What is the management and prevention of Delayed Onset Muscle Soreness (DOMS)?

Management and Prevention of Delayed Onset Muscle Soreness (DOMS)

Massage is the single most effective intervention for reducing DOMS and perceived fatigue, with moderate-to-large effect sizes for symptom relief, while most other commonly used treatments including NSAIDs, stretching, and topical remedies show minimal to no benefit. 1, 2

Understanding DOMS Pathophysiology

DOMS develops 1-5 days following unaccustomed exercise, particularly eccentric (muscle-lengthening) activities, peaking around 24-48 hours post-exercise. 3, 4 The mechanism involves:

• Structural damage from high mechanical tensions in muscle fibers, especially at the muscle-tendon junction initially, then spreading throughout the muscle 3, 4
• Calcium homeostasis disruption leading to fiber necrosis that peaks approximately 2 days post-exercise 3
• Inflammatory response with macrophage infiltration and accumulation of intracellular contents in the interstitium, stimulating sensory nerve endings 3, 4

Critical distinction: Loss of muscle force occurs immediately after exercise and represents a separate phenomenon from the delayed pain sensation. 4 A second force loss may occur 1-3 days post-exercise, potentially correlating with DOMS timing. 4

Evidence-Based Treatment Hierarchy

First-Line: Massage Therapy

Massage demonstrates the strongest evidence for DOMS relief, showing small-to-large effect sizes (standardized mean difference -2.26 to -0.40) for reducing both soreness and perceived fatigue. 1 Massage also produces:

• Moderate reduction in creatine kinase (SMD -0.37), indicating decreased muscle damage markers 1
• Small reductions in inflammatory markers: IL-6 (SMD -0.36) and CRP (SMD -0.38) 1

Second-Line: Compression and Cold Modalities

Compression garments effectively manage perceived fatigue and produce small-to-large decreases in DOMS magnitude. 1

Cold exposure techniques (cryotherapy, cold water immersion, contrast water therapy) show:

• Small-to-large decreases in DOMS severity 1
• Most powerful effects for reducing inflammation alongside massage 1

Active recovery produces small-to-large decreases in DOMS but less consistently than massage. 1

Ineffective Treatments to Avoid

NSAIDs show no benefit and may impede recovery. Despite theoretical anti-inflammatory rationale, controlled trials demonstrate NSAIDs do not reduce DOMS signs or symptoms and may actually delay functional recovery. 2, 5

Static stretching (10 minutes or longer) provides no relief from DOMS symptoms or functional deficits. 2

Topical and homeopathic remedies (including Arnica montana ointment and pellets) demonstrate no efficacy. 2

Ultrasound therapy lacks supporting evidence for DOMS treatment. 5

Prevention Strategies

Progressive training adaptation is the most effective prevention method. Training specifically for eccentric activities that cause DOMS substantially reduces the soreness response in subsequent exposures. 3

Practical prevention approach:

• Begin new eccentric activities at low volume (single set of 10-15 repetitions) 3
• Progress gradually over 2-3 weeks before increasing intensity 3
• Allow 9+ weeks of consistent exposure before expecting full adaptation 2

Monitoring and Load Management Considerations

Biomarkers have limited utility for DOMS management. While creatine kinase (CK) and myoglobin elevate rapidly after muscle-damaging exercise, these markers:

• Show high inter-individual variability 6
• Lack specificity for training load versus other factors 6
• Do not correlate well with subjective soreness or functional capacity 6

Combine objective and subjective measures: Biomarker changes should be interpreted alongside subjective questionnaires (RPE, sleep quality, soreness scales) and functional performance metrics rather than used in isolation for training decisions. 6

Clinical Pitfalls to Avoid

Do not prescribe NSAIDs for DOMS treatment, as evidence shows potential harm to recovery despite widespread use. 2, 5

Do not rely on stretching protocols as primary DOMS treatment, as controlled trials consistently show no benefit. 2

Recognize that DOMS is self-limiting and typically requires no medical intervention unless symptoms persist beyond 5-7 days or are accompanied by severe weakness, dark urine (suggesting rhabdomyolysis), or systemic symptoms. 3, 4

Distinguish DOMS from pathological conditions: Exertional rhabdomyolysis represents the extreme form of exercise-induced muscle damage and requires immediate medical evaluation if suspected. 3

Practical Implementation Algorithm

For acute DOMS (24-72 hours post-exercise):

1. Apply massage therapy as primary intervention 1
2. Consider compression garments for additional fatigue management 1
3. Use cold water immersion or cryotherapy if inflammation markers are elevated 1
4. Engage in light muscular activity despite discomfort, as movement temporarily reduces symptoms 3

For recurrent DOMS:

1. Reassess training progression—likely advancing volume/intensity too rapidly 3
2. Implement 2-3 week gradual adaptation period for new eccentric activities 3, 2
3. Monitor for warning signs: increasing soreness, performance decrements, excessive fatigue 6