Nocturnal Calf Cramps and Restless Leg Syndrome

Paul L. Reller L.Ac. / Last Updated: August 03, 2017

Nocturnal calf or leg cramps, usually in the medial gastrocnemius muscle, occur in a high percentage of the population. Studies in the past have found that greater than 40 percent of a randomly selected patient population in the United States reported some incidence of nocturnal calf cramps, with higher incidence among women in the older age groups. Both young and old complain of this problem, though, and certain habitual work habits, such as sitting too long without movement, especially with the foot held in plantar flexion, create a very high incidence of this problem. Given the varied demographics, an individualized assessment may be necessary for the patient to fully understand the perpetuating factors in each case. This article describes the scientific research and various components of the problem, so that the patient with a more troublesome syndrome may gain some insight into the causes, perpetuating factors, disease contributors, and various therapeutic protocols that may be utilized. Since most of these problems involve a myofascial neuromuscular disease mechanism, a Licensed Acupuncturist with skills and knowledge of myofascial release, trigger point needling, and soft tissue physiotherapy, as well as herbal and nutrient therapy, may be an excellent choice to cure this problem with a comprehensive strategy.

In 2012, the medical journal American Family Physician published a report that nocturnal leg cramps may be increasing in prevalence, with up to 60 percent of adults reporting a history of this problem. Research still has not produced a clear mechanism for these nocturnal leg cramps, but muscle fatigue and nerve dysfunction, such as akathisia in Restless Leg Syndrome, appear to be more central to most cases than electrolyte imbalances or other abnormalities. Simple remedies thus may not work for a majority of patients, and a more holistic approach may be necessary. Not only an array of treatment modalities, but avoidance of primary causes may be necessary to fully cure nocturnal calf or leg cramps. A number of medications are now found to be strongly associated with nocturnal leg cramps. These include conjugated estrogens (estradiol sulfates, estrone, equilin) commonly used to treat postmenopausal symptoms and osteoporosis, raloxifene (Evista), a selective estrogen receptor modulator (SERM) used to treat osteoporosis and breast cancer, naproxen, an NSAID pain reliever (Aleve, Midol, Naprosyn, Synflex), and Teriparatide, a synthesized parathyroid hormone used to treat osteoporosis, and perhaps chronic use of statin drugs to control cholesterol. This report stated that evidence supports targeted stretch and exercise, magnesium potassium supplement, magnesium and calcium aspartate supplement, and Vitamin B12 (PMID: 22963024). A differential diagnosis of nocturnal leg cramps should rule out restless leg syndrome, intermittent claudication, myositis (chronic muscle inflammation), and peripheral neuropathy.

Nocturnal calf or leg cramps are an increasingly common health problem for adults and the aging population in the United States, and standard medicine has little to offer to treat this problem. Scientific study in recent years have identified an array of causes that may work together to produce this annoying problem that decreases sleep quality and increases stress. These factors, myofascial syndromes of muscle contracture and fatigue, peripheral nerve dysfunction and neuropathy, poor delivery of magnesium, sleep disorders, restless leg syndrome, peripheral vascular disease, and hormonal imbalance, call for a holistic treatment approach that combines physiotherapy, instruction in targeted stretch and exercise, nutrient and herbal medicine, and acupuncture. Traditional Chinese Medicine, and the Licensed Acupuncturist, may be an ideal addition to your medical care to finally stop nocturnal calf and leg cramps.

Increasingly, modern medicine is now equating nocturnal calf cramps, or nighttime leg cramps (NLC), called systremma, with Restless Leg Syndrome (RLS), a pathology that was treated with derision in standard medicine for decades, as if it didn't really exist. Both of these pathologies are hard to objectively diagnose, depending on clinical assessment and a diagnosis of exclusion, meaning that standard medicine will first conduct a number of tests and refer to various specialists to rule out other causes of leg pain, which may be very frustrating to the patient. In 2014, experts at the Parkinson's Clinic of Eastern Toronto and Movement Disorders Centre, in Scarborough, Ontario, Canada, released a report on these now prevalent pathologies and stated: "The similarity of RLS (Restless Leg Syndrome) and (nocturnal) leg cramps poses the issue of errors in diagnosing and differentiating the two" (PMID: 24931546). There is obviously a potential comorbidity for these two problems, but a definite difference in cause and pathological mechanisms that must be addressed in treatment protocol. A one-size-fits-all approach in modern allopathic medicine, hoping for a simple single drug regimen to alleviate symptoms, not correct the underlying problem, leads to such broad oversimplification and generalization, but does not help the intelligent patient try to understand and take a holistic approach to correcting their problem. If simple solutions work, great, if not, one must proceed to a more complex treatment protocol with Complementary and Integrative Medicine (CIM). Many intelligent patients may question the need to start with a harsh drug regimen in standard medicine, with multiple Parkinson's disease dopaminergic drugs, especially as these drugs come with considerable incidence of adverse health effects. The course of therapy in CIM may start with a very simple holistic approach, and if these are not effective, progress to more complex holistic treatment protocols.

Restless Leg Syndrome (RLS) is still a poorly understood Movement Disorder, and affects up to 15 percent of the U.S. population now. The specific term for this CNS movement disorder is akathisia, defined as a state of restlessness, agitation or distress that is an occasional side effect of antidepressant and antipsychotic medication. With the enormous rise in prescriptions for these drugs, often now given cute generic names such as Abilify, there is little doubt of the association with the large concurrent rise in Restless Leg Syndrome, and while the newer atypical antipsychotic medications showed a lower risk of akathisia and extrapyramidal symptoms than prior antipsychotic medications, clinical trials of aripiprazole (Abilify) still showed an incidence of this side effect in up to 15 percent of the subjects with short-term use. Long-term studies are not available. Since such newer atypical antipsychotic medications are heavily marketed and prescribed for depression that is poorly controlled by standard SSRI and SSNRI medications, and prescribed as an additional drug, this presents increased risk of Restless Leg Syndrome over time, as these antidepressant drugs are also well known to cause akathisia. Chronic concurrent use of these drugs affects the liver function and may lead to gradual higher dosage accumulation of these drugs in individuals as well, increasing the risk for RLS over time. Many experts now distinguish drug-induced akathisia from Restless Leg Syndrome, a sensorimotor CNS disorder, perhaps in the category of dystonias, or periodic and rhythmic movement disorders. This may be true, but unclear, and the diagnosis of these various disorders is even less clear. Since Restless Leg Syndrome is now associated with imbalance in the dopamine system, as well as imbalances in endorphins and orexin, and iron metabolism dysfunction in the CNS, inflammatory and immune dysfunction, and multiple genetic and epigenetic links, this disorder obviously demands a holistic approach, and will need some persistence to reverse. Other medications that have been implicated in the triggering of akathisia, or Restless Leg Syndrome, include the anti-anxiety medication buspirone (Buspar), calcium channel blockers for hypertension, antivertigo medication, anti-emetics, and pre-operative sedatives, and many cases are chronic and tardive (delayed onset) that are difficult to directly equate with acute use of the drug or combination of drugs, which of course would increase the risk.

Differentiation of these 2 similar presentations, Nocturnal Calf Cramps (systremma) and Restless Leg Syndrome (akathisia) is very important, and identifying patients with both of these disorders is obviously very important as well. The approaches to therapy must address the array of causative underlying factors in each of these pathologies, and Complementary and Integrative Medicine (CIM), in the form of the Licensed Acupuncturist and herbalist that is skilled in soft tissue mobilization, or Tui na, is an ideal addition to the treatment team. Of course, a real diagnosis and understanding is important, and discussion of these disorders as possible side effects of chronic use of medications with the M.D. is essential. By understanding the issues, each patient will be able to take the proactive approach that often resolves these issues quickly and efficiently. To reiterate, many patients with Restless Leg Syndrome, a still poorly understood pathology, may experience an aggravation of their nocturnal calf cramps, which is a pathology related to myofascial syndromes and peripheral vascular disease.

Study of the pathology of akathisia has found that imbalances of neurohormones in the brain and their receptors are implicated, although a number of these imbalances are implicated, meaning that a one-size-fits-all approach to restorative therapy may not provide relief. Imbalances between the dopaminergic and cholinergic systems, and the dopamine and serotonin balance have been noted, as well as imbalances between the inner membrane and outer membrane function of neurons in the nucleus accumbens, due in part to excitotoxicity. Over time, these imbalances lead to an imbalance between the dopamine receptor types on the cell membranes, and restorative approaches that are persistent are needed to achieve the normal homeostasis that is programmed into our genes. To correct such imbalances, one may need to reduce medication dependency of drugs that could be triggering these imbalances, and also use both specific acupuncture stimulations that affect these areas of the brain to restore homeostatic balance, as well as herbs and supplements that supply the bioavailability of chemicals such as serotonin, dopamine and acetylcholine. Aids to cell membrane function, with phosphotidylcholine and phosphotidylserine are shown to be very helpful as well. To read more about restorative approaches to brain health and function, go to the article on this website entitled Brain Health and Function. Such therapy may be more complex than taking a single pharmaceutical pill, but even more comprehensive and holistic regimens are temporary in restorative medicine, and the only side effects are better overall health and function. The main problem with utilization of Complementary and Integrative Medicine and Traditional Chinese Medicine (CIM/TCM) is often the reluctance to just utilize a more comprehensive protocol. Using just one modality, such as acupuncture needle stimulation alone, and then just once every 2 weeks, may not be enough to correct the problem and restore health, obviously. A proactive and informed approach by the patient, with short courses of frequent acupuncture and physiotherapy, with more persistent prescription of herbal and nutrient medicine, is sure to work.

Pathophysiology of nocturnal leg cramps and simple therapeutic routines

Nocturnal calf cramps, or systremma, usually occur when the patient has been lying too long with the diseased muscle in a shortened position, such as the foot in plantar flexion during sleep. Various problems contribute to the firing of the muscle during sleep, and the shortened position of the muscle creates a problem with the muscle relaxation phase, a myofascial syndrome, resulting in continuous firing, or motor hyperexciatability. The problem usually has both a peripheral myofascial and central nervous component.

When a patient with nocturnal calf cramps rises from the bed and puts the muscle into a passive stretch of the fibers, the cramp almost always stops. Walking itself sometimes temporarily relieves the cramp, but the active use of the muscle in a shortened position usually leads to a return of the cramp, and a therapeutic passive stretch is recommended. When the nocturnal cramp is not addressed promptly in this fashion, it is more likely to recur during the night. A sustained cramp, or reactivated cramping, may cause soreness to result for a day or two, and contribute to the perpetuation of the problem. If the patient experiencing the nocturnal cramp either rises from the bed and properly stetches the calf muscles in a passive stretch (holding the muscles in a maximum gentle stretch while deep breathing for a minute or more), or has a partner passively stretch the muscle by dorsiflexing the foot, there will be less chance of reactivation of the cramp, and a better healing process to prevent recurrence. Stretching with passive stretch before bedtime may also be very helpful to prevent the nocturnal calf cramps, and use of heat to the calf, with a heating pad applies prior to passive stretch, or use of a heating blanket over the leg during the night, or even a soft blanket or down comforter over the leg to provide more warmth, may also be helpful. If possible, a firm pillow or rolled blanket can be placed at the foot of the bed against the bedboard, or a wall, to help hold the foot in dorsiflexion during the night. Heavy bedding, wearing of tight socks, or a poor sleeping posture may contribute to stimulation of the muscle cramp as well. Even though the cramp is painful, and passive stretch may be painful, using this technique rather than just walking off the cramp will do much to solve the problem.

The recommended passive gastrocnemius stretch involves standing with the the hands against a wall and the affected side foot extended in back of the supporting leg. The affected side foot should not be turned out, but pointed straight ahead, and the foot should be placed medial to the supporting foot. Step far enough back so that the muscle can be adequately stretched by slowly lowering the heel to the ground. Keep the back and body relaxed during stretch. slowly lower heel to the floor, and patiently wait for passive stretch to occur, breathing deeply, relaxing with the outbreath. Pushing the muscle into stretch too hard wil be counterproductive. Another way to stretch the gastrocnemius is with seated self-stretch with postisometric relaxation. You may do this without rising from bed. Sit up wtih the back supported and use a towel wrapped around the affected side foot and held with both hands. As you breath in, slowly plantar flex (away from the head) the foot against resistance, and then when the breath is exhaled in a relaxing sigh, let the foot and calf release and pull it into passive dorsiflexion stretch with the towel. Repeat this stretch and breathing technique until the full stretch of the muscle is achieved. Another reflex that may help is to look upward with the inbreath and downward with the relaxing outbreath. Be sure to not blow the air out hard with the outbreath, and try to calm yourself and relax the body despite the pain of the cramp.

In the evening, before bedtime, a number of simple activities may help prevent the nocturnal calf cramps. As you rest on the couch with the leg elevated rotate the foot slowly in circles for a few minutes, and then rotate and flex the knee. This muscular movement will increase veinous return and bring healthier oxygenated blood to the muscle. The above stretches should be performed before bedtime to insure that the muscles are not in a shortened or contracted position before bedtime and the long period of poor circulation that occurs during sleep. You might use a heating pad to increase circulation to the muscle as you fall asleep. These usually come with a timer that turns the heating pad off. Keep the pad under the leg, and the on switch within reach, so that if you wake with discomfort, you may try heating the calf muscles to increase circulation. The affected leg might be elevated with a pillow if this is comfortable with your normal sleep position, to insure better veinous return. The head of the bed might also be slightly raised with risers under the bedposts, so that circulation to the lower body is aided, and upper body muscles that may become contracted and inhibit circulation relaxed. If there is a footboard to the bed, a rolled blanket may be placed to help the affected leg's foot from plantar flexing too much. If you move in your sleep, these measures will be less effective. Sleeping on your side, with the affected leg placed on a cushion that is in front of the lower leg, is the preferred position for preventing lower leg calf cramps. This allows the muscles to stay relaxed, and the veinous return to be easy, and allows the pelvis to stay in a position where the nerve flow is not impinged.

Several physiological mechanisms may be involved in nocturnal leg cramps. Spinal disinhibition, myofascial motor excitability, and the central neural mechanisms of restless leg syndrome all have been implicated, yet no single clear mechanism has been confirmed. Electrolyte imbalances, nutrient deficiency, thyroid imbalance, nerve root compression, peripheral nerve injury, and demyelination disorders have also been implicated. Each case must be treated according to the condition of the individual. Deficient blood sodium, or hyponatremia, may cause muscle cramps, and could be due to adrenal insufficiency, hypothyroidism, or even caused by taking SSRI antidepressants. The nocturnal nature of this electrolyte imbalance may be due to a problem with the diurnal cortisol release of the adrenals. Over consumption of fluids during the day may also deplete blood sodium during the night if hormonal diuresis is not properly stimulated. Low blood potassium may also be implicated, although this is thought to be uncommon. Low blood sugar, or hypoglycemia, could also be a cause of nocturnal muscle cramps. Blood tests rarely reveal a distinct cause of nocturnal cramps, though. Studies of the elderly population correlate nocturnal leg cramps with the number of health problems in the individual. The various theories and possibilities point to a need to treat overall health and hormonal balance, and a holistic therapy may be necessary if simple myofascial release and change of habits do not solve the problem.

Statin drugs used for lowering cholesterol levels may also be implicated if taken for a long time. These drugs cause accumulation of protein fragments in the muscle tissues, and the gastrocnemius is particularly prone to these accumulations, since the blood return is more difficult in the lower extremities, the calf muscles are often in contracture with use during the day, and these muscle tissues are composed of compartments of fibers that run between two aponeuroses. Use of proteolytic enzymes and antioxidants may help clear the tissues in this case, especially if improved circulation and myofascial release and soft tissue mobilization are utilized. Calcium channel blockers, sometimes prescribed for high blood pressure may also cause the nocturnal cramps.

A number of studies of the physiological mechanism for nocturnal calf cramps show that various chemical and neurological stimulations can cause these cramps, but only when there are active or latent myofascial trigger points in the muscle. The most important step in the treatment is first the normalization of the myofascial trigger point in the affected muscle. Secondly, electrical conduction studies of nocturnal calf cramps show that there is a dysfunctional firing at the spinal cord, with both shifting of the electrical activity in the muscle, and failure of the reciprocal muscle to fire. With muscle relaxation, the reciprocal muscle must contract to achieve a strong relaxation phase, and electrical studies show that this mechanism is often absent in nocturnal calf cramps. The reciprocal muscle to the gastrocnemius is the tibialis anterior. Both of these muscles should be treated in the therapy, as well as the spinal cord and spinal nerve roots. Innervation of the gastrocnemius emerges as the first sacral nerve root, and the tibialis anterior is supplied at the fourth lumbar through the first sacral nerve roots. If there are problems with cord or root irritation, such as bulging degenerative discs, or tissue inflammation around the facet joints, these problems need to be resolved.

In the chronic myofascial pain syndrome, we see that a growing neuromuscular dysfunction spreads from the local muscle trigger point tissues to affect the whole nerve to the spinal cord, and eventually related nerve axons affecting other muscles and causing autonomic nerve dysfunction. Hyperexcitability occurs in the affected nerves, and overstimulation of the sympathetic nervous system causes dysfunction autonomic firing of the affected muscles. If the syndrome of nocturnal calf cramps is chronic, these physiological mechanisms may be occurring, and the disease mechanism treated with persistance until the neuromuscular firing is normalized. The complete treatment protocol for chronic myofascial dysfunction is key to the therapy, and involves trigger point release and needling, soft tissue mobilization and clearing, antispasmodic herbal and nutrient therapy, antioxdant therapy, and increased mobilization and circulation of the soft tissues at the spine.

While the complete explanation for the central nervous system spasticity, hyperactive motor response, myofascial trigger point pathology, and nutrient dysfunction involved in nocturnal calf cramp syndrome is still not fully understood, a comprehensive and persistent therapeutic protocol that addresses these issues has a high degree of success. This involves the above mentioned comprehensive myofascial therapy as well as correction of any potential problem with elecrolytes or muscle nutrients. In addition, the aggravating factors that caused and perpetuate the syndrome must be eliminated. Without both the correct and comprehensive therapy, and the elimination of the causes and perpetuating factors in daily activity, there will be much less chance of success.

Activities that cause and perpetuate trigger points in the gastrocnemius muscle

Walking in high heels or working in hard soled boots will put greater stress on the gastrocnemius muscle. Contracture of the foot and toes, seen in high arches as well as flat arches, hammer toes, and inversion of the feet, all put added stress on the gastrocnemius. Soft insoles, proper footwear, and perhaps professional orthotics may be helpful. Driving long distances with the foot plantar flexed against an accelerator or clutch pedal may aggravate the muscle, also. Exercise involving jogging uphill, climbing rocks, or riding a bicycle with a low seat may strain the muscle. Walking or running on the beach or a sloped surface may also create strain. Poor posture at work with locked knees while standing and forward lean may cause strain.

The gastrocnemius muscle may be sensitive to cold, tight elastic socks, or postural positions with the heel placed on the chair leg. Too high of a seat or too low may also strain the muscle with prolonged sitting. Repeated viral illnesses are known to cause muscle irritation in this muscle.

Herbs and herbal formulas that have been proven successful

Since the conditions that create and perpetuate nocturnal calf cramps are varied, the various herbal treatments are effective for some patients and not so effective for others. A variety of herbal formulas have been effective to relieve muscle spasm, aid tissue repair, and reduce spasm. Other formulas address the array of health problems that could be contributing. A professional herbalist will take a step-by-step approach to solving these health problems and relieving spasm. Here is a list of herbal remedies that are proven effective for a large percentage of patients:

  • quinine sulfate: this inexpensive herbal supplement, a membrane stabilizing herbal chemical and potassium channel blocker, can be purchased from a number of sources, although it's use is discouraged in the United States. The effects may be temporary, but it is proven to decrease incidence of cramps in the younger ambulatory population, although it may be ineffective for the elderly, who often have a number of contributing factors that must be addressed. It is often given in low dosage with homeopathic remedies, and this may be effective. The standard prescription is 300 mg orally at bedtime, but some studies have found that 60 mg was effective, especially when combined with other herbs or supplements. Quinine used to be found in tonic water, and gin and tonic was a classic drink for ages, since quinine could prevent malaria. It is still a common ingredient in soft drinks around the world, and is found in Sprite sold in Australia. It is still the most widely prescribed treatment for malaria in the world, and risk of side effects are considered very low. Since a very small percentage of the population could react to quinine negatively, the companies in the United States quit using quinine in tonic water. The FDA received 157 reports of possible health problems with quinine use over a 33 year period, but the research is questionable concerning quinine as a cause of problems. It is extracted from the bark of the Cinchona tree, and has been widely consumed for over a century around the world. Reports of rare health problems generally involved dizziness, tinnitus, nausea, and diarrhea, thought to be allergic reactions, but a very small number of patients have a genetic allele that predisposes to a rare platelet deficiency and bleeding problems. The study of patients with rare bleeding disorders found that a small number of patients tested positive for antibodies thought to be quinine-dependent, and had taken quinine, and no other explanation of cause was found. These antibodies can be sensitized by a wide number of drugs, causing a sudden autoimmune attack against blood cells, especially platelets. The exact mechanism by which the quinine, or other drugs, could induce this atuoimmune reaction is still not fully understood. Although the evidence is circumstantial, the use of quinine was discouraged in 1995. As of 2006, Qualaquin is the only brand of quinine still approved by the FDA, and it is recommended that physician monitoring is observed. Various drugs may negatively interact with quinine, including cholesterol lowering statins, antiarrhythmic drugs, macrolide antibiotics (e.g. erythromycin), and seizure medications. Antifungal medications and anticoagulants are also considered to increase risk. Many experts around the world consider the U.S. FDA warnings excessive, and the evidence of risk to be inadequate. A number of herbal products have been subjected to similar questionable risk assessments in the U.S., that many believe are driven by economic interests and lobbying pressure. Instead of prescribing quinine, or Qualaquin, the patient may be simply prescribed an alcohol tincture extract of Cinchona calisaya, or Cinchona bark, which taken in low dose as part of the treatment protocol will have significant antispasmodic effects, with no adverse side effects.
  • The equivalent to quinine in Chinese herbal medicine is the herb Chang Shan, or Dichroa febrifuga, which contains the quinine-like alkaloid 4-Quinazolone, which may dilate blood vessels, lower blood pressure, and decrease fever, but has dose-dependent toxicity, and is not recommended except in short courses and small doses. Quinine works because it is a potassium channel block and membrane stabilizer, and other herbs may accomplish these effects. Hawthorn is an herb that has proven potassium channel inhibition in animal studies, and is also rich in flavonoids and proanthocyanins for antioxidant effect. A 2003 meta-analysis of double-blind placebo trials of high quality, published in the 2003 American Journal of Medicine, found that hawthorn was proven effective for reducing vascular stress via these mechanisms. A Chinese formula that utilizes hawthorn (Shan zha) may be helpful.
  • Kava kava: approved by the Commission E, an internationally recognized German commission of safety and proof of botanical medicines, for nervous restlessness, and works as a muscle relaxant, antispasmodic, anticonvulsant, analgesic and hypnotic/sedative. Kava kava has been contraindicated in the past with concurrent use of various drugs that treat depression and anxiety, but no clinical proof of problems has emerged from studies. This herb is dose dependent, and excess dosage may have an opposite effect on the nervous system. It is thus a good added herb in the protocol at low dosage.
  • Cat's claw, or Uncaria tomentosa: approved by the Commission E, and extensively studied, for increase in serotonin, inhibition of platelet aggregation (thrombus or blood clot), and is dopamine stimulating. This uncaria is equivalent to the Chinese Uncaria rhyncophylla or sinensis, commonly used for neurological spasms that are episodic, and has a mild sedative and antihypertensive effect. This herb is useful in the overall treatment protocol, depending on the individual's presentation.
  • Horse Chestnut: the herbs commonly called Butcher's broom and horse chestnut have been proven to benefit vascular problems and aid the health of veinous return. If chronic veinous insuffiency is suspected as part of your nocturnal calf cramp syndrome, these herbs will help.
  • A variety of herbal extracts have demonstrated muscle relaxant and spasmolytic effects, though, and these may be combined in formulas or tinctures to aid in the treatment. Herbal extracts such as Valerian, Luo shi teng, Shan dou gen, Ren dong teng, and He huan pi have demonstrated these effects, and are commonly found in Chinese herbal formulas.

Nutritional supplements that may help cure nocturnal calf cramps

There are a number of nutritional supplements that may or may not benefit the particular individual with nocturnal calf cramps. The variety of problems that could cause of contribute to the syndrome makes this possible. Try the most common supplements, along with a more thorough therapeutic protocol, and see what happens. Of course, if the myofascial syndrome is not resolved, or the perpetuating factors with daily muscle strain are not addressed, these nutritional aids might not produce enough results. If the condition is related to a neuropathy, or to restless leg syndrome, the benefits might also go unnoticed until these conditions are properly treated. Here are a list of studied nutrient therapies for nocturnal calf cramps.

  • Vitamin E, 400 IU daily: a percentage of patients are responsive to Vitamin E supplementation for two weeks. Take the vitamin with fatty foods to insure greater assimilation.
  • Vitamin B2 and B6: this deficiency is noted especially in pregnant women with nocturnal calf cramps, but may affect anyone. B2 riboflavin facilitates the use of oxygen by the tissues, aids absorption of iron and Vitamin B6 (P5P is the active form), is needed for the conversion of the amino acid tryptophan to niacin in the body, which facilitates blood flow. B2 is easily destroyed with antibiotic use and excess alcohol consumption, and is often deficient with use of oral contraceptives and when excercising strenuously.
  • L-arginine with Vitamine B6: this amino acid improves nitric oxide vasodilation, and could help increase blood flow to the calf muscles at night. Other benefits are also listed below.
  • Niacin: aids vasodilation and muscle nourishment. Many patients hate the niacin flush that occurs with a high percentage of users during the first weeks of supplementation. Studies show that this flush is not harmful, and is in fact beneficial to vascular health. A non-flushing version of niacin is also available in the form of niacinamide or inositol hexacotinate. A combination of these nutrients for a few months could aid the treatment significantly, combining Vitamin E tocopherols, riboflavin, P5P, L-arginine, inositol hexacotinate, and perhaps L-tryptophan or 5HTP, and calcium/magnesium glycinate with short courses of circulatory and antispasmodic herbs (SPZM), and acupuncture to increase efficacy with low-cost and ease of therapy. Are there side effects? Only improved overall health.
  • Magnesium: either a magnesium plus potassium aspartate supplement, which would better effect the cellular membrane function, or a magnesium plus calcium glycinate chelate, which would better effect the contract relax function of the muscles, is recommended as a potential aid to muscle function to decrease cramp and contracture.


    Supplements that may help the general health of the calf muscles, especially if there is strong exercise or work contributing, or if there is a neuropathic condition

  • Creatine: while supplements are popular, there is a healthier way to insure adequate creatine availability. 50% of creatine is made from other amino acids in the liver, kidney and pancreas. Ingested creatine is highest in wild game meats and fish. Wild ocean fish (not farmed) will supply much creatine along with healthy fatty acids. Vegetarian foods high in certain amino acids (arginine, methionine & glycine) will provide the building blocks for creatine production in the body. Glycine is abundant in a healthy diet, but these other amino acids may be supplemented. Supplementing with L-arginine, SamE is recommended. L-arginine is the enzyme most crucial to efficient creatine biosynthesis. Herbs with arginine include shudi/rehmannia, coriander and white mustard seed/baijiezi, as well as yiyiren/white pearl barley. Foods with arginine, methionine & glycine include lentil, mungbean, chickpea/garbanzo, fava bean, kale, spinach, asparagus, pistachio, sunflower seed, sesame seed & pumpkin seed, as well as soy. Barleygrass is also rich in methionine and many important nutrients. Dried barleygrass spout is a valuable supplement, both for nutrition and as an inflammatory regulator. Herbal formulas to aid kidney and liver function and health along with the synergistic acupuncture treatments will greatly benefit efficiency in creating creatine for athletic training.
  • Myelin: essential fatty acids, EPAQ/krill oil, L-arginine, & 5HTP, along with intake of healthy oils, nuts and seeds, will all be helpful to increase efficiency of myelin biosynthesis to aid training. Pumpkin seed oil, for example, will help build myelin and creatine as well as providing rich essential fatty acids for inflammatory regulation.
  • Antioxidants & Collagen: whole grape extract, a potent antioxidant for the tissues that contains resveratrol (increasing endurance), is combined with natural collagen type 2 in the supplement Collagenex. Other antioxidants of merit include Vitamin C (Astr C) and coenzymeQ10.
  • Flavonoids: a balanced blend of gentle herbs that contain a variety of flavonoids is found in Flavonex. This will enhance capillary or microcirculation health in the muscle tissues, especially benfiting fast twitch muscle, or heavy, exercise.
  • Calcium and magnesium aspartate: this is the calcium used in the muscle to power the nerve signaling contraction and relaxation as well as to buffer the excess acids produced by heavy anaerobic activity. They are combined with a few herbs in SPZM.
  • PKA: a metabolic cofactor in utilization of fats and carbs by the tissues as well as steroid hormone production in the adrenal and other cells is found in Adrenosen, which combines adrenal cortex extract with gentle herbs to enhance athletic performance.
  • L-carnitine and alpha lipoic acid: together are shown to increase mitochondrial health to produce ATP, the fuel of your muscles.
  • L-arginine: an essential component of creatine and myelin, this amino acid also aids tendon repair, as well as other tissues, benefits liver function, and aids antioxidant activity.
  • SamE: methionine: an essential component of creatine which also aids membrane fluidity for more efficient nerve firing and cellular metabolism, and has been shown to aid tendon repair and antioxidant activity
  • Proteolytic enzymes: serratiopeptidase is a powerful enzyme clinically proven to aid tissue repair and inflammatory disorders, and is available in SerraMend. Other more common enzymes are available in Resinal E, a tissue repair anti-inflammatory herbal formula with enzymes, and in Chzyme, an herbal formula to aid digestive function.
  • Barley grass powder: more digestible than wheat grass but similar in makeup, containing 3 types of anti-inflammatory biologics, enzymes, SOD antioxidant, and many other nutrients.

Information Resources and Links to Scientific Studies

  1. In 1998, a large meta-analysis of published clinical trials of quinine for nocturnal calf cramps showed that this extract was very beneficial: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1497008
  2. In 2006 the FDA announced that it was only approving one form of pharmaceutical grade quinine extract, Qualaquin, for malaria. Reports of a significant number of problems with drug interactions and genetic propensity for G6PD deficiency in patients, leading to rare cases of platelet deficiency, with severe risk for a handful of people, resulted in the FDA considering this rare risk as not worth the benefits. Other countries, including Canada, continue to allow the population to consume quinine in tonic water, and have not been convinced of risk: http://209.85.173.132/search?q=cache:Fzfm39eOu7kJ:www.pswi.org/irx/Qualaquin.pdf+quinine+health+problems&cd=10&hl=en&ct=clnk&gl=us&client=firefox-a
  3. In 2002 a large double-blind placebo-controlled multicentre clinical trial of the use of 400mg quinine prescription for leg cramps in Germany found a 50% reduction in nocturnal leg cramps and no significant difference with respect to purported quinine side effects between the quinine and placebo groups: http://www.ncbi.nlm.nih.gov/pubmed/12074203
  4. A 2012 study by Hanze University of Applied Sciences in Groningen, Netherlands, found that nightly targeted stretch of calf and hamstring muscles significantly reduced the frequency and severity of nocturnal leg cramps: http://www.ncbi.nlm.nih.gov/pubmed/22341378
  5. Studies consistently show a relationship in frequency of nocturnal leg cramps and accumulation of health problems. One health problem linked is metabolic syndrome, commonly called a pre-diabetic state: http://www.ncbi.nlm.nih.gov/pubmed/19202219
  6. Another common condition linked to nocturnal leg cramps is varicose veins: http:/www.ncbi.nlm.nih.gov/pubmed/11141650
  7. A 2013 assessment of statin drug-induced nocturnal leg cramps, by experts at the University of Banja Luka Medical School, in the Republic of Srpska, Bosnia and Herzegovia, showed that a combination of factors appeared to cause these Nocturnal Leg Cramp syndromes, including statin drug use, atherosclerotic changes, aging, liver function, and inadequate blood circulation to these muscles. This assessment obviously calls for a more holistic approach in treatment: http://www.ncbi.nlm.nih.gov/pubmed/23858814
  8. A 2006 assessment of newer atypical antipsychotic medications such as Abilify (aripiprazole) and incidence and pathology of akathisia (Restlessness or Restless Leg Syndrome) by experts at the University of Pittsburgh School of Medicine showed that this side effect still occurred in up to 15 percent of subjects in the short-term clinical trials by the manufacturer, and is tied to changes in dopamine receptor expression and balance, and partly tied to individual rates of catabolism of the drugs in the liver and accumulation over time, as well as concurrent use with SSRI and SSNRI antidepressants: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2671776/
  9. The underlying pathophysiology of Restless Leg Syndrome and akathisia induced by atypical antipsychotic medications may be different, requiring different approaches in therapy. Here, experts at The Medical College of Georgia, in Augusta, Georgia, U.S.A. discuss the difficulties in distinguishing such diagnosis: http://www.ncbi.nlm.nih.gov/pubmed/25325577
  10. A 2015 assessment of Restless Leg Syndrome, or Akathisia, by experts at the renowned Memorial Sloan Kettering Cancer Center, in New York, U.S.A. concluded that "in clinical settings, akathisia is a side effect of medication. Antipsychotics, serotonin reuptake inhibitors, and buspirone (Buspar) are common triggers, but akathisia also has been associated with some antiemetics, preoperative sedatives, calcium channel blockers, and antivertigo agents. It can also be caused by withdrawal from an antipsychotic or related to a substance use disorder, especially cocaine. Akathisia can be acute or chronic, occurring in a tardive (delayed onset) form with symptoms that last >6 months." With so many patients taking antidepressants, anti-anxiety medication, atypical antipsychotic drugs, and blood pressure medication, or a combination of these drugs, it is obvious that Restless Leg Syndrome is often caused or triggered by medication use, but needs a more holistic restorative treatment protocol to correct this problem: http://www.currentpsychiatry.com/home/article/akathisia-is-restlessness.html
  11. As far back as 2003, international experts on Restless Leg Syndrome, Nocturnal Calf Cramp Syndromes, Nocturnal Bruxism and other movement disorders under the category of Tardive Dyskinesia, or a delayed and persistent dysfunction to the control of movement (kinetics), by experts as the Panjab University Institute of Pharmaceutical Sciences, in Chandigarh, India, noted that "induction of free radicals (oxidative stress) induced by neuroleptic drugs (atypical antipsychotics and GABA-ergic medications, along with other anti-seizue medications often used off-label for neurological symptoms) and resultant structural abnormality could be the key factor in the pathogenesis of tardive dyskinesia." Estimates of the incidence of the tardive movement disorders in patents taking these drugs ranges up to 70 percent, and treatment with pharmaceuticals has seen "limited success". Despite this knowledge, the growth in prescription of these drugs has exploded since 2003, and standard medicine has not integrated CIM and various strategies to reduce oxidative stress and neurohormonal imbalance: http://www.ncbi.nlm.nih.gov/pubmed/12669107
  12. A 2009 assessment of the pathophysiology of Restless Leg Syndrome, by the Dokkyo Medical University School of Medicine, links this sensorimotor disorder to periodic leg movements, or dystonia, considered to be a Central Nervous System disorder. This periodic, or rhythmic movement disorder is demonstrated to involve imbalance of dopamine receptors or the dopaminergic system, disturbances in iron metabolism in the brain (similar to findings in Multiple Sclerosis), and a variety of genetic abnormalities: http://www.ncbi.nlm.nih.gov/pubmed/19514512
  13. A 2013 assessment of the pathophysiology of Restless Leg Syndrome, by the Melaka Manipal Medical College of Melaka, Malaysia, noted that evidence suggests dysfunction in the dopamine system, reduced iron metabolism in the brain, multiple genetic linkages, alteration in neurotransmitters such as endorphins and hypocretins (orexin), and immune dysfunction with inflammatory dysregulation. Obviously, this complex multifactorial pathology demands a holistic approach to therapy. Unfortunately, standard medicine recommends a chronic prescription of harsh medications, such as gabapentin (Neurontin), pramipexole (Mirapex), ropinirole (Requip), and other medications created to treat Parkinson's disease. Use of Complementary and Integrative Medicine seems like a less problematic to reduce the need for a harsh and complex drug therapy: http://www.ncbi.nlm.nih.gov/pubmed/23524988
  14. An assessment of altered iron homeostasis in Restless Leg Syndrome by experts at Johns Hopkins University Medical School shows that localized CNS iron deficiency may occur even when blood labs show a normal serum iron ferritin level. This clearly shows that iron homeostasis and not a simple deficiency of iron is occurring, and while iron supplementation may benefit a percentage of RLS patients, attention to restoration of the iron homeostasis with a more holistic approach is needed: http://www.hopkinsmedicine.org/neurology_neurosurgery/centers_clinics/restless-legs-syndrome/what-is-rls/causes.html
  15. A 2015 randomized controlled human clinical trial of acupuncture as an adjunct treatment for Restless Leg Syndrome, at the Shanghai University of Traditional Chinese Medicine, in Shanghai, China, found that standard acupuncture might improve abnormal leg activity in RLS significantly with short courses of therapy. In 2008, a meta-review of such studies by the Cochrane Database System found that only 14 small trials were published at that time, with only 2 trials meeting high standards, which showed that acupuncture worked as well as standard medications, and that a combination of short courses of acupuncture with soft tissue physiotherapy and medication produced better long-term results than medication and massage alone. This review called for more and larger RCTs to evaluate the integration of acupuncture into this treatment protocol (PMID: 18843716): http://www.ncbi.nlm.nih.gov/pubmed/25763089
  16. A review of the potential for integration of Traditional Chinese Medicine to treat Restless Leg Syndrome, by the Vanderbilt University School of Medicine in Nashville, Tennessee, U.S.A. noted that this syndrome was addressed historically in TCM medical texts in 1529, leading to a long history of successful treatment strategies, and that currently, there is no effective cure in standard medicine: http://www.ncbi.nlm.nih.gov/pubmed/22459934
  17. A 2015 randomized controlled human clinical study of acupuncture to improve sleep quality and stress depression in the elderly population, a the Pontifical Catholic University of the Rio Grande do Sul, in Porto Alegro, Brazil, found that acupuncture was highly effective for improving these health problems: http://www.ncbi.nlm.nih.gov/pubmed/25511549
  18. A 2012 meta-review of all studies of oriental herbal medicine to treat restless leg syndrome, by Vanderbilt University School of Medicine, in Nashville, Tennessee, U.S.A., the first meta-review of this treatment for RLS published in the West, found 9 randomized controlled human clinical trials of high quality of the 85 reviewed, and evidence that Chinese herbal medicine outperforms standard treatment in modern medicine: http://www.ncbi.nlm.nih.gov/pubmed/22459934
  19. A 2015 study of the effects of myofascial trigger point injections in the gastrocnemius muscle to treat nocturnal leg cramps, at the Yonsei University College of Medicine, in Seoul, South Korea, found that this treatment worked well to both relieve pain and decrease the frequency of cramps, and indirectly helped with insomnia. Decades of study by the famed Dr. Janet Travell showed that dry needling, or needling the myofascial trigger points without a pharmaceutical injection, worked better than injecting chemicals, and that the stiffer acupuncture needle was ideal for this treatment: http://www.ncbi.nlm.nih.gov/pubmed/25567819

Maintenance and repair of the body are both aided by a therapeutic regime of acupuncture and soft tissue mobilization, or TuiNa. Acupuncture is able to stimulate any physiological mechanism to help cure illness or improve health. The effectiveness depends on the skill of the practitioner. Acupuncture is also symbiotic with herbal therapies and tonics to achieve maximum effect, and when combined with manual physiotherapies, creates a very effective course of therapy. Repair of tissue injury can be accelerated, pain relieved, and overall health and function of the liver, kidney and hormonal system can be enhanced. Steroid hormones can be at their peak naturally without cheating. Many acupuncturists are now knowledgeable in modern sports medicine and work to complement the care of the trainer and M.D. Peak athletic performance requires a well tuned body and the Licensed Acupuncturist can provide that extra addition to the athletic regime that prevents injury and allows the best performance.