://journals.humankinetics.com/jab-back-issues/jabvolume7issue2may/musclesorenessduringrunningbiomechanicalandphysiologicalconsiderations
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24. ↑ K. Nosaka, M. Newton, Concentric or eccentric training effect on eccentric exercise-induced muscle damage., Med Sci Sports Exerc, volume 34, issue 1, pages 63-9, Jan 2002, PMID 11782649
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26. ↑ K. Nosaka, K. Sakamoto, M. Newton, P. Sacco, How long does the protective effect on eccentric exercise-induced muscle damage last?, Med Sci Sports Exerc, volume 33, issue 9, pages 1490-5, Sep 2001, PMID 11528337
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28. ↑ J. Mair, M. Mayr, E. Müller, A. Koller, C. Haid, E. Artner-Dworzak, C. Calzolari, C. Larue, B. Puschendorf, Rapid adaptation to eccentric exercise-induced muscle damage., Int J Sports Med, volume 16, issue 6, pages 352-6, Aug 1995, doi 10.1055/s-2007-973019, PMID 7591384
29. ↑ CB. Ebbeling, PM. Clarkson, Exercise-induced muscle damage and adaptation., Sports Med, volume 7, issue 4, pages 207-34, Apr 1989, PMID 2657962
30. ↑ TC. Chen, SS. Hsieh, Effects of a 7-day eccentric training period on muscle damage and inflammation., Med Sci Sports Exerc, volume 33, issue 10, pages 1732-8, Oct 2001, PMID 11581559
31. ↑ Glyn Howatson, Michael Hoad, Stuart Goodall, Jamie Tallent, Phillip G Bell, Duncan N French, Exercise-induced muscle damage is reduced in resistance-trained males by branched chain amino acids: a randomized, double-blind, placebo controlled study, Journal of the International Society of Sports Nutrition, volume 9, issue 1, 2012, pages 20, ISSN 1550-2783, doi 10.1186/1550-2783-9-20
32. ↑ ^{32.0 32.1} BK. Greer, JL. Woodard, JP. White, EM. Arguello, EM. Haymes, Branched-chain amino acid supplementation and indicators of muscle damage after endurance exercise., Int J Sport Nutr Exerc Metab, volume 17, issue 6, pages 595-607, Dec 2007, PMID 18156664
33. ↑ K. Matsumoto, T. Koba, K. Hamada, M. Sakurai, T. Higuchi, H. Miyata, Branched-chain amino acid supplementation attenuates muscle soreness, muscle damage and inflammation during an intensive training program., J Sports Med Phys Fitness, volume 49, issue 4, pages 424-31, Dec 2009, PMID 20087302
34. ↑ ^{34.0 34.1} Y. Shimomura, A. Inaguma, S. Watanabe, Y. Yamamoto, Y. Muramatsu, G. Bajotto, J. Sato, N. Shimomura, H. Kobayashi, Branched-chain amino acid supplementation before squat exercise and delayed-onset muscle soreness., Int J Sport Nutr Exerc Metab, volume 20, issue 3, pages 236-44, Jun 2010, PMID 20601741
35. ↑ ^{35.0 35.1} SR. Jackman, OC. Witard, AE. Jeukendrup, KD. Tipton, Branched-chain amino acid ingestion can ameliorate soreness from eccentric exercise., Med Sci Sports Exerc, volume 42, issue 5, pages 962-70, May 2010, doi 10.1249/MSS.0b013e3181c1b798, PMID 19997002
36. ↑ K. Nosaka, P. Sacco, K. Mawatari, Effects of amino acid supplementation on muscle soreness and damage., Int J Sport Nutr Exerc Metab, volume 16, issue 6, pages 620-35, Dec 2006, PMID 17342883
37. ↑ ^{37.0 37.1} Emma Cockburn, Philip R. Hayes, Duncan N. French, Emma Stevenson, Alan St Clair Gibson, Acute milk-based protein–CHO supplementation attenuates exercise-induced muscle damage, Applied Physiology, Nutrition, and Metabolism, volume 33, issue 4, 2008, pages 775–783, ISSN 1715-5312, doi 10.1139/H08-057
38. ↑ RJ. Valentine, MJ. Saunders, MK. Todd, TG. St Laurent, Influence of carbohydrate-protein beverage on cycling endurance and indices of muscle disruption., Int J Sport Nutr Exerc Metab, volume 18, issue 4, pages 363-78, Aug 2008, PMID 18708686
39. ↑ Matthew B Cooke, Emma Rybalka, Christos G Stathis, Paul J Cribb, Alan Hayes, Whey protein isolate attenuates strength decline after eccentrically-induced muscle damage in healthy individuals, Journal of the International Society of Sports Nutrition, volume 7, issue 1, 2010, pages 30, ISSN 1550-2783, doi 10.1186/1550-2783-7-30
40. ↑ ^{40.0 40.1 40.2} E. Cockburn, E. Stevenson, PR. Hayes, P. Robson-Ansley, G. Howatson, Effect of milk-based carbohydrate-protein supplement timing on the attenuation of exercise-induced muscle damage., Appl Physiol Nutr Metab, volume 35, issue 3, pages 270-7, Jun 2010, doi 10.1139/H10-017, PMID 20555370
41. ↑ ^{41.0 41.1 41.2} T. Etheridge, A. Philp, PW. Watt, A single protein meal increases recovery of muscle function following an acute eccentric exercise bout., Appl Physiol Nutr Metab, volume 33, issue 3, pages 483-8, Jun 2008, doi 10.1139/H08-028, PMID 18461101
42. ↑ JR. Wojcik, J. Walber-Rankin, LL. Smith, FC. Gwazdauskas, Comparison of carbohydrate and milk-based beverages on muscle damage and glycogen following exercise., Int J Sport Nutr Exerc Metab, volume 11, issue 4, pages 406-19, Dec 2001, PMID 11915776
43. ↑ ^{43.0 43.1} MS. Green, BT. Corona, JA. Doyle, CP. Ingalls, Carbohydrate-protein drinks do not enhance recovery from exercise-induced muscle injury., Int J Sport Nutr Exerc Metab, volume 18, issue 1, pages 1-18, Feb 2008, PMID 18272930
44. ↑ ND. Luden, MJ. Saunders, MK. Todd, Postexercise carbohydrate-protein- antioxidant ingestion decreases plasma creatine kinase and muscle soreness., Int J Sport Nutr Exerc Metab, volume 17, issue 1, pages 109-23, Feb 2007, PMID 17460336
45. ↑ ^{45.0 45.1} PJ. Flakoll, T. Judy, K. Flinn, C. Carr, S. Flinn, Postexercise protein supplementation improves health and muscle soreness during basic military training in Marine recruits., J Appl Physiol, volume 96, issue 3, pages 951-6, Mar 2004, doi 10.1152/japplphysiol.00811.2003, PMID 14657039
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