After 33 years of being an ER doc, I had a first time chief complaint. A 60+ year old patient came to the ER around 0400 complaining of painful leg cramps. The patient reeked of Ben-Gay and it took a great deal of control, to not start laughing at the less than urgent nature of the patient's problem. As an example of Karma, I spent my first not at home (after my usual three 10 hour nights from hell) walking around the house trying to relieve my own painful calf and foot cramps. I especially hated the fact that my left big toe was painfully sticking up like a flag pole.
Leg cramps, aka Charley horse, are not restless leg syndrome. RLS is a movement disorder that is treated with meds for Parkinson's disease. Although RLS is uncomfortable and may be associated with some muscle cramping, it is not nocturnal leg cramps. Cramps are painful contractions of the thigh, calf and/or foot muscles.
Any athlete will recognize the painful muscle cramping that occurs during or immediately after heavy exercise, especially in hot weather. Dehydration, electrolyte loss through sweating, and the build up of lactic acid in the muscles from anaerobic metabolism can lead to these painful muscle contractions, sometimes referred to as heat cramps. When the diaphragm is involved the dolorous spasm may be called a "stitch".
Nocturnal leg cramps have been linked to sitting for long periods of time, dehydration, overuse of the muscles, standing or working on concrete floors and a number of medications. The list of prescriptions medication includes diuretics, statins, lithium, and morphine. The incidence of nocturnal leg cramps increases with age and is occasionally associated with diabetes and peripheral vascular disease and infrequently with endocrine disorders such as hypothyroidism and hypoglycemia.
There is no well established treatment for nocturnal leg cramps. Good hydration, stretching of the calf muscles before bed, having loose bed clothes and linen, even riding an exercise bike have been proposed as preventatives. Eating potassium rich foods, such as bananas and oranges is recommended. Drinking water before bed may be helpful but, will lead to another night problem for men in my age demographic.
Quinine is a medication that was (and sometimes still is) used to treat malaria. As a doctor back in the 70's, many of the elderly patients that I treated were taking quinine nightly to prevent leg cramps. There is no double blind study that definitely shows improvement in the frequency or intensity of leg cramps by taking quinine. Anecdotal reports have perpetrated the continued use of quinine for this condition. My patient had taken quinine sulfate when he was awakened by his painful cramps. The down side of quinine is significant. Side effects include headache and tinnitus (ringing in the ears), thrombocytopenia (low platelet count), cardiac rhythm disturbances, and fatal hypersenitivity reactions.
Diltiazem, a calcium channel blocker used to treat hypertension and rapid heart rates, has been tried with some success to treat nocturnal leg cramps. Vitamin B6 30 mg daily has also been proffered as a treatment option. Neither has been subjected to a well controlled study.
So it is 3 AM and you are awakened by painful cramps in your lower extremities; what do you do? First, get out of bed and begin to walk around. Drink some water. Gently massage the involved muscles. Take a warm shower or bath. Do some stretching of your calves.
If you are plagued with frequent nocturnal leg cramps, talk to your primary care doctor. A check of your electrolyte levels, thyroid function and possibly even EMG (electromyelography) may be helpful in finding a treatable cause.
Update on my status: I have 12 shifts left at the General Hospital. Working another Sunday- Tuesday for the Memorial Day Weekend, will reinforce the need to find greener (less stressful) pastures. The new night shift at The General will commence in June. The hours will be 10PM to 6AM. I have nine of these truncated shifts before my final night on June 25. I will begin my new job around July 18th. My schedule will be 11PM to 7 AM working 12 shifts per month. The night shift census is 4-6 patients. I have been averaging 25 patients per 10 hour night at The General.
