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By: Kayla Ng

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We’ve all heard of DOMS (delayed onset muscle soreness) and the majority of us have experienced it at least once.

It’s that muscle pain and weakness that we feel a day or two after some exercise. It can be caused by any type of muscle contraction but it is most commonly caused by an eccentric exercise such as downhill running and resistance training. (Reminder: an eccentric exercise is a movement where the muscle is under load as it lengthens. For example, a raising part of a bicep curl is a concentric exercise but the lowering part of a bicep curl is the eccentric part)

The typical symptoms include strength loss, pain, muscle tenderness, stiffness and swelling. Symptoms typically peak 24-48 hours after exercise and fade within 96 hours. The severity of DOMS depends on several factors but in general, more damage occurs with higher intensity and unfamiliar actions.

Physiologists do not have clear understanding of the mechanism behind DOMS, however the proposed theory involves a mechanical disruption to the sarcomeres (the fundamental unit of a muscle structure) which then sets off an inflammatory response. The swelling is caused from the movement of cells and fluid from the blood stream to the muscle, where it contributes to the sensation of pain.

I’ve often been asked if it’s okay to continue exercising and/or what can someone do to help reduce the feeling of DOMS. A recent meta-analysis looked to compare the effects of the most commonly used recovery techniques on muscle damage, DOMS, inflammation and the feeling of fatigue from physical exercise. The authors looked at the effects of 1 session of several different types of recovery techniques after physical exercise on:

  • DOMS
  • Perceived fatigue (ie: how much someone feels tired)
  • Inflammatory markers (IL-6, CRP)
  • Muscle damage markers (CK – creatine kinase)

Let’s have a look at the evidence!

Massage

Based on this meta-analysis, massage was the most effective for DOMS and perceived fatigue! The authors reported that a 20-30 min massage performed immediately after or up to 2 hours after exercise has been shown to help reduce DOMS for 24-96 hours after exercise. Elite athletes (in this case ultra-marathon runners) reported a significant improvement in lower perceived pain after massage. Not only does a massage feel good, but it has also been shown to reduce CK and IL-6 in the blood after exercise which may help towards a faster recovery.

Rationale:

Massage seems to help the symptoms of exercise-induced muscle damage by increasing blood and lymph flow which can stop the CK response and clear it from the blood. It’s assumed that massage flushes out neutrophils (an immune cell that responds to inflammation) from the damaged area which would otherwise cause more CK in the area.

Compression Garments

Compression garments have a significant and positive impact on DOMS up to 96 hours after exercise. It has been shown that wearing a whole-body compression garment over a 24-h period after intense heavy resistance training significantly reduces perceived fatigue. That might not be realistic for us but other compression garments such as leggings and socks can be used.36391146502_1bd4d6090e_k (2)

Rationale:

The beneficial effect of compression garments might be explained by:

  • A reduction in the space available for swelling and edema
  • Better venous return (blood flow back to the hear)

Cold Water Immersion

Cold water immersion (CWI), aka: ice baths, showed a significant effect on DOMS and perceived fatigue after training and competitions/tournaments as well as after strenuous exercise in both trained athletes and recreational subjects.

Ice baths in water at 11-15⁰C for 11-15 minutes is considered the optimal dose to have a positive impact and reduce DOMS.

Rationale:

CWI seems to help reduce exercise-induced inflammation, edema, pain sensation, and muscle damage through these ways:

  • The hydrostatic pressure from being immersed in water may help transport fluids from the muscle to the blood and therefore eliminate inflammatory products
  • Narrowing of blood vessels from the cold temperature may reduce fluid diffusion into space in the muscle and reduce the inflammatory reaction

Contrast Water Therapy

Contrast Water Therapy (CWT) which is bathing alternately in warm and cold water seems to have a small effect on DOMS but not perceived fatigue. CWT has been able to reduce the perception of pain at 24, 48, and 72 hours post-eccentric exercise. CWT also reduced CK concentrations in the blood.

Rationale:

CWT promotes the opening and narrowing opening of blood vessels which may reduce the formation of edema, inflammatory pathways and decrease feeling of pain.

Active Recovery

Active recovery also has a significant effect on DOMS, but not effect on perceived fatigue however, the impact of active recovery is only significant during a short period after exercise. There seems to be no influence of active recovery on CK, IL-6 and CRP concentrations in the blood.

Rationale:

Active recovery seems to help DOMS by enhancing blood flow in muscle tissue, which helps to remove metabolic waste and therefore reduce muscle pain.

Cryotherapy

Cryotherapy is the exposure to a cold chamber and appears to be effective in reducing DOMS after exercise. The authors found that cryotherapy had an effect on DOMS but only for about up to 6 hours after exercise and any cryotherapy done 24 hours after the end of exercise is ineffective in alleviating DOMS.

Stretching/Electrostimulation

The meta-analysis did not find any significant influence of stretching or electrostimulation on DOMS and fatigue. In fact, results showed that stretching less than 6 hours after exercise might even produce DOMS.

Take Home Points!

At some point we will experience DOMS and with time, it will go away on its own but there are some ways to help reduce the feeling and possibly recover faster. Massage seems to be the most effective in relieving DOMS and fatigue. Ice baths and compression garments can also help but are less effective.

Keep in mind that the outcomes from this meta-analysis looked at many studies with different protocols and the results can vary depending on many things such as the type of exercise, level of immersion in water, and amount of pressure from compression garments to name a few.

One final note is that while research shows that these post-workout techniques can make us feel better faster, over time we might we lose some of the benefit from that hard workout or training session since the signal to adapt to the training is blunted from using these recovery methods. So, it is important to use them strategically (ie: after a race where you went too hard or leading into a big race) and to avoid using them during base training and instead just give yourself more time to recover.

Hope this helps with your recovery!  If you have any other questions, or would like to learn more about me, check out my profile HERE.

References:

Dupay et al. 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. 2018

 Connolly et al. Treatment and prevention of delayed onset muscle soreness. Journal of Strength and Conditioning Research. 2003

What is Acupuncture?

Modern acupuncture is defined as a therapeutic technique in which sharp, thin needles are inserted into specific points on the body. Mechanical, electrical or physical stimulation is sometimes added to the needle to increase the effect. Needles are inserted into acupuncture points, aka: acupoints which were first established in traditional Chinese medicine.

Classical vs. Anatomical Acupuncture: What’s the difference?

Classical acupuncture is based on Tradition Chinese Medicine (TCM). Ancient Chinese believed that everything in the universe was energy. The philosophy that emerged from this thinking is called Taoism which translates to the energy of the universe. The energy is also referred to as Qi (chi).

Qi consists of two equal and opposing energies, Yin and Yang and is commonly represented by the picture above. The curved line represents movement and dynamic fluid between the 2 energies. They are mutually supportive and interdependent.

It was believed that Qi flows through the body along energy channels (referred to as meridians) and could flow into specific sites aka: acupoints. If Qi was deficient, blocked, or out of balance, symptoms such as pain would appear. Needling these sites relieved the symptoms by unblocking and restoring flow of Qi and re-establishing energy balance in the body.

Anatomical acupuncture was originated by Dr. Joseph Wong in the mid 1970s and bridges the gap between TCM and Western medicine. The acupoints are chosen based on anatomy and physiology.

The main difference between classical and anatomical acupuncture is the paradigm used in the selection of points.

The Points

Early studies show most acupoints are located on or near peripheral nerves. There is no evidence to support the existence of new or special structures under these acupoints, however, histological studies (ie: looking under a microscope) have shown a higher concentration of neural tissue and neuroactive components at acupoints compared to non-acupoints.

Neural tissues are the actual tissues themselves and include nerve endings and sensory receptors. Neuraoactive components are cells that release chemical mediators that can excite or inhibit signals to the brain.

The Neural Acupuncture Unit (NAU)

The NAU is a collection of the neural and neuroactive components surrounding the needle. In the diagram, the NAU is the area within the dotted lines. These tissues would be stimulated by the needle.

What Happens When the Needle is Inserted?

Local Effects

When a needle is inserted, it causes some damage to the issue near the insertion point, which stimulates a chain of biochemical reactions in your body. As a result, your body produces various inflammatory and immune response in the NAU. Basically, it is a micro-injury which does negligible harm to the body while creating a therapeutic response.acu2

Non-local Effects

Without getting too in-depth, the non-local effects involve altering pain signals through receptors in the spinal cord and how they relay messages to the brain. The nerve signals from the local tissue travel to the spinal cord and through complex mechanisms, block the original pain signals from getting to the brain.

Another area of the brain is also involved. The hypothalamus-pituitary complex (don’t have to remember this name!) is also stimulated when a needle is inserted and releases anti-inflammatory chemicals into the bloodstream that can help to reduce pain.

These local and systemic responses help to explain the pain-relieving effects of acupuncture.

In my next article, we’ll look at the effects that acupuncture can have for different injuries!

REFERENCES:

Wang, Kain, White. Acupuncture analgesia: I. The scientific basis. Pain Medicine. 2008

Zhang, Wang, McAlonan. Neural acupuncture unit: A new concept for interpreting effects and mechanisms of acupuncture. Evidence-Based Complementary and Alternative Medicine. 2012

What is it?!

Overuse injury associated with pain on the outside (lateral) part of the knee

Anatomy

The ITB is a band or sheath of fibrous connective tissue that surrounds the muscles on the outside of the thigh and crosses both the hip and knee joint. It originates from the tensor fascia latae (TFL) and gluteus maximus muscles and then continues down the femur (thigh bone) where it attaches to both the femur and tibia (shin bone) on several bony landmarks.

The function of the IT band is to stabilize the hip and knee as well as limit hip adduction (leg moving towards the midline) and internal rotation of the knee.

Epidemiology and Risk Factors

The knee is the most commonly injured area in runners – accounting for 25-42% of all running injuries. ITBs is the second most common knee injury for runners with patellofemoral pain syndrome being first.

ITBSigns/Symptoms

Runners usually have no exact history of trauma and find that the pain comes on gradually over the outside of the knee during a run. The pain usually appears within a few km of a run and increases in intensity. That same area can also be tender to touch.

Pathophysiology/Etiology

There are a couple theories on the pathophysiology of ITBs.

Some researchers believe that ITB inflammation is a result of excessive friction between the ITB and the boney prominences which occur when the ITB slides over the boney structure and causing inflammation during repetitive movements such as running. Others have argued that rather than the ITB band causing excessive friction, the inflammation is caused by the ITB compressing an area of highly innervated fatty tissue between the IT band and boney prominence

Contributing Factors to Developing ITB Syndrome

The most common factor in developing ITBs is an increase in exercise intensity through mileage, hill training or speed work.

Other reported possible causes which may increase tension in the ITB by altering hip and knee angles include:

  • Downhill running
  • Wearing old shoes
  • Always running on same side of road
  • Leg length discrepancies
  • Excessive pronation of the foot (foot rolling inward)
  • Tight ITB
  • Weakness of glute medius muscle

ITBs and Running Biomechanics

It has been suggested that injuries can manifest as a result of an increase in exercise intensity beyond a threshold level, combined with certain intrinsic factors in athletes.

A recent systematic review looked at biomechanical variables and investigated whether distance runners who suffer from or develop ITBs have different biomechanics than runners who do not develop ITBs.

The evidence shows that it is unlikely that abnormal biomechanics at the foot or shin bone can contribute to increasing tension of the ITB.

The results suggest more is happening at the hip and knee. Runners who eventually develop ITBs have more internal rotation at the knee and greater glut medhip adduction angles during the stance phase of running (when the foot is in contact with the ground) compared to healthy controls.

Some researchers have found that this internal rotation of the knee is due more to an externally rotated femur (thigh bone rotated outside) and suggests this may be due to insufficient activity in the medial rotators of the hip (gluteus medius, gluteus minimus, TFL).

As for muscle strength and endurance, there is currently no evidence to suggest that reduced muscle strength plays a role in ITBs. However, the research is limited because many of the trials give inaccurate impressions of a muscle’s functional strength. Future research is needed to look at the timing of muscle action rather than the magnitude of strength.

Research also suggests that runners with current ITBs tend to have more trunk flexion than healthy controls. It is uncertain whether the increased trunk flexion is due to a tight ITB or if the ITB becomes tight as a consequence of the flexed trunk (aka: the torso leaning forward)

How do we treat it!?

Stay tuned to my next article on the latest evidence for treating and managing ITBs!

References:

Foch et la. Associations b/n IT band injury status and running biomechanics in women. Gait & Posture. 2014.

Louw & Deary. The biomechanical variables involved in the aetiology of iliotibial band syndrome in distance runners – a SR. Physical Therapy in Sport. 2014

Let’s target the hip abductor muscles! In my last article I discussed the importance of core strength and control to stabilize our trunk when we run – specifically the importance of the hip abductor muscles.

To refresh, the hip abductors help to bring the leg to the outside of our midline to counteract the moment of force where our leg naturally wants to move toward the midline each time our foot hits the ground.

We have several hip abductor muscles in our body, the majority of them are in our butt muscles! Gluteus medius (Gmglut meded), gluteus maximus (GMax), gluteus minimus (GMin) and TFL (tensor fascia latae). The focus of this article is going to be on the gluteus medius because of its important role in stabilizing the pelvis.

Why do the gluteal muscles become weak? Most of us spend our days sitting and therefore develop weak gluteal muscles making it harder to recruit them during exercise. This can lead to improper use and poor muscle patterning of other muscles to try to compensate for a weak GMed which may increase risk of injury somewhere down the road.

Using techniques to help isolate these muscles can increase their activation and ultimately improve performance. So, how do we target these muscles? A few electromyographic (EMG) studies can help us out!

Study #1: One leg vs. two legs for Gmed activation 

This study used EMG signal amplitude to measure GMed activation in 5 different weight-bearing exercises; double leg stance, single leg (SL) stance, single leg squat, single leg stance on a cushion, and single leg squat on a cushion, where the cushion was an unstable surface underneath the foot to make the exercise more difficult.

To no surprise, the results showed that a SL stance placed higher demands on the GMed than double leg stance and SL squats are more demanding than SL stance. As for the SL exercises on the cushion; the GMed muscle was activated more, but not significantly more than on flat ground.

Study #2: How do we activate Gmed even more?

This study used EMG signals to measure muscle activation patterns of the GMed (among 3 other hip muscles) during 5 unilateral weight-bearing exercises as shown here:
picss

They compared the level of activation to the subject’s maximal voluntary contraction. The EMG signal amplitude had to be between 40-60% of the maximal voluntary contraction to have sufficient intensity for strengthening.

Of the 5 exercises, the results for the GMed showed the highest amount of activation during the wall squat! The next exercises for activation were as follows: forward step-up, lateral step-up, backward step-up and then mini squat. The authors suggested that these exercises may be used as progression exercises towards the wall squat.

TFLStudy #3: What happens when the gluts are weak?

The last article looked at hip abductor muscle activity during resisted side-stepping exercises in either a squatted or standing position. They found that both the GMax and GMed had greater muscle activity during the squatted position than the upright posture. By being in this squatted position, the TFL muscle is less active which means the gluteal muscles should, in theory, be more active. This is important because if the gluteal muscles are weak, the
TFL will compensate which may lead to further underuse and weakening of the gluteal muscles.

Practical Applications

Here are a few key take home points for activating the Gmed to help enhance our running:

  • The GMed plays an important role in stabilizing the pelvis/hip joint during weight-bearing
  • GMed activation is greater when the base of support is less ie: during a side bridge, unilateral squat and lateral step up
  • Some key exercises to get the most activation from the GMed:
    • Single Leg Stance
    • Single Leg Wall Squats
    • Forward Step Ups
    • Lateral Step Ups
    • Side Steps with a resistance band around the knees/ankle (aka: Monster Walks)

And does strengthening GMed actually help to prevent injuries?  As always, the answer is that it depends, but check out this article  from Dr. Delanghe exploring how GMed strength work can decrease injury-causing variability of motion at the knee.

Happy strengthening!

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