- Risk Factors
What are muscle spasms?
- Spasms can affect many different types of muscles in the body, leading to many different symptoms.
- Spasms of skeletal muscles are most common and are often due to overuse and muscle fatigue, dehydration, and electrolyte abnormalities. The spasm occurs abruptly, is painful, and is usually short-lived. It may be relieved by gently stretching the muscle.
- If muscle spasms are especially painful, if they do not resolve or if they recur, medical care should be accessed to look for other possible underlying causes.
- Smooth muscles that are within the walls of hollow organs (like the colon) can go into spasm, causing significant pain. Often this pain is colicky, meaning that it comes and goes. Examples include the pain associated with menstrual cramps, diarrhea, gallbladder pain, and passing a kidney stone.
- A special form of muscle spasms is the dystonias where an abnormality perhaps exists with the chemicals that help transmit signals within the brain. Examples include torticollis and blepharospasm. Treatment may include medications to help restore the neurotransmitter levels to normal and Botox injections to paralyze the affected muscle and relieve the spasm.
What are the types of muscle?
Muscles are complex structures that cause movement in the body. There are three types of muscle in the body:
- Heart muscle pumps blood (cardiac muscle).
- Skeletal muscle moves the external body parts, like the arms and legs, neck, back, trunk, and face.
- Smooth muscle moves portions of hollow structures inside the body. Examples include the muscles that line the esophagus, stomach, and intestines, muscles that line large arteries, and the muscles of the uterus.
What is skeletal muscle?
Skeletal muscles are anchored to bone, either directly or by a tendon. When the muscle contracts, the associated body part moves. This allows arms to lift, legs to run, and the face to smile. Most of these muscles are under the willful or conscious control of the brain. This type of muscle is striated or striped with dark-colored muscle fibers containing large amounts of myoglobin, the protein that helps carry oxygen, and light-colored fibers that have lesser amounts of protein. The contraction of a skeletal muscle requires numerous steps within its fibers and cells. The nutrients required to produce energy, oxygen, electrolytes, and glucose are supplied by the bloodstream.
What is smooth muscle?
Smooth muscle is located in the walls of hollow internal structures in the body, like the arteries, intestines, bladder, and iris of the eye. They tend to circle the structure and when they contract, the hollow structure is squeezed. These muscles are involuntary and are controlled by the unconscious part of our brain function using the autonomic nervous system. The autonomic nervous system always runs in the background, regulating processes within the body. There is a balance between the sympathetic system (adrenergic nerves) that speeds things up and the parasympathetic system (cholinergic nerves) that slows things down. These names are based on the type of chemical that is used to transmit signals at the nerve endings. Adrenaline (epinephrine from the sympathetic nervous system) allows the body to respond to stress. Imagine seeing a bear in the woods; your heart beats faster, your palms get sweaty, your eyes dilate, your hair stands on end, and your bowels move, all because the sympathetic nervous system is activated. Acetylcholine is the chemical that is anti-adrenaline and is involved in the parasympathetic nervous system that acts to calm us down. Smooth muscle has the same basic contraction mechanism as skeletal muscle, though different proteins are involved.
What causes muscle spasms?
A muscle spasm, or muscle cramp, is an involuntary contraction of a muscle. Muscle spasms occur suddenly, usually resolve quickly, and are often painful.
A muscle spasm is different than a muscle twitch. A muscle twitch, or fasciculation, is an uncontrolled fine movement of a small segment of a larger muscle that can be seen under the skin.
There are a variety of causes of muscle spasms, and each depends upon predisposing factors, the part of the body involved, and the environment that the body is in.
Spasms may occur when a muscle is overused, tired, previously injured, or strained.
- The spasm may occur if the muscle has been overstretched or if it has been held in the same position for a prolonged period of time.
- In effect, the muscle cell runs out of energy and fluid and becomes hyperexcitable, resulting in a forceful contraction.
- This spasm may involve part of a muscle, the whole muscle, or even adjacent muscles.
Overuse as a cause of skeletal muscle spasm is often seen in athletes who are doing strenuous exercise in a hot environment.
- This is also an occupational issue with construction workers or others working in a hot environment.
- Usually, the spasms will occur in the large muscles that are strained, being asked to do the work.
- When this occurs associated with heat exposure, the condition is also known as heat cramps.
Overuse can also occur with routine daily activities like shoveling snow or mowing or raking grass, causing muscle spasms of the neck, shoulder, and back.
Other causes of muscle spasms
- Unfamiliar exercise activities can also cause muscle spasms to occur. Abdominal spasms can occur when a person decides to begin working their abdominal muscles by doing sit-ups and repeating too many too quickly.
- The writer's cramps of the hand and fingers are similarly caused by prolonged use of the small muscles in the hand and the overused muscles cramp. People will routinely rest and stretch their fingers either to prevent or treat this situation.
- It is commonly thought that dehydration and depletion of electrolytes will lead to muscle spasms and cramping. Muscle cells require enough water, glucose, sodium, potassium, calcium, and magnesium to allow the proteins within them to develop an organized contraction. An abnormal supply of these elements can cause the muscle to become irritable and develop spasms.
- Atherosclerosis or narrowing of the arteries (peripheral artery disease) may also lead to muscle spasms and cramps, again because an inadequate blood supply and nutrients are delivered to the muscle. Peripheral artery disease can decrease the flow of blood to the legs, causing pain in the legs with activity. There may also be associated muscle cramps.
- Leg spasms are often seen related to exercise, but cramps may also be seen at night involving calf and toe muscles. Nocturnal leg cramps and restless legs syndrome are considered a type of sleep disturbance. Their prevalence increases with age and often a precise cause is not found.
- Chronic neck and back pain can lead to recurrent muscle spasms. Large muscle groups make up the trunk, including the neck, chest wall, upper back, lower back, arms, and legs. Spasms in these muscles can be a result of an injury or they may develop over time because of arthritic changes in the spine. Obesity can cause stress and strain of the core muscles of the trunk, resulting in muscle cramps of the neck and upper and lower back. Systemic illnesses like diabetes, anemia (low red blood cell count), kidney disease, and thyroid and other hormone issues are also potential causes of muscle spasms.
- Diseases of the nervous system, such as amyotrophic lateral sclerosis, multiple sclerosis, or spinal cord injury, can be associated with muscle spasms.
- Smooth muscle can also go into spasm. When a hollow structure filled with air or fluid is squeezed by the muscle spasm, significant pain may occur, since the fluid or air cannot be compressed. For example, smooth muscle in the intestinal wall can go into spasm, causing waves of pain called colic. Colicky pain which tends to come and go may also occur within the bile duct that empties the gallbladder and may develop after eating.
- When kidney stones try to pass through the urinary tract, the smooth muscles that are in the walls of the ureter (that connects the kidney to the bladder) may spasm rhythmically and cause significant pain. Often this type of pain is associated with nausea and vomiting and is called renal colic.
- Muscles that surround the esophagus can go into spasm when acid reflux causes irritation of the lining of the esophagus, resulting in esophagitis or GERD (gastroesophageal reflux disease).
- Diarrhea can be associated with colicky pain, where the muscles within the colon wall spasm just before a watery bowel movement.
- Menstrual cramps occur when the walls of the uterus contract forcefully.
- The coronary arteries that supply the heart muscle with blood also have smooth muscle within their walls that may go into spasm. This can cause chest pain that may be indistinguishable from the pain of coronary artery disease (where plaque has accumulated and narrowed the arteries). Coronary artery spasm often occurs in smokers or those who have high cholesterol blood levels. Coronary artery spasm may be triggered by stress, alcohol withdrawal, stimulant drug abuse (especially cocaine), or medications that can constrict or narrow blood vessels. Coronary artery spasm is also known as Prinzmetal's angina.
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Dystonias and muscle spasms
- Dystonias are movement disorders where groups of muscles forcefully contract and cause twisting. Uncontrolled repetitive movements and the inability to maintain normal posture may be the result of this type of muscle spasm and cramping. The symptoms may be very mild initially but gradually progress to become more frequent and aggressive. Occasionally, there is no progression. Examples of this type of muscle spasm include torticollis (where the neck muscles spasm and cause the head to turn to one side), blepharospasm (where there is uncontrolled blinking of the eyes), and laryngeal dystonia that affects the muscles that control speech. Dystonias may be caused by abnormally functioning neurotransmitter chemicals within part of the brain called the basal ganglia. These chemicals (serotonin, dopamine, acetylcholine, and GABA) are required to properly send messages between brain cells that begin muscle contraction. Dystonia symptoms may occur as a complication of stroke.
What are risk factors for muscle spasms?
Most people are at risk for developing a muscle spasm at one time in their life, from infant colic to kidney stones. The risks differ depending upon the person's past medical history, their occupation, and level of physical activity. Examples include the following:
- Construction and factory workers who work in hot environments are at risk for becoming dehydrated and developing heat cramps. This same situation can occur in athletes, both elite and recreational.
- Patients with peripheral artery disease can develop leg cramps at night. Risk factors are the same as for stroke and heart attack: high blood pressure, high cholesterol, diabetes, and smoking.
- Patients who have underlying neurologic disorders are at risk for developing muscle spasms.
What are the symptoms of muscle spasms?
The symptoms and signs of muscle spasm depend upon the muscle involved and the circumstances leading up to the spasm.
- Skeletal muscle spasm usually involves muscles that are being asked to do excessive work. There is acute onset of muscle pain as it contracts. A bulging, tight muscle may be seen or felt underneath the skin where the muscle is located. Most often, the spasm resolves spontaneously after a few seconds though it may last many minutes or longer. Usually, those affected will feel the need to stretch the muscle involved, thus relieving the spasm and resolving the episode. With heat cramps, the muscle spasm may occur minutes or hours after the activity is completed.
- A muscle fasciculation or twitch may last just a few seconds or may be a recurrent event. Usually, it's just a momentary repetitive contraction of just a few muscle fibers of a larger muscle in a localized area served by one nerve fiber. This often involves the eyelid, calf, thigh, or thumb. The fasciculations often come and go and may be related to stress, anxiety, or the ingestion of stimulants like caffeine. The stimulants pseudoephedrine or phenylephrine found in over-the-counter cold medications may also cause this twitch. Medications such as albuterol (Ventolin, Proventil, AccuNeb, VoSpire, ProAir) used for the treatment of asthma and medications used to treat attention deficit disorder (Adderall) may be associated with twitching. These twitches are considered harmless and are referred to as benign fasciculations.
- However, muscle twitching may also be associated with neurologic disorders such as muscular dystrophy, amyotrophic lateral sclerosis, and myopathy (a primary muscle illness). With these diseases, associated symptoms include weakness, muscle wasting with loss of muscle size, and change in sensation.
- Smooth muscle spasm will cause colicky pain that comes and goes. The symptoms will depend upon the organ involved.
How long do muscle spasms last?
Skeletal muscles cramps or spasms tend to last only a few seconds, and the patient feels the need to stretch the muscle to resolve the spasm.
Smooth muscle cramps may last for a prolonged period of time until the underlying problem that caused the spasm is resolved. Renal colic can last for hours, as can colicky pain with diarrhea or menstrual cramps.
Involuntary muscle twitching is a significant problem because it may last for prolonged time frames and need medications to control or resolve the spasm and the associated pain.
Diagnosis of muscle spasms
Most people have experienced a skeletal muscle spasm due to overexertion, especially in a warm environment, and are able to self-diagnose. However, if the spasms are severe, last a long time, or keep recurring, it is reasonable to see a health-care professional for an evaluation.
The diagnosis usually begins with a history and physical examination. It is helpful to know the circumstances surrounding the muscle spasms.
- When did they begin? How long do they last? How frequently do they occur? Are they rhythmic or more random? Is it always the same muscle group of the body involved?
- Other information that is helpful includes understanding the general health of the patient and whether there have been any recent illnesses or whether any medications have been taken, including prescription medications, over-the-counter medications, food supplements, and herbal remedies.
- The past medical history may give a clue as to the reason for the muscle cramps. These may include a history of diabetes, hypothyroidism, kidney disease, and spinal cord injury.
- Work or exercise history may be of importance.
- The environment is also important information regarding heat exposure and associated signs and symptoms of dehydration.
Sometimes the physical examination may be normal since the muscle spasms may not be present during the visit. However, the physical examination may useful in detecting underlying health issues that may be helpful in making the diagnosis. For example, if the patient is complaining of leg muscle cramps, the examination may include palpating or feeling for pulses in the feet. Atherosclerosis, or hardening of the arteries, may be associated with the loss of arterial pulse in the involved extremity.
For those having pain from smooth muscle spasms, the pain may be severe enough to present to an emergency department. The history and physical examination will be directed to finding the source of the pain, while at the same time trying to control the symptoms. Kidney stone pain (renal colic) and gallbladder pain sometimes require anti-inflammatory or narcotic pain medication. They are often associated with nausea and vomiting and these symptoms may also require treatment. Some patients with irritable bowel conditions may also present with significant intestinal spasms, abdominal pain, and constipation or diarrhea.
For patients with recurrent muscle spasms where the cause is not easily diagnosed by history and physical examination, testing may be necessary to give direction as to potential causes. Blood tests may or may not be indicated depending upon the situation and whether or not the diagnosis can be adequately attained by history and physical examination. Blood tests may include a complete blood count (CBC) looking for anemia, electrolytes (especially sodium, potassium, calcium, and magnesium), glucose, and creatinine (to check for kidney function). Thyroid function tests may also be considered.
If muscle spasms are prolonged and ongoing, there may be a concern that muscle breakdown and damage are occurring. A creatine phosphokinase (CPK) blood test can be used to detect this. It is an enzyme released into the bloodstream by irritated or damaged muscle tissue. Rhabdomyolysis can lead to kidney failure.
If there is concern that the spasms are due to a nerve or muscle disorder, electromyography (EMG) may be done to determine whether there may be an abnormality of the muscle, of the nerves, or both.
If there is concern about the potential for peripheral artery disease, tests of blood flow to the legs may be considered, including an ankle-brachial index (ABI) which compares blood pressures in the arms and legs and ultrasound and angiography (often using CT or MRI) to directly assess the blood vessels.
If nocturnal leg cramps are thought to be associated with a sleep disturbance, sleep studies might be indicated.
What are the treatments for muscle spasms?
Primary-care providers treat patients with muscle spasms. Often, the spasms tend not to cause prolonged symptoms that require emergent or urgent care, and the patient sees their regular health care provider for evaluation and treatment.
However, some situations require more aggressive intervention, depending upon the situation, and emergency providers often see those with illnesses associated with smooth muscle spasm, including abdominal or chest pain that may ultimately be diagnosed as kidney or gallbladder colic, irritable bowel syndrome, or esophageal spasm.
Skeletal muscle spasm might be evaluated by emergency physicians when there is also heat-related illness present or there is concern regarding muscle damage.
Different situations may require the services of specific specialists. For example, patients who have leg cramps may have a sleep disorder and may need care by a sleep specialist. Neurologists care for patients with movement disorders. Endocrinologists help control diabetes. Vascular surgeons may be required to discuss treatment options for patients with peripheral vascular disease.
Should a large skeletal muscle go into spasm (often referred to as a charley horse), the initial treatment is to gently stretch the muscle back to length to break the spasm cycle and resolve the acute situation. For example, first aid for a hamstring spasm (where the muscles in the back of the thigh are affected) includes straightening the knee joint and flexing the hip, which stretches the muscles and helps resolve their spasm.
Further treatment will depend upon the underlying cause of the muscle spasms. For muscles that have been damaged or strained, medications may be required for short-term pain relief, including anti-inflammatories (ibuprofen [Advil, Motrin]), narcotics, and muscle relaxants.
The treatment of smooth muscle spasms, such as bowel spasm, depends upon diagnosing and treating the underlying cause.
Nocturnal leg cramps are difficult to control and treat. Historically, quinine has been prescribed to help with the muscle spasms, but this drug can have side effects including abnormal bleeding problems. Other medications, including B-complex vitamins, gabapentin, and diltiazem, may be helpful.
Many possible treatments are available for dystonias. The decision as to which medication to use depends upon the individual situation. It may take trial and error to find the right medication in the right dose to control symptoms.
- Anti-Parkinsonism drugs, like trihexyphenidyl HCl (Artane) and benztropine mesylate (Cogentin), decrease acetylcholine levels.
- Muscle relaxants like diazepam (Valium) and baclofen (Lioresal) affect GABA receptors.
- Levodopa (Sinemet) and reserpine (Harmonyl) affect dopamine levels.
- Carbamazepine (Tegretol), a seizure-control drug, may be useful in some patients.
- Botulinum toxin type A (Botox) may be injected into a specific muscle to paralyze it and relieve the muscle spasm of dystonia, such as for blepharospasms.
What is the prognosis for muscle spasms?
Most people experience infrequent muscle spasms and do well with prevention (keeping well hydrated and not overusing their body).
However, those who have an underlying medical condition as a cause of muscle spasms often need to treat the original medical problem to help control the muscle spasms. This is especially true for those with peripheral artery disease or movement disorders.
Is it possible to prevent muscle spasms?
Prevention is the key to most skeletal muscle spasm episodes. Since they are often associated with dehydration and electrolyte disturbances, it is important to keep the body well hydrated. If the fluid loss is due to an illness with fever or vomiting and diarrhea, controlling the symptoms will help limit the fluid loss and prevent spasms. Similarly, for those who work or exercise in a hot environment, drinking enough fluids to keep hydrated is very important. It is often helpful to hydrate prior to activities in warm environments.
Muscles should also be prepared for the activity that they are expected to do. Just as athletes stretch and warm-up before the game, nonathletes should warm-up before heavy labor, including jobs like raking, mowing, and shoveling snow.
Daroff, R.B., et al. Bradleys' Neurology in Clinical Practice, 6th Edition. Philadelphia: Elsevier Saunders, 2012.
Kasper, D., et al. Harrison's Principles of Internal Medicine, 19th Edition. McGraw Hill Education/Medical, 2015.
Rakel, Robert E., and David P. Rakel. Textbook of Family Medicine, 9th Edition. Philadelphia: Elsevier Saunders, 2015.
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