Muscle cramps are mostly benign and self-limited, but may also be indicative of a wide variety of potentially serious systemic disorders.
Idiopathic (ordinary) muscle cramps are common, short-lived, and usually involve the calf muscle and/or foot.
The diagnostic approach for idiopathic muscle cramps is one of exclusion. Cramps due to known pathologies can be ruled out reasonably quickly and easily by medical history and targeted physical examination.
Non-pharmacological therapy forms the cornerstone of management of muscle cramps in the acute phase. Passive and/or active stretching of the affected muscle(s) is by far the most effective and safest therapy for most acute idiopathic muscle cramps.
Data are extremely sparse regarding ongoing prevention of muscle cramps. With the exception of drug therapies targeted at underlying/precipitating conditions, there are no proven, specific, effective, and safe drug therapies for muscle cramps. Quinine is used in some countries for the prevention of idiopathic cramps, but is associated with serious side effects (e.g., cardiac arrhythmias, thrombocytopenia, hepatotoxicity, blindness). Therapeutic trialling of various medications used for symptomatic benefit is a reasonable approach.
A muscle cramp is a sudden, involuntary, painful muscle contraction or spasm, associated with an increase in frequency of motor action potentials. Idiopathic (ordinary) muscle cramps are common.
About 80% of episodes involve the gastrocnemius, with a mean duration per episode of 8 to 9 minutes in adults and 2 minutes in children.
The focus of this topic is true cramps (motor unit hyperactivity). These are most commonly idiopathic cramps, but can be associated with other conditions.
History and exam
Key diagnostic factors
- presence of risk factors
- nocturnal onset (idiopathic cramp)
- gastrocnemius muscle involvement, with or without foot involvement (idiopathic cramp)
- duration <10 minutes (idiopathic cramp)
- unilateral (idiopathic cramp)
- precipitation by both trivial movements and forceful contractions (idiopathic cramp)
- visible or palpable muscular knotting
- good response to passive/active stretching (idiopathic cramp)
- normal neurological examination (idiopathic cramp)
- normal general physical examination (idiopathic cramp)
- other local muscle involvement (neuromuscular disease cramp)
- widespread muscle cramps (lower motor neuron disease)
- duration >10 minutes (organic cause)
- abnormal neurological examination (organic cause)
- abnormal musculoskeletal examination (organic cause)
Other diagnostic factors
- signs of a chronic medical condition (organic cause)
- strenuous exercise
- beta-blockers with intrinsic sympathomimetic activity
- age >60 years
- female sex
- family history of cramp
- other agents
- hypoglycaemia in patients with diabetes mellitus
- chronic diseases
- home parenteral nutrition
1st investigations to order
- clinical diagnosis
Investigations to consider
- serum or urine hCG
- fasting serum metabolic panel
- thyroid-stimulating hormone (TSH)
- serum liver function tests
- prothrombin time (PT) and INR
- serum myoglobin and urinalysis
- serum creatine kinase (CK)-MM
- serum alpha-tocopherol (vitamin E)
- serum zinc
- nerve conduction studies
- serum aldolase
- muscle biopsy
- genetic studies
hypoglycaemia-associated in diabetes mellitus
multiple sclerosis- or lower motor neuron disease-associated
Michael Rubin, MD, FRCP(C)
Professor of Clinical Neurology
Weill Cornell Medical College
Director, Neuromuscular Service and EMG Laboratory
New York Presbyterian Hospital
MR states that he has no competing interests.
Dr Michael Rubin would like to gratefully acknowledge Dr Justin Mhoon and Dr David R.P. Guay, previous contributors to this topic. JM declares that he has no competing interests. DRPG is an author of a reference cited in this topic.
Timothy M. Miller, MD, PhD
Assistant Professor of Neurology
Department of Neurology
Washington University School of Medicine
TMM is an author of a reference cited in this topic.
Sami Khella, MD
Department of Neurology
Penn Presbyterian Medical Center
University of Pennsylvania Health System
SK declares that he has no competing interests.
Felicity Goodyear-Smith, MB CHB, DipObs, MGP, FRNZCGP, MFFLM, RCP
Professor and Goodfellow Postgraduate Chair
Department of General Practice & Primary Health Care
University of Auckland
FG-S declares that she has no competing interests.
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