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Delayed Onset Muscle Soreness

Revision as of 06:32, 17 April 2014 by User:Fellrnr (User talk:Fellrnr | contribs)

Revision as of 06:32, 17 April 2014 by User:Fellrnr (User talk:Fellrnr | contribs)

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.

Contents

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.

4.1 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.

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.)

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.

Strategy Timing Soreness Weakness Downsides
Repeated Bout Effect Before (days to months) Strong evidence of reduced soreness Some evidence of reduced weakness None
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
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 Nonea
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 Nonec
TENS After Transient pain reduction No benefit None
Icing After No benefit No benefit Noneb
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

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]. One study[31] 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.

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.

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[32][33] [34][35], and may[35][33] or may not reduce weakness[36][37][36].
  • Most studies have shown that protein will reduce muscle weakness after DOMS inducing exercise[38][39] [40][41][42], with only two studies showing no improvement[43][44].
  • The effect of protein on soreness is more mixed with some studies showing improvement[45] [46][42], but others not[38][47][44].
  • 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[41], as shown below.
  • In addition to reducing muscle soreness, protein supplementation in military recruits also reduced illness and injury[46].
  • Taking carbohydrate alone after DOMS inducing exercise does not appear to help[48][49].
The change in strength after DOMS inducing exercise. CON: control, PRE: protein before, POST: protein immediately after, TWENTY-FOUR: protein 24 horus after[41].

Protein helps with recovery from DOMS[42]. 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[50]. This change in DOMS is not surprising given that an increased cadence reduces the impact forces of running[51][52][53]. The impact forces from a lower cadence are mostly absorbed by the knee[54], which would create greater eccentric loading of the quads. In addition, most[55][56] (but not all[57]) 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[58][59][60][61][62][63][64] and weakness[59][61][62] of DOMS. Relatively few studies showed no benefit from compression clothing[65][66]. 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[67]. 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[68]. (The reduction in weakness did not reach statistical significance in regular caffeine users[69].) 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[70][71], though the mechanisms are unclear[72]. Studies that give massage 2-3 hours after DOMS inducing exercise showed reduced soreness[73][74][75], but not weakness[74][75]. One study that gave massage 2 days after exercise that resulted in reduced soreness and improved muscle function[76], but other studies that use massage 24 hours or more after exercise showed no benefit[77][78]. 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[79][80], but not all studies support this[81].

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[82][83][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[84]. (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[85], but the effect seems to be transient[86] and the effect is reduced if combined with icing[87]. Not all studies show any pain reduction[88] and none show a reduction in the weakness.

6.10 Icing

Main article: Cryotherapy

Icing does not help[89][90][91][9], and can make DOMS worse[92][93]. Ice reduces pain slightly, but does not restore strength[87]

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[94][95][96] or they do not[97][98] [99].

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[100]
3,000mg/day 3 days prior and 4 days post-exercise reduced soreness[101]
400mg/day 14 days prior to exercise reduced soreness[102]
3,000mg/day 3 days prior and 5 days post-exercise no effect[103]
1,000mg/day 2 hours prior and 4 days post-exercise no soreness change, but impaired strength recovery 7 and 14 days after exercise[104]
1,000mg 2 hours prior to exercise no effect[105]
400mg/day 12 days prior and 3 days post-exercise no change in soreness[106]
1,200 IU/day 30 days prior to exercise No effect[107]
500mg/day 1,200 IU/day 30 days prior and 7 days post-exercise improved muscle function but no change in soreness[108]
1,000mg/day 300 mg/d 6 weeks prior to exercise no change in function[109]

6.12 Stretching

Main article: Stretching

Stretching before[110][111] [112], after [111][113][114], or both before and after[115] exercise does not help with DOMS. In fact, stretching alone can induce DOMS[116].

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[117]. 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[118][119]

7xNo Effect[120][121][80] [122][123][124][125]

 1xMaybe[118]

8xNo Effect[120][121][80] [122][123][124][119][125]

Ibuprofen Gel 1xNo Effect[126]
Acetaminophen (Paracetamol) 2xNo Effect[127][128]
Aspirin 2xImproved[129][130]

2xNo Effect[127][128]

 2xNo Effect[129][130]
Naproxen 4xImproved[131][132][133][134]

1xNo Effect[135]

 3xImproved[131][132][133]

1xNo Effect[135]

Diclofenac Possible slight reduction[136]
Codeine 1xNo Effect[127]
Rofecoxib 1xNo Effect[137]
Ketoprofen 1xImproved[138] 1xImproved[138]
Bromelain 1xNo Effect[125]

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[139].
  • 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)[140][141]:

  • 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

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
  6. ↑ 6.0 6.1 6.2 JM. Saxton, PM. Clarkson, R. James, M. Miles, M. Westerfer, S. Clark, AE. Donnelly, Neuromuscular dysfunction following eccentric exercise., Med Sci Sports Exerc, volume 27, issue 8, pages 1185-93, Aug 1995, PMID 7476064
  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
  8. ↑ 8.0 8.1 DT. Gulick, IF. Kimura, M. Sitler, A. Paolone, JD. Kelly, Various treatment techniques on signs and symptoms of delayed onset muscle soreness., J Athl Train, volume 31, issue 2, pages 145-52, Apr 1996, PMID 16558388
  9. ↑ 9.0 9.1 DJ. Paddon-Jones, BM. Quigley, Effect of cryotherapy on muscle soreness and strength following eccentric exercise., Int J Sports Med, volume 18, issue 8, pages 588-93, Nov 1997, doi 10.1055/s-2007-972686, PMID 9443590
  10. ↑ 10.0 10.1 A. Baldwin Lanier, Use of nonsteroidal anti-inflammatory drugs following exercise-induced muscle injury., Sports Med, volume 33, issue 3, pages 177-85, 2003, PMID 12656639
  11. ↑ 11.0 11.1 11.2 11.3 K. Cheung, P. Hume, L. Maxwell, Delayed onset muscle soreness : treatment strategies and performance factors., Sports Med, volume 33, issue 2, pages 145-64, 2003, PMID 12617692
  12. ↑ 12.0 12.1 12.2 12.3 12.4 G. Howatson, KA. van Someren, The prevention and treatment of exercise-induced muscle damage., Sports Med, volume 38, issue 6, pages 483-503, 2008, PMID 18489195
  13. ↑ Muscle Soreness During Running: Biomechanical and Physiological Considerations http://journals.humankinetics.com/jab-back-issues/jabvolume7issue2may/musclesorenessduringrunningbiomechanicalandphysiologicalconsiderations
  14. ↑ 14.0 14.1 Smith LL. Causes of delayed onset muscle soreness and the impact on athletic performance: a review. J Appl Sport Sci Res 1992; 6 (3): 135-41
  15. ↑ 15.0 15.1 WA. Braun, DJ. Dutto, The effects of a single bout of downhill running and ensuing delayed onset of muscle soreness on running economy performed 48 h later., Eur J Appl Physiol, volume 90, issue 1-2, pages 29-34, Sep 2003, doi 10.1007/s00421-003-0857-8, PMID 12783232
  16. ↑ DL. Costill, DD. Pascoe, WJ. Fink, RA. Robergs, SI. Barr, D. Pearson, Impaired muscle glycogen resynthesis after eccentric exercise., J Appl Physiol, volume 69, issue 1, pages 46-50, Jul 1990, PMID 2394662
  17. ↑ M. Zehnder, M. Muelli, R. Buchli, G. Kuehne, U. Boutellier, Further glycogen decrease during early recovery after eccentric exercise despite a high carbohydrate intake., Eur J Nutr, volume 43, issue 3, pages 148-59, Jun 2004, doi 10.1007/s00394-004-0453-7, PMID 15168037
  18. ↑ 18.0 18.1 JJ. Widrick, DL. Costill, GK. McConell, DE. Anderson, DR. Pearson, JJ. Zachwieja, Time course of glycogen accumulation after eccentric exercise., J Appl Physiol, volume 72, issue 5, pages 1999-2004, May 1992, PMID 1601811
  19. ↑ MP. Miles, JC. Ives, KR. Vincent, Neuromuscular control following maximal eccentric exercise., Eur J Appl Physiol Occup Physiol, volume 76, issue 4, pages 368-74, 1997, PMID 9349654
  20. ↑ S. Zhou, MF. Carey, RJ. Snow, DL. Lawson, WE. Morrison, Effects of muscle fatigue and temperature on electromechanical delay., Electromyogr Clin Neurophysiol, volume 38, issue 2, pages 67-73, Mar 1998, PMID 9553743
  21. ↑ S. Zhou, Acute effect of repeated maximal isometric contraction on electromechanical delay of knee extensor muscle., J Electromyogr Kinesiol, volume 6, issue 2, pages 117-27, Jun 1996, PMID 20719669
  22. ↑ PM. Clarkson, WC. Byrnes, E. Gillisson, E. Harper, Adaptation to exercise-induced muscle damage., Clin Sci (Lond), volume 73, issue 4, pages 383-6, Oct 1987, PMID 3665359
  23. ↑ SJ. Brown, RB. Child, SH. Day, AE. Donnelly, Exercise-induced skeletal muscle damage and adaptation following repeated bouts of eccentric muscle contractions., J Sports Sci, volume 15, issue 2, pages 215-22, Apr 1997, doi 10.1080/026404197367498, PMID 9258852
  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
  25. ↑ RG. Eston, S. Finney, S. Baker, V. Baltzopoulos, Muscle tenderness and peak torque changes after downhill running following a prior bout of isokinetic eccentric exercise., J Sports Sci, volume 14, issue 4, pages 291-9, Aug 1996, doi 10.1080/02640419608727714, PMID 8887208
  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
  27. ↑ WC. Byrnes, PM. Clarkson, JS. White, SS. Hsieh, PN. Frykman, RJ. Maughan, Delayed onset muscle soreness following repeated bouts of downhill running., J Appl Physiol, volume 59, issue 3, pages 710-5, Sep 1985, PMID 4055561
  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. ↑ CL. Brockett, DL. Morgan, U. Proske, Human hamstring muscles adapt to eccentric exercise by changing optimum length., Med Sci Sports Exerc, volume 33, issue 5, pages 783-90, May 2001, PMID 11323549
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  140. ↑ MP. McHugh, 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, volume 13, issue 2, pages 88-97, Apr 2003, PMID 12641640
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