Cramp

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Co-Editor-In-Chief: Elliot B. Tapper, M.D., Department of Medicine, Beth Israel Deaconess Medical Center; Co-Editor-In-Chief: C. Michael Gibson, M.S., M.D.

Overview

Cramps are unpleasant, often painful, sensations caused by contraction or over shortening of muscles. Cramps have many causes - from overexertion to imbalances of electrolytes (e.g. calcium)or more complex conditions. They can be fleeting or disabling. Cramps can occur in virtually any muscle-bound organ. This is a broad overview of all muscular cramps.

Classification

Nocturnal Leg Cramps

Nocturnal leg cramps are involuntary, often very painful muscle contractions that occur in the calves, soles of the feet, or other muscles in the body during the night or (less commonly) while resting. The duration of nocturnal leg cramps is highly variable with cramps sometimes only lasting a few seconds and other times several minutes. Soreness in the muscles may remain for some time after the cramp ends. These leg cramps are a common occurrence in late-term pregnancy and frequently afflict patients cirrhosis and those on dialysis. Most cramps, however, occur outside the context of systemic disease. These cramps are more common in older people but may happen to anyone. In population studies in the Netherlands and Sweden, 36% of all adults reported one or more disabling cramps per year and 2% report weekly cramps. As many as 50-60% of Americans over the age of 65 complain of more than one disabling muscle cramp per week.

The precise cause of these cramps is unclear. Potential contributing factors are believed to include dehydration, low levels of certain minerals (magnesium, potassium, calcium, and sodium), and the reduced blood flow through the muscles attendant in prolonged sitting or lying down. An important cause specific to nocturnal leg cramps is iron deficiency. Through an unknown mechanism, low levels of iron can result in occasional or disabling cramps. It can often manifest as the so-called Restless Legs Syndrome of irresistible nocturnal movement impulses that resolve with standing or walking around. Anyone seeking evaluation for cramps or restless legs should have their hemoglobin or iron levels checked as iron repletion will improve and, often, stop the cramps altogether. There is no role, however, for iron supplementation in patients with a normal ferritin level.

The treatment of cramps can be difficult; there is very sparse data in the literature guiding treatment decisions. The medication with the best data support its use is Quinine, whose effects have been known since the 1940's and are both significant and long lasting. However, Quinine is exceptionally toxic, famously causing Thrombotic Thrombocytopoenic Purpura (TTP), and has been pulled off of the market for this indication.

There are some measures which have been studied and found to be ineffective: stretching, magnesium, vitamin E and gabapentin have all been evaluated with no benefit. Some measures are used by clinicians, but have never been formally evaluated by trial: baclofen, carbamazepine, and oxcarbazepine. Finally, there are a few medications that have proven benefit with small trial data: injected lidocaine (however impractical), vitamin B6, verapamil and diltiazem.

Smooth Muscle Cramps

Smooth muscle contractions lie at the heart of the cramping (or colicky) pain of internal organs. These include the intestine, uterus, ureter (in kidney stone pain), and various others.

Menstrual Cramps

Main article: Dysmenorrhea

Menstruation is also highly likely to cause cramps of varying severity in the abdomen that may radiate to the lower back and thighs. Menstrual cramps can be treated with ibuprofen, acetaminophen or paracetamol, stretching exercises, or the application of heat through such means as warm baths or heating pads. Menstrual cramps that do not respond to self-treatment can be a symptom of endometriosis or other health problems.

Skeletal Muscle Cramps

Skeletal muscles are muscles that can be voluntarily controlled. Of the skeletal muscles, those which cramp the most often are the calves, thighs, and arches of the foot. These cramps are seemingly associated with strenuous activity and can be intensely painful.

Self Induced Cramp

Self-induced cramp is brought on purposefully by individuals for the purpose of stretching muscle in a position where standing or greater movement is difficult or impossible. For instance, certain workers or craftsmen may find inducing cramp in the lower legs enables them to stretch desirable muscle groups without the need to physically stand in tight spaces.

Iatrogenic Causes

Statins are known to cause myalgia and cramps among other side effects. Additional factors increasing probability for this adverse side effects are physical exercise, age, female gender, history of cramps and hypothyroidism. Up to 80% of athletes using statins suffer significant muscular adverse effects including cramps , the rate appears to be approximately 10-25% in typical population using statins . In some cases this adverse effects will disappear after switching to a different statin, however they should not be ignored if they persist as they can rarely develop into a more serious problem. Coenzyme Q10 supplementation can be helpful to avoid some statin related adverse effects but currently there is not enough evidence to prove effectiveness in avoiding myopathy or myalgia .

Causes

There are numerous causes of cramping: hyperflexion; inadequate oxygenation; exposure to large changes in temperature; dehydration; low blood salt; or low blood calcium. Muscle cramps may also be a symptom/complication of pregnancy, kidney disease, thyroid disease, severe hypokalemia or hypocalcemia, restless legs syndrome, and neurologic disorders like multiple sclerosis or ALS. Cramps can also occur 'idiopathically' with no apparent cause.

Electrolyte disturbance may cause cramping and tetany of muscles, particularly critical hypokalaemia (a low level of potassium) and hypocalcaemia (a low level of calcium). This disturbance arises as the body loses large amounts of interstitial fluid through sweat. This interstitial fluid is composed mostly of water and table salt (NaCl). The loss of osmotically active particles outside muscle cells(NaCl) leads to a disturbance of the osmotic balance and swelling of muscle cells as these contain more osmotically active particles. This causes the calcium pump between the muscle lumen and sarcoplasmic reticulum to short circuit and the calcium ions remain bound to the tropomyosin and the muscle contraction is continued. This may occur when the lactic acid is high in the cells.

Causes by Organ System

Cardiovascular	Arterial insufficiency, Deep Venous Thrombosis, Peripheral arterial disease, Systemic capillary leak syndrome, Varicose veins, Venous insufficiency
Chemical / poisoning	Arachnidism, Carbon monoxide intoxication, Clupeotoxin, Dry cell battery poisoning, Tacrine, Tin poisoning
Dermatologic	No underlying causes
Drug Side Effect	Amlodipine, Amphetamine , Amphetamine abuse, Angiotensin II receptor antagonists, Bendrofluazide, Benzodiazepines, Bumetanide, Cidofovir, Cimetidine, Cisplatin, Clofibrate, Cocaine, Donepezil, Frusemide, Hydrochlorothiazide, Lactulose, Lenalidomide, Lisinopril and Hydrochlorothiazide, Misoprostol, Neostigmine, Niacin, Nifedipine, Nitrendipine, Opium withdrawl, Oral contraceptives, Paratide, Pyrazinamide, Pyridostigmine, Progesterone, Raloxifene, Reproterol, Salbutamol, Statins, Spironolactone,Teriparatide, Tolcapone, Vincristine
Ear Nose Throat	No underlying causes
Endocrine	Conn's syndrome, Diabetes Mellitus, Hashimoto's Thyroiditis, Hyperinsulinemia, Hyperthyroidism, Hypoparathyroidism, Hypoparathyroidism, Hypopituitarism, Hypothyroidism, Insulin-resistance syndrome
Environmental	No underlying causes
Gastroenterologic	Celiac disease, Diverticular Disease , Diverticulitis, Early bowel obstruction, Intestinal obstruction, Malabsorption, Nonalcoholic cirrhosis, Severe diarrhea, Small bowel bacterial overgrowth syndrome , Ulcerative colitis
Genetic	Acanthosis nigricans - Insulin resistance - muscle cramps - acral enlargement, Adenosine Monophosphate Deaminase Deficiency type 1, Autosomal dominant familial hematuria - retinal arteriolar tortuosity - contractures, Bartter's syndrome, Distal hereditary motor neuropathy, Ehlers-Danlos Syndrome, Familial Limb-Girdle Myasthenic Syndrome With Tubular Aggregates, Genetic recurrent myoglobinuria, Gitelman syndrome, Hereditary spastic paraplegia, Hypokalemic periodic paralysis, Lactate dehydrogenase deficiency, Limb-girdle muscular dystrophy, Phosphogylcerate mutase 2 deficiency, Rippling muscle disease , Sarcoglycanopathy , Torsion dystonia , Young Simpson syndrome , Zadik–Barak–Levin syndrome
Hematologic	Anemia
Iatrogenic	Bariatric surgery, Blind loop syndrome, Dialysis, Short bowel syndrome,Hyperinsulinemia
Infectious Disease	Amoebiasis, BrucellosisCoxsackie B virus, Cryptosporiosis, Cyclosporiasis, Influenza, Leptospirosis, Malaria, Salmonellosis, Shigellosis, Staphylococcus aureus food poisoning, Tetanus, Toxoplasmosis, Trichinosis
Musculoskeletal / Ortho	Adult progressive spinal muscular atrophy, Aran Duchenne type, Flat feet, Genu recurvatum, Gonarthrosis , Hypermobility syndrome, Isaacs syndrome, Kashin-Beck disease, Lipid storage myopathy, Mitochondrial myopathies, Muscle overstrain , Muscle phosphoglycerate mutase deficiency, Muscular phosphorylase kinase deficiency, Myokymia, Myopathies, Rickets, Structural disorders of the foot, Tubular aggregate myopathy, Limb-girdle muscular dystrophy, Lipid storage myopathy , Fibromyalgia
Neurologic	Alcoholic Neuropathy, Amyotropic lateral sclerosis, Cramp fasciculation syndrome, Motor neuron disease, Multifocal motor neuropathy, Multiple sclerosis, Peripheral nerve injury , Radicular syndrome, Spinal Muscular Atrophy
Nutritional / Metabolic	Acute alkalosis, Glycogen storage disease, Hypoglycemia, Inadequate dietary calcium intake , Lactate dehydrogenase deficiency, Lipid storage myopathy , Metabolic Acidosis, Reactive hypoglycemia, Respiratory alkalosis, Vitamin B12 Deficiency, Chronic renal failure, Disequilibrium syndrome, Hyperkalemia, Hypocalcemia, Hypokalemia, Hypomagnesemia, Hyponatremia, Hypophosphatemia, Uremia
Obstetric/Gynecologic	Adenomyosis, Asherman's syndrome, Dysmenorrhea, Dysmenorrhea, Endometriosis, Menstruation, Miscarraige, Pregnancy
Oncologic	Conn's syndrome
Opthalmologic	No underlying causes
Overdose / Toxicity	No underlying causes
Psychiatric	Fibromyalgia, Hysterical hyperventilation , Restless leg syndrome
Pulmonary	No underlying causes
Renal / Electrolyte	Bartter's syndrome
Rheum / Immune / Allergy	Anaphylaxis, Raynaud syndrome
Sexual	No underlying causes
Trauma	No underlying causes
Urologic	No underlying causes
Dental	No underlying causes
Miscellaneous	Dehydration, Excessive playing of musical instrument , Excessive sweating, Excessive writing , Exposure to large changes in temperature, Hard physical work in a hot environment , Heat cramps, Heat exhaustion, Heatstroke, Hyperoxia, Hypoxia, Inappropriate leg position during sedentary activity, Living or working on concrete flooring, Prolonged sitting, Severe water and salt depletion , Water intoxication

Causes in Alphabetical Order

Acanthosis nigricans - Insulin resistance - muscle cramps - acral enlargement Acute alkalosis Adenomyosis Adenosine Monophosphate Deaminase Deficiency type 1 Adult progressive spinal muscular atrophy, Aran Duchenne type Alcoholic Neuropathy Amlodipine Amoebiasis Amphetamine Amphetamine abuse Amyotropic lateral sclerosis Anaphylaxis Anemia Angiotensin II receptor antagonists Arachnidism Arterial insufficiency Asherman's syndrome Autosomal dominant familial hematuria - retinal arteriolar tortuosity - contractures Bariatric surgery Bartter's syndrome Bendrofluazide Benzodiazepines Blind loop syndrome Brucellosis Bumetanide Carbon monoxide intoxication Celiac disease Chronic renal failure Cidofovir Cimetidine Cisplatin Clofibrate Clupeotoxin Cocaine Conn's syndrome Coxsackie B virus Cramp fasciculation syndrome Cryptosporiosis Cyclosporiasis Deep Venous Thrombosis Dehydration Diabetes Mellitus Dialysis Disequilibrium syndrome Distal hereditary motor neuropathy Diverticular Disease Diverticulitis Donepezil Dry cell battery poisoning Dysmenorrhea Dysmenorrhea Early bowel obstruction Ehlers-Danlos Syndrome Endometriosis Excessive playing of musical instrument Excessive sweating Excessive writing Exposure to large changes in temperature Familial Limb-Girdle Myasthenic Syndrome With Tubular Aggregates Fibromyalgia Flat feet Frusemide Genetic recurrent myoglobinuria Genu recurvatum Gitelman syndrome Glycogen storage disease Gonarthrosis Hard physical work in a hot environment Hashimoto's Thyroiditis Heat cramps Heat exhaustion Heatstroke Hereditary spastic paraplegia Hydrochlorothiazide Hyperinsulinemia Hyperkalemia Hypermobility syndrome Hyperoxia Hyperthyroidism Hypocalcemia Hypoglycemia Hypokalemia Hypokalemic periodic paralysis Hypomagnesemia Hyponatremia Hypoparathyroidism

Hypophosphatemia Hypopituitarism Hypothyroidism Hypoxia Hysterical hyperventilation Inadequate dietary calcium intake Inappropriate leg position during sedentary activity Influenza Insulin-resistance syndrome Intestinal obstruction Isaacs syndrome Kashin-Beck disease Lactate dehydrogenase deficiency Lactate dehydrogenase deficiency Leptospirosis Limb-girdle muscular dystrophy Lipid storage myopathy Lipid storage myopathy Lisinopril and Hydrochlorothiazide Living or working on concrete flooring Malabsorption Malaria Menstruation Metabolic Acidosis Miscarraige Misoprostol Mitochondrial myopathies Motor neuron disease Multifocal motor neuropathy Multiple sclerosis Muscle overstrain Muscle phosphoglycerate mutase deficiency Muscular phosphorylase kinase deficiency Myokymia Myopathies Neostigmine Niacin Nifedipine Nitrendipine Nonalcoholic cirrhosis Opium withdrawl Oral contraceptives Paratide Peripheral arterial disease Peripheral nerve injury Phosphogylcerate mutase 2 deficiency Progesterone Pregnancy Prolonged sitting Pyrazinamide Pyridostigmine Radicular syndrome Raloxifene Raynaud syndrome Reactive hypoglycemia Reproterol Respiratory alkalosis Restless leg syndrome Rickets Rippling muscle disease Salbutamol Salmonellosis Sarcoglycanopathy Severe diarrhea Severe water and salt depletion Shigellosis Short bowel syndrome Small bowel bacterial overgrowth syndrome Spinal Muscular Atrophy Staphylococcus aureus food poisoning Statins Structural disorders of the foot Systemic capillary leak syndrome Tacrine Teriparatide Tetanus Tin poisoning Tolcapone Torsion dystonia Toxoplasmosis Trichinosis Tubular aggregate myopathy Ulcerative colitis Uremia Varicose veins Venous insufficiency Vincristine Vitamin B12 Deficiency Water intoxication Young Simpson syndrome Zadik–Barak–Levin syndrome

Treatment

Muscle cramps can be treated by applying a soft massage on the cramped muscle, stretching the muscle and applying heat or cold. Heat improves superficial blood circulation and makes muscles more flexible, so some people find that heat is more soothing for muscle cramps. Application of excessive heat or cold to sore muscles may bring on cramps. Pounding on a cramped muscle can increase soreness.

• In the case of inadequate oxygenation, excess lactic acid, produced by anaerobic respiration, builds up and stresses the muscle. In addition to the methods described above, cramps from poor oxygenation can be improved by rapid deep breathing.

• Cramps from lack of water and/or salt can be treated by drinking water and/or increasing salt intake, respectively.

There is no scientific evidence to support the widely held claim by the sports nutrition industry that intake of specially composed electrolyte drinks has any advantage over intake of plain table salt (via drink or food) and water to counter these electrolyte disturbances and muscle cramps in people with a well-functioning renal system.

Eating foods high in potassium can help prevent muscle cramps. Foods with high sources of potassium include, in order from highest to lowest: avocados, potatoes, bananas, broccoli, orange juice, soybeans and apricots, although it is also common in most fruits, vegetables and meats.

Leg cramps may also be due to vitamin D deficiency (also needed for calcium absorption). Due to change in diet, shunning milk because of high cholesterol content, or, in children, preference for soft drinks, and decreased sun exposure, vitamin D deficiency is widespread. Correcting this deficiency will in many cases also eliminate, or reduce, frequency of leg cramps.

Related Chapters

• Trigger points
• Side Stitch
• Delayed onset muscle soreness

External Links

• What are Cramps?
• Cramps at Patient UK
• Leg cramps at night
• [Cramps of Skeletal Muscles)

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