Muscle cramps are very common and 'cramp' is usually taken to mean 'a spasmodic, painful, involuntary contraction of skeletal muscle'. This transient, involuntary episode of pain is usually brief (<10 minutes). The lower limbs are almost invariably involved. However, no single accepted definition of muscle cramp exists and many classifications of muscular cramps have been attempted.
There are many causes. Cramps can be grouped according to their underlying aetiology:
- Paraphysiological cramps
- Symptomatic cramps
- Idiopathic cramps
When patients complain of cramps it is important to clarify exactly what they mean, as the term is frequently used to describe any muscular 'tightness'.
Groups at increased risk:
- Up to 60% of adults report that they have had nocturnal leg cramps.
- The problem is often distressing, impacting on sleep, and has an adverse effect on quality of life.
- Pregnant women - up to 30% of women can be affected by leg cramps during pregnancy.
- Muscle cramps are common in children, especially at night.
- Those with metabolic disorders; for example, 50% of patients with uraemia and 20-50% of those with hypothyroidism complain of muscle cramps.
- Athletes and individuals working under hot conditions - eg, firemen.
Find out what the patient means by cramps:
- Where do they occur?
- When do they occur?
- How often do they occur?
- How long do they last?
- Is there any other relevant medical history such as thyroid disease or cardiovascular disease?
- Are drugs taken? For example, diuretics, salbutamol, nifedipine.
- What is their alcohol consumption?
- Do they undertake any sporting activities?
Most often, cramps involve the calf or thigh muscles and small muscles of the foot. Of these, the most commonly affected is the calf and it tends to be unilateral.
Cramps occur at rest and usually at night. The most likely explanation is that leg cramps occur when a muscle that is already in a shortened position is involuntarily stimulated. This commonly happens at night where the plantar flexed foot places the calf and ventral foot muscles in the most shortened and vulnerable position. The cramp may last seconds or minutes but post-cramp tenderness may last up to 24 hours.
- During an attack the affected muscle or group is hard and tender.
- Between attacks examination is unlikely to be rewarding.
- The muscle may be tender for up to 24 hours after the previous attack.
- In the elderly or where peripheral arterial disease is suspected, check for peripheral pulses and capillary refill.
- Look for signs of neurological disease - eg, muscle wasting and fasciculations, altered reflexes, sensory or power loss.
- Paraphysiological cramps occur in healthy people in response to a physiological stimulus. They are very common and may occur during sport or in unaccustomed exercise. They are especially likely to occur during endurance sports.
- They are thought to result from hydro-electrolyte imbalance following repeated and chronic use of the same muscle group, producing increased excitation of the neuromuscular nerve endings.
- It is thought that low levels of magnesium and other electrolytes may also play a part.
- They are also very common in pregnancy. The aetiology in pregnancy is unknown: pressure on nerves and blood vessels, circulatory changes and low levels of calcium and magnesium have all been suggested.
- They may also occur in healthy individuals as a result of a sustained posture over a prolonged period of time.
Cramps may also occur in association with metabolic disturbance, including:
One or more of these may be the underlying aetiology in many of the causes listed below. Blood tests measure the extracellular environment but do not reflect the intracellular fluid which is probably more important.
- Arterial insufficiency.
- Acute or chronic diarrhoea.
- Excessive heat and sweating causing Na+ depletion.
- Hypothyroidism (associated with weakness, enlarged muscles and painful muscle spasms).
- Hyperthyroidism (associated with myopathy).
- Lead poisoning.
- Hyperparathyroidism (hypercalcaemia).
- Heavy alcohol ingestion and cirrhosis.
- Hyperventilation-induced respiratory alkalosis.
- Parenteral nutrition.
- Lower motor neurone disorders including amyotrophic lateral sclerosis, polyneuropathies, recovered poliomyelitis, peripheral nerve injury and nerve root compression.
Drugs causing crampsAlways exclude a medicine-related cause. Implicated drugs include:
- Salbutamol and terbutaline
- Opiate withdrawal
- Diuretics cause electrolyte loss
- Nicotinic acid
This is a diagnosis of exclusion but represents the majority of those experiencing the condition. Familial forms exist which appear to have an autosomal dominant mode of transmission.This group also contains conditions such as idiopathic nocturnal cramps and fasciculation-cramp syndrome.
- Restless legs (Ekbom's syndrome).
- Intermittent claudication and ischaemic rest pain.
- Muscle injury or strain.
- Hypnagogic muscle jerking (when falling asleep).
- Lumbar nerve root entrapment.
- Ruptured Baker's cyst.
- Deep vein thrombosis or thrombophlebitis.
- Peripheral neuropathy.
- Occupational cramps - eg, writer's cramp or musician's cramp (focal dystonias, usually affecting the upper limb).
- Causes of generalised muscle pain - eg, polymyositis, toxoplasmosis, alcohol-related myopathy, Guillain-Barré syndrome, polymyalgia rheumatica, Parkinsonism, fibromyalgia.
Usually no investigation is indicated. They may be performed if an underlying cause is suspected.
Potential investigations include:
- Serum calcium or magnesium
- Creatine kinase
- Lead levels
Limited evidence supports treating nocturnal leg cramps with exercise and stretching, or with medications such as magnesium, calcium-channel blockers, vitamin B or vitamin C. Quinine is no longer recommended to treat leg cramps.
- In most cases the aetiology is benign and the patient needs to be reassured of this whilst steps are taken to help alleviate the problem. Exclude known causes of muscle cramps without excessive and unnecessary investigation.
- Management depends upon the cause of the problem. Review drugs. Address any correctable problems - eg, use of diuretics and electrolyte imbalance.
- The severity of symptoms and their impact on sleep, mood and quality of life will determine whether treatment is required. Asking patients to keep a sleep and cramp diary may be helpful to assess progress.
- The evidence base for management of this common but usually benign condition is not strong.
There is only limited evidence for the use of non-drug therapies for the treatment of lower-limb muscle cramps.
- Passive stretching and massage of the affected muscle. This will help ease the pain of an acute attack - eg, for calf cramping, straighten the leg with dorsiflexion of the ankle or heel walk until the acute pain resolves.
- Regular stretching of the calf muscles throughout the day. This may help to prevent acute attacks. Some people recommend stretching three times daily whilst others advocate stretching before going to bed.
- Using a pillow to raise the feet through the night or raising the foot of the bed. This may help to prevent attacks in some people.
Note that whilst stretching exercises are unlikely to do harm, evidence for their efficacy is contradictory. In sport, stretching is widely advocated as likely to reduce injury and cramp but the quality of evidence tends to be poor, with failure to distinguish benefit from that due to improvement in physical fitness from training.Avoiding over-training and risky conditions (eg, hot and humid environmental conditions) can be useful in preventing cramps.
The value of massage, over and above psychological benefit, is also questioned.
- Quinine sulfate has been the most frequently used drug in the UK for the treatment of leg cramps in non-pregnant individuals who have not responded to conservative measures.
- However, it is not generally recommended due to the poor benefit-to-risk ratio. The Food and Drug Administration (FDA) in America has banned the use of quinine for this indication.
- Quinine has an extensive side-effect profile, including thrombocytopenia as an important but rare complication. Evidence for its long-term efficacy is lacking.
- However, a Cochrane review found that there was moderate evidence that quinine significantly reduces cramp frequency, intensity and cramp days in dosages between 200 mg and 500 mg/day. There was moderate evidence that with use up to 60 days, the incidence of serious adverse events was not significantly greater than for placebo in the identified trials.
- A therapeutic trial approach may be used where self-care measures fail and leg cramps are frequent and affecting the person's quality of life:[3, 12]
- Prescribe 200-300 mg nocte for 4-6 weeks.
- Monitor using a sleep and cramp diary.
- If helpful, continue treatment for three months; then stop to reassess ongoing need.
- If ongoing treatment is required, regular medication reviews should occur every 3-6 months.
- Quinine can frequently be stopped without a recurrence of troublesome symptoms.
- Potential drug alternatives to quinine include verapamil and gabapentin in the general population and vitamin E or L-carnitine in the dialysis population.
- There is no evidence that magnesium supplementation is effective prophylaxis for older adults experiencing skeletal muscle cramps.
- Avoid quinine in pregnancy and concentrate on non-drug measures where possible. The evidence is unclear as to whether oral magnesium, oral calcium, oral vitamin B or oral vitamin C do provide effective treatment for leg cramps in pregnancy.
Further reading and references
Allen RE, Kirby KA; Nocturnal leg cramps. Am Fam Physician. 2012 Aug 1586(4):350-5.
Hensley JG; Leg cramps and restless legs syndrome during pregnancy. J Midwifery Womens Health. 2009 May-Jun54(3):211-8. doi: 10.1016/j.jmwh.2009.01.003.
Leg cramps; NICE CKS, September 2012 (UK access only)
Parisi L, Pierelli F, Amabile G, et al; Muscular cramps: proposals for a new classification. Acta Neurol Scand. 2003 Mar107(3):176-86.
Muscle Cramps, Familial; Online Mendelian Inheritance in Man (OMIM)
Butler JV, Mulkerrin EC, O'Keeffe ST; Nocturnal leg cramps in older people. (Review) Postgraduate Medical Journal 2002
Blyton F, Chuter V, Walter KE, et al; Non-drug therapies for lower limb muscle cramps. Cochrane Database Syst Rev. 2012 Jan 181:CD008496. doi: 10.1002/14651858.CD008496.pub2.
Ingraham SJ; The role of flexibility in injury prevention and athletic performance: have we stretched the truth? Minn Med. 2003 May86(5):58-61.
Schwellnus MP, Drew N, Collins M; Muscle cramping in athletes--risk factors, clinical assessment, and management. Clin Sports Med. 2008 Jan27(1):183-94, ix-x.
Weerapong P, Hume PA, Kolt GS; The mechanisms of massage and effects on performance, muscle recovery and injury prevention. Sports Med. 200535(3):235-56.
El-Tawil S, Al Musa T, Valli H, et al; Quinine for muscle cramps. Cochrane Database Syst Rev. 2015 Apr 54:CD005044. doi: 10.1002/14651858.CD005044.pub3.
Woodfield R, Goodyear-Smith F, Arroll B; N-of-1 trials of quinine efficacy in skeletal muscle cramps of the leg. Br J Gen Pract. 2005 Mar55(512):181-5.
Coppin RJ, Wicke DM, Little PS; Managing nocturnal leg cramps--calf-stretching exercises and cessation of quinine treatment: a factorial randomised controlled trial. Br J Gen Pract. 2005 Mar55(512):186-91.
Guay DR; Are there alternatives to the use of quinine to treat nocturnal leg cramps? Consult Pharm. 2008 Feb23(2):141-56.
Garrison SR, Allan GM, Sekhon RK, et al; Magnesium for skeletal muscle cramps. Cochrane Database Syst Rev. 2012 Sep 129:CD009402. doi: 10.1002/14651858.CD009402.pub2.
Zhou K, West HM, Zhang J, et al; Interventions for leg cramps in pregnancy. Cochrane Database Syst Rev. 2015 Aug 118:CD010655. doi: 10.1002/14651858.CD010655.pub2.