It is a common condition, particularly in older persons and pregnant women. Characterised by painful cramps in the legs or feet, it affects sleep quality. Is there an effective treatment? Unfortunately, treatment options are limited, but lifestyle modifications and gentle stretching may make a difference.

What Are They?

These pains not only occur in the legs during the night, but they usually disrupt your sleep. They may also happen while awake at night during periods of inactivity.  Most often present in the calf muscles, they can affect the thighs or feet too. It is quite a painful experience which causes the affected muscles to feel tight or knotted, lasting from a few seconds to several minutes. Though the cramps themselves are benign, the affected muscle may be painful for some hours after being awakened. In fact,  the consequences of sleep impairment can be considerable. Both men and women seem to be equally affected but they also do occur in younger adults and children.

Causes

The cause of nocturnal cramps for many people is unknown; however, dehydration, electrolyte and mineral imbalances, muscle fatigue, and reduced peripheral blood flow, have been suggested as possible contributory factors.

Factors known to be associated with an increased risk of these cramps include:

• Age – over 50 years
• Pregnancy
• Exercise, particularly over-exertion
• Leg positioning, e.g. prolonged sitting with legs crossed; tight bed covers, which cause the toes to point downwards
• Excessive consumption of alcohol
• Chronic dehydration
• Structural disorders, e.g. flat feet or other foot and ankle malformations
• Medicines, e.g. diuretics, some anti-inflammatories, statins, etc.
• Co-morbidities, e.g. osteoarthritis, vascular diseases, diabetes, Parkinson’s disease, hypo and hyperthyroidism.

Are These Cramps the Same as Restless Leg Syndrome?

Nocturnal cramps are diagnosed clinically. The patient’s description of their symptoms is usually sufficient to diagnose, e.g. the patient may describe a sudden onset of painful cramping of the leg or foot muscles that wakes them from sleep. The history (including a review of medicines), and a focussed physical examination can help to identify any underlying conditions that may be causing, or contributing to the leg cramps. Examination should include blood pressure management, neurological, and vascular examination of the legs.

No they are not. While both types of leg disturbances tend to happen at night, or at rest, restless leg syndrome does not cause pain or cramping. Restless leg syndrome is more of a discomfort, or a crawling sensation, that results in a desire to move the legs. While moving, the restlessness is relieved, but the discomfort returns when movement stops. This does not happen with nocturnal leg cramps, where the tightened muscle needs to be actively stretched out for relief.

Treatment

The aim of treatment of nocturnal cramps is symptom control, unless an underlying cause has been identified and can be managed. Lifestyle modifications to prevent the cramp from occurring can be trialled first. If the patient remains symptomatic and symptoms are severe, pharmacological treatment may be considered. However, there is currently no pharmacological treatment for leg cramps that has been proven to be both safe and significantly effective.

Acute management

Patients should be given advice on what to do when they experience a cramp. Physically stretching the muscle that is cramping, e.g. for cramp in the calf, flexing the ankle by pulling the toes upward in the direction of the shin, is the most effective way of stopping the cramp, but this can be painful.  Passive stretching may also work and is less painful. This involves relieving the tension on the affected muscle by massage and postural changes.Getting out of bed and briefly walking, may provide relief as well. You might be able to relieve the cramp by walking around, jiggling your leg, or massaging the leg. Warm baths or showers may be helpful too.

Lifestyle interventions include diet, exercise and stretching. Encourage sufficient fluid intake during the day, mainly water, and avoidance of caffeine and alcohol. There is mixed evidence as to whether brief stretching prior to sleep is beneficial, however, it can be tried. Brief light exercise, such as walking or cycling on a stationary bike prior to bed time can be tried, although evidence of significant benefit is also lacking.

Pharmacological interventions and supplements

Mineral and vitamin supplements are unlikely to be beneficial for most people. Magnesium supplementation has no benefit in the treatment of nocturnal cramps, although there is conflicting evidence that it may reduce same in pregnant women. 

Over-the-counter “anti-cramp” formulations, contain some variation or combination of calcium, magnesium, high-dose vitamin B6 or B12 and associated supplements. There is no evidence of benefit from these preparations, although there is anecdotal evidence that they may be helpful for some people. If medicines are used, they should be initiated at the lowest possible dose, and discontinued if no obvious benefit is observed.

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