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Muscle Cramps

Muscle cramps range in intensity from a slight twitch or tic to severe pain. A cramped muscle can feel rock-hard and last a few seconds to several minutes or longer. It is not uncommon for cramps to ease up and then return several times before they goes away entirely.

Causes The exact cause of muscle cramps is unknown, but many experts think it is related to poor flexibility, muscle fatigue or doing new activity. Other factors associated with muscle cramps include exercising in extreme heat, dehydration and electrolyte depletion. Cramps are more common during exercise in the heat because sweat contains fluids as well as electrolyte (salt, potassium, magnesium and calcium). When these nutrients fall to certain levels, the incidence of muscle spasms increases.

Athletes are more likely to get cramps in the preseason when the body is not conditioned and therefore more subject to fatigue. Cramps often develop near the end of intense or prolonged exercise, or the night after.

Treatment of Muscle Cramps

• Stop the activity that cause the cramp.
• Gently stretch and massage the cramping muscle. [LI} Hold the joint in a stretched position until the cramp stops.

Prevention of Muscle Cramps

• Improve fitness and avoid muscle fatigue
• Stretch regularly after exercise [LI} Warm up before exercise
• Stretch the calf muscle: In a standing lunge with both feet pointed forward, straighten the rear leg.
• Stretch the hamstring muscle: Sit with one leg folded in and the other straight out, foot upright and toes and ankle relaxed. Lean forward slightly, touch foot of straightened leg. (Repeat with opposite leg.)
• Stretch the Quadriceps muscle: While standing, hold top of foot with opposite hand and gently pull heel toward buttocks. (Repeat with opposite leg.)

Most muscle cramps are not serious. If your muscle cramps are severe, frequent, constant or of concern, see your doctor.

Muscle Cramps At A Glance

• A muscle cramp is an involuntarily and forcibly contracted muscle that does not relax.
• Almost everyone experiences a muscle cramp at some time in their life.
• There are a variety of types and causes of muscle cramps.
• Numerous medicines can cause muscle cramps.
• Most muscle cramps can be stopped if the muscle can be stretched.
• Muscle cramps can often be prevented.

What are muscle cramps?

When we use the muscles that can voluntarily be controlled, such as those of our arms and legs, they alternately contract and relax as we move our limbs. Muscles that support our head, neck, and trunk contract similarly in a synchronized fashion to maintain our posture. A muscle (or even a few fibers of a muscle) that involuntarily (without consciously willing it) contracts is called a "spasm." If the spasm is forceful and sustained, it becomes a cramp. A muscle cramp is thus defined as an involuntarily and forcibly contracted muscle that does not relax. This causes a visible or palpable hardening of the involved muscle.

Muscle cramps can last anywhere from a few seconds to a quarter of an hour or occasionally longer. It is not uncommon for a cramp to recur multiple times until it finally goes away. The cramp may involve a part of a muscle, the entire muscle, or several muscles that usually act together, such as those that flex adjacent fingers. Some cramps involve the simultaneous contraction of muscles that ordinarily move body parts in opposite directions.

Cramps are extremely common. Almost everyone (one estimate is about 95%) experiences a cramp at some time in their life. Cramps are common in adults and become increasingly frequent with aging. However, children also experience cramps.

Any of the muscles that are under our voluntary control (skeletal muscles) can cramp. Cramps of the extremities, especially the legs and feet, and most particularly the calf (the classic "charley horse"), are very common. Involuntary muscles of the various organs (uterus, blood vessel wall, intestinal tract, bile and urine passages, bronchial tree, etc.) are also subject to cramps. Cramps of the involuntary muscles will not be further considered in this review. This article focuses on cramps of skeletal muscle.

Cramps are sometimes noted in addicted individuals during withdrawal from medications and substances that have sedative effects, including alcohol, barbiturates and other sedatives, anti-anxiety agents such as benzodiazepines (for example, Valium and Xanax), narcotics, and other drugs.

What is the treatment of skeletal muscle cramps?

Most cramps can be stopped if the muscle can be stretched. For many cramps of the feet and legs, this stretching can often be accomplished by standing up and walking around. For a calf muscle cramp, the person can stand about two to two and a half feet from a wall (possibly farther for a tall person) and lean into the wall to place the forearms against the wall with the knees and back straight and the heels in contact with the floor. (Learn this maneuver at a time when you don't have the cramp!) Another technique involves flexing the ankle by pulling the toes up toward the head while still lying in bed with the leg as straight as possible. For writer's cramp (contractures in the hand), pressing the hand on a wall with the fingers facing down will stretch the cramping finger flexor muscles.

Gently massaging the muscle will often help it to relax, as will applying warmth from a heating pad or hot soak. If the cramp is associated with fluid loss, as is often the case with vigorous physical activity, fluid and electrolyte (especially sodium and potassium) replacement is essential. Medicines are not generally needed to treat an ordinary cramp that is active since most cramps subside spontaneously before enough medicine would be absorbed to even have an effect.

One enthusiastic nonscientific recommendation has been to firmly pinch the tissues above the lip, just under the nose, and hold the pinch until the cramp stops (said to be within 15 minutes.) Of course, why this might be effective is uncertain, and no scientific study of this technique has been reported.

In recent years, injections of therapeutic doses of botulism toxin (Botox) have been used successfully for some dystonic muscle disorders that are localized to a limited group of muscles. A good response may last several months or more, and the injection may then be repeated.

The treatment of cramps that are associated with specific medical conditions generally focuses on treating the underlying condition. Sometimes, additional medications specifically for cramps are prescribed with certain of these conditions.

Of course, if cramps are severe, frequent, persistent, respond poorly to simple treatments, or are not associated with an obvious cause, then the patient and the doctor need to consider the possibility that more intensive treatment is indicated or that the cramps are a manifestation of another disease. As alluded to above, the possibilities are extremely varied and include problems with circulation, nerves, metabolism, hormones, medications, and nutrition. It is uncommon for muscle cramps to occur as the result of a medical condition without other obvious signs that the medical condition is present.

Cramps are inevitable, but if possible, it would be best to prevent them.

Can vitamin deficiencies cause muscle cramps?

Several vitamin deficiency states may directly or indirectly lead to muscle cramps. These include deficiencies of thiamine (B1), pantothenic acid (B5), and pyridoxine (B6). The role of deficiency of these vitamins in causing cramps is unknown.

Can poor circulation cause muscle cramps?

Poor circulation to the legs, which results in inadequate oxygen to the muscle tissue, can cause severe pain in the muscle (sometimes known as claudication pain). This commonly occurs in the calf muscles. While the pain feels virtually identical to that of a severely cramped muscle, the pain does not seem to be a result of the actual muscle cramping. This pain may be due to accumulation of lactic acid and other chemicals in the muscle tissues. It's important to see your doctor if you have pain like this.

What are the symptoms of common muscle cramps? How are they diagnosed?

Characteristically, a cramp is painful, often severely so. Usually, the sufferer must stop whatever activity is under way and seek relief from the cramp; the person is unable to use the affected muscle while it is cramping. Severe cramps may be associated with soreness and swelling, which can occasionally persist up to several days after the cramp has subsided. At the time of cramping, the knotted muscle will bulge, feel very firm, and may be tender.

There are no special tests for cramps. Most people know what cramps are and when they have one. If present during a cramp, the doctor, or any other bystander, can feel the tense, firm bulge of the cramped muscle.

How can muscle cramps be prevented?

Activity: Authorities recommend stretching before and after cramps that are caused by vigorous physical activity, along with an adequate warm-up and cool down. Good hydration before, during, and after the activity is important, especially if the duration exceeds one hour, and replacement of lost electrolytes (especially sodium and potassium, which are major components of perspiration) can also be helpful. Excessive fatigue, especially in warm weather, should be avoided.

How much should I drink?

Hydration guidelines should be individualized for each person. The goal is to prevent excessive weight loss (>2% of body weight). You should weigh yourself before and after exercise to see how much fluid you lose through sweat. One liter of water weighs 2.25 pounds. Depending on the amount of exercise, temperature and humidity, body weight, and other factors, you can lose anywhere from approximately .4 to 1.8 liters per hour.

Pre-exercise hydration (if needed):

1. 0.5 liters per hour for a 180-pound person several hours (three to four hours) prior to exercise.

2. Consuming beverages with sodium and/or small amounts of salted snacks or sodium-containing foods at meals will help to stimulate thirst and retain the consumed fluids.

During exercise:

1. Suggested starting points for marathon runners is 0.4 to 0.8 liters per hour, but again, it should be individualized based on body weight loss.

2. There should be no more than 10% carbohydrate in the beverage, and 7% has generally been considered close to optimal. Carbohydrate consumption is generally recommended only after one hour of exertion.

3. Electrolyte repletion (sodium and potassium) can help sustain electrolyte balance during exercise. Particularly when


• there is inadequate access to meals or meals are not eaten,
• physical activity exceeds four hours in duration, or
• during the initial days of hot weather.

Under these conditions, adding modest amounts of salt (0.3 to 0.7 g/L) can offset salt loss in sweat and minimize medical events associated with electrolyte imbalances (for example, muscle cramps, hyponatremia).

Post-exercise:

1. Drink approximately 0.5 liters of water for every pound of body weight lost.
2. Consuming beverages and snacks with sodium will help expedite rapid and complete recovery by stimulating thirst and fluid retention.

Pregnancy: Supplemental calcium and magnesium have each been shown to help prevent cramps associated with pregnancy. An adequate intake of both of these minerals during pregnancy is important for this and other reasons, but supervision by a qualified health professional is essential.

Dystonic cramps: Cramps that are induced by repetitive nonvigorous activities can sometimes be prevented or minimized by careful attention to ergonomic factors such as wrist supports, avoiding high heels, adjusting chair position, activity breaks, and using comfortable positions and equipment while performing the activity. Learning to avoid excessive tension while executing problem activities can help. However, cramps can remain very troublesome for activities that are difficult to modify, such as playing a musical instrument.

Rest cramps: Night cramps and other rest cramps can often be prevented by regular stretching exercises, particularly if done before going to bed. Even the simple calf-stretching maneuver (described in the first paragraph of the section on treatment), if held for 10 to 15 seconds and repeated two or three times just before going to bed, can be a great help in preventing cramps. The maneuver can be repeated each time you get up to go to the bathroom during the night and also once or twice during the day. If nocturnal leg cramps are severe and recurrent, a foot board can be used to simulate walking even while recumbent and may prevent awkward positioning of the feet during sleep. Ask your doctor about this remedy.

Another important aspect of prevention of night cramps is adequate calcium and magnesium. Blood levels may not be sensitive enough to accurately reflect what is happening at the tissue surfaces where the hyperexcitability of the nerve occurs. Calcium intake of at least 1 gram daily is reasonable, and 1.5 grams may be appropriate, particularly for women with osteoporosis. An extra dose of calcium at bedtime may help prevent cramps.

Supplemental magnesium may be very beneficial for some, particularly if the person has a magnesium deficiency. However, added magnesium can be very hazardous for people who have difficulty eliminating magnesium, as happens with kidney insufficiency. The vigorous use of diuretics usually increases magnesium loss, and high levels of calcium intake (and therefore of calcium excretion) tend to increase magnesium excretion. Magnesium is present in many foods (greens, grains, meat and fish, bananas, apricots, nuts, and soybeans) and some laxatives and antacids, but a supplemental dose of 50 to 100 milligrams of magnesium daily may be appropriate. Splitting the dose and taking a portion several times during the day minimizes the tendency to diarrhea that magnesium can cause.

Vitamin E has also been said to help minimize cramp occurrence. Scientific studies documenting this effect are lacking, but anecdotal reports are common and sometimes quite enthusiastic. Since vitamin E is thought to have other beneficial health effects and is not toxic in usual doses, taking 400 units of vitamin E daily is approved, recognizing that documentation on its effect on cramps is lacking.

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