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{{DISPLAYTITLE:Delayed Onset Muscle Soreness (DOMS) for Runners}}DOMS is of critical importance for runners. Unlike many other types of exercise, running requires your muscles to extend under load, absorbing your weight as you land. This extension under load, called eccentric, is a prime cause of DOMS, and while the soreness is delayed, the accompanying weakness is immediate. This eccentric stress is why marathon runners are often hobbling around the day after a race. The good news is that a bout of DOMS inducing exercise provides protection against future DOMS, and so it's a critical part of training. This "Repeated Bout Effect" (RBE) is a core aspect of training, and by intentionally inducing DOMS you can prevent the soreness that occurs after long distance races. The less obvious, but more important benefit is that you also prevent some of the weakness that occurs towards the end of longer races. This is a key benefit to [[Downhill Running]] and especially the [[Treadmill Descent]]. I believe that incorporating Treadmill Descents into my training is the reason I've completed 100-mile races with little muscle soreness. =Introduction =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| 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| 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. This Repeated Bout Effect (RBE) is a critical part of endurance training. Running with the correct [[Cadence]] can help prevent DOMS, and [[Nutrient Timing| taking protein]] after DOMS inducing exercise ]] is one of the best treatments, though [[Why compression clothes| compression clothing]], [[Caffeine| caffeine]] and [[Massage| massage]] can also help. It seems that [[Vitamin C]] may be critical to the RBE.

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 your 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"/>:

The soreness of DOMS is different to other forms of muscle soreness. With DOMS, large areas of the muscle are tender to the touch and painful when the muscle is used. With other forms of muscle soreness the area of tenderness is usually more localized and the pain of massage is sometimes described as a 'good pain'. The pain of DOMS will normally lessen with light exercise such as walking, which is often described as 'loosening' up. However, the soreness of DOMS is not the best indicator of the muscle damage, and similar levels of soreness can result from differing levels of muscle damage<ref name="NosakaNewton2002"/>. In addition, there are other symptoms, such as:

{| class="wikitable" style="margin-left: auto; margin-right: auto; border: none;"! '''Strategy'''! '''Timing'''! '''Soreness'''! '''Weakness'''! '''Downsides'''

| Repeated Bout Effect| Before (days to months)| Strong evidence of reduced soreness| Some evidence of reduced weakness| None

| After| Some evidence of reduced soreness| Strong evidence of reduced weakness| None

| During| Some evidence of reduced soreness| Some evidence of reduced soreness| None

| After| Some evidence of reduced soreness| Some evidence of reduced weakness| None

| After

| Some evidence of reduced weakness| None^a

| After| Some evidence of reduced soreness| No benefitSome evidence of reduced weakness | None

| Immediately before| Some evidence of reduced soreness| No benefit| None

| After

| No benefit| None^c

| TENS| After

| No benefit| None

| After| No benefit| No benefit| None^b

| Antioxidents| Before and/or After| Mixed evidence| Mixed evidence

| Before and/or After| No benefit| No benefit| * # [[Stretching]] temporarily weakens muscles* # Can induce DOMS* # Can lead to injury

| Before and/or After| Most evidence indicates no benefit| Most evidence indicates no benefit| Can impair recovery

[[File:Length Tension Curve and DOMS.jpg|right|thumb|500px|A chart of a subject before and 7 days after DOMS inducing hamstring exercise. The chart shows the angle and the torque developed, indicating that after training the hamstrings are not only stronger, but are able to generate power at significantly longer length. This may be part of the underlying mechanism for the repeated bout effect.]]The DOMS that follows an initial bout of eccentric exercise is much less on subsequent similar bouts. This is often called the Repeated Bout Effect (RBE)<ref name="Howatson-2008"/><ref name="Cheung-2003"/>. The initial bout does not have to cause significant soreness or damage<ref name="Clarkson-1987"/>. As few as 2-10 maximal eccentric repetitions can protect against a subsequent larger bout (24-50), but the initial bout must be close to maximal effort<ref name="Brown-1997"/>. By contrast, eight weeks of training with 50% of the maximal eccentric load did not provide protection against a subsequent maximal bout<ref name="Nosaka-2002"/>. There is some cross-over of protection between different forms of exercise. For instance, eccentric weight training protects against soreness and weakness in subsequent downhill running<ref name="Eston-1996"/>. The protection from the RBE is long lived. One study showed that while the initial weakness was not reduced by the RBE, the recovery of strength was much faster for up to 9 months, and soreness was less for up to 6 months<ref name="Nosaka-2001"/>. Another study showed that 30 minutes of downhill running provides protection for between 6 and 9 weeks<ref name="Byrnes-1985"/>. There is evidence that the RBE may rapidly start to provide protection from soreness and weakness<ref name="Mair-1995"/>, within 5 days<ref name="Ebbeling-1989"/>, and possibly within 24 hours<ref name="Chen-2001"/>. One study<ref name="Brockett-2001"/> demonstrated a change in the length-tension curve of DOMS trained muscles. As shown on the chart to the rightbelow, 7 days after a bout of DOMS inducing exercise, the hamstring is able to generate more force and generate it at a greater angle. [[File:Length Tension Curve and DOMS.jpg|none|thumb|500px|A chart of a subject before and 7 days after DOMS inducing hamstring exercise. The chart shows the angle and the torque developed, indicating that after training the hamstrings are not only stronger, but are able to generate power at significantly longer length. This may be part of the underlying mechanism for the repeated bout effect.]]===Repeated Bout and Vitamin C===I found a single study that looked at how the repeated bout effect changes with [[Vitamin C]]<ref name="HeHockemeyer2015"/>. As described below, most studies have found a small reduction in DOMS with Vitamin C. This 2014 study found that for the first bout, Vitamin C reduced the muscle soreness for the hamstrings, Quads, and Tibialis Anterior (shin), but the soreness of the glutes and calves were similar. However, for the second bout, not only was the soreness was reduced for the placebo, but it was further reduced with the Vitamin C. While this is just one study, it is intriguing with some profound implications. If the protective benefits of the repeated bout effect are dependent on nutritional (or other) factors, some runners may not get the benefit from their training. Personally, I've been taking ~1g/day of Vitamin C for many years due to [[Epidermolysis Bullosa| skin condition]]. However, the evidence that Vitamin C impairs the adaptation to exercise caused me to take a break for about 15 months. During that break from Vitamin C, I found my ability to perform downhill running was quite impaired, and I didn't seem to be able to build up resistance from the repeated bout effect. [[File:Does Combined Antioxidant Vitamin Supplementation Blunt Repeated Bout Effect.jpg|center|thumb|500px|]]

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 I found one studies were found that looked at the effect of wearing compression clothing during DOMS inducing exercise on the subsequent recovery<ref name="McDonnellCooper2018"/>. This study used either or both graduated or uniform compression socks on hiking, a trail run, or calf exercise, with the socks also worn for the following four days. Graduated socks reduced DOMS pain on the hike compared with no compression, the only test with no compression as a control. The uniform compression reduced the pain compared with graduated on the run, and there was no difference between them on the calf exercise. This suggests to me that uniform compression might be better than graduated, or at least, it might not be worth paying extra for graduated compression.

[[Massage]] is widely used to prevent and treat injuries. Most meta-analysis suggest that post-exercise massage helps with the soreness of DOMS<ref name="Ernst-1998"/><ref name="Moraska-2005"/>, though the mechanisms are unclear<ref name="Tiidus-1997"/>. Studies that give massage 2-3 hours after DOMS inducing exercise showed reduced soreness<ref name="Smith-1994"/><ref name="Zainuddin-2005"/><ref name="Hilbert2003"/>, but not weakness<ref name="Zainuddin-2005"/><ref name="Hilbert2003"/>. One study that gave massage 2 days after exercise that resulted in reduced soreness and improved muscle function<ref name="MancinelliDavis2006"/>, but other studies that use massage 24 hours or more after exercise showed no benefit<ref name="Hart-"/><ref name="Dawson-2004"/>. A study that used 20 minutes of foam rolling immediately following the DOMS inducing exercise, then again at 24 and 48 hours showed a significant improvement in both pain and muscular performance<ref name="Pearcey-2015"/>. Therefore it seems likely that the timing of the massage is important, though other factors, such as the style of massage and the extent of the DOMS may also change the outcome. My personal experience suggests that massage immediately after the exercise is more effective than when the massage is delayed. (All too often, the muscles are too painful under pressure to allow any form of massage.)

Light training in the days following DOMS inducing exercise generally accepted to be one of the most effective ways of reducing muscle soreness, but unfortunately the reduction in pain is temporary<ref name="Armstrong-1984"/><ref name="Zainuddin-2006"/><ref name="Howatson-2008"/><ref name="Cheung-2003"/>. A study that looked at running 30 minutes/day after DOMS inducing downhill running shows that the extra exercise neither helped nor hindered with soreness, weakness or [[Running Economy]]<ref name="ChenNosaka2008"/>. (The study only looked at the 7 days following the downhill running, and it would be interesting to know if there are any longer -term differences.)One study used cycling at light (30%) or moderate (70%) immediately after DOMS inducing exercise<ref name="TufanoBrown2012"/>. The moderate intensity cycling prevented the loss of strength, and actually increased strength on days 3 and 4. There were no differences between the control and the light exercise, nor between any of the conditions for soreness. This is an interesting suggestion that higher intensity exercise might be beneficial, but the study has a number of flaws, including the use of predicted [[Maximum Heart Rate]] to set exercise intensity.

Sadly, [[Cryotherapy| Icing]] does not helpwith DOMS<ref name="Yackzan-"/><ref name="Shunsuke-2004"/><ref name="Gulick-17"/><ref name="Paddon-Jones-1997"/>, and can make DOMS worse<ref name="TsengLee2012"/><ref name="Isabell-1992"/>. Ice reduces pain slightly, but does not restore strength<ref name="Denegar-1992"/> . (In my experience, ice can be extremely effective at helping heal muscle tears and non-DOMS muscle injuries, but not DOMS.)==Protracted Heat==One study looked at applying heat for 8 hours, either directly after DOMS inducing exercise or 24 hours later<ref name="PetrofskyBerk2017"/>. The study used "ThermaCare" chemically generated heat wraps, and I suspect the study was sponsored by the company. The 60 subjects underwent 5 minutes of squats to induce DOMS, then 20 were controls, 20 had immediate heat for 8 hours and the remainder had heat applied 24 hours after exercise. The immediate heat subjects had little reduction in strength over the follow three days, where the 24-hour delayed heat was no different from the controls. The strength drop was about 24% in controls/delayed-heat, which is a meaningful improvement. There was some reduction in pain over the first two days, with the immediate heat doing better than the delayed heat, which was slightly better than the controls.

The evidence for anti-oxidants is mixed, with some studies showing a benefit but not others. Note that one study below showed an impaired recovery with vitamin C supplementation. In addition, there is mixed evidence that vitamin C and/or vitamin E reduces [[Endurance Adaptations]] from exercise<ref name="Gomez-Cabrera-2008"/><ref name="RistowZarse2009"/><ref name="Strobel-2011"/> or they do not<ref name="Wadley-2010"/><ref name="Higashida-2011"/> <ref name="YfantiAkerstrom2009"/>. A 2019 systematic review of 50 studies covering 1,089 subjects concluded that there was moderate quality evidence that Vitamin C reduced DOMS at 48 and 96 hours, with lower quality evidence for 6 and 24 hours, but the reduction was quite small<ref name="RanchordasRogerson2018"/>.{| class="wikitable" style="margin-left: auto; margin-right: auto; border: none;"

[[Stretching]] before<ref name="High-1989"/><ref name="Johansson-1999"/> <ref name="Wessel-1994"/>, after <ref name="Johansson-1999"/><ref name="Buroker-1989"/><ref name="Herbert-2007"/>, or both before and after<ref name="Lund-1998"/> exercise does not help with DOMS. In fact, stretching alone can induce DOMS<ref name="Smith-1993"/>. Both static and dynamic stretching are ineffective<ref name="XieFeng2018"/>.

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. Studies of Turmeric, which acts as a selective COX-2 NSAID<ref name="RamsewakDeWitt2000"/>, are promising. Reduction in soreness is mixed, with some studies showing reduced soreness<ref name="Nicol-2015"/><ref name="Drobnic-2014"/> <ref name="NicolRowlands2015"/>, while others do not<ref name="McFarlinVenable2016"/><ref name="TanabeMaeda2015"/>. However, one study shoes reduced weakness and inflammation markers<ref name="TanabeMaeda2015"/> and an animal study showed less subsequent reduction in running performance in mice<ref name="Davis-2007"/>. Several studies showed reduced markers of damage<ref name="Kawanishi-2013"/><ref name="Davis-2007"/><ref name="TanabeMaeda2015"/><ref name="McFarlinVenable2016"/> <ref name="NicolRowlands2015"/>. However, Turmeric should be treated like any other medication as there are safety concerns; see [[NSAIDs_and_Running#Turmeric_as_an_NSAID| Turmeric as an NSAID]] for details.{| class="wikitable" style="margin-left: auto; margin-right: auto; border: none;"

** '''Increased sarcomeres. '''The sarcomeres are part of the contracting mechanism of the muscles. The contraction of a muscle comes from parts of the sarcomere sliding over each other. One adaptation to eccentric exercise may be that the overlap in these sliding areas becomes larger. A study in rats suggests that the adaptation may include more sarcomeres in series, which produces a greater Range Of Motion and greater force at longer muscle lengths<ref name="Lynn-1998"/>.

<ref name="pmid12580656">author Tokmakidis SP, Kokkinidis EA, Smilios I, Douda H, The effects of ibuprofen on delayed muscle soreness and muscular performance after eccentric exercise., J Strength Cond Res, 2003, volume 17, issue 1, pages 53-9, PMID [http://www.ncbi.nlm.nih.gov/pubmed/12580656 12580656] </ref>