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Muscle Cramps - Draft

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Overview

Muscle cramps are sudden, involuntary contractions of one or more muscles. They are common in primary care and usually benign, but can sometimes indicate underlying pathology.

Common causes:

Benign/Physiological

Nocturnal leg cramps (idiopathic, common in older adults)
Exercise-associated cramps
Dehydration or electrolyte imbalance
Pregnancy
Medications:
- Diuretics
- Beta-agonists
- Statins
- Calcium channel blockers
- Raloxifene

Secondary to Medical Conditions

Peripheral artery disease
Neuropathies (e.g. diabetic neuropathy)
Motor neurone disease
Hypothyroidism
Liver cirrhosis (electrolyte disturbances)
Chronic kidney disease (uraemia, electrolyte imbalance)

Who to Refer

See Leg cramps | CKS for advice on assessment in primary care.

If secondary causes have been excluded then most patients can be reassured and managed in primary care.

Referral or request for advice and guidance should only be considered if there are atypical symptoms or diagnostic uncertainty.

What to do before referral

Consider the following investigations if indicated:

Bloods: U and E, LFT, calcium, magnesium, HbA1c, TSH, CK.
Nerve conduction studies - if neuromuscular disorder suspected.
Vascular studies- if vascular cause suspected.

Manage in primary care if underlying cause not suspected. See Management | Leg cramps | CKS

Lifestyle advice and prevention

Hydration and electrolyte replacement
Regular stretching before bed or after exercise
Physiotherapy for tight or shortened muscles
Avoid triggers (e.g. caffeine, alcohol, prolonged standing)

Pharmacological

Quinine sulphate 200mg -300mg nocte - Quinine is not a routine treatment for nocturnal leg cramps (risk of thrombocytopenia , arrhythmia), and should only be tried when cramps regularly disturb sleep (if lifestyle fails and no contraindications). See MHRA Drug Safety Update June 2010
Alternatives that are not recommended and are not on the BNSSG formulary for treatment of leg cramps: Magnesium (limited evidence), Naftidrofuryl (not licensed for use in leg cramps)

Advice and Guidance

Consider requesting advice and guidance if an underlying cause is suspected (e.g. neurology or vascular)

Referral

Referral is rarely required unless an underlying cause is suspected.

If neuromuscular cause is suspected then consider referral to Neurology via eRS.

If vascular cause is suspected then consider referral to Vascular RAS via eRS.

Resources

Patient advice

Leg cramps - NHS

Clinical Knowledge Summaries

Leg cramps | Health topics A to Z | CKS | NICE

BNSSG Formulary

10.3 Neuromuscular disorders (Remedy BNSSG ICB)

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