29 Delayed Onset Muscle Soreness

Delayed Onset Muscle Soreness

Delayed onset muscle soreness (DOMS) is the distinct feeling of discomfort after strenuous physical activity, symptoms typically peak at 24-72 hours.


There are different theories of what accounts for this delayed discomfort 24-48 hours post exercise. The inflammation theory proposes that delayed onset muscle soreness is due to the accumulation of histamines, cytokines, and prostaglandins (Vadasz et al., 2020). Another theory is that delayed onset muscle soreness is caused by an acute axonopathy, where increased fluid pressure mechanically irritates nerve endings in the muscle spindle (Sonkodi et al., 2020). Current evidence suggests that lactic acid does not play a role in this condition.

SciShow: Does Lactic Acid Really Cause Muscle Pain?


A thorough health history intake can be done to gather information about patients’ limitations, course of pain, and prognostic factors for delayed recovery (e.g., low self-efficacy, fear of movement, ineffective coping strategies, fear-avoidance, pain catastrophizing) and answers to health-related questions. Screen patients to identify those with a higher likelihood of serious pathology/red flag conditions. Then undertake a physical examination: neurological screening test, assess mobility and/or muscle strength.

Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:

  • Self-Rated Recovery Question
  • Brief Pain Inventory (BPI)
  • Visual Analog Scale (VAS)
  • Patient Global Impression of Change (PGIC)


Massage therapists are professionally trained to treat active individuals from grassroots sports to professional athletes. They specialize in specific techniques for pre-event, post event and restorative/ training massage. There are important considerations to be made around dosage and timing of massage, but most treatment lengths vary between five and twenty minutes. Therapists use many different techniques, Swedish massage, sports massage, myofascial release and cupping massage, most often patients will feel a difference once they get off the table.


Provide reassurance and patient education on condition and management options and encourage the use of active approaches (lifestyle, physical activity) to help manage symptoms.

Manual Therapy

Researchers have investigated the effect of soft-tissue massage on cellular signaling and tissue remodeling; this is referred to as mechanotherapy. Research has demonstrated that massage therapy (effleurage in particular) has a modest effect on local circulation and perfusion both in the massaged limb and in the contralateral limb (Monteiro Rodrigues et al., 2020). Furthermore, a recent joint research effort between Timothy Butterfield of the University of Kentucky and researchers at Colorado State University demonstrated that modelled massage enhanced satellite cell numbers (Miller et al., 2018Hunt et al., 2019). This was in addition to earlier research from Butterfield and his collaborators at the University of Kentucky, which proposes the idea that mechanical stimulation prompts a phenotype change of pro-inflammatory M1 macrophages into anti-inflammatory M2 macrophages (Waters-Banker et al., 2014). Taken together the increase in satellite cell numbers and reduction in inflammatory signaling may improve the body’s ability to respond to subsequent rehabilitation.

Also, worth noting is that ascribing a patient’s pain solely a tissue-driven pain problem is often an oversimplification of a complex process. This insight provides us with an opportunity to re-frame our clinical models. Gently stretching the skin, muscles, neurovascular structures, and investing fascia activates endogenous pain modulating systems that help to modulate neuro-immune responses. There is evidence indicating that conservative methods (exercise or manual therapy) can help to ease pain and muscle soreness (Davis et al., 2020; Dupuy et al., 2018Guo et al., 2017).

Self-Management Strategies

When massage therapy is combined with a healthy diet, active recovery and sleep it can be part of an effective post-exercise recovery strategy (Van Hooren & Peake, 2018). The goal of post-exercise recovery is to ensure that athletes possess the physical & mental capacities to compete at their highest level. Which can be a challenge, due to the number of variables can affect athletic performance (e.g., fatigue, recovery, training status, health and well-being). However short-term gains in recovery may be balanced out by longer-term costs, ice baths and massage that may artificially accelerate recovery from exercise may carry a hidden cost, since post-exercise inflammation signals your body to adapt and get stronger.


The growing body of literature supports the use of massage therapy to help alleviate the musculoskeletal disorders associated with everyday stress, physical manifestation of mental distress, muscular overuse and many persistent pain syndromes (Skelley et al., 2020). Massage therapy may be an effective recovery tool considering it provides both physical and psychological benefits, examining the basic science behind massage therapy enables us to speculate how specific and nonspecific effects of massage can help to ease pain and muscle soreness (Best & Crawford, 2017). Existing evidence suggests that massage therapy (soft tissue massage, neural mobilization, joint mobilization) can be utilized to help relieve pain, improve function, and reduce anxiety when integrated with standard care (Davis et al., 2020; Dupuy et al., 2018Guo et al., 2017).

Key Takeaways

Contemporary multimodal massage therapists are uniquely suited to incorporate a number of rehabilitation strategies for delayed onset muscle soreness based on patient-specific assessment findings including, but not limited to:

  • Manual Therapy (soft tissue massage, neural mobilization, joint mobilization)
  • Education that is Person-Centered (e.g., biopsychosocial model of health and disease, self-efficacy beliefs, active coping strategies)
  • Stretching & Loading Programs (e.g., concentric, eccentric, isometric exercises)
  • Hydrotherapy (hot & cold)
  • Self-Management Strategies (e.g., engaging in physical activity and exercise, social activities, and healthy sleep habits)

References and Sources

Best, T. M., & Crawford, S. K. (2017). Massage and postexercise recovery: the science is emerging. British journal of sports medicine, 51(19), 1386–1387. https://doi.org/10.1136/bjsports-2016-096528

Chazaud, B. (2016). Inflammation during skeletal muscle regeneration and tissue remodeling: application to exercise-induced muscle damage management. Immunology and cell biology, 94(2), 140–145. https://doi.org/10.1038/icb.2015.97

Crane, J. D., Ogborn, D. I., Cupido, C., Melov, S., Hubbard, A., Bourgeois, J. M., & Tarnopolsky, M. A. (2012). Massage therapy attenuates inflammatory signaling after exercise-induced muscle damage. Science translational medicine, 4(119), 119ra13. https://doi.org/10.1126/scitranslmed.3002882

Davis, H. L., Alabed, S., & Chico, T. J. A. (2020). Effect of sports massage on performance and recovery: a systematic review and meta-analysis. BMJ Open Sport & Exercise Medicine, 6(1), e000614. doi: 10.1136/bmjsem-2019-000614

Duchesne, E., Dufresne, S. S., & Dumont, N. A. (2017). Impact of Inflammation and Anti-inflammatory Modalities on Skeletal Muscle Healing: From Fundamental Research to the Clinic. Physical therapy, 97(8), 807–817. https://doi.org/10.1093/ptj/pzx056

Dupuy, O., Douzi, W., Theurot, D., Bosquet, L., & Dugué, B. (2018). An Evidence-Based Approach for Choosing Post-exercise Recovery Techniques to Reduce Markers of Muscle Damage, Soreness, Fatigue, and Inflammation: A Systematic Review With Meta-Analysis. Frontiers in physiology, 9, 403. https://doi.org/10.3389/fphys.2018.00403

Gong, W. Y., Abdelhamid, R. E., Carvalho, C. S., & Sluka, K. A. (2016). Resident Macrophages in Muscle Contribute to Development of Hyperalgesia in a Mouse Model of Noninflammatory Muscle Pain. The journal of pain: official journal of the American Pain Society, 17(10), 1081–1094. https://doi.org/10.1016/j.jpain.2016.06.010

Guo, J., Li, L., Gong, Y., Zhu, R., Xu, J., Zou, J., & Chen, X. (2017). Massage Alleviates Delayed Onset Muscle Soreness after Strenuous Exercise: A Systematic Review and Meta-Analysis. Frontiers in physiology, 8, 747. https://doi.org/10.3389/fphys.2017.00747

Hainline, B., Turner, J. A., Caneiro, J. P., Stewart, M., & Lorimer Moseley, G. (2017). Pain in elite athletes-neurophysiological, biomechanical and psychosocial considerations: a narrative review. British journal of sports medicine, 51(17), 1259–1264. https://doi.org/10.1136/bjsports-2017-097890

Hunt, E. R., Confides, A. L., Abshire, S. M., Dupont-Versteegden, E. E., & Butterfield, T. A. (2019). Massage increases satellite cell number independent of the age-associated alterations in sarcolemma permeability. Physiological reports, 7(17), e14200. doi:10.14814/phy2.14200

Hunt, E. R., Baez, S. E., Olson, A. D., Butterfield, T. A., & Dupont-Versteegden, E. (2019). Using Massage to Combat Fear-Avoidance and the Pain Tension Cycle. International Journal of Athletic Therapy and Training, 24(5), 198-201.

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Kellmann, M., Bertollo, M., Bosquet, L., Brink, M., Coutts, A. J., Duffield, R., … Beckmann, J. (2018). Recovery and Performance in Sport: Consensus Statement. International journal of sports physiology and performance, 13(2), 240–245. https://doi.org/10.1123/ijspp.2017-0759

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Evidence-Based Massage Therapy by Richard Lebert is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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