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EBMG

Leg Cramps

Essentials

  • Leg cramps refer to painful, involuntary and sustained muscle contractions in the lower limbs that often occur during the night or waking up.
  • The symptom is usually benign when appearing alone, and its prevalence increases with age.
  • Additional investigations are not often needed. Stretching and massage are usually sufficient treatments.

Aetiology

  • The following factors, among others, may predispose to leg cramps.
    • Local causes
      • Hypoxia in the muscles
      • Sustained or abnormal straining of the lower limbs
      • Sudden movement after a longer rest
      • Lower limb oedema
    • Systemic diseases
      • Liver failure and cirrhosis
      • Kidney diseases
      • Hypothyroidism
      • Malignant neoplastic diseases and their treatments
      • Neurological diseases, such as Parkinson's disease, MS, ALS, peripheral neuropathy
      • Spinal stenosis
    • Pharmaceuticals
      • Diuretics and inhaled long-acting beta2 agonists
      • Also many other drugs have been associated with the symptom
    • Other conditions affecting the whole body
      • Pregnancy
      • Aging
      • Electrolyte disturbances (hyponatraemia, hypokalaemia, hypomagnesaemia)
      • Dehydration
      • Alcohol use
  • A significant proportion of patients have no known predisposing factors. Leg cramps are common without any specific cause particularly in the elderly.

Investigations

  • A clinical examination of the lower limbs (swelling, varicose veins, stasis dermatitis, arterial circulation of the legs, sensation, muscle wasting)
  • General physical examination to detect diseases that predispose to the symptom.
  • Leg cramps without any other symptoms or signs usually do not warrant any additional investigations.
  • Laboratory examinations, selectively
    • Plasma sodium, potassium, calcium and magnesium levels
    • TSH
    • Fasting blood glucose, HbA1C
    • Creatine kinase
    • ALT, GT
    • Transcobalamin II-bound vitamin B12

Treatment

  • The first aid treatment of leg cramps involves passive stretching Non-Drug Therapies for Lower Limb Muscle Cramps or massage of the tight muscle.
  • Prevention consists of the elimination of predisposing factors and reducing the consumption of alcohol and caffeine.
  • Pharmacotherapy
    • Calcium-channel blockers, particularly diltiazem 30-60 mg in the evening
    • Vitamin B and E preparations
    • Gabapentin, especially for patients with a predisposing neurological disease; initial dose 300 mg twice daily
    • Diazepam or clonazepam may be considered in severe cases, but the patient must be monitored to evaluate the efficacy of the treatment and the emergence of adverse effects.
  • Magnesium has not been shown to be efficacious in the treatment of leg cramps in the elderly Magnesium for Skeletal Muscle Cramps. Evidence of the efficacy of magnesium in the treatment of leg cramps during pregnancy is uncertain.
  • Quinine has been shown to be effective in the treatment of leg cramps, but due to potential severe adverse effects, its use is not generally recommended, and the drug is not available for this indication.

References

  • Hawke F, Sadler SG, Katzberg HD, et al. Non-drug therapies for the secondary prevention of lower limb muscle cramps. Cochrane Database Syst Rev 2021;(5):CD008496. [PubMed]
  • Garrison SR, Korownyk CS, Kolber MR, et al. Magnesium for skeletal muscle cramps. Cochrane Database Syst Rev 2020;(9):CD009402. [PubMed]
  • Luo L, Zhou K, Zhang J, et al. Interventions for leg cramps in pregnancy. Cochrane Database Syst Rev 2020;(12):CD010655. [PubMed]
  • El-Tawil S, Al Musa T, Valli H, et al. Quinine for muscle cramps. Cochrane Database Syst Rev 2015;(4):CD005044. [PubMed]