Oh no ! It’s a cramp.

Dr Yogesh Panchwagh
Orthopaedic Oncosurgeon

Recreational triathlete
Long distance runner
Trekker
 EAMC = Exercise Associated Muscle Cramps
• painful, involuntary contraction of a
skeletal muscle during or shortly after
exercise.

• typically occur in muscles that span

multiple joints and are frequently used
during exercise
Inaccurate terms
• Heat Cramps
( Not asso. With body temp / not relieved imme. with cooling modalities)

• spasms
• contractures
• tics
• Fasciculations
• Tremors
(Not painful or are asso. with other disorders)
Severity range…

• An Evidence-Based Review of the Pathophysiology, Treatment, and Prevention of Exercise-Associated Muscle Cramps, Kevin
C. Miller et al, Journal of Athletic Training 2022;57(1):5–15
Incidence
• Varies considerably with sports / age / sex

• American football: 3.07/1000 athlete exposures

• 56 km Ultramarathon: Severe EAMCs: 1.01 – 2.2 / 1000 race
starters

• Risk factors:
less experienced , older , faster runners
 Pathophysiology
• Dehydration & Electrolyte imbalance
• Sweating – reduces interstitial fluid space – increases excitatory
neurotransmitters & mechl pressure on the nerve terminals

Highly Debated :

• Na+ loss with fluid loss should maintain interstitial fluid

• no differences in plasma volume, red cell volume, body mass lost, or
plasma electrolyte concentrations during competition between
athletes with and those without EAMCs
• Losses are systemic : why only working muscles cramp ?
• Crampers drink equivalent liquids as non crampers
• Altered neuro-muscular control theory:
• Fatigue + other risk factors : overexcitation of the motor nerves.

• Pro :
• fatigue in working muscles, near end of competition
• Non crampers produce greater amount of muscle inhibition through Golgi tendon
organs

• Con:
• well conditioned athletes also develop EAMCs
• So, fatigue can't be the sole generator of cramps
• Multifactorial theory:
• Numerous unique intrinsic and extrinsic factors coalesce through
different pathways and elicit EAMCs

• a factor threshold must be reached before EAMCs occur and that this
threshold may be positively or negatively mitigated by other risk factors

• when predisposed individuals with intrinsic risk factors are exposed to

extrinsic factors and exceed their factor threshold, EAMCs occur.
Pathophysiology
 Diagnosis
• Occurs acutely during or after exercise

• noticeable pain, often resulting in slowing or ceasing

activity altogether

• Prior symptoms: muscle twitching (cramp-prone state)

• Muscle – rigid; joint – locked in its end range of motion

 Signs
• visible and palpable knotting or tautness

• Fasciculations that wander over the muscle

• EAMC + other medical conditions (hyponatremia):

immediate referral
Treatment :
• Rest & pain relievers

• Some finish activity, some can’t

• Rest : normalizes NM activity , reduces underlying cause e.g.
depleted energy
• Pain relievers : cryotherapy , massage, electrical stimulation
interrupt the pain-spasm-pain cycle
Treatment
• Stretching

• fastest, safest, and most effective treatment

• self-administered or clinician-administered

• static stretching increases tendon tension, and elongated muscles

produce the greatest Golgi tendon organ inhibition

• physically separates the contractile proteins

• If this fails -> seek advance medical care

 Treatment
• Rehydration

• water or carbohydrate-electrolyte
beverages as necessary

• Oral fluids require about 13 minutes

(or more) to be absorbed

• hypotonic compared with plasma,

large quantities needed -> dilutional
hyponatremia : life threatening
• Rehydration : route

• Oral : simplicity, accessibility

• i.v. : only by professionals , in time sensitive situations, lot of pain / vomitting

• Comparable restoration of parameters by either oral or i.v.

• perceptual measures (eg, thirst, thermal sensation, and rating of perceived

exertion) are often lower with oral rehydration because IV fluid delivery
bypasses fluid volume receptors in the mouth (i.e. baroreceptors)
• Transient Receptor Potential channel Agonists

• Transient receptor potential (TRP) channels detect temperature and

sensations in the mouth, oropharynx, esophagus, and stomach.

• vinegar, cinnamon, capsaicin, and ginger activate these receptors and, in

theory, may affect neural function – inhibits cramping (pickle juice)

• Mustard : anecdotal evidence

Does not prevent cramps if ingested prior ( or has insignificant +ve changes)

• Ingestion : benign , <100ml, needs GI Tolerance and no allergy, takes 50-69

seconds to act
• Bananas ??

• High potassium and glucose content

• Sometimes used
• No evidence
• Does not increase plasma potassium concentrations or plasma
volume until 60 minutes after consumption
• Quinine and quinine products (Tonic water)

• Out of favour now

• Cochrane review 23 studies :
reduces number & intensity , but not duration of cramps
• Adverse effects : GI , thrombocytopenia

• Not recommended
 Recurrent EAMC : frequent cramping
• risk factors
history of injury,
past EAMC history,
chronic medical conditions
medication use
muscle damage
prolonged exercise durations
faster finishing times than anticipated
• Correction :

• sufficient sleep

• incorporating rest and recovery sessions in training schedules

• training at similar intensities and in similar environments to competition

Prevention of EAMCs
• Anecdotal, lacks evidence
• Address the risk factors

• Hydration and electrolytes are overemphasized

• Mg supplementation : no benefit in a Cochrane review
• Carb – electrolyte drinks : theoretically increase glycogen, delay
fatigue
• Caffeine : be careful : increases NM excitability
Hydration assessment ?
• Sweat testing
• Same conditions as in competition
• Weight before and after

• Sweat electrolyte loss : requires sophisticated set up

• well-balanced, nutritious diet that considers the athlete’s unique

carbohydrate, fluid, and electrolyte needs.
Prophylatic stretching ?
• Good for treating EAMC
• Ineffective as prophylaxis
Exercise and Neuromuscular Retraining Protocols
• Strength training reduces cramps
• Study: Once a week ST in 3 months before race -> less cramping
• Appropriate work-to-rest ratios
• An Evidence-Based Review of the Pathophysiology, Treatment, and Prevention of Exercise-Associated Muscle Cramps, Kevin
C. Miller et al, Journal of Athletic Training 2022;57(1):5–15
Summary
• alterations in neuromuscular excitability - predominant factor in EAMC
pathogenesis.

• Dehydration and electrolyte losses : less significant

• EAMC treatments include exercise cessation(rest) and gentle

stretching until abatement, followed by techniques to address the
underlying precipitating factors

• Individualised targeted approach that incorporates an individual’s

unique EAMC risk factors when trying to prevent EAMCs