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The first 48: fighting DOMS and tendonitis.

Muscle and tendon soreness sooner or later will affect virtually everyone, regardless if you are a serious athlete or engage in exercise on an intermittent, recreational basis. The widespread appearance of muscle discomfort is due partly to the activities that produce it and partly to the muscles not being adequately conditioned to handle stressful loads repeatedly placed upon them. Those who think they are "in shape" usually suffer the consequences of pushing through bouts of increasing intensity on a too-much-too-soon basis. They can feel the effects of this as quickly as two hours later or as long as two or three days later. Within hours post-exercise, "weekend warriors" often develop delayed onset muscle soreness (DOMS), often lasting about two days.

It is also never a surprise to see tendons become inflamed and sore either right along with muscle tissue or noticeably before. Tendonitis is a common musculoskeletal complication of overuse, improper use through faulty technique, or an imbalance of use from having some muscle groupings pulling harder against others.

Assessing the Damage

Beginning tendonitis associated with muscle overuse usually presents itself as localized pain after a few minutes into a training session. Early on in the injury process, discomfort often eases a few hours after training. As the condition worsens, pain, weakness, and loss of range-of-motion in the affected area become more constant to the point of continuous discomfort throughout the day.

After a single, intense bout of vigorous activity in a short period of time, DOMS could occur and still be climbing about 24 to 48 hours after, reaching a peak within 48 to 72 hours. It disappears five to seven days after the activity. Inflammation also increases to reach its peak in a few days after the bout, and this delays healing. But as the body becomes exposed to repeated physical effort, recovery happens sooner and full and even increasing strength return more quickly as adaptation becomes manifest.

Another cause of muscle and tendon soreness occurs when muscle groups are repeatedly used under force in a certain way day after day with no or very little change in routine. This is known as repetitive use injury or cumulative trauma disorder. Think of military boot camp: The young men and women are pushed through grueling body movements every day for eight to nine weeks. Prescribed increases in physical demand are presented and expected to be handled, amounting to intense exposure to physical stress at the expense of everything else. More attention to appropriate recovery in basic training and in competitive sports would go further in the long run than immediate, intense overload of the muscles and tendons.

It is usually only after the athlete begins to notice pain, suffer weakness, and endure limited mobility that he or she realize that steps are needed to get things turned around. Try and prevent the need for rehabilitation by making the musculature as strong as possible along with all the supportive connective tissue. In addition, rest and recovery (even with specific workouts geared to provide this) are always appropriate to allow the body to catch up with the adaptation process. If the need for medicinal and/or physiotherapy intervention becomes a given, then the following suggestions should be heeded. We are now guided by the anagram PRICE where the letters stand for the five activities that should begin as soon as possible after perceived injury: protection, rest, ice, compression, and elevation (above the heart).

Choose Heat over Cold

Sandy Koufax, the great fastballer for the Dodgers in the 1960s, was famous for holding photo ops with ice packs strapped to his elbow immediately following his games. This probably provided some relief to the tendons in his elbow by delaying the inflammatory response and lessening swelling to some degree, but in the long run heat would have been better on a repetitive basis to enhance the blood supply.

While you should apply cold immediately after trauma to reduce swelling and lessen tissue damage at the site, cold therapy is not the treatment of choice for non-acute muscle problems, such as muscle soreness and repetitive-use syndrome. Here we need heat application which dilates blood vessels and increases blood flow to the affected area to provide true warmth and soothing and to allow certain enzymes and cellular types carried in the blood to be sent to the injured site to help in the clearing away of damaged tissue.

When choosing the method of applying heat, note that moist heat penetrates tissue better than dry heat, so a moist heating pad is best--but caution must be taken to prevent skin burns. An extended hot shower provides good relief if only for a relatively brief period. What has proved to be the best source of heat application is the recently-developed therapeutic heat wrap (e.g., ThermaCare). This product has disks of iron salts that oxidize when the package is opened, providing a safe 104 degrees of sustainable heat which should not burn the skin over the extended eight-hour wearing time. After the eight-hour wearing, most patients usually experience pain relief for a full 24 hours.

There's the Rub

As a practicing pharmacist for 30 years I have never found rubs of any kind that provided substantial reproducible pain relief, and none have helped in the repair process. I do not believe external irritants benefit athletes in any way except to provide a superficial short-acting warming sensation where applied. Active ingredients in these familiar products include menthol, eucalyptol, camphor, methyl salicylate, trolamine, capsicum, and capsaicin. They all carry the potential to do more harm than good. They can irritate the surface of the skin more than provide relief to the underlying muscle and can produce contact dermatitis at the place of application.

Analgesics and NSAIDs

Damaged tissue emits pain which causes most muscular tissue to go into spasm, and that in turn leads to more pain. This escalating cycle can be broken with analgesics. Quell the pain sufficiently, and you might prevent muscle spasms which lead to further damage. The most common and relatively safe product is acetaminophen (e.g., Tylenol). Four grams (4,000 mg) is the maximum safe daily dose for an extended period with half that or less if this drug is consumed in proximity with alcohol to prevent liver toxicity. Aside from this and assuming no allergy to the active ingredient, acetaminophen should be the first product taken for pain relief on the road to recovery.

NSAIDs can be safely taken in concert with acetaminophen to enhance analgesia. The two act in different sites in the brain and body and actually provide a positive synergistic effect. The NSAIDs have an added benefit of providing an anti-inflammatory effect which helps to keep swelling and internal damage somewhat under control.

These enhanced pain and inflammation antagonists bring a few cautions with them. Since they interfere with blood circulation and tissue repair throughout the body they must be taken with food to protect the stomach lining. They also carry a caution limiting the number of days taken because they can diminish blood circulation to the kidneys over time. Administer for five consecutive days, if needed, with a two-day "drug holiday." If continuous treatment is needed, then this cycle usually can be safely repeated up to two more times in otherwise healthy patients with no intestinal ulcerations or decompensated kidney function.

As they interfere with circulation throughout the body, NSAIDs can have a delaying effect in the absolute healing process, presenting a bit of a double-edged sword: reducing inflammation, which is what we want, but, with continuous use, delaying total healing at the injured site. This, again, emphasizes the need to be cautious with administration over several days.


There is another class of products that has as its primary use the lessening of cold and allergy symptoms but that can produce a positive outcome on healing trauma. Antihistamines act, as the name implies, to reduce the release of histamine--which is usually secreted in areas of inflammation, whether in the nasal passages or at any site of trauma. The sooner these products are taken, the better. Histamine causes blood leakage into the affected area with concomitant swelling. An antihistamine that can reduce swelling can aid in the body's ability to recover. The stronger the antihistamine, the better it can perform but this brings along the side effect of drowsiness, so much so that some products in this class are used to as sleep aids.


While supplements like glucosamine have had mixed results in the literature, the one healing supplement that truly seems to work with some consistency is found naturally in tropical fruit, mostly pineapples. It is the enzyme bromelain. Initially found to aid in digestion, subsequent research has shown that the enzyme helps the body clear itself of dead and damaged tissue almost anywhere, thus accelerating the healing process. Consumed regularly, bromelain has proved its worth in athletes training hard, aiding them to recover from both injury and the "planned trauma" of intense workouts.

There are several syndromes designated to body parts and to activities where muscle and tendon become adversely affected due to excessive usage: tennis elbow (outside aspect of the elbow joint), golfer's and breaststroker's elbow (inside aspect of the elbow joint), jumper's knees, breaststroker's knees, bowler's thumb, and swimmer's shoulder--just to name a few. These usually occur around and in the actual articular systems (joints) proper which bear great force against which the athlete must propel himself. With the help of these treatment strategies, you can minimize pain, spasms, and swelling to get through "the first 48" and back in the game, with, hopefully, many happy returns.

Ed Nessel is a nationally known swimming coach with forty years experience coaching age-group, high school, collegiate, and masters swimmers of every ilk, including Olympic gold medalist Cullen Jones.

By Edward H. Nessel, RPh, MS, MPH, PharmD
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Title Annotation:delayed onset muscle soreness
Author:Nessel, Edward H.
Publication:Running & FitNews
Geographic Code:1USA
Date:Mar 1, 2010
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