Cramps: What a Pain!
Editor’s Note: As USA Fencing photographer (and fencer), I’ve noticed over the past couple of years that cramps are a common, debilitating and painful phenomenon among the various injuries at a competition, and especially seem to happen later in the course of an event. With the help of Dr. Peggy Chin, USA Director of Sports Medicine, we reached out to the medical experts at the Mt. Sinai Physical Medicine and Rehabilitation Residency Program to delve deeper into this issue to find out more about cramps, what causes them, how they can be prevented and how to deal with them when they occur. Thanks to the entire team for their explanations, thoughts and advice, and we hope this article will be useful for all our athletes, of all ages! —Serge Timacheff
Only minutes left on the clock, and your body starts to give out. You try to take an assertive step forward, but your front leg simply won’t cooperate. It spasms painfully and tenses as if it’s in a strait jacket. You’ve lost control. Your opponent, now with free rein, can attack from all angles. You simply can’t wait for a timeout. When it eventually comes, you wonder what you can do. What could you have done? This dreaded feeling pervades nearly every sport and fencing is no exception.
Cramping is a common ailment among athletes, with fencers being particularly vulnerable due to the repetitive movements involved in the sport and the long nature of competition, often spanning a full day. It is important for fencers to understand how to prevent and treat exercise-associated muscle cramps to optimize their performance.
What is a cramp?
A muscle cramp is a sudden, involuntary and painful contraction of a muscle or group of muscles.
A muscle cramp is a sudden, involuntary and painful contraction of a muscle or group of muscles. The incidence of muscle cramping is 50–60% in the healthy adult population and increases with age and during exercise. This painful phenomenon can be divided into three main categories based on etiology. The first two categories include nocturnal muscle cramps that occur during sleep without a clear cause and cramps caused by pathological conditions such as metabolic disorders, diabetes and neuropathy. The third category includes exercise-associated muscle cramps, which occur during or after physical exertion. Despite research dating to the early 1900s, the mechanism for muscle cramps remains a topic of debate. The literature highlights two main hypotheses: the dehydration or electrolyte depletion hypothesis and the neuromuscular hypothesis.
The mechanism of the dehydration/electrolyte depletion hypothesis involves massive sweating causing contracture of the space between cells. This puts mechanical pressure on nerve pathways, altering muscle excitability and leading to muscle contraction. Alternatively, the neuromuscular hypothesis posits cramps are due to an imbalance in excitatory and inhibitory nerve signals to the muscle. This imbalance often occurs during periods of muscle fatigue and leads to involuntary muscle contraction. Recent studies increasingly support this second hypothesis.
Am I more susceptible to cramps than my opponent? What can I do to prevent them in the first place?
Exercise-associated muscle cramps can occur in any athletic environment with a few noteworthy patterns. The highest incidence of cramps occurs during the beginning of the season, usually the first three weeks of training after a relative period of rest. At that time, an athlete’s fitness level is often at its lowest and their body is not yet acclimated to an intense level of training. This early part of the season often also coincides with the period of highest training load, resulting in high levels of physical exertion and increased athlete vulnerability to cramps. Additional risk factors for cramps include older age, a higher body mass index (BMI), less time spent stretching, irregular stretching patterns, warm weather conditions and history of cramping in an athlete’s family.
Some of the most beneficial strategies to reduce the risk of cramps involve stretching and hydrating. Stretching regularly with a targeted routine can reduce the risk. Adequate hydration with fluids that include salts or additional electrolytes as opposed to water alone has also been shown to be important in cramp reduction. This is based on the electrolyte depletion theory and targets cramp prevention by lessening the impact of electrolytes lost via sweat during exercise. Interestingly, taking in significant amounts of water without salt or electrolytes dilutes some of our body’s important electrolytes, and has been found to increase the likelihood of cramping.
To relieve muscle cramps during competition, stop the triggering movement immediately.
Salty foods and drinks with high potassium are ideal for preventing and treating cramps. While this requires an individualized approach for each fencer, fluids like coconut water, tonics with quinine and low sugar electrolyte sports drinks are good options. Similarly, nuts, sweet potatoes, cooked spinach and melon are all easily digestible food items with a lot of salt and nutrients.
Contrary to popular belief, while they do not hurt, bananas have not shown beneficial effects on prevention or treatment of cramps. Bananas do not lead to a large-enough or fast-enough potassium or glucose surge to have a significant impact on the muscles.
There is preliminary evidence that supplementation with vitamin B-complex may decrease the frequency of exercise-associated muscle cramps in individuals who endure more than five cramping episodes per week. However, more studies are needed to be conducted to verify this hypothesis. While the strategies discussed have been successful for some, it is important to note that the evidence is still inconclusive, and the overall cause of cramping is thought to be multifactorial. Thus, we are still learning how to best prevent exercise-associated muscle cramps.
When a cramp comes on during competition, is there anything I can do?
Prevention of cramping is the most effective approach, as outlined above, since muscle cramps can be challenging to manage during competition. If cramps do occur, key strategies to treat them include stopping the aggravating movement, static stretching of the affected muscle and rehydrating with replenishing electrolytes. Collaborating with a coach and strength trainer is crucial to identify and address any weaknesses in fencing technique or musculoskeletal imbalances that may predispose a fencer to cramps. For instance, improper grip technique can lead to hand and wrist cramping, while inadequate footwork or core strength can place excessive strain on the lower extremities, increasing the likelihood of cramps. Additionally, attempting to delay or reduce exercise-induced fatigue with proper conditioning and pacing during exercise can help reduce cramps.
To relieve muscle cramps during competition, stop the triggering movement immediately. The most effective immediate treatment of the cramp is static stretching of the muscle. Gently stretch and massage the affected muscle, keeping it in a stretched position until the cramp subsides. This likely requires a medical break, at which time medical professionals may also apply heat to relax tense or tight muscles. It is important to also use the medical break to restore electrolytes by consuming easily digestible, electrolyte- and salt-rich food or fluids. Some athletes may also use the medical break to consume products containing acetic acid, such as pickle juice or yellow mustard, to alleviate cramps.
To date, there do not seem to be any long-term complications or lasting damage from exercise-associated muscle cramping.
If a fencer sustains an injury or cramp during a bout, the referee may grant a single ten-minute break for treatment if recommended by the doctor or medical professional on duty. No further breaks are allowed for the same cramp that day and the fencer must withdraw if deemed unfit to continue by the doctor. According to literature, cramps have been previously noted to account for approximately 5% of time-loss injuries at studied USA Fencing national events. The medical break rule allows the athletes time to evaluate their cramp with a medical professional and mitigate the impact of the cramp on performance. If a cramp is adversely affecting a fencer’s focus, form or ability to compete safely in any way, the medical professional will recommend or require the athlete withdraw to prevent further injury.
Once I start to cramp, am I hurting myself more by continuing to compete?
To date, there do not seem to be any long-term complications or lasting damage from exercise-associated muscle cramping. There is no current evidence of cramps leading to more significant injuries to muscles and their surrounding structures. The instances of a tear or rupture related to cramping are very few and far between. Nevertheless, cramps can be a debilitating ailment that can interfere with competition and performance. Therefore, it is important that fencers maximize their cramp prevention and management strategies in order to optimize performance and enjoyment of the sport.
The authors of this article are all 3rd- and 4th-year residents at the Mount Sinai Physical Medicine and Rehabilitation Residency Program:
Ian O’Connor, M.D.
Irene Kalbian, M.D.
Marya Ghazzi, D.O.
Ray Espinosa, M.D.
Jacob Levine, M.D.