Delayed Onset Muscle Soreness (DOMS) after Hamstring Injury: Pathophysiology, Imaging Insights, Diagnosis, and Treatment

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Introduction

Delayed onset muscle soreness (DOMS) represents a common yet clinically significant phenomenon encountered in sports medicine, musculoskeletal radiology, rehabilitation, and orthopedics. While DOMS is typically self-limiting, its manifestation following hamstring injury poses diagnostic challenges because its symptoms overlap with partial muscle tears, hematomas, or myotendinous junction injuries.

In this post, we present an in-depth discussion of DOMS following hamstring injury, anchored on the case of a 31-year-old male with right hamstring pain. Using the latest global evidence and imaging findings, this column will explore DOMS from pathophysiology to prognosis, highlighting the role of magnetic resonance imaging (MRI) and evidence-based treatment strategies.

Pathophysiology

DOMS after hamstring injury is primarily associated with eccentric contractions during running, sprinting, or resistance training. The mechanisms include:

  1. Microscopic myofibrillar disruption

    • Z-line streaming and sarcomere overstretching cause structural injury.

    • Sarcolemma permeability increases, facilitating calcium influx.

  2. Calcium overload and protease activation

    • Calpains and cathepsins degrade contractile proteins.

    • Disrupted mitochondria exacerbate oxidative stress.

  3. Inflammatory cascade

    • Neutrophil infiltration, cytokine release (IL-6, TNF-α), and prostaglandin accumulation induce edema and hyperalgesia.

  4. Peripheral sensitization

    • Bradykinin and prostaglandins sensitize nociceptors, explaining the delayed nature of pain (24–72 hours post-exercise).

Thus, DOMS is not merely mechanical injury but a multifactorial biochemical process bridging exercise physiology, immunology, and pain science.

Epidemiology

  • Incidence: Up to 80% of adults experience DOMS after intense or unaccustomed exercise.

  • Risk factors:

    • Eccentric exercises (e.g., downhill running, Nordic hamstring curls).

    • Previous hamstring injuries.

    • High-performance athletes, military recruits, and individuals in rehabilitation programs.

  • Hamstring vulnerability:

    • Long fascicle length, frequent eccentric loading during sprinting, and relatively poor vascular supply increase susceptibility to DOMS.

Clinical Presentation

  • Onset: 12–24 hours post-exercise.

  • Peak: 48–72 hours, resolving within 5–7 days.

  • Key symptoms:

    • Localized posterior thigh pain.

    • Palpation tenderness and stiffness.

    • Restricted range of motion.

    • Mild strength reduction.

  • Hamstring-specific pattern:

    • Pain during lunges and sprinting.

    • Walking often remains tolerable, distinguishing DOMS from more severe injuries.

Imaging Features

While clinical history is often sufficient, imaging plays a vital role in differentiating DOMS from muscle tears or hematomas.

MRI findings in DOMS:

  • T1-weighted images: Normal or subtle signal alterations.

  • STIR/T2-weighted images: Diffuse hyperintensity reflecting interstitial edema.

  • Absence of structural disruption: No fiber discontinuity, hematoma, or tendon avulsion.

Case Example (31-year-old male, right hamstring):

  • MRI revealed diffuse T2/STIR hyperintensity within the posterior thigh muscles, without evidence of focal tear or hematoma.

  • Findings were consistent with DOMS rather than traumatic muscle rupture.

Figure 1. Axial STIR MRI of the right hamstring

Diffuse high signal intensity within the posterior thigh muscles, especially the biceps femoris, consistent with edema. No definite tear identified.


Figure 2. Axial STIR MRI of the right hamstring (mid–distal portion)

Edema involving the mid-distal biceps femoris, with preservation of the myotendinous junction.


Figure 3. Coronal STIR MRI of the right thigh

Diffuse intermuscular edema extending along the lateral aponeurosis and intermuscular plane, without evidence of tendon rupture or hematoma.

Differential Diagnosis

DOMS must be differentiated from conditions with overlapping imaging and clinical features:

  1. Acute muscle tear

    • Focal fiber discontinuity, hematoma, tendon retraction.

  2. Myotendinous junction injury

    • Hyperintensity localized near tendon insertion.

  3. Intramuscular hematoma

    • Well-defined fluid collection with evolving signal characteristics.

  4. Myositis

    • Diffuse signal abnormality but often accompanied by systemic symptoms.

  5. Compartment syndrome

    • Severe pain out of proportion, with neurovascular compromise.

Diagnosis

The diagnosis of DOMS following hamstring injury is based on:

  • Clinical timing of pain (delayed onset, peak at 48–72 hours).

  • Absence of acute trauma markers (no audible pop, no immediate swelling).

  • MRI findings: diffuse edema without structural disruption.

Treatment

Most DOMS cases resolve spontaneously. Evidence-based interventions include:

  • Rest and active recovery: Light activity enhances circulation.

  • Cryotherapy: Ice packs reduce inflammation and nociceptor activation.

  • NSAIDs: Short-term use alleviates pain, though caution is warranted regarding muscle healing.

  • Foam rolling and stretching: Improve blood flow and reduce stiffness.

  • Nutritional support: Omega-3 fatty acids, antioxidants, and optimal protein intake aid recovery.

  • Emerging therapies: Low-level laser therapy and cryo-chambers have shown promise in elite athletes.

Prognosis

  • Excellent prognosis: Symptoms resolve within 5–7 days without permanent damage.

  • No long-term sequelae: DOMS does not predispose to chronic hamstring dysfunction.

  • Performance impact: Temporary reduction in explosive power and sprinting ability, relevant in professional athletes.

Quiz

Q1. What is the primary mechanism behind delayed pain in DOMS?

  • A) Muscle fiber necrosis

  • B) Accumulation of lactic acid

  • C) Peripheral sensitization due to inflammatory mediators

  • D) Complete tendon rupture

Answer: C
Explanation: Pain in DOMS arises from inflammatory mediators (prostaglandins, bradykinin) sensitizing nociceptors, not lactic acid accumulation.

Q2. On MRI, which feature distinguishes DOMS from hamstring tear?

  • A) Diffuse T2 hyperintensity without fiber disruption

  • B) Hematoma with fluid-fluid level

  • C) Tendon discontinuity

  • D) Muscle retraction

Answer: A
Explanation: DOMS shows diffuse edema, whereas tears display focal disruption and hematoma.

Q3. What is the typical peak time of DOMS symptoms after exercise?

  • A) Immediately after exercise

  • B) 6–12 hours

  • C) 24 hours

  • D) 48–72 hours

Answer: D
Explanation: DOMS peaks between 48–72 hours post-exercise.

Q4. Which treatment is most evidence-based for symptomatic DOMS relief?

  • A) Long-term corticosteroids

  • B) Active recovery and cryotherapy

  • C) Prolonged immobilization

  • D) Immediate surgical intervention

Answer: B
Explanation: DOMS is self-limiting; active recovery and cryotherapy are standard.

Q5. Which epidemiologic group is most prone to DOMS?

  • A) Patients with systemic lupus erythematosus

  • B) Endurance runners

  • C) Individuals undergoing eccentric resistance training

  • D) Sedentary elderly individuals

Answer: C
Explanation: Eccentric exercises such as weight lowering or downhill running strongly induce DOMS.

References

[1] C. Proske and D. L. Morgan, "Muscle damage from eccentric exercise: mechanism, mechanical signs, adaptation and clinical applications," J. Physiol., vol. 537, no. 2, pp. 333–345, 2001.

[2] P. Cheung, F. Hume, and L. Maxwell, "Delayed onset muscle soreness: treatment strategies and performance factors," Sports Med., vol. 33, no. 2, pp. 145–164, 2003.

[3] R. B. Stauber, "Eccentric action of muscles: physiology, injury, and adaptation," Exerc. Sport Sci. Rev., vol. 14, pp. 137–168, 1986.

[4] K. Opar et al., "Hamstring strain injuries: factors that lead to injury and re-injury," Sports Med., vol. 42, no. 3, pp. 209–226, 2012.

[5] S. Paulsen, U. R. Mikkelsen, and T. Raastad, "Permeability of the muscle membrane after eccentric exercise: time course and effect of age," Scand. J. Med. Sci. Sports, vol. 22, no. 4, pp. 462–469, 2012.

[6] M. Leeder et al., "Cryotherapy for muscle recovery after exercise: a meta-analysis," Br. J. Sports Med., vol. 46, no. 4, pp. 233–240, 2012.

[7] M. Connolly, J. Sayers, and P. McHugh, "Treatment and prevention of delayed onset muscle soreness," J. Strength Cond. Res., vol. 17, no. 1, pp. 197–208, 2003.

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