Leg Cramps
ALBERT FIELDS, M.D., Los Angeles
THE TERM leg cramps applies to involuntary tetanic * Foot and leg cramps are among the most fre-
contractions of the calf muscles. Such cramping may quent complaints presented by patients of both
sexes, especially older persons. Similar cramping
be experienced by any patient. An example is the may occur in the thighs or in other skeletal mus-
so-called "charley horse" following stretching of a cles of the extremities and trunk. Foot and leg
fatigued or injured extremity, or after the leg has cramps usually occur after unusual exertion or
been held in a cramped position for a time. Similar during sleep. "Nocturnal leg cramps" may be of
cramping may occur in the feet or in other skeletal sufficient intensity to prevent sleep. "Pregnancy
cramps" are particularly distressing.
muscles of the trunk or the extremities. Effective treatment of foot and leg cramps
requires an understanding of the etiology, patho-
ETIOLOGIC AND PATHOPHYSIOLOGIC FEATURES physiology and diagnostic techniques. Weight
reduction and improved diet are essential.
The causes of many cases of foot and leg cramps Among the useful supplementary medications
are obscure. Practically anything that interferes with are calcium lactate or gluconate, vitamin-mineral
supplements, sympathetic blocking agents, vaso-
nutrition and gas exchange of normally innervated dilators, ataraxics, muscle relaxants, quinine,
skeletal muscle can cause cramps. Thus cramps are hydrochloride, antihistamines, and nonmercurial
seen both in sodium intoxication and sodium deple- diuretics.
tion, in oxygen intoxication and oxygen deficiency. Improved foot care and correction of foot im-
Cramps occur more frequently in association with balance is usually required. Edema and venous
insufficiency are improved by elastic support, by
certain diseases or conditions: repeated foot elevation for massages, by manipu-
During or after unusual activity or muscular lations and exercises and by the use of diuretics.
effort. There may be need for operations on the veins
and for sclerotherapy. Patients with arterial in-
After retiring or during sleep following a day of sufficiency are often benefited by lumbar sympa-
much use of the legs - that is, "nocturnal leg thetic blocks with long-acting anesthetics and
cramps," which may be so severe that they awaken intra-arterial injections with relaxants, vasodila-
the patient or prevent sleep. tors, thrombolytic enzymes and anticoagulants.
Sympathectomy, angiography and reconstruc-
"Pregnancy leg cramps," occurring between the tive arterial operations are indicated in only a
24th and 36th weeks of gestation. small proportion of patients with foot and leg
cramps.
Disturbances of mineral metabolism, frequently
related to dietary and vitamin deficiencies. (a) Hy-
percalcemia may produce cramps through peripheral tients are more likely to have nocturnal cramps than
sympathetic overactivity causing vasoconstriction. are younger patients.
Cramps are far more commonly associated with hy- Spontaneous fasciculation is more frequently ob-
pocalcemia-latent tetanic states, hypoparathyroid- served in muscles likely to cramp than in normal
ism, sprue, rickets, renal insufficiency and alkalosis muscles. There appears to be a heightened excitabil-
in hyperventilation syndrome. Calcium ions, which ity of the motor units involved. Even during maximal
are skeletal muscle relaxants, are reduced by phos- voluntary effort the motor units contract asynchro-
phates and in turn antagonize the relaxant effects of nously. With even maximal voluntary contraction no
magnesium and postassium ions as well as the muscle pain is experienced. Pain can be elicited during elec-
stimulant effects of sodium ions. (b) Chronic low trical stimulation of the muscle or motor nerve
sodium diet also may lead to cramps, especially when which induces much greater muscle tension than
sodium-depleting agents are being used or in asso- voluntary contraction.
ciation with excessive sweating.
During voluntary contraction the normal muscle
Weakness in a neighboring muscle due to nervous fiber has a contraction rate of 10 to 50 per second;
system disease or to skeletal deformity. in the myotonic muscle this rate may be higher, 100
Circulatory deficiencies, such as those occurring to 150 per second. In skeletal muscle cramps, the
with atherosclerosis, vasospasm, varicose veins, or rate of contraction of a single fiber is still higher,
thrombophlebitis of the lower extremities. Older pa- reaching to 300 per second.
Submitted May 20, 1959. The sensory elements and nerve fibers subserving
204 CALIFORNIA MEDICINE
the conduction of afferent impulses from the muscles Some muscle relaxants are effective in decreasing
which are interpreted as pain are not clearly identi- the frequency, duration and severity of foot and
fied. The excessive tension developed in the muscle leg cramps. Among the most effective and nontoxic
may cause afferent impulses to arise in a manner agents is Orphenadrine hydrochloride (Disipal®)
analogous to pain production when a viscus (intes- 25 mg. twice a day or, for nocturnal cramps, 50 mg.
tine, urinary bladder, gall bladder) is distended. at bedtime.
Ataraxic drugs (tranquilizers) and antihista-
MANAGEMENT OF FOOT AND LEG CRAMPS mines may be of indirect benefit but should be used
After adequate examination to attempt to deter- only in small doses and for short periods. The cen-
mine specific etiological factors a multiple therapeu- tral depressant action that sometimes accompanies
tic routine should be instituted. the use of muscle relaxants, ataraxics and antihista-
mines may be combatted with monoamine-oxidase
Diet inhibitors (MAOI) such as 2-dimethyl aminoethane
He who takes medicine and neglects diet (Deaner®), 25 mg. twice daily.
wastes the skill of his physician.
-OLD CHINESE PROVERB Sympathetic and adrenergic blocking and adreno-
Reduce overweight. A low calory, low fat, low lytic agents may be indicated in patients with periph-
carbohydrate, low salt, high protein diet is essential. eral vascular insufficiency. There is need for im-
Saturated, hydrogenated solid fats are to be avoided. proved preparations with regional specificity and
Linolenic acid, linoleic, and arachnoidic polyunsatu- less hypotensive effect.
rated fatty acids, found in cottonseed, corn, walnut, Diuretics are indicated for edema. Small doses of
peanut, safflower and sunflower seed oils are cur- renal carbonic-anhydrase inhibitors (hydrochloro-
rently popular. Varying success has been achieved thiazide) are preferred for their greater selectivity in
with cholesterol-reducing and lipotropic agents (hy- eliminating sodium rather than potassium ions.
aluronic acid, sitosterols and niacin). Inhibition of Quinine hydrochloride has long been used but its
cholesterol biosynthesis may prove more effective in prophylactic and therapeutic value in leg cramps has
retarding atherosclerosis. not been conclusively established. Pregnancy, tinni-
Reduce whole milk intake. Powdered, low-fat milk tus and impairment of hearing or vision are contra-
and soya derivatives may be used freely. Food indications to its use.
should be eaten slowly and chewed thoroughly.
Foot Care, Physical Therapy and Other Measures
Medications Keep your mouth wet, feet dry.
Qui medice vivit, misere vivit. -POOR RICHARD'S ALMANAC, 1733
-MEDIEVAL LATIN
Foot Care. Fungus infections can be controlled by
Many drugs have been advocated for prevention a nonirritating agent such as borotannic complex.
and treatment of muscle cramps. Addictive analge- Proper treatment of corns and calluses and clean
sics should be avoided. Except in frank calcium socks and good shoes are essential. Warm soaks and
deficiency, medication should be considered as pal- contrast sprays should be taken at least twice daily.
liative and supplementary. Massage with a vasodilator ointment, muscle stretch-
Mineral vitamin supplements high in vitamins ing exercises and exercises against increasing resist-
B, C, and D should be prescribed routinely. In preg- ance should be carried out many times every day.
nancy and lactation adequate calcium is necessary Foot Balance. For depressed metatarsal heads in-
to replace the large amounts taken up by the fetus or sert, a 1/8-inch to 3/16-inch sponge rubber metatar-
lost in nursing the infant. Calcium lactate or gluco- sal pad. For internal rotation, a sponge rubber sca-
nate (0.6 gm. four times a day), or Calglucon® phoid "cookie" and 1/8-inch inner wedges on a
syrup, 1 tablespoonful (3.6 gm.) at bedtime. In se- Thomas heel and sole should be used. Pronounced
vere spasm, calcium gluconate given intravenously foot imbalance requires a soft, flexible appliance, in-
often provides prompt relief. The rationale of low dividually fitted by an expert orthopedist or podi-
phosphate intake is still debatable. atrist.
Nicotinic acid (or nicotinamide) in repeated doses Physical Therapy. In the presence of vascular in-
or in a form that releases slowly for sustained effect sufficiency, it is dangerous to use diathermy, heat
produces cutaneous vasodilation and has consider- lamps, ultra violet lamps, paraffin baths, ultra sound,
able lipid-clearing action. Apparently by elevating vibrators and similar devices on the foot or leg.
the diphosphopyridine nucleotide concentration in Careful use of sine wave, iontophoresis, rocking bed
the body tissues, nicotinic acid also potentiates the and repeated hydromassage, warm (not hot) baths
action of ataraxic agents. and soaks and contrast sprays is encouraged. An
VOL. 92. NO. 3 * MARCH 1960 205
B
2 minutes 3 minutes 2 Minutes
Buerger-Allen exercises-Fields' Modification
electric pad set at low temperature applied to the walking and exercises to a point short of severe
buttocks in the lumbar region provides some foot pain.
and leg comfort through reflex vasodilations and 2. After each exercise session manipulate and mas-
reflex muscle relaxations. sage each leg and foot for five minutes with vaso-
Venous Insufficiency. Elastic support (bandage or dilator ointment, or liniment diluted in oil. Apply
stocking) and foot elevation (5 minutes every two dusting powders.
hours) for massage, manipulations and exercises are 3. Keep off feet for five minutes every hour. If there
usually of considerable benefit. With edema, low salt was previous serious infection increase rest period
diet and diuretics (hydrochlorothiazide) and a con- to fifteen minutes. Do not bear weight if skin is
tinued self-care routine (Luke's "New Life"*) are broken or inflamed.
essential. Sclerotherapy should be reserved for mi- 4. Flex and extend toes slowly to full range 1,000
nute venules after operation. Pregnancy is usually a times. While doing back and leg exercises con-
contraindication to sclerotherapy. Vein ligations and tinue with foot and toe movements.
strippings may be indicated. The postthrombophle- 5. Finish each step on toes, not on ball of foot. Take
bitic syndrome is often benefited by some of the shorter steps and slower rate (90 steps per min-
measures noted below for dealing with arterial in-
sufficiency.
ute). If only one leg is involved, hold it stiff,
throwing weight onto sound limb for longer
Arterial Insufficiency. Vascular study may indi- intervals.
cate the need for lumbar sympathetic blocks (with 6. Lie flat on back. With knees stiff, elevate alter-
long-acting local anesthetics), intra-arterial vasodi- nately right leg then left to 900. At the same time
lator-relaxants (methocarbamol), thrombolytic en- do foot and toe bending. Repeat 10 times. Do bi-
zymes (Plasmin), oxygen and anticoagulants. Some cycle exercises for 30 seconds. Repeat leg raising
patients require sympathectomy, angiography and with a five-pound weight across foot; increase to
reconstructive arterial surgical procedures. It is sug- 20 pounds for 20 elevations. Repeat lift, with
gested that some patients with foot and leg cramps knees flexed, sitting on edge of table.
due to vasospasm, arterial or venous insufficiency 7. Go swimming as often as possible. Twice daily
and other causes will be benefited by "stunning" the relax in warm bath and use contrast sprays. Mas-
lumbar sympathetic trunk with proton beams or with sage, and manipulate toes, feet, and legs while in
an insulated percutaneous electrocoagulator.
warm bath. Hydrotherapy stimulates circulation
Associated Disease. Control of obesity, undernu- and "tones" up tissues.
trition, anemia, diabetes, cardiovascular-renal dis- 8. Buerger-Allen Exercises -Fields' Modification
orders and other systemic diseases is essential. (see illustration):
* Lie flat on back in bed. and elevate legs to 450
Foot and Leg Exercises
for two minutes or until feet become blanched.
Those who do not find time for exercise * Sit on edge of bed and allow legs to hang for
will find time for illness.
-EARL OF DERBY, 1873 three minutes or until feet become pink. Move
feet up and down, in and out, and open and
Instructions for foot and leg exercises are: close toes. Massage and manipulate toes, feet
1. Exercise slowly. Relax slowly. Repeat exercises and lower legs.
six times daily. Shorten rest periods and increase * Rest on back in bed for two minutes. Keep
Luke's "New Life" (a term introduced by Joseph Luke of Mon- warm with blankets. Repeat exercises six times
treal) is a routine of daily living for persons with edema and Pst- at each session six times a day.
thrombophlebitis. It entails weight reduction, elastic support and re-
peated elevation of the legs. 523 West Sixth Street, Los Angeles.
206 CALIFORNIA MEDICINE