Anyone who has ever completed a workout knows the feeling that muscle soreness brings. A painful, but sometimes also somewhat pleasant, sensation in the muscles you used the day (or days) before. The sensation of muscle soreness can be experienced as unpleasant or limiting and carries a few potential risks. There are various ways to treat muscle soreness. But is it even necessary to treat muscle soreness? How effective are these treatments? Are there downsides to treating muscle soreness? In this article we answer these questions.
What is muscle soreness and when does it occur?
Muscle soreness is the sensation of discomfort and tenderness in muscles. The intensity of the pain sensation peaks between 24 and 48 hours after the training activity and eventually disappears completely after 5 to 7 days. Muscle soreness is a subjective and individual sensation and ranges from tenderness in the muscles to pain that hinders daily activities. In other words, a day after your workout you feel that your muscles are somewhat locally sensitive to touch or contraction. Or you can no longer brush your hair because your biceps cramp at every minimal movement, and sitting down on the toilet after leg day amounts to a free fall onto the seat. Because muscle soreness does not occur immediately but with a delay after training, it is called Delayed Onset Muscle Soreness (DOMS). DOMS shows up mainly at the transition from muscle to tendon, the primary site for force transfer, and then spreads through the muscle.
How muscle soreness arises is not entirely clear. Various theories describe the possible causes, none of which can fully explain it on its own. Researchers have therefore proposed that a combination of these theories is best suited to explain how muscle soreness develops. In short, an unfamiliar training stimulus leads to a mechanical and biochemical disruption in the muscle cell (muscle damage). The immune system responds to the resulting damage to muscle fibers and connective tissue, so that after a few intermediate steps the inflammatory activity rises, edema develops, sensory nerves become stimulated and DOMS is the result. Mainly eccentrically oriented contractions lead to muscle soreness, although concentric contractions can also cause muscle soreness to a lesser extent.
How do we measure muscle soreness?
Pain is a subjective matter, and with the same objective damage to the body, individuals can experience a different degree of pain. You can experience pain without damage and experience no pain with damage. Mood, environment and experience are a few of the variety of variables that influence the feeling of pain. This makes pain a complicated construct to measure and one that can be subject to placebo effects. Measuring muscle soreness is usually done using a visual analogue scale (VAS). Muscle damage is mostly measured by the presence of indicators in the blood. Creatine kinase (CK), C-reactive protein (CRP) and interleukin-6 (IL-6) values are elevated as a result of muscle damage and are associated with the presence of DOMS.
What is an unfamiliar training stimulus?
A new training stimulus means an exercise you have never done before, an exercise you have not done for a while, a sudden increase in training volume, and training to failure. Even a change in the position of the barbell can lead to muscle soreness. A high bar back squat is not exactly the same movement as a low bar back squat, even though both are squat patterns. Eccentric contractions (the lowering phase of a biceps curl) lead to more muscle soreness than concentric contractions (the raising phase of a biceps curl). This is in line with muscle damage, which follows the same pattern. Exercises in which a large part of the tension is produced when the muscle or muscles are brought into a stretched position lead to muscle soreness more quickly and are more sensitive to changes in volume. An example is performing a dumbbell chest fly through a full range of motion (ROM). The shoulder muscles rarely end up in such a stretched position through strength training. As a result, very few people complain of enormous muscle soreness in their shoulders.
The protective effect of training
After a repeated training stimulus, muscle soreness will decrease. Your body arms itself, as it were, against the muscle soreness. This is called the repeated bout effect (RBE) and occurs after just a single training session. You will experience less muscle soreness when you perform an exercise more often. The exercise is no longer unfamiliar to your body. Muscle soreness can continue to occur to a lesser extent, certainly when using high intensities. The protective effect is temporary and disappears when you do not train for a number of weeks. This is why you experience muscle soreness after your holiday, even though you do the same exercises as before the holiday.
What are the consequences of muscle soreness?
Researchers state that muscle soreness, in combination with damage to muscle and connective tissue, leads to changes in kinematics, a limitation in ROM, a loss of strength and changes in the control and activation of muscle fibers. The greatest amount of strength loss occurs in the first hours after training, while muscle soreness only makes its entrance later. It is plausible that the immediate loss of strength is caused by damage to proteins that help control muscle fibers. However, the swelling that develops as a result of damage, and that is related to muscle soreness, appears to slow down the recovery of strength loss. During DOMS the capacity to absorb shocks decreases, which is a risk factor for athletes who perform activities of a plyometric nature. As a result of muscle soreness, compensatory behavior can occur in another part of the muscle or in other muscles. Other tissue structures therefore have to deal with an unfamiliar load. An athlete may have an incorrect perception of these changes. An overestimation of strength and a reduced proprioception have been observed in research on athletes. In summary, muscle soreness can be a risk factor for developing an injury.
Which techniques for treating muscle soreness are there?
Improving recovery after training is one way to positively influence performance. In addition, muscle soreness apparently brings a number of potentially negative consequences. It is therefore only logical that methods have been devised to treat muscle soreness. The idea is that the negative consequences can be prevented or eased and that performance can be improved. It is clear in advance, however, that this is a difficult task. When there is uncertainty about how DOMS develops, can we then devise suitable treatments for it? This, incidentally, does explain the diversity found in review articles on treatments for DOMS.
To find out whether a treatment method is effective, we need to scrutinize the mechanism of action and examine relevant studies. Outcome measures are usually a reduction in pain, visible on a VAS, and reductions in blood concentrations of CK, CRP or IL-6. In general, treatments aim to lower muscle damage and inflammatory activity. The mechanism behind this is a limitation of the available space for swelling and edema. This allows the transport of metabolites, neutrophils and damaged proteins from the muscle to the blood to take place more effectively. In this article we focus mainly on treating muscle soreness, with the awareness that this cannot be fully separated from muscle damage.
Before we delve deeper into a number of possible treatments, let us summarize what we have established so far.
- The experience of muscle soreness is subjective, yet it is measurable.
- The consequences are an increased risk of injuries, mainly due to compensatory behavior of other muscles and due to disrupted neural control.
- The RBE protects your body against future muscle damage and soreness.
- Treatments for muscle soreness focus on the accelerated removal of waste products in the muscle, on lowering edema and swelling, and on reducing the pain sensation.
Massage
What is the mechanism of action?
Massage as a treatment for muscle soreness is thought to be effective because massage raises the temperature of the skin and muscles, stimulates blood and lymph flow and leads to increased parasympathetic activity. An improved blood flow ensures faster removal of biochemical markers (such as CK) of muscle damage. An increase of oxygen-rich blood to the affected site leads to a reduced production of prostaglandins, which causes less pain and a less limited ROM. In addition, the supply of oxygen-rich blood is thought to stimulate the recovery of ATP renewal in the mitochondria and the active transport of calcium. The accumulation of calcium in the muscle cell is probably the biggest cause of strength loss with muscle damage. A reduction in calcium accumulation might therefore be able to limit strength loss. Finally, massage has a psychophysiological effect because you relax, your mood improves and fatigue is thereby reduced.
What research results are there?
A somewhat older review shows mixed outcomes of massage on blood flow. The variety in massage techniques, the duration and the timing in research probably lead to this conclusion. Two recent reviews with meta-analyses, however, conclude a clear positive effect of massage on muscle soreness. A review of randomized intervention studies by Guo and colleagues shows a strong effect of massage on muscle soreness rating. Massage appears to be most effective mainly between 48 and 72 hours after training. They also observed an effect of massage on maximal isometric strength, which was greatest 72 hours after training. Creatine kinase levels were lower between 48 and 72 hours after training in people who had received a massage. The reviewers do rightly conclude, however, that the quality of the included studies is moderate. Dupuy and colleagues investigated in their review with meta-analysis the effect of various recovery therapies on muscle soreness and relevant blood parameters. A massage directly after training had the greatest effect on muscle soreness and lasted up to 96 hours after training. In addition, they observed an effect of massage on IL-6 and CK values at 72 and 96 hours after training.
What is the verdict?
Massage appears to have a good and long-lasting effect as a therapy for muscle soreness. When you want to experience less muscle soreness, massage is probably the best therapy. It will have to take place shortly after the training session, though. When you perform multiple workouts per week, the costs quickly add up. Unless your mother-in-law happens to be good at massage.
Compression clothing
What is the mechanism of action?
Because of the compression on the limbs, there is less space for swelling and edema. The outflow and inflow of blood and waste products can take place more effectively, so that in theory less muscle soreness should develop.
What research results are there?
There are mixed research results, which will mainly have to do with the preceding intensity of the training protocols. One review saw a clear effect of wearing compression clothing on experienced muscle soreness. This effect was most visible between 72 and 96 hours after training. In this review, no effect of compression clothing on indicators of muscle damage was seen. An intervention study shows no effect of wearing compression stockings on experienced muscle soreness after an eccentric calf workout.
What is the verdict?
Compression clothing can be a way to experience less muscle soreness, although the results are very mixed. The effect of compression clothing is smaller than massage, but it is a cheaper therapy in return.
Cryotherapy
What is the mechanism of action?
Cold therapies come from the RICE line of thinking: Rest, Ice, Compression and Elevation. The idea is that exposure to cold causes a drop in the temperature of the skin and the subcutaneous tissue. With cryotherapy the body is briefly exposed to very cold air (-30 to -140 degrees). Receptors in the skin then activate nerve fibers that cause local arterioles and venules to narrow. This means less swelling, lower inflammatory activity, lower vascular permeability and less edema.
What research results are there?
Studies show divergent results, which mainly has to do with the heterogeneity in the applied methodology. The temperature, the duration, the timing and the frequency of the treatments possibly influence the effectiveness. Costello and colleagues conclude in their review study that there is not enough evidence to recommend cryotherapy for the treatment of DOMS. A recent review only found an effect of cryotherapy on muscle soreness directly after training and up to 6 hours afterwards. At later time points no effect was seen.
The influence of cold therapies on muscle growth has been examined in other studies and appears to be negative. Because of the drop in temperature and the reduced blood flow to the muscles, the signal for muscle growth is dampened.
What is the verdict?
Because of the differing results from research, it is unclear whether cryotherapy has a positive effect on muscle soreness. Other therapies that apply cold appear to dampen the signal for muscle growth. Whether this applies to cryotherapy has not been directly investigated, but it is nonetheless plausible. So you might have less muscle soreness, but also less muscle growth. That is a trade-off no one is likely to want to make. In short, the therapy is possibly effective, but it has an undesirable side effect when
muscle growth is the goal.
(Cold) Immersion
What is the mechanism of action?
Taking a bath is thought to lead to lower inflammatory activity, less muscle damage and therefore less muscle soreness. The pressure of the water stimulates the transport of fluid from the muscle to the blood. As a result, metabolites are removed faster. Cold immersion has a numbing effect and veins narrow (vasoconstriction) as a result of the low temperature. This can bring about a reduction in edema, because less fluid enters the spaces around the muscle. Less edema will lead to a lower inflammatory response and therefore a lower pain sensation.
What research results are there?
A recent review only saw an effect of immersion on inflammatory activity at a temperature lower than 15 degrees. Although this effect depended on the duration, the temperature of the water and the type of training preceding the therapy. This review observed a small effect of immersion on muscle soreness and CK values, but no effect on CRP and IL-6 values. Earlier studies observed a larger effect on DOMS, which can be explained by the diversity within the applied therapy. Cold immersion possibly leads to a dampening of the signal for muscle growth. The protein balance is negatively influenced by lower protein synthesis. A recent and well-designed study concludes that cold immersion leads to a reduced growth of type 2 muscle fibers, although an increase in strength was not inhibited by this. This can be explained by the fact that strength has a large neurological component, which apparently is not influenced by cold immersion. Another study investigated the mechanism by which
muscle growth can be inhibited by applying cold immersion for two weeks and measuring protein synthesis. The researchers concluded that the cold has a direct negative effect on the buildup of protein elements in the muscle.
What is the verdict?
A great diversity in the way immersion is applied probably explains the discrepancies in the results. There does appear to be a small effect of cold immersion on muscle soreness, so this therapy cannot be ruled out as a potential option. The danger, however, lies in the long term, where cold immersion dampens the signal for muscle growth. As a result, this therapy is not advisable when building muscle mass is the goal.
Contrast water therapy
What is the mechanism of action?
Contrast water therapy alternates baths in warm and cold water. This stimulates both the widening (vasodilation) and narrowing (vasoconstriction) of veins and thereby limits edema and inflammatory activity, and can reduce the feeling of pain.
What research results are there?
A review observed a small effect on muscle soreness and a drop in CK values in the blood.
What is the verdict?
A small effect can be reason enough to give this form of therapy a chance. The application is fairly simple and can perhaps be done in the shower. However, exposure to cold is not without drawbacks. The signal for muscle growth could be dampened. As we explained with cryotherapy and cold immersion, this is probably not worth the trade-off.
Stretching
What is the mechanism of action?
Frequent and prolonged stretching lowers the tension in a muscle-tendon unit at a given length. The muscle-tendon unit is viscoelastic and will slowly lengthen under constant tension, which is called creep. When the muscle-tendon unit is stretched to a new length and held there, the tension will decrease. This is called stretch relaxation. Because of these properties, stretching would in theory lead to less muscle damage during eccentric contractions, provided the stretch is applied for longer than 6 seconds.
What research results are there?
In the past, research showed mixed results when stretching was used to prevent or treat muscle soreness. A recent review saw no effect of stretching on muscle soreness and blood parameters for muscle damage. Incidentally, stretching in itself can also cause muscle damage or muscle soreness. A rise in CK values after an intense stretching session, and the rise in muscle soreness after training caused by stretching, confirm this.
What is the verdict?
Stretching muscles does not appear to be a way to reduce muscle soreness. If you are unfamiliar with stretching, it might actually cause muscle soreness.
Vibration
What is the mechanism of action?
With vibration therapy, the body is partly or fully exposed to a repetitive force. Muscles then contract and relax in rapid succession. In daily life you are exposed to various forms of vibration, such as on a train or bus. Vibrating platforms are used to train the body with both static and dynamic movements. Vibration therapy before training improves the activity of muscle spindles and muscle pre-activation. This results in a lower threshold for the motor neurons to control the muscle fibers. As a result, a larger pool of muscle fibers is recruited during training and less muscle damage develops. Vibration therapy after training could lower the pain sensation by directly influencing the sensitivity of the nerve endings or by removing waste products in the muscle faster.
What research results are there?
A review observed an effect of vibration therapy on muscle soreness 24, 48 and 72 hours after training. The researchers also saw an effect on CK values 24 and 48 hours after training. The effect on both outcomes peaked 48 hours after training. The studies included in this review are of moderate quality and varied quite a bit in their approach.
What is the verdict?
Vibration therapy is a potential option for lowering muscle soreness. More high-quality experimental studies are, however, desirable. It is unclear what the effect is on performance and muscle growth, including possible negative effects. In addition, it is unclear which application and timing of vibration achieves the best effect. At the moment there is simply not enough information to give a recommendation.
Active recovery
What is the mechanism of action?
It may seem peculiar to name movement as a treatment for muscle soreness that is the result of movement. But there is in fact a good theory behind it. Moving is very effective for relieving muscle soreness in the short term. Just think of the enormous muscle soreness you feel in your legs when you have been sitting still for a while on the day after your leg workout. As soon as you start walking, the muscle soreness eases somewhat again. An increased blood supply, removal of waste products and/or an increased release of endorphins can explain this effect.
What research results are there?
A review confirms the short-term effect of movement. Up to six hours after training, active recovery was effective for relieving muscle soreness; in all the hours after that this was no longer the case. Research, however, shows no drop in CK, IL-6 and CRP values as a result of active recovery.
What is the verdict?
Active recovery is a way to reduce the feeling of muscle soreness for a short time. It probably will not be able to do much more than that for you. If you experience a lot of muscle soreness, moving is a quick but short-lived solution.
Anti-inflammatory medication
What is the mechanism of action?
From the line of thinking that increased inflammatory activity and edema contribute to the development of muscle soreness, anti-inflammatory medication has been proposed as a treatment. A well-known example is ibuprofen. Anti-inflammatory drugs inhibit the enzyme cyclooxygenase (COX), which converts arachidonic acid into prostaglandins. Prostaglandins sensitize nerve endings, which can cause pain. Taking anti-inflammatory drugs leads to a reduction of the inflammatory response and edema and therefore to a reduction in pain.
What research results are there?
The effectiveness of anti-inflammatory medication shows mixed results in research. A distinction can be made between taking anti-inflammatory drugs before training, after training, or both. Taking anti-inflammatory drugs proactively in particular appears to be the most effective
[2
]. Although anti-inflammatory medication appears to work as intended, chronic use can have a negative effect on muscle growth. COX possibly fulfills an important role in muscle growth, so limiting COX activity is potentially counterproductive.
What is the verdict?
Although anti-inflammatory drugs have no negative influence on muscle growth in the short term, this is unclear for the long term. Taking an anti-inflammatory drug for the treatment of muscle soreness is probably not problematic for a one-off occasion and can ease the pain sensation. Possible side effects of anti-inflammatory medication are gastrointestinal complaints. The potential drawbacks outweigh the benefits.
Antioxidants
What is the mechanism of action?
Every form of training leads to oxidative stress due to the high processing of oxygen, with the production of free radicals as a result. Taking antioxidants is thought to reduce oxidative stress by lowering the concentration of free radicals.
What research results are there?
A very comprehensive and recent review looked at the effect of antioxidants on muscle soreness. A total of 50 studies were examined and assessed. Muscle soreness was measured from 6 up to and including 96 hours after training. Antioxidants have an effect on muscle soreness, but this effect is so small that it is not relevant in practice. This was the case at every measured time point. The overall body of evidence is of low to moderate quality, which makes the results less reliable. Turmeric is worth mentioning separately. A well-designed experimental study shows a clear effect of turmeric supplementation on muscle soreness, provided it is taken for 7 days after training. High doses of antioxidants can cause side effects such as gastrointestinal complaints, but this occurs very rarely. In addition, there is a possibility that high doses of antioxidants disrupt the signaling for muscle growth. Although this is mainly theoretical, the slight positive effect of antioxidants on muscle soreness will not be worth the potential trade-off.
What is the verdict?
Taking antioxidants for treating muscle soreness gives an effect that is so small that it is not relevant in practice. Turmeric supplementation offers more promise, although it is not clear what the consequences are of a high intake over the long term.
The RBE as a therapy for muscle soreness
The repeated bout effect is the best therapy for muscle soreness, with the advantage that the body brings it about itself. When you give the same training stimuli, over time they will no longer lead to the same muscle soreness as in the beginning. You experience the most muscle soreness when introducing new exercises or by rapidly increasing the training volume. Some exercises, however, always seem to generate muscle soreness, which has to do with a high peak load during a stretch phase, such as with a romanian deadlift. The RBE is temporary and will have to be maintained to benefit from it. Not training for four to 12 weeks can cause the effect to be lost. You can therefore influence muscle soreness positively by letting the RBE work for you. That means you do not switch exercises unnecessarily often and you do not crank up the volume aggressively. You keep complex exercises in your program for at least 10 weeks. Simple isolation exercises can be switched more often, but at least 5 weeks is preferable. In addition, you can use an introduction week when you start a new program so that you are not overloaded with buckets of muscle soreness.
The limitations of research
Review studies show a high degree of heterogeneity in the results. This means that many different treatment protocols are used in research. That is logical, because there are very many ways to apply treatments. Think here of frequency, timing, duration and the execution of the treatment. Moreover, the effect of a therapy will be more visible when the training preceding the therapy is intensive. If you put someone through the wringer with all sorts of eccentrically oriented training protocols, a therapy will have an effect sooner. In research, that is a good way to statistically be able to see an effect. The question is whether this is a representation of reality. In reality you do not impose so much muscle damage on yourself every workout. In addition, the RBE will do its work when you perform exercises multiple times.
It is also important to understand that the discussed studies look at an effect of therapies on muscle soreness and indicators of muscle damage. These studies do not look at an effect of these therapies on performance or muscle growth. It is therefore not possible to draw conclusions from these studies about possible performance improvements. The effect on performance and muscle growth is a different research question that requires a different design. A review from 2020 observed no effect of massage on strength, jumping power, sprint performance or endurance, even though massage does have an effect on muscle soreness. An effective therapy for muscle soreness therefore does not by definition translate into performance improvements. In fact, it can even lead to reduced performance. We see this reflected in research. Cold water therapies are effective for the treatment of muscle soreness, but dampen the signal for muscle growth. And that is precisely what you do not want. On the other hand, it cannot be ruled out that the discussed treatments can in some way have an effect on muscle soreness and perhaps on sports performance. At the moment, however, there appears to be little evidence for the latter. It also cannot be ruled out that there is a range of other potentially effective treatments. More research is necessary to fill the gaps in our knowledge.
Conclusion
Muscle soreness is a common side effect of unfamiliar training stimuli. Muscle soreness can lead to a loss of strength, ROM and changes in the control of muscle fibers. Some therapies for treating muscle soreness are effective, although the majority are not. Some treatments only help with muscle soreness, and others achieve a reduction of the underlying inflammatory activity. It is precisely the treatments that influence inflammatory activity that appear to have a negative effect on muscle growth by dampening protein synthesis. The big question is whether you should apply treatments for muscle soreness in your current training protocol at all. You experience muscle soreness mainly with unfamiliar training stimuli. This is the case when you have not trained for a while, introduce new exercises, or suddenly start training much more. You manage these variables by following a somewhat logical and structured training program so that the RBE can make its entrance. In that case you do not cause excessive amounts of muscle soreness. Moreover, it is not necessary to make big jumps in training volume or intensity to make progress. If your training program is a string of unfamiliar training stimuli, then treating muscle soreness is like mopping with the tap running. Logically structuring your training schedule is the solution, and that is where you can best put your energy. Nonetheless, there will be situations in which you experience muscle soreness; that is simply part of the game. If you want to reduce the pain, massage is probably your best option. Active recovery can ease your muscle soreness in the short term. Therapies that expose you to cold are better avoided given the negative effect on muscle growth. Improving sports performance through therapies that ease muscle soreness is not plausible given the current evidence.
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Wouter Middelbos
