Delayed onset symptoms remain a bit of a mystery, despite being extremely common. But neuroscience is starting to clarify the confusing, intense, and fear-inducing phenomenon. There are 2 ways delayed onset symptoms show up. One is delayed soreness, common in high-performing athletes and weekend warriors alike. People who push their bodies super hard. The other is delayed pain, common in chronic pain as people struggle to get back to doing everything from getting out of bed, to basic activities of daily living, to returning to even low levels of athletic movement. Delayed pain is one of the most common symptom behaviors that indicate nervous system-driven symptoms rather than a structural body injury. Delayed onset pain, strangely, can be triggered by a wide range of movements from the most basic to the most athletic.
So what’s the difference between the common athlete phenomenon called delayed onset muscle soreness (DOMS) and the way chronic pain behaves as you’re working to get moving again at some meaningful level? I call this later type delayed onset pain (DOPS); the type that inevitably threatens to derail your progress as you do the brave work of challenging your nervous system’s opinion of whether the world (and activities therein) is safe or not.
For people overcoming pain, there’s often confusion about the difference because the two can feel similar. Mostly in that, there can be a delayed onset to both phenomena, but also because they both result in sensation. Both sensations can create confusion, threaten to interrupt progress, and discourage people from trying an activity again when they’re working to return to exercise. Do you have DOMS or DOPS, and what can you do about it? The first thing I want you to know is that NEITHER delayed onset muscle soreness (DOMS), nor delayed onset pain (DOPS), is dangerous. Neither is an injury or a structural problem. An important distinction between DOMS/DOPS and a structural injury to your body (ie: stress fracture or overt fracture, muscle tear, tendon injury, joint inflammation, disc herniation, facet injury, or nerve compression), is those will hurt DURING exercise. If you have pain when you start to exercise, it won’t get better the more you move if it’s an injury. Similarly, symptoms won’t come on hours or days later if you’re injured. While DOMS and DOPS are similar in this way, they have some important differences that will help you navigate better.
The first difference between DOMS and DOPS is that they don’t behave the same. DOMS tends to come on 12+ hours to 2 days after exercise and sticks around for a few days before resolving on its own. DOPS tends to come on hours, days, or weeks after some activity and can stick around indefinitely, especially when stress or fear is present. People often attribute DOPS to something they did weeks or even months before! They’ll make up stories about what hypothetically caused the pain despite it never really adding up. However, these assumptions are not benign in that they create fear, stress, and thus persistent pain. You likely know by now that fear tends to result in pain sticking around longer than it needs to. DOPS is a perfect example of how this happens.
The second differentiator between DOMS and DOPS is that DOMS is caused by high-intensity exercise that’s significantly beyond your current level of fitness. Think heavy weightlifting, sprinting, skiing on the first day of the season, playing competitive soccer after time off, or running downhill fast when you’re not used to those things. These are eccentric movements where the muscles and tendons are lengthening under very high tension. The tissue AND the nervous system get overwhelmed by this intensity. Meanwhile, DOPS Can be triggered by just about anything, including the most benign activities. While DOPS can be caused by challenging yourself in new ways as you engage in a gradual exposure process to overcome pain, it is NOT the result of high-intensity or superhuman effort. It’s simply the nervous system’s opinion of whether you’re safe or not based on many non-physical factors. In chronic pain, the nervous system gets in the habit of predicting that lots of things are dangerous. So DOPS is very common, despite being harmless.
While we don’t know much about either DOMS or DOPS mechanistically, we do know that both sensations are constructed and experienced in the brain. There’s a shift in thinking away from a physical cause and more toward a neurological cause. With DOMS, the brain’s decision to create the experience of symptoms, including any physical changes that result, is informed partly by accurate information from the body that something significant happened to the tissues (overload beyond your current fitness level). DOMS has theoretically been associated with micro-injury, minor damage, and local inflammation of the tissues due to overload. Some propose that DOMS is like a mild version of “rhabdomyolysis” where protein spills into the blood as muscles experience micro-tearing. Contrary to a common myth, DOMS is NOT caused by lactic acid - the short-acting byproduct of exercise that limits performance during exercise. Some research suggests that not only is DOMS not caused by inflammation, but there’s evidence that creating more inflammation by moving through the soreness actually helps shorten its duration. Regardless of the cause, one benefit of DOMS is that it ultimately leads to adaptation and more fitness. So it’s actually considered positive in the long term.
On the contrary, while DOPS may be partially informed by information from the body, there is usually no objective damage or injury to the body. Most of the time, normal and benign information is being misinterpreted by the brain as dangerous. And in many cases, the brain decides to create delayed onset pain WITHOUT ANY information from the body at all! DOPS is thus likely more neurological than physical. DOPS is mostly generated by your expectations, beliefs, emotions, thoughts, predictions, context, and fear. As a part of the process of overcoming pain, DOPS is also important and helpful because it’s how the nervous system starts to de-sensitize to movement and healthy functional activities again. Without a thoughtful process of graded exposure to movement that includes regular moderate amounts of DOPS, pain doesn’t tend to ease as quickly as it does with DOMS. Paradoxically, with DOPS, you have to move into some pain to overcome pain! See my video on return to movement HERE to learn more about this process.
While mechanistically DOMS and DOPS are quite different, despite sometimes FEELING very similar, they do have a few other features in common. Because both sensations are constructed and experienced in the brain (based on your brain’s opinion of how much danger you’re in) they are both influenced by psychological and social factors like stress, fear, self-talk, mindset, your support system, and other thoughts, feelings, and behaviors that influence ALL pain. Research also suggests that both are affected by sleep quality, diet, and genetics. One article even proposed that DOMS is relieved by modalities like heat, cold, and even eating Indian food! But you’ll have to test that theory of yourself.
Another thing they have in common is that they both tend to respond better to movement than to rest, as long as your fear level is low. While DOMS requires a mandatory multi-day course of soreness that resolves itself naturally, movement tends to shorten recovery time and support recovery. Similarly, you can learn to move through DOPS in a matter of minutes or hours as you learn the skills to do so. Essentially, DOPS is optional and responds well to reassurance and other mind/body strategies. Interestingly, while DOPS can stick around forever in the presence of fear, it can go away almost instantaneously as fear recedes.
If you’d like to learn more about DOPS and how to use strategies like mental rehearsal, visualization, somatic tracking, emotional awareness, gratitude, distraction, polyvagal strategies, family systems therapy, or inner child work, it would be my pleasure to share with you. Navigating and interrupting DOPS quickly is a critical skill in overcoming pain, regardless of your activity level. A superpower that ultimately leads to less pain. As you learn the skills, you’ll find you’re able to break through previous and existing barriers to get back to high-intensity activities. Activities that result in the familiar sensation of DOMS that athletes appreciate as a sign of overload, fitness gains, and the improved performance that follows.
If you’d like to learn more about delayed onset pain and the other symptom behaviors that we use to rule OUT the body (structural injury issues) and to diagnose brain/nervous system-driven pain, please book an appointment via my website at Mperformance.com. If you’re a clinician who’d like to learn more about mind-body medicine, the diagnostic process, and the strategies that can help your clients unlearn chronic symptoms, please message me directly. If you’re an athlete who wants support in overcoming chronic nagging symptoms, I now offer an immersive 12-week course that will teach you everything you’ll need to know to self-heal. Reach out to me directly.
charlie@Mperormance.com or 303.717.8351
In the meantime, enjoy all the sensations in your body and remember that they’re all a sign that you’re alive and lucky to enjoy this generous present moment.