Accelerating recovery from delayed muscle soreness in Triathletes

by Elizabeth Kwon, SPT

The triathlon race is unique in that it combines running, swimming, and cycling requiring high amounts of endurance and strength. As the sport grows in popularity and relevance, studies have continued to ask how do best improve the performance of these athletes. Past studies have shown that exercise-induced muscle damage, which contributes to muscle soreness, is a key component in the performance of and level of muscle fatigue present in triathletes. Thus, the authors aimed to describe what is currently best-known regarding recovery from muscle soreness.

What is ‘muscle soreness’?

Delayed onset muscle soreness (DOMS), also known as exercise-induced muscle damage (EIMD), occurs when muscle fibers are overloaded during a workout thus resulting in damage to the muscle. This requires the muscle fibers to be restructured in order to be stronger, and it typically results in the feeling of soreness, stiffness, mild swelling, and less ability to generate maximum force beginning 6-12 hours after exercise that resolves within 2-3 days. Additionally, metabolic exhaustion, caused by electrolyte imbalances, dehydration, inflammation, and/or nutrition, can contribute to the severity of DOMS.

Treatments for DOMS:

Various treatments attempt to enhance recovery via several different methods including: preventing the breakdown of muscle fibers during exercise (prevent DOMS), decreasing inflammation, and/or improving recovery from DOMS.

  • Sleep
    • Increased quantity and quality of sleep is associated with better performance and less risk of injury
    • Long-term rest is more effective than short-term rest; it is better to get a good night’s sleep rather than taking power naps!
  • Compression Therapy
    • Post exercise compression therapy may speed up recovery from DOMS, particularly improvements in muscle stiffness
    • Compression therapy during exercise (intermittent) can neither be recommended or discouraged at this time; however, if an athlete feels it is beneficial to them, then it may have a positive impact.
  • Cold water immersion therapy (CWI)
    • CWI is able to enhance regeneration of the muscle fibers and is effective in reducing DOMS, especially up to 96 hours post exercise
    • It is recommended to use a water temp of 11-15 deg C for 11-15 min
  • Heat therapy
    • Evidence for heat therapy has mixed results so that heat can neither be recommended or discouraged. Post-exercise heat therapy may have a positive effect on regaining range of motion and improving muscle contraction and mass; however, heat pre-exercise may inhibit improvements in muscle mass.
    • Cold therapy is preferred for acute injuries and with inflammation, but for non-inflammatory conditions, heat can improve tissue healing.
  • Active regeneration
    • Low intensity training of 15 min of pedaling is recommended for after eccentric or high-intensity training for its potential short-term alleviation of DOMS pain, but there is limited evidence on its effectiveness
    • Stretching may be ineffective for reducing DOMS; however, there is limited data to form a conclusive decision
    • Foam rolling is effective in reducing pain with DOMS and may or may not be effective in improving performance with DOMS
  • Nutrition
    • Protein supplementation post-exercise is recommended to increase muscle regeneration
    • Branched-chain amino acids (BCAAs) are effective in improving immune response, stimulating muscle recovery, and decreasing some symptoms of DOMS.
      • A 2-3g leucine/isoleucine to 1 g valine amino acids is suggestive of best recovery
      • For masters athletes (> 40 yrs), high daily BCAAs supplementation of >200 mg/kg per day for at least 10 days may be most effective for better recovery
    • Omega 3-fatty acids can significantly reduce DOMS due to their anti-inflammatory effect and ability to reduce oxidative stress
      • It is recommended to take 1.8-3 g of omega 3-fatty acids after exercise

Overall, evidence is mixed on the efficacy of many of the treatments for DOMS and recovery can vary for each athlete depending on the individual’s body and type of sport. At Physical Therapy First, your physical therapist develops an individualized exercise plan for you that may result in DOMS and they can discuss with you the various methods for reducing post exercise muscle soreness. Talk to your physical therapist about if you are experiencing DOMS, what it means, and how you can reduce its effects; however, understand that DOMS is a normal and temporary condition that demonstrates that the muscles are getting stronger.


Hotfiel T, Mayer I, Huettel M, Hoppe MW, Engelhardt M, Lutter C, Pottgen K, Heiss R, Kastner T, Grim C. Accelerating recovery from exercise-induced muscle injuries in triathletes: considerations for Olympic distance races. Sports. 2019; 7 (143): 1-17.

Nutrition status is an indicator of outcomes after distal radius fracture

by Elizabeth Kwon, SPT

Among older adults, distal radius fractures (DRF) are a common injury usually sustained after falling on an outstretched hand. Past studies have shown that adults with low bone mineral density, associated with malnutrition, are at a higher risk for DRF, and likewise, those with a previous DRF are at a higher risk for subsequent falls. Thus, this retrospective cohort study attempts to bridge the relationship between nutritional status and outcomes after DRF in older adults.

  • The prevalence for malnutrition in the older adult population is generally between 13.5-17.9%
  • 229 participants were enrolled. Participants were 65+ years old who underwent surgical treatment and rehabilitation after a DRF, and they were placed into the malnutrition or nutrition group based upon their nutritional score on the Geriatric Nutritional Risk Index (GNRI)
    • 198 adults were placed in the normal nutrition group and 31 adults were placed in the malnutrition group
  • GNRI was calculated based on the level of serum albumin relative to each participant’s body weight.
  • Functional outcomes for performing and activities of daily living (ADL’s) and wrist function were measured using the Barthel Index (BI) and Mayo wrist score.
  • Those in the malnutrition group had a lower functional status (BI score), greater number of subsequent falls, and greater degree of post-surgical complications compared to the normal group at 1 year follow-up.
  • Nutritional status (GNRI) was significantly correlated to the number of subsequent falls and level of functional gains made (BI efficacy), and serum albumin levels additionally have the ability to determine the probability of subsequent falls.
  • No relationship was significantly found relating to wrist function (Mayo wrist score)
  • Bone mineral density was not significantly correlated to any of the outcome measures; however, researchers hypothesize that this may be due to the high proportion of participants who were taking medication to address decreased BMD prior to this study.

From this study, we can conclude that nutritional status, as determined by serum albumin levels, plays a role in the functional outcomes and risk of subsequent falls for older adults who have sustained a distal radius fracture. Serum albumin is important in maintaining muscle synthesis and skeletal muscle mass, and researchers hypothesize that the effects of low albumin levels lead to decreased balance and walking ability thus resulting in greater risk for falls. At Physical Therapy First, your physical therapist can discuss ways to incorporate nutrition and create an individualized falls avoidance program to initiate a safe exercise plan that can improve your balance, improve your walking ability, and increase your strength.

Nagai T, Tanimoto K, Tomizuka Y, Uei H, Nagoaka M. Nutrition status and functional prognosis among elderly patients with distal radius fracture: a retrospective cohort study. Journal of Orthopaedic Surgery and Research 2020; 15(133): 1-7.

Adipose-Derived Mesenchymal Stem Cell treatment for moderate knee OA

By Elizabeth Kwon, SPT

Mesenchymal stem cells (MSCs) are a prospective intervention for treating osteoarthritis for the potential of cartilage tissue repair and regenerative ability. MSC therapies primarily work by reducing inflammatory cell properties, expressing anti-inflammatory cell signals, and increasing the activity of cartilage-producing cells. In this randomized controlled trial of 30 participants, researchers specifically aimed to determine if adipose-derived mesenchymal stem cell (ADMSC) therapy was a safe and effective intervention for decreasing pain, improving function, and modifying the progression of disease in patients with moderate knee OA.

  • Patients were randomly allocated into either a single or double injection treatment group or a control group. Injections were given at baseline and at 6 months for the two-injection group. The control group underwent conservative management, including analgesics, weight management, and exercise.
  • Patients were on average in their early to mid 50’s, had moderate (grade II-III) knee OA in one leg.
  • Outcome measurements were recorded at 1, 3, 6 and 12 months follow-up using the Numeric Pain Rating Scale (NPRS), Knee Injury and Osteoarthritis Outcome Measures Scale (KOOS), Western Ontario and McMaster Universities Arthritis Index (WOMAC), MRI, and the MRI Osteoarthritis Knee Score (MOAKS).
  • The effectiveness of ADMSC treatment on pain and function
    • Both single and double injection groups had significantly improved pain scores on the NPRS and KOOS subscales compared to conservative management at 12 months
    • Both single and double injection groups had significantly improved function on the WOMAC and KOOS subscales compared to conservative management at 12 months
    • Comparing single and double injection groups, neither had a more significant effect than the other for pain and function, but the single injection group generally also had significant improvements over the control group at 3 and 6 months.
  • Minimal clinically important differences at 12-month follow-up were achieved on average in 84.1% of subjects in the single injection group, 87.1% in the double injection group, and 25.7% in the control group
  • The effectiveness of ADMSC treatment on disease progression at 12-month follow-up
    • The two-injection group had the greatest improvements in cartilage or the prevention of progressive of cartilage loss (89%) as well as prevention of osteophyte formation (89%) suggesting it may assist with the stabilization of knee OA
    • In comparison, the single-injection group was able to improve or prevent degradation of cartilage in 70% of subjects; however, 50% of subjects experienced a progression of osteophyte formation.
  • Limitations of the study include:
    • sample size may or may not have been sufficient
    • starting BMI between the three groups were significantly different potentially affecting the results
    • some subjects experienced pain and swelling after the second injection at 6 months potentially altering results of the two-injection group

In conclusion, ADMSC is a promising treatment for osteoarthritis that is being currently researched. This study demonstrates that ADMSC is safe and effective at reducing pain, improving function, and moderating disease progression for those with moderate knee OA. Differences between the effectiveness of one versus two injections can be debated as the one-injection group experienced more significant changes at 3 and 6 months, but the two-injection group saw a greater number of subjects with minimal clinically important difference and stabilization of OA. At Physical Therapy First, your physical therapist can discuss MSC and other alternative treatments for your knee osteoarthritis to determine if you are a potential candidate to benefit from ADMSC, as well as provide you with other conservative rehabilitative interventions.

Freitag, Julien. Bates, Dan. Wickham, James. Shah, Kiran. Huguenin, Leesa, Tenen, Abi. Paterson, Kade. Boyd, Richard. Adipose-derive mesenchymal stem cell therapy in the treatment of knee osteoarthritis: a randomized controlled trial. Regenerative Medicine 2019; 14 (3), 213-230.


Vitamin D deficiency adversely affects early post operative functional outcomes after total knee arthroplasty

by Sarah Voelkel Feierstein PT, DPT, OCS, CMPT


There is increasing evidence of the importance of adequate Vitamin D levels on muscle function and performance. Vitamin D is essential for calcium homeostasis and bone turnover which are essential following orthopedic surgeries. Total knee arthroplasties (TKAs) are a type of orthopedic surgery utilized for pain relief and improving quality of life in patients with end stage knee osteoarthritis (OA). The role of Vitamin D and its influence on functional recovery following TKA is not clearly established. The authors of the article, Vitamin D deficiency adversely affects early post‑operative functional outcomes after total knee arthroplasty, observed the effect of Vitamin D deficiency on post-operative functional outcomes following TKA.

Materials and Methods:

Ninety-two patients with a diagnosis of primary knee OA and scheduled for a unilateral TKA were included in the study. Patients were excluded if they had taken Vitamin D supplementation or had other comorbidities. Blood serum Vitamin D levels were obtained and the participants were divided into two categories: Vitamin D deficient (<12 ng/mL) and Vitamin D sufficient (>12ng/mL).

Following the surgeries, patients were scored on the American Knee Society Score (KSS) and four performance tests which included the alternative step test (AST), six-meter walk test (SMT), sit to stand test (STS) and timed up and go test (TUGT). Patients performed these tests one day before and three months after their TKA.

  • KSS: The KSS includes both a clinical and a functional portion. The clinical KSS includes pain, stability, and range of motion as the main parameters with deductions for flexion contractures, extension lag, and malalignment. The functional KSS includes walking distance and stair climbing with deductions for the use of a walking aid.
  • AST: This test is performed by alternatively placing the entire right and left foot as fast as possible on a step.
  • SMT: This test measures walking speed along a six-meter course.
  • STS: The number of times a participant can perform a sit to stand transfer with arms folded in thirty seconds is recorded.
  • TUGT: The participant is timed from rising from a chair wand walking around a cone 3 meters distance and returning to the chair.


There were no differences in the study population with respect to demographic data and clinical characteristics such as age, gender, BMI, and side of the surgery. There were no differences between groups in terms of post-operative clinical KSS. The man post-operative functional KSS was significantly lesser in the Vitamin D deficient group versus the non-deficient group. Additionally, the mean value times for the post-operative AST and SMT wee significantly longer in the Vitamin-D deficient group than in the non-deficient group. Both the STS and TUGT demonstrated high values for mean time taken in the Vitamin D deficient group but they were not statistically significant.


The most important finding of the present study was that early post-operative outcomes following TKA were affected by patients’ preoperative vitamin D status, and those in the vitamin D-deficient group had significantly poorer post-operative outcomes. Recent evidence suggests that Vitamin D deficiency associated with the development and progression of OA, though the underlying pathophysiology is unclear. There is also increasing evidence on the important role played by vitamin D in skeletal muscle pathology and supplementation of Vitamin D increase diameter of muscles. Because TKA results in substantial injury to the extensor mechanism of the knee, it is pertinent to evaluate the association between Vitamin D levels and functional recovery following TKA. Since vitamin D deficiency can usually be corrected by 6 weeks of oral supplementation, preoperative vitamin D supplementation may be considered for patients with deficiencies.

Conclusion and Clinical Implications:  

In the current study, early post-operative functional outcomes following TKA appear to be adversely affected by vitamin D deficiency. Surgeons should confirm vitamin D levels before performing a TKA and consider preoperative supplementation if necessary. As therapists, we many patients prior to their TKA surgeries and it is important to discuss this evidence with patients to determine whether supplementation is indicated due to the correlation between Vitamin D sufficiency and improved clinical outcomes post-operatively.


Shin, K-Y., Park, K., Moon, S-H., Yang, I., Choi, H., Lee, W (2017). Vitamin D deficiency adversely affects early post‑operative functional outcomes after total knee arthroplasty. European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA), Vol 25:3424-3430.

Physical Therapy Examination for the Diagnosis of Cervicogenic Headaches

By Stephanie Beatty, SPT

What is a cervicogenic headache?

  • At some point in their lives, ~96% of people will experience headaches. The cause of headaches may be unknown, due to another condition, or due to referred pain from an adjacent area of the body such as the ears, neck, or facial structures including the mouth and nose. A cervicogenic headache is a headache that results from a musculoskeletal impairment in the upper part of the neck, known as the upper cervical spine. Cervicogenic headaches stem from a dysfunction in the complex nervous system connections between the trigeminal nerve (a nerve the originates in the region between the spinal cord and the brain) and the nerves of the upper cervical spine. This dysfunction causes neck pain to refer to different areas of the head, resulting in a headache. People will often experience referred pain around one or both eyes as well.

How are cervicogenic headaches diagnosed?

  • Cervicogenic headaches are typically diagnosed through a subjective examination, also known as a patient interview, and an objective examination during which a physical therapist examines the cervical spine and uses tests and measures to determine the cause of the patient’s headaches. According to a systematic review by Rubio-Ochoa et al., a physical examination of the cervical spine for a patient presenting with cervicogenic headaches should consist of sensitive tests such as accessory motion testing (PAIVMs) of the joints of the upper cervical spine as well as specific tests such as the cervical flexion-rotation test. During this test, the therapist will bend your head forward and rotate it side to side while monitoring any changes in your symptoms. The use of these tests assists the therapist in accurately diagnosing cervicogenic headaches and can guide treatment planning. Cervicogenic headaches have been shown to respond well to physical therapy intervention, so an accurate diagnosis is essential.

How can Physical Therapy First help with cervicogenic headaches?

  • Here at Physical Therapy First, we will evaluate you to determine the cause of your headaches and the best approach to treating them. Your initial examination will begin with a subjective interview during which the physical therapist asks questions about your headaches, any neck pain, and other pertinent medical history. The physical therapist will then conduct a physical examination that includes evidence-based tests and measures such as the ones mentioned above. The physical therapist will then develop a comprehensive, individualized treatment plan consisting of exercises and manual therapy to help alleviate your cervicogenic headaches and other symptoms.


Rubio-Ochoa J, et al., Physical examination tests for screening and diagnosis of cervicogenic headache: A systematic review, Manual Therapy (2015),



FOOD FOR THOUGHT: Role of Nutrition Supplements on the Recovery from Total Hip Replacement and Total Knee Replacement Surgeries

by  Tyler Tice PT, DPT, ATC

Nutrition is a major part of health and nutritional habits can influence outcomes for people after surgery, especially in older adults. Two of the more popular orthopedic surgeries that older adults receive are hip replacements and knee replacements. These are major surgeries that create a stressful stimulus to our bodies which result in an increased inflammatory response and impairs our immune system due to metabolic changes. It is known that it is always good to optimize nutrition, especially prior to surgery. There are multiple supplements available as well that can stimulate our body’s metabolic response with the potential to speed up recovery.

In an article titled: What Is the Role of Nutritional Supplements in Support of Total Hip Replacement and Total Knee Replacement Surgeries? A Systematic Review; the authors analyzed nine research studies to determine the effectiveness of nutritional supplements specifically on the recovery after hip and knee replacement surgeries.

After review, there were three types of supplements studied including carbohydrate drink supplements prior to surgery, amino acid supplements prior to surgery, and Beta-Hydroxy Beta-Methylbutyrate, L-Arginine, and L-Glutamine (HMB/Arg/Gln) supplements, as well as other conclusions the authors have made from the available research.

  • Carbohydrate Drinks Before Hip and Knee Replacement Surgery :
    • evidence is limited
    • may increase insulin-like growth factor 1 (IGF-1) levels which can be beneficial in reversing the metabolism changes that occur after the stress induced from surgery.
    • may reduce hunger, nausea, and help regulate insulin growth sensitivity.
    • One pilot study found that patients who took multiple nutritional interventions, one being a carbohydrate drink prior to surgery, had shorter hospital stays and decreased inflammation after hip replacement surgery.
    • No conclusive evidence for benefits; HOWEVER low risk and high potential benefits which may be most beneficial for those who are frail or with multiple co-morbidities
  • Amino Acids
    • Some evidence to suggest decreased muscle atrophy (muscle loss) after surgery and better performance on functional tests at 2 weeks and 6 weeks post surgery
  • Beta-Hydroxy Beta-Methylbutyrate, L-Arginine, and L-Glutamine (HMB/Arg/Gln)
    • HMB is reported to promote muscle protein synthesis and suppress muscle protein breakdown
    • Some evidence to suggest decreased muscle loss in quad muscle from 0-14 days post surgery
    • Might lead to early improvements in physical function and fall prevention
  • Additional Findings
    • Consumption of protein is vital for stimulating muscle protein synthesis and can have greater impacts in frail or malnourished individuals.
    • Pre-operative period is the most effective intervention time
    • future work needs to be done in researching nutritional influence on muscle inflammation susceptibility using antioxidant ingredients or polyunsaturated fatty acids
  • Study Limitations:
    • Limited amount of data
    • Small sample size in most research articles
    • 2 pilot studies were used

Nutritional therapy is most beneficial to support individuals with a high risk of developing post-operative complications or are sarcopenic, frail, malnourished/undernourished and have a limited protein reserve. There are multiple factors that go into recovery from joint replacement surgery and nutritional supplements can be one of these important factors. It is supported that a combination of physical, nutritional, and psychological pre-operative preparation all have positive impacts on the recovery from surgery.

For more information on this topic and for more details regarding the research that was reviewed, please see the article referenced below. It is important for each person to understand the multiple factors that go into recovery from joint replacement surgery and to know that each person’s recovery is unique. At Physical Therapy First, we want to help make your recovery as smooth as possible. We understand that each person’s recovery is unique, that’s why we spend a full hour with each of our patients and provide each person with a rehabilitative routine that is specific for them. Check out our website and give us a call to schedule an appointment with us!


Burgess, L., Phillips, S. and Wainwright, T., 2018. What Is the Role of Nutritional Supplements in Support of Total Hip Replacement and Total Knee Replacement Surgeries? A Systematic Review. Nutrients, 10(7), p.820


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