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Muscle Spasms: Don’t Ignore. Let’s Explore.

As a physician, I tend to take all pathologies seriously. Like all providers, I spent years studying the human body and the various ways to improve health. In general, when patients present to me with their complaints, I take them at face value, listen carefully, and try to resolve the issue. 

Except when it comes to muscle spasms. 

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I’m almost embarrassed to admit it, but in the past, I didn’t take muscle spasms particularly seriously. Patients would sometimes present with their podiatric complaint, and most of the time, complaints of nighttime muscle spasms would come up near the end of the encounter. In fairness to me, most of the time these complaints are afterthought, almost as patients are about to walk out the door, as in, “You know, doc, I also get these occasional muscle cramps….” I would give some general advice about staying hydrated, especially at night, and speaking to their primary care doctor if they continued. 

Looking back on this, I think my past opinion was shortsighted. Considering the commonality of this complaint, it really does behoove all providers to be updated so we can provide the best care to our patients. To that end, here’s a high-yield review of muscle spasms in a question-and-answer format. 

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Without meaning to sound like a broken record, the evidence behind the evaluation and treatment of muscle cramps isn’t strong, so it’s up to each of us to work with our suffering patients to decide the best course of action.

What is the pathophysiology of muscle cramps?

The evidence appears to lean strongly in the direction that cramps arise from spontaneous motor nerve discharges rather than from the muscle fibers themselves.1 Muscle cramps, then, are a neurological problem with a muscular manifestation.

Muscle cramps are a neurological problem with a muscular manifestation.

If abnormal motor nerve discharges are the event, what is the etiology of muscle cramps?

Since the lower motor neuron is the locus of this issue, it makes logical sense that the etiology would include conditions that potentially cause abnormal nerve firing. The table below breaks down the major categories of muscle cramp causes along with diagnostic hints and some comments. 

Table 1. Causes of muscle spasms with diagnostic comments modified from Miller and Layzer.1

Etiology Disorder Diagnosis
Idiopathic Nocturnal leg cramps in the elderly Occur in calf and foot
Nighttime
Elderly patients
Absence of muscle weakness & atrophy
Exercise-related Occur during, after activity.
Fluid intake, environmental heat are factors.
Lower motor neuron disorders Amyotrophic lateral sclerosis (ALS)
Radiculopathy
Neuropathy
Widespread cramps
Daytime
Provoked by minimal activity
Fasciculations present
Metabolic changes Uremia
Cirrhosis
Hypothyroidism
Hypoadrenalism
Pregnancy
Most often present with a history of these disorders.
Acute extracellular volume depletion Perspiration
Hemodialysis
Diarrhea, vomiting
Volume changes.
Medications Diuretics
Statins
Beta agonists
Clofibrate
Diuretics cause spasms most likely through volume changes rather than a direct effect of the medication.
The others listed in this category cause myopathy more than spams.
Hereditary disorders Very rare autosomal dominant disorders found in some families. Family history
Onset seen in adolescence.

What parts of the physical exam are helpful?

The history should guide the physical exam. Check for weakness or loss of muscle bulk (ie atrophy) and fasciculations. This is done by directly visualizing relaxed muscles and palpating larger muscles at the muscle belly near the origin (sometimes they can be felt and not seen). Look for upper motor neuron signs such as hyperreflexia and clonus since atrophy plus upper motor neuron signs is indicative of ALS.

What treatments are available for patients with muscle cramps? 

First, it is fair to tell patients that rare, isolated, and temporary episodes of calf muscle cramps do not require investigation or treatment. If a specific diagnosis is made, treatment should be focused on that diagnosis. 

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Non-pharmacologic treatments should be explored first when a neurological or metabolic cause is not obvious. These include the following:

  1. Stretching the cramping muscle while simultaneously activating the antagonist muscle has been shown to stop most muscle cramps.2 For anterior calf cramps, this may be accomplished by standing with the foot flat and pushing hard against the floor. For posterior calf cramps, dorsiflexing the foot will be helpful.
  2. Wearing night splints as a prophylactic measure.1
  3. In cases of exercise-related cramps, replacing sodium should resolve the issue. Drinking water or sports drinks will replace fluids but not sodium. It has been recommended to eat a small meal with slightly increased salt content to replace that ion.4
  4. Stretching regularly and before exercise may also prevent muscle spasms.

Pharmacologic treatments are a bit more complicated. Quinine sulfate 260 mg at bedtime is the classic medication for treatment of muscle cramps and has been shown to be effective. However, due to the potential for serious adverse effects (tinnitus, toxicity, thrombocytopenia, and drug interactions), not balanced by the benefits, this medication is no longer recommended

Other medications found to be helpful include1,5:

  • Carbamazepine and phenytoin (due to their sodium-channel blocking mechanisms)
  • Gabapentin 600-900 mg in 2 doses between dinner and bed
  • Supplemental magnesium for pregnant women
  • Botulinum toxin injections
  • L-carnitine for hemodialysis patients
  • Verapamil 30 mg or diltiazem 120 mg before bed (due to their calcium channel blocking mechanism)
  • Baclofen in motor neuron disease
  • Vitamin E 800 IU in patients with liver or renal disease
  • Vitamin B complex TID

Keep in mind each of these medications have potential side effects and drug-drug interactions. Patients should be thoroughly educated to watch for complications. 

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As in all things, referral to the patient’s primary care physician should be initiated if underlying disorders are found. In most cases, idiopathic muscle spasms may be successfully treated with nonpharmacologic therapies or limited prescription medications. 

Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
jarrod@podiatry.com
References
  1. Miller TM, Layzer RB. Muscle cramps. Muscle Nerve. 2005 Oct;32(4):431-442.
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  2. Weiner IH, Weiner HL. Nocturnal leg muscle cramps. JAMA. 1980 Nov 21;244(20):2332-2333.
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  3. Davison S. Standing: a good remedy. JAMA. 1984 Dec 28;252(24):3367.
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  4. Ray ML, Bryan MW, Ruden TM, Baier SM, Sharp RL, King DS. Effect of sodium in a rehydration beverage when consumed as a fluid or meal. J Appl Physiol. 1998 Oct;85(4):1329-1336.
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  5. Winkleman J, et al. Nocturnal leg cramps. UpToDate. Last updated 10/17/2019. Last accessed 12/13/2020.
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