Summary
Definition
History and exam
Key diagnostic factors
- concurrent hemodialysis (organic cause)
- cirrhosis (organic cause)
- pregnancy (idiopathic cramp)
- strenuous exercise (idiopathic cramp)
- drug use (idiopathic cramp)
- 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 neurologic exam (idiopathic cramp)
- normal general physical exam (idiopathic cramp)
- other local muscle involvement (neuromuscular disease cramp)
- widespread muscle cramps (lower motor neuron disease)
- duration >10 minutes (organic cause)
- abnormal neurologic exam (organic cause)
- abnormal musculoskeletal exam (organic cause)
Other diagnostic factors
- signs of a chronic medical condition (organic cause)
Risk factors
- pregnancy
- strenuous exercise
- hemodialysis
- cirrhosis
- use of imatinib
- use of beta-blockers with intrinsic sympathomimetic activity
- age >60 years
- female sex
- family history of cramp
- use of statins
- use of other agents that may cause muscle cramps
- hypoglycemia in patients with diabetes mellitus
- chronic diseases
- home parenteral nutrition
Diagnostic tests
1st tests to order
- clinical diagnosis
Tests to consider
- serum or urine hCG
- fasting serum metabolic panel
- thyroid-stimulating hormone (TSH)
- HbA1c
- 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
- electromyogram
- nerve conduction studies
- serum aldolase
- muscle biopsy
- genetic studies
Treatment algorithm
idiopathic cramps
exercise-associated
hypoglycemia-associated in diabetes mellitus
pregnancy-associated
dialysis-associated
cirrhosis-associated
multiple sclerosis- or lower motor neuron disease-associated
familial syndrome-associated
drug-associated
Contributors
Authors
Joome Suh, MD
Assistant Professor of Neurology
Department of Neurology
Brigham and Women’s Hospital
Harvard Medical School
Boston, MA
Disclosures
JS states she has been on advisory boards for UCB, Argenx, and Alexion.
Lindsay Tetreault, MD, PhD
Instructor of Neurology
Harvard Medical School
Department of Neuromuscular Medicine
Massachusetts General Brigham
Boston, MA
Disclosures
LT states that she has no competing interests.
Acknowledgements
Dr Joome Suh and Dr Lindsay Tetreault would like to gratefully acknowledge Dr Michael Rubin, Dr Justin Mhoon and Dr David R.P. Guay, previous contributors to this topic. MR and JM declare that they have no competing interests. DRPG is an author of a reference cited in this topic.
Peer reviewers
Timothy M. Miller, MD, PhD
Assistant Professor of Neurology
Department of Neurology
Washington University School of Medicine
St. Louis, MO
Disclosures
TMM is an author of a reference cited in this topic.
Sami Khella, MD
Physician
Department of Neurology
Penn Presbyterian Medical Center
University of Pennsylvania Health System
Philadelphia, PA
Disclosures
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
Auckland
New Zealand
Disclosures
FG-S declares that she has no competing interests.
Peer reviewer acknowledgements
BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.
Disclosures
Peer reviewer affiliations and disclosures pertain to the time of the review.
References
Key articles
American Academy of Sleep Medicine. International classification of sleep disorders - third edition, text revision (ICSD-3-TR). Jun 2023 [internet publication].Full text
American Academy of Neurology. Symptomatic treatment for muscle cramps. Feb 2010 [internet publication].Full text
Luo L, Zhou K, Zhang J, et al. Interventions for leg cramps in pregnancy. Cochrane Database Syst Rev. 2020 Dec 4;12(12):CD010655Full text Abstract
Garrison SR, Korownyk CS, Kolber MR, et al. Magnesium for skeletal muscle cramps. Cochrane Database Syst Rev. 2020 Sep 21;(9):CD009402.Full text Abstract
American Academy of Neurology. Update: the care of the patient with amyotrophic lateral sclerosis: multidisciplinary care, symptom management, and cognitive/behavioral impairment. Oct 2009 [internet publication].Full text
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
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