Why does the calf cramp and what to do?

Among these many symptoms, abnormal involuntary movements stand out - convulsions and spasms, which include focal myoclonic cramps in the calves of the legs, which are rather painful contractions of the biceps gastrocnemius muscle (Musculus gastrocnemius).

Epidemiology

There is no domestic statistics on the manifestation of this symptom, and according to the American Academy of Family Physicians, up to 60% of adult patients and about 7% of children complain of cramps in the calves at night. Seizures are slightly more common in women, and their frequency increases with age. [1]

Almost 20% of elderly people have cramps in the calves and feet almost daily. In six to seven cases out of ten, calf muscle cramps occur at night - during sleep.

Causes of the cramps in the calves

Sometimes the cause of cramps in the calves is not clearly identified, so that primary cramps in healthy people can be considered idiopathic, for example, as a result of muscle fatigue, especially if there is insufficient fluid intake, which negatively affects the water-salt (electrolyte) balance of the body. [2]

An electrolyte imbalance can be caused by impaired calcium metabolism - hypocalcemia, lack of magnesium in the body -  hypomagnesemia , potassium deficiency -  hypokalemia , low sodium levels - hyponatremia, as well as excess phosphorus. [3], [4]

Read more:

• Reasons for the increase and decrease in magnesium in the blood
• Causes of a decrease in calcium in the blood (hypocalcemia)
• Causes of increased phosphorus in the blood (hyperphosphatemia)

Defined reasons include:

• excessive stress on the muscles of the lower leg (in people with standing work) or their overstrain (long training in athletes); [5]
• dehydration (with diarrhea and frequent vomiting); 
• violation of blood circulation in the legs , for example, with a sedentary lifestyle, sedentary work or prolonged bed rest, in the presence of varicose veins or thrombophlebitis. Phlebologists note that cramps in the calves of the legs at night - with swelling of the legs and feet - are clinical manifestations of chronic venous insufficiency;
• neurological conditions such as motor neuron (skeletomotor nerve cell) disease or  leg neuropathy ;
• pathology of peripheral nerves, including the tibial nerve (Nervus tibialis), which provides innervation to the gastrocnemius muscle;
• narrowing of the spinal canal (stenosis), irritation or compression of the spinal nerve (radiculopathy), pinched nerve in the cervical vertebrae.

Cramps of the calf and other muscles can be a side effect of certain drugs, for example, diuretics, antihypertensive drugs, calcium channel blockers, statins, cholinomimetics, oral contraceptives, etc. [6]

With the appearance of edema, an increase in body weight, a deterioration in blood circulation in the lower extremities and a lack of trace elements, cramps during pregnancy in the calves of the legs are associated. [7],  [8] Full information about this in the material -  Why do legs reduce during pregnancy and what to do? 

Risk factors

The main risk factors for the appearance of secondary (not related to physical exertion) gastrocnemius cramps are seen by experts in the predisposition of older people to them - in connection with the age-related tendency of shortening of the tendons that connect the muscles to the bone.

The likelihood of seizures increases with:

• physical activity in conditions of extreme heat or cold;
• overweight;
• lack of vitamins D and group B;
• alcoholism;
• the presence of diabetes mellitus, in which a significant part of patients have a magnesium deficiency, a low level of ATP, a deterioration in the blood supply to the lower extremities (due to diabetic angiopathy), as well as metabolic acidosis (primarily in decompensated diabetes mellitus);
• chronic kidney failure;
• hemodialysis;
• liver diseases, including cirrhosis (with the accumulation of toxic substances in the blood);
• disorders of the secretion of the parathyroid glands (hypoparathyroidism);
• adrenal insufficiency (Addison's disease).

By the way, the risk of developing cramps in the calves of the legs in the morning is not only all of the above, but also a night's sleep on the back: due to the compression of the muscles of the lower leg and a decrease in blood flow in them. According to another version, when a person is asleep lying on his back, the feet are passively bent, and the fibers of the calf muscles are shortened as much as possible, so slight nerve stimulation can lead to seizures. [9]

Pathogenesis

With increased physical exertion, the pathogenesis of cramps in the calves of the legs is associated with the fact that the cells of the muscle tissue find themselves in conditions of hypoxia - insufficient tissue respiration. Then the mitochondria of myocytes under the action of adenosine diphosphate (ATP) switch to anaerobic respiration by glucose catabolism - glycolysis. As a result, pyruvic acid is formed, which enzymes transform to lactate, that is, lactic acid. When it accumulates in the muscles, convulsions occur.

A spasm in the left and right calf of the leg not related to physical activity is the result of an electrolyte imbalance that provokes a short-term failure of the electrochemical mechanism, which ensures the process of excitation of the synapses of nerve cells (neurons) and the transmission of nerve impulses to the cells of muscle tissue.

This process can be disrupted with a decrease in the concentration of ATP, which is necessary for the oxidative phosphorylation of calcium channel proteins, their opening and the release of myocytes mediating the transmission of signals of calcium ions from the sarcoplasmic reticulum to their membranes, where a difference in electrical potentials is created, leading to a reduction in muscle tissue fibrils.

When the action potentials dry up, fast calcium pumps (oligomeric proteins of ATPase), activated by sodium ions, return calcium back to the sarcoplasm, and the muscle relaxes. With a lack of sodium, ATPases do not work, calcium ions remain in the myofibrils, forcing the muscles to contract and causing convulsions.

Involuntary muscle contraction may also be due to the fact that the level of the excitatory neurotransmitter acetylcholine in the synaptic cleft of the processes of nerve cells (axons) increases - due to a lack of magnesium in the body, which, as an electrolyte, also participates in the regulation of the transmission of nerve signals by inhibiting the release of calcium and relaxing muscle fibers.

In addition, experts see the involvement in the pathogenesis of convulsive spasms of striated skeletal muscles of increased activity of the neuromuscular reflex arc at the site of tension receptors, stretching and contraction of muscles - the Golgi tendon organs of muscle spindles. [10]

Symptoms of the cramps in the calves

A spasm of the calf muscles can last from several seconds to several minutes, and the first signs that are felt at the onset of a convulsion are a sudden tension of the biceps gastrocnemius muscle: from a slight (accompanied by involuntary twitching of muscle fibers - fasciculation) to a very strong and painful - tetanic muscle contraction. [11]

In this case, the muscle is hard to the touch, often with visible irregularities; feet and toes also become stiff and tense; a feeling of tightness extends to both the popliteal fossa and the Achilles tendon area. In many cases, a leg hurts for some time after a cramp in the calf - in the back of the lower leg, below the popliteal fossa. [12]

But if there is pain in the calf of the leg like a spasm, then this may indicate deep vein thrombosis or atherosclerosis of the branches of the tibial artery; If there is sudden pain in the lower leg, muscle tear or tendonitis may be suspected. Read more in the publication -  Calf pain

Calf cramps at night are considered "normal" in late pregnancy and can range in intensity from mild to very painful. [13], [14]

Complications and consequences

If intense training causes severe cramps in the calves, then a day or two after such stress, excess lactate accumulates in the blood and muscle tissue. And this is manifested not only by cramps and a burning sensation and pain in the muscles, but also by weakness and nausea.

In some cases, consequences and complications appear with frequent and prolonged seizures of a tetanic nature, which can lead to weakening of muscles and tendon reflexes with partial atrophy of muscle fibers, as well as the development of intermittent claudication. [15]

Diagnostics of the cramps in the calves

If leg cramps occur from time to time, then medical diagnosis is not required. But when muscle cramps in the calves are frequent or unusually severe, unrelated to exercise, or do not improve with stretching and massage, then you cannot do without a doctor's appointment.

History is key because physical examination rarely shows seizures due to their unpredictability. However, the examination includes examination of the legs and feet, palpation of impulses and assessment of the sensation of touch and prick, the strength and depth of tendon reflexes. Blood tests (general, biochemical, sugar, electrolyte, creatinine, L-lactate, parathyroid hormone) and urine tests may be required. [16]

Instrumental diagnostics -  muscle study  - with frequent secondary seizures is carried out using muscle ultrasound, electromyography, ultrasound angiography (determining the state of the vessels of the legs), etc.

Differential diagnosis

The doctor must distinguish seizures from fasciculations in diseases of motor neurons and motor-sensory disorders, from restless legs syndrome and nocturnal myoclonus, myopathic and neuropathic conditions, from tonic seizures in case of dyskinesias of cerebral or toxic origin, for which it is based on anamnesis and examination results, differential diagnosis is carried out...

Treatment of the cramps in the calves

Most calf cramps resolve spontaneously within seconds or minutes.

But what if the spasm is very strong and painful, how to relieve the cramp in the calves of the legs? Strong stretching of the contracted muscle quickly relieves pain by slowly and smoothly bending the ankle to the front of the lower leg (this is easy to do with your hand on the toes). If the cramp does not go away from the first time, you need to repeat the indicated action, or straighten your leg and lift it up, bending at the ankle towards the lower leg. [17]

At the same time, it is necessary to massage the muscle, rubbing it with the palm or knuckles clenched into a fist, as well as pinching it with your fingers.

You can stand barefoot on a cold floor and lift your toes up, apply ice or a cold compress to the muscle. This will ease the pain, but a hot compress (hot water bottle) can help speed up muscle relaxation.

Treatment as such deals with cases of secondary seizures, the cause of which is known: etiological drug therapy can help alleviate this symptom.

If the convulsions are idiopathic, then a combination of exercises and drugs that help normalize the level of electrolytes is usually recommended:  Magne B6 forte  (Magvit B6, Magnefar B6, Magnikum, etc.),  Calcium glycerophosphate , Asparkam containing magnesium and potassium asparaginate or its synonym  Panangin . [18], [19]

Vitamins E, [20] D, B1, B6, B12 should be taken in courses .

And the antimalarial drug Quinine, which was previously used for seizures, has not been recommended by the FDA since 2004 because of its toxicity: there have been cases of fatal side effects provoked by thrombocytopenia and the breakdown of red blood cells. [21], [22]

Medicines of the muscle relaxant group are usually required only in the most persistent cases. Most often, Midocalm (Tolperisone) is used - 0.05 g three times a day (during meals). The drug can have side effects in the form of headaches and muscle weakness, as well as nausea and vomiting.

Do not look in pharmacies for special ointments or creams for cramps in the legs in the calves: they are not available, but ointments with menthol, camphor and essential clove oil can help. These are Efkamon ointments (Gavkamen (Flukoldeks) and Bom-benge. And also capsaicin ointments - Espol or Nikoflex, Apizartron (Virapin) ointment with bee venom.

Homeopathy recommends: Magnesia Phosphorica or  Magnesium phosphoricum salt of Dr. Schlusser No. 7 , Kali phosphoricum, Gnaphalium Polycephalum, Rhus Toxicodendron, Aconitum Napellus.

Physiotherapy treatment

For cramps in the calf muscles, physical therapy includes massage and stretching exercises.

Exercise 1: stand facing the wall at a distance of outstretched arms and, leaning on it with your palms, lean forward - without bending your legs and without lifting your heels off the floor; hold this position for 5-10 seconds and return to the starting position. Start with 5 repetitions, working up to 15-20.

Exercise 2: stand in the same way, but one leg is slightly bent at the knee and put forward; when leaning against the wall, the heel of the straightened leg does not come off the floor surface. Hold this position for 15-20 seconds; change legs, then alternate them for 5 reps.

Exercise 3: Stand on a step (fitness step) with the front of both feet, with your heels hanging over the edge. Slowly lower your heels below the level of the step; linger for a few seconds and return to the starting position. Repeat 10-15 times. [23]

Alternative treatment

For cramps, alternative treatment offers rubbing the calf muscles with bischofite containing magnesium and calcium chlorides. [24] This tool cannot be used for skin, cardiovascular and oncological diseases. 

It is also recommended to take a bath with Epsom salts (magnesium sulfate heptahydrate), and if you sweat a lot, drink water slightly salted with regular table salt.

It is useful to drink water once (in the evening) a day with the addition of apple cider vinegar (a tablespoon in a glass of warm water, you can put a teaspoon of honey).

To rub the muscles, an oil mixture is made based on ordinary vegetable oil (4 tablespoons of refined sunflower oil) with the addition of 20 drops of clove essential oil.

For seizures, herbal treatment is limited to peppermint and thyme (thyme), preferably fresh, since dried plants lose a significant amount of magnesium. It should be borne in mind that mint is contraindicated in hypotension, varicose veins and pregnancy, and thyme cannot be used by both pregnant women and people with kidney problems or stomach ulcers. [25]

Also, herbal medicine advises to drink decoctions of rose hips, tricolor violets and three-leaf watch. Decoctions are prepared at the rate of a tablespoon of dry herb per 250 ml of water, take 50 ml two to three times a day.

Ginger root contains a lot of magnesium, so it is advisable to drink ginger tea to reduce muscle cramps and, ultimately, to completely eliminate them. [26]

Prevention

The best prevention of calf muscle cramps is moderate physical activity, which helps to activate blood flow and improve muscle tissue trophism. Therefore, before training, athletes warm up.

And for people far from sports, it is useful to perform several light stretches of the muscles of the lower legs in the morning and in the evening (the exercises were described above).

Also take note of the following expert tips:

• do not overexert yourself, listen to your body and do not try to go beyond your capabilities;
• wear comfortable shoes;
• drink enough water;
• Limit alcohol and coffee as they can drain fluid from your body.

The diet should contain more foods that contain a lot of magnesium (bran bread, legumes, nuts, bananas, black currants, cherries, dried apricots, prunes, persimmons, seaweed, spinach, parsley and dill, sea fish), potassium (raisins, nuts, jacket potatoes, bananas, apricots, tomatoes, oatmeal, buckwheat), calcium (dairy products, cabbage, garlic, parsley).

Forecast

For most people, the prognosis for occasional cramps in the calves is good. If convulsions are regular, then, given their possible causes, this symptom can be considered chronic, requiring treatment of the underlying pathology.