Cramping My Style

Stay the CourseCramping sucks. I know, from experience, dude.

Cramping, or more specifically, exercise-associated muscle cramping (EAMC), is as much a part of the ultra experience as GU and handhelds. Yet, it is remarkable how little The Communities – both the scientific and ultra – truly know about cramping.

I wish I’d known more. I thought I did. But sometimes knowing what we do not know is nearly as good.

In order to clear the air, and clean the slate, I’d like to review some old concepts, introduce some new ones and try to put forth practical, evidence-based troubleshooting plan if and when cramps threaten to derail your ultra experience.

The Origins of the Cramp & Salt Myth

It’s funny how often a small, inconsequential event can snowball into dogmatic law.

If you were to poll a hundred ultramarathon runners, the vast majority of respondents would claim that muscle cramps were due to “an electrolyte imbalance” or a deficiency in sodium, potassium, or other elements. The belief pervades beyond the trails: I can only smile and nod politely when my patients tell me they combat their night cramps by “eating more bananas,” implying that a potassium deficit somehow causes their cramps.

It does not.

We don’t know much about EAMC, but what we do know, definitively, is this: There is no association between blood (or sweat, or urine) sodium concentrations – or hydration status – and muscle cramps.

None. Zero.

Tim Noakes, MD, devoted 429 pages in his 2012 work, Waterlogged, to the effort of disposing that myth. I, too, did my part, with a good ten-thousand words in this column a year ago. Yet, the presence of S!Caps, Salt Stick, table salt and other supplements in ultrarunner’s pockets hasn’t diminished in the slightest.

Why? There several reasons, beginning with a miniscule but impactful study nearly a hundred years ago. Then, it was the Gatorade revolution. On top of that, mounds of anecdotal evidence: runners implicitly know that salt helps.

And you know what? It does work. We know that, with scientific evidence to boot. But why it helps is not why you think.

Exercise-Associated Muscle Cramping – What We Know

In Waterlogged, Noakes provides historic context to our belief of a salt and cramping association.

The belief in the association between cramping and sodium deficit came from a study nearly a hundred years ago, involving British mine workers. Mine owners and scientists were curious about the cause of muscle cramping in miners, so they conducted a study examining cramping miners and the sodium content of their body secretions: sweat and urine. Based on this single study, the belief that cramps were caused by low sodium was born. And, in the 1960s, scientists jumped on this nugget and ran with it.

The study was tragically flawed: insufficient subjects, a lack of controls, and – most outrageously – completely failed to show any correlation between cramping and sodium. Instead, they found a single subject with low sodium in his urine. That’s it. Thus, our belief of salt and cramping originated from a urine sodium sample of a single study, of a single miner… who did not even experience muscle cramping!

This finding lay dormant, until the 1960s. The history of Gatorade and performance is well-documented in Waterlogged, and described in detail in last August’s column. Because of several confounding factors (ad libitum hydration, sugar intake, and placebo effect, to name a few), the belief that salt benefits performance ran roughshod through the athletic community.

Today, that belief is nearly unshakable.

However, since then, all subsequent studies of sodium concentrations – in blood, muscle tissue, and urine – failed to show any association between cramping and sodium levels.

Noakes reviews the literature, and outlines the current research:

  • There is not a single study that shows blood electrolyte concentrations – including sodium – are abnormal at times of muscle cramping. On the contrary, four recent studies (1984-2009) have shown that cramping athletes have completely normal blood sodium levels.
  • There is not a single study that demonstrates dehydration to be a factor in cramping: in fact, the same aforementioned studies noted that cramping athletes are no more dehydrated than controls.
  • There is no evidence that body temperature of exercising athletes has any effect – that cramping athletes have higher core temperatures – on cramping during endurance activities. In fact, studies on swimmers demonstrate cramping can occur in extreme cold water conditions.
  • One body of studies that did find that “salty sweaters” experienced more cramps (Bergerson, 1996, 2003; Stofan, Zachwieja et al 2005), but these studies failed to have adequate control groups, and they failed to measure blood or sweat sodium concentrations at the time of cramping. Interestingly, one particular finding from these studies found that crampers had higher dietary sodium intakes, and that they sweated higher concentrations of sodium – opposite of the author’s conclusions.
  • When cramping occurs in people with medical conditions (such as hyponatremia), the cramps are generalized throughout the body, affecting multiple groups. In contrast, exercise-induced cramping invariably affects only specific groups involved in repetitive contractions. Therefore, it is unclear as to how a general body or blood sodium deficiency could cause cramping localized only to specific groups.

So, we may not know exactly what causes cramping, but we know what does not cause cramping: low blood or muscle sodium content does not affect cramping.

But… before you un-bookmark iRunFar.com from your browser, and cancel your order of “Stay the Course” trucker hats and racing bun huggers (release date, TBD) hang on:

There is evidence that salt helps us in racing. But it’s not why you think. Hang in there.

What We Think We Know: Cramping & the Altered Neuromuscular Control Theory

Noakes and his colleague, Dr Martin Schwellnus (1997) have proposed another theory to explain EAMC, where a reflex – found somewhere in the muscle or nervous system – that normally balance muscle contractions, fatigues. Because of that fatigue, the exercising muscle becomes too excited and begins to cramp.

In a recent podcast interview with Trail Runner Nation, Noakes elaborates:

[Dr. Martin] Schwellnus developed the theory that there are reflexes in the muscle that prevent them from cramping…. When we run, and, in particular, when we run slightly faster than we want to (or that we really should be running), it seems that that reflex gets tired, and the inhibitory reflexes become less strong. And as a consequence, the excitatory impulses… become dominant. And as a consequence, the muscle goes into cramp.

And we know that, because if we look at the electrical activity in the muscles, we notice that before they cramp, the activity starts to rise. So something’s changing in the muscle, that’s making it more prone to going into cramp. And then, you continue for a bit further, and it goes into a full cramp.

And the point is, it is an electrical phenomenon, a reflex, that may originate in the brain (or more likely originates in the spinal cord), but has almost certainly got nothing to do with dehydration or sodium balance, and has almost everything to do with genetic predisposition and also has got everything to do with how tired you are, and how hard you’ve exercised.

Noakes adds,

The remedy, unfortunately, is to do lots of stretching to the [affected] muscle, lengthening the muscle, because what we have also found, is that, muscles that haven’t been lengthened – muscles that have been working in a small arc, and working in a shortened position – those are the muscles that are going to cramp. So you need to stretch the muscle, lengthen it, to make it less susceptible to cramping.

Several studies have helped to confirm this nerve-plus-muscle mechanism for cramping. (Norris, Gasteiger et al. 1957; Minetto, Botter, et al. 2008; Stone, Edwards et al. 2003) In these studies, cramps were induced by stimulating certain muscles, and cramps were abated by stimulating other muscles – reinforcing the notion of a balance between motor firing occurs in a non-cramped state, and that this is disrupted with prolonged, fatiguing activity.

Who Cramps & Why

More recent work has studied the incidence and prevalence of cramping. (Schwellnus, Drew et al. 2011) Once again, these studies found that no difference in hydration or blood sodium concentrations between crampers and non-crampers.

However, two factors did emerge that separated crampers from non-crampers: the crampers ran faster (e.g., they were among the fastest, most competitive athletes) versus the rest of the field, and they had a history of cramping in previous efforts.

This is insightful: you cramp when you run hard, and when you have “the habit.” Since both exercise intensity and previous experience are central nervous systems, these findings support the neuromuscular control theory of cramping.

Salt Intake & Performance: The Pickle Juice Study

Athletes have known for a long time that salty foods and drinks decrease cramping and enhance performance. You start to cramp, so you stop at the aid station and dip that potato in salt. Or you pop the S!Cap. Then, within seconds, you feel better.

We just don’t know how or why. A recent study now sheds some light on that.

The intriguing “Pickle Juice Study” was performed in 2010 by a group of exercise scientists at North Dakota State University. The researchers exercised a group of subjects for a prolonged period of time to elicit the following effects: a water loss of 3% of body weight, a sodium loss of at least 145mmol in sweat, and onset of exercise-induced muscle cramping.

Immediately after all three conditions were met, the subjects consumed 75mL of pickle juice, while a control group drank 75mL of water (and a third group, no intake). The study found that, for both drinker groups, a reduction in cramping occurred in under 90 seconds, and the pickle juice reduced the duration of cramping 49 seconds faster, compared to a just-water group.

Because of this rapidity, the effect of the pickle juice could not have been due to changes in blood sodium or overall hydration levels, as insufficient time had elapsed for the stomach or intestines to absorb the salt or water. Moreover, a follow-up study noted that – even with sufficient absorption time – drinking 75mL of pickle juice had no effect on blood sodium (or hydration levels).

So, an effect was measured, but systemic changes were impossibly fast. What, then, caused the change?

The authors speculated that drinking the pickle juice – either through its salinity or acidity – triggered a neurological reflex, somewhere in the mouth or throat, that traveled to the brain. Therefore, it was a brain effect – not a GI or blood effect – that reduced the cramping. This study supports the neuromuscular muscle cramp theory, that the nervous system has ultimate control over cramping.

Noakes discusses this, as well, in the same podcast:

As far as sodium balance goes, we do not need to take sodium, because you will be excreting during the race any excess sodium you’d take the day before. And any excess sodium you take during the race will simply appear in your urine…. We know that, so you don’t actually need it to manage your sodium balance.

But there is a component we know, that the brain has a link to the tongue, and when you put salt on your tongue, the brain recognizes that you are putting salt into the body, and it may well modify your performance. We certainly know that if we put food in your mouth, particularly carbohydrates, but I think protein and fat, but they haven’t been studied yet… your brain immediately interprets that, ‘This is good!’, and allows you to run faster.

We know that if you’ve got a cramp, and you put a salty drink on your tongue, you will reduce the cramp, it will tend to break, within about 40 seconds. So that can’t be because of salt entering your intestine and being absorbed, it’s because the salt is acting through a reflex in the brain, and the brain is for some reason responding to the salt and saying, ‘OK, we mustn’t have muscle cramping at this time.’

Because muscle cramping is a brain/spinal cord phenomenon, and has got nothing to do with the salt balance in your body. So my point is… people may take salt, and they may say, ‘My gosh! It does improve my performance!’, and I would not discount that, but it’s not acting by improving the salt balance, it’s acting in the brain… it’s not confusing the brain, but it’s interpreting that salt is coming into the body and that is good, and therefore you can run faster.

Muscle Cramping & The Central Governor

Let’s review what we know (or think we know, or know what we don’t know) so far:

  • Muscle cramping is a neurological, “electrical” phenomenon, likely centered in the central nervous system, where reflexes become unbalanced, affecting the muscle.
  • The muscle is most susceptible to cramping with prolonged fatigue and (according to Noakes), when we “run faster than we should.”
  • Sodium or electrolyte balance – in the blood stream or muscle cell – has zero effect on cramping.
  • Sodium (and possibly water, sugar, and fat) tasting in the mouth (and possibly upper GI tract) does have a positive effect: dampening cramping and improving performance. But the rapidity of this effect suggests that it is the brain alone that creates this effect.
  • Muscles most affected by cramping are those repetitively used and confined to a small arc of motion.
  • The only known treatments to cramping are to slow down, stop, and stretch the muscle to a maximally lengthened state.

These concepts suggest that muscle cramping, therefore, might be an action of the Central Governor. Recall from last month’s column: the Central Governor protects the body from danger, and is likely the major determinant for running performance. As such, the mechanisms above suggest the brain is trying to protect the body – either the brain, heart, or muscles – from damage. And in this instance, that protective mechanism is cramping.

To add to that idea, Noakes notes that cramping might also be a protective response to chronic, micro-trauma to over-trained, over-stressed muscle tissue:

What we used to think of as muscle tears… now we’re beginning to think… it’s something to do with the fascia surrounding the muscle, that becomes irritated, and that then causes the electrical activity in the muscles to go up, and they start to cramp…. I think what we’re going to find is that injury is a part of it: if you’ve been training hard and the muscle fascia is slightly damaged in some way (that we don’t yet fully understand). Go out and race, and after a time, what happens is, the muscle starts to cramp a little bit, they’re too small for you to notice, and then all of a sudden, the whole muscle goes into cramp. But as it resolves, you find that there are these little nodules that continue to be cramping. And in my view, that is likely to be injury, rather than anything else…. It may be a protective reflex that stops you from running and damaging your muscle any more.

Put it all together: cramping, then, very well could be a self-preserving act: “This guy won’t slow down, he’s working too hard – I’m going to make him slow down.”

Based on these concepts, soothing the Central Governor is the key to treating and preventing cramps.

The List: Strategies to Treat & Prevent Muscle Cramping in Training & Racing

Based on what we know, I propose the following strategies to treat and prevent muscle cramping:

#1 – Run Sustainably

Through some mechanism – either neurological, cardiac, or neuromuscular – the brain judges your current effort and decides whether or not it is sustainable. Maintaining an unsustainable pace early in a long ultramarathon may trigger the onset of muscle cramping. Why this happens, in absence of energy deficit or other perceived physical duress, is unclear.

That said, if you have a cramping issue – make note of the paces and conditions (heat, altitude, terrain) at which cramping occurred. Adjust your pace downward, accordingly, and gauge the effect.

An even better way to gauge sustainability is to use a metric, such as heart rate. Heart rate is all-encompassing: it takes into account those variables, as well as fatigue, anxiety and stress, and tissue trauma. If heart rate is high, your system is stressed, and needs a break.

For me, I failed to make any adjustment to pace or effort at this year’s Western States 100: I continued onward with little slowing, or stopping. My cramps continued, unremittingly, and irreversibly, as a result.

Conversely, it’s worth noting two successful examples of cramp-management at last week’s Western States. Firstly, was iRunFar’s Andy Jones-Wilkins. As noted in his race report:

By the time I rolled into Robinson in 53rd place my quads and hamstrings were cramping pretty intensely, so I knew I had to top off pretty aggressively on electrolytes.

My plan from the outset was to spend a bit more time at the early aid stations to make sure I was taking care of myself and dosing my effort sufficiently to have legs from the River in. However, the eight minutes I spent at Robinson Flat were, perhaps, a bit too long…. I ate my yogurt/granola concoction, topped off my fluids, and had a double shot of “Witch’s Brew” (double strength chicken broth made with coconut water), so I ultimately didn’t get out of there until 10:45, a full 15 minutes slower than my planned split.

The question is, what decreased the cramping? Was it that barely-potable concoction of salty fluids, or scores of S!Caps? Or was it simply stopping at the aid station for nearly ten minutes – and resting the skeletal and cardiac muscle – that decreased the cramp response?

The research would suggest it was the rest, not the “Witch’s Brew,” that was successful.

Additionally, ultra veteran Scott Wolfe raced himself to an impressive 11th place male finish, noting that he took two prolonged breaks, lying in both the Middle Fork American River (mile 45) and Volcano Creek (mile 60) “until my heart rate got below a hundred” beats per minute. Was it the cooling effect that aided performance, or simply stopping and allowing his muscle tissue to rest? We don’t have a definitive answer, but again, the research suggests it was the resting of muscle tissue that was the primary benefit. However, cooling the system also provides vital positive input to a cautious, stressed-out Central Governor.

Either way, these decisions paid off in a big way for both Andy and Scott: they ran sustainably and kept the Central Governor appeased throughout the day.

#2 – Run Efficiently!

Given what Dr. Noakes stated about repetitive muscle use playing a role in cramping, it is vital that the run stride be as efficient as possible. Muscle groups such as the medial quad and calf tend to cramp because these groups bear the brunt of braking forces in an efficient stride: a foot strike too far in front of the center of mass causes excess force absorption, “braking,” to occur in these groups. An efficient foot strike will minimize stress on these groups.

Moreover, having a compact, but balance stride will also help: as Dr. Noakes notes, muscles that function in a “small arc” – or small pattern of movement – are most susceptible to cramping. Having adequate hip and knee flexion/extension provides maximal range of motion and “stretch break” for the working muscles.

Be form-focused!

#3 – Ply the Central Governor With Its Favorites

Low salt doesn’t cause cramps, but taking small portions of salt helps. Keep the Governor happy with frequent – but measured – doses of its favorite go-to food groups: water, salt, sugar, and even fat. Maintain a “see-food diet”: if it looks (and tastes) good, eat it. The Governor will be pleased, and allow for improved performance.

But don’t take this too far. The diminishing law of returns is a steep slope: over-doing water, food, and salt are dangerous, their effects ranging from general malaise (in the case of a sour or full stomach) to dire (hyponatremia).

#4 – RELAX. SMILE. LAUGH!

Cramping is a neurological phenomenon. So is pain. If cramping, like pain and other complex neurological processes, are of central origin, we, then, have more control than we realize. In discussing the physiology of pain, we noted the impact of stress, anxiety and mood on pain – and how it acts as an amplifier of electrical (and chemical) signals.

If this is also true of cramping, we do have some conscious control.

Cramping is a threat to performance. Threats cause tension. Cramps are neurological tension gone overboard.

Defuse the threat. Recognize that anxiety, worry, and grief about cramping – and its impact on your performance – may increase its severity. Conversely, simply relaxing and – taking it to the extreme – going out of one’s way to smile and even laugh – may have a potently dampening effect!

Anecdotal evidence exists for this: me. In reflecting after Western States, I remembered this experience near the end of my 2011 North Face Endurance Challenge race:

I fought the blips constantly, as if tip-toeing across a mine field –one false move and it was a death of tetany, and at best a painful limp to the finish. At worst? A DNF.

Strategizing, I realized I needed total relaxation. Moreover, I had to smile. So I did. A huge, ridiculous grin, almost non-stop, was pinned on my face as I floated along down the road and onto the final climbs…. I had to soften it as to not look insane as I passed a Park Ranger in his squad, then a random aberration of [Dave Mackey] running downhill past me. “Hey Dave!”, I said, the smile slightly less ridiculous. But it worked!

Indeed, after spending hours that day, literally eating Nuun electrolyte tabs (deserving of a trip to the periodontist, post-race), what ultimately resulting in the cramps ceasing was relaxation: smiling, and – albeit forced – laughing out loud. The cramps abated and did not return for the remainder of the race, despite maintaining and ultimately increasing pace at the end.

#5 – Slow down.

Should those mid-run strategies fail to curb cramping, you must slow down. Period. Again, the science states that – outside neurological disruption – a slowing of pace – thus lowering the demand on the muscle and nervous system – is required.

Slow down. Gauge the effect. Should cramps alleviate, gradually increase pace, as tolerated.

#6 – Stop. Stretch. Ice.

Should slowing fail to stop the cramps, it is time to stop running. Walk, or stop at an aid station. Per Noakes: stretch the repetitively-shortened muscle with copious stretching. Also try icing, as much for the neurological input as for cooling. Ice is a frequent tool for health-care practitioners to use to “break” (or decrease) high muscle tone in neurological patients.

#7 – …Know When to Fold ‘Em.

Should cramps persist and muscle cramps segue into severe muscle pain, perhaps it is time to stop. This is a deeply personal decision, depending on your race goals, that point at which you are at in the race, and personal experience.

But recognize that, with severe muscle cramping, pain, and greatly reduced pace, the brain is trying to tell you something: you’ve over-done it, tissue is compromised, and you need to stop. Ultimately, it is up to you as to whether you listen to that message. If we always stopped when the brain said so, no one would ever finish an ultra. However, much severe suffering might be avoided by doing a better job of listening to the body, early and often.

* * * * *

Knowledge is power, and muscle cramping is the body telling you that something isn’t right. Listen to the body, recognize that there is a problem, and act accordingly. Few things are more rewarding than problem-solving, and over-coming obstacles, in training, racing, and life. My hope is these nuggets will help you solve your problems and “keep moving to the finish line.”

Call for Comments (from Bryon)

So, it’s probably unnecessary to make an express call for comments here, but

  • When have you experienced cramps in the past? Do the above stated causes likely apply?
  • How (do you think you) have you resolved cramps in the past?
  • What are your thoughts on the growing evidence for mental stimulus greatly affecting physical performance during endurance sports?
Joe Uhan

is a physical therapist, coach, and ultrarunner in Eugene, Oregon. He is a Minnesota native and has been a competitive runner for over 20 years. He has a Master’s Degree in Kinesiology, a Doctorate in Physical Therapy, and is a USATF Level II Certified Coach. Joe ran his first ultra at Autumn Leaves 50 Mile in October 2010, was 4th place at the 2015 USATF 100K Trail Championships (and 3rd in 2012), second at the 2014 Waldo 100K, and finished M9 at the 2012 Western States 100. Joe owns and operates Uhan Performance Physiotherapy in Eugene, Oregon, and offers online coaching and running analysis at uhanperformance.com.

There are 139 comments

  1. Ethan

    Hi Joe – interesting article. I wonder if you have some good references apart from Dr. Noakes' book? I started poking around on pubmed a little bit after my race weekend before last, but more direction would be helpful. Like you, I am prone to muscle cramps in races, and I think it's interesting that we don't really seem to know what causes them (although several theories have been put forward). While I appreciate the appeal of the CNS theory of cramping, I'm not sure that it really makes that much sense – or at least the use of the word 'fatigue' seems inappropriate – on the basis of personal experience. For example, in my first 50 mile race, I started cramping about an hour into the race (extremely early, and shorter than pretty much all my training runs, which have yet to result in a single cramp). I was forced to slow down until about the halfway point, when I took a rest and a bunch of salt. Voila – no more cramps – and I did my fastest running in the heat of the day during the third quarter of the race. Just a couple thoughts: an imbalance in PNS/SNS signaling could be a component (a poor night's sleep before the race would exacerbate this problem by increasing sympathetic drive). Also, some studies have been done that show (in animals) a transient hypocalcemia following prolonged exercise. This would certainly explain cramping. Again, the evidence is anecdotal, but I don't really buy Noakes' suggestion about the body avoiding injury – my most characteristic cramp occurs in the brachioradialis muscle of my left arm. This is generally the 'herald cramp' that warns me others will follow; when they do they may be quadriceps , adductors, hamstrings, or rarely gastroc/soleus. I'm becoming increasingly curious about cramping though, as the explanations I've heard all seem unsatisfactory.

    1. OOJ

      Ethan-

      Thanks for the detailed response. I'll respond in-line, first:

      >Hi Joe – interesting article. I wonder if you have some good references apart from Dr. Noakes’ book? I started poking around on pubmed a little bit after my race weekend before last, but more direction would be helpful.

      Pick up a copy of Waterlogged. It represents an objective, comprehensive review of literature from the past 90 years. And/or, contact Dr. Noakes, who notes (in this TRN podcast) that "publishers made me cut out about 40% of the total material" he wanted to put in the book.

      >Like you, I am prone to muscle cramps in races, and I think it’s interesting that we don’t really seem to know what causes them (although several theories have been put forward). While I appreciate the appeal of the CNS theory of cramping, I’m not sure that it really makes that much sense – or at least the use of the word ‘fatigue’ seems inappropriate – on the basis of personal experience.

      Recall from last month's column how 'fatigue' is defined. Fatigue – and we know this from both muscle tissue and sleep studies – is a neurological phenomenon. Thus, it is a brain phenomenon. Fatigue is also a "feed-forward mechanism", based on the brain taking a job at hand, evaluating current condition, then making decision on outputs.

      Think about how your body responds differently during a work-day, when you've still got 6 hours' work, versus 1 hour to go. When are most people truly most motivated and productive?

      >For example, in my first 50 mile race, I started cramping about an hour into the race (extremely early, and shorter than pretty much all my training runs, which have yet to result in a single cramp). I was forced to slow down until about the halfway point, when I took a rest and a bunch of salt. Voila – no more cramps – and I did my fastest running in the heat of the day during the third quarter of the race.

      See below.

      >Just a couple thoughts: an imbalance in PNS/SNS signaling could be a component (a poor night’s sleep before the race would exacerbate this problem by increasing sympathetic drive). Also, some studies have been done that show (in animals) a transient hypocalcemia following prolonged exercise. This would certainly explain cramping.

      How "prolonged" was the animals' exercise in the study? Every human study failed to show ANY electrolye imbalance, even with multi-hour, multi-DAY forced-exercise with NO electrolye intake. That said, having an electrolye imbalance (in an otherwise healthy individual) after only AN HOUR of exercise, seems pretty far-fetched.

      >Again, the evidence is anecdotal, but I don’t really buy Noakes’ suggestion about the body avoiding injury – my most characteristic cramp occurs in the brachioradialis muscle of my left arm. This is generally the ‘herald cramp’ that warns me others will follow; when they do they may be quadriceps , adductors, hamstrings, or rarely gastroc/soleus. I’m becoming increasingly curious about cramping though, as the explanations I’ve heard all seem unsatisfactory.

      OK, here's a study I want to conduct. You can help me:

      – Clone about 100 of yourself. We need you-clones, as Noakes notes that cramping has a "genetic pre-disposition". Divide the yous into the following groups running a race of "unknown origin".

      GROUP 1: The Yous are told you're running 50 miles at x pace (control group).

      GROUP 2: Same as #1, except they're told they're ONLY running 10 miles at x pace (Central Governor group).

      GROUP 3: Same as #1, except this groups wears a wrist brace (brachioradialis cramp/"run efficiently" group).

      GROUP 4: Same as #1, except they must run 0.9x pace (effort group).

      GROUP 5: Same as #1, except they get to "eat Nuun tablets" (as I did, ridiculously, at TNF, 2011 – the salted group).

      GROUP 6: Same as #1, except they get to run with sunglasses projecting a comedy movie (e.g. Dumb & Dumber, Tommy Boy, Jackass – The Movie – the "relaxation group").

      GROUP 7: Same as #1, except this group stops and stretches (and schmoozes with the cute girls working) at the AS, without salt intake (the rest/stretch group).

      I would hypothesize that Groups 2-7 – with ALL ELSE controlled – would not cramp. Most notably is Group 2: thinking you're only running ten miles, I feel the brain would "let 'er rip" without cramping (which, if it were purely salt, would cramp at 6 miles/1 hr, regardless race distance).

      If you get that cloning down, let me know. ;-) But if not, be an experiment of one! Try these strategies in your next race!

  2. Jeff

    The only time I have had cramps during racing is transitioning from bike to run in a triathlon – clearly a neuromusclar response to the change in disciplines.

    But I do use salt for other reasons in races – anecdotally, I've found that it helps water absorption (or stomach bloating) and can help clear up a "foggy mind" especially on a hot day. Is there a possible physical association with these symptoms and salt?

    1. OOJ

      Jeff-

      I do believe there is data out there to suggest that some elements (namely low concentrated glucose) that aid in gastric emptying, versus water alone.

      Salt may do the same; however, beware: stomach (and intestinal) sloshing is a sign of too much water in the system. Salt has been known (anecdotally at least) to curb this and aid absorption. However…plugging scores of salt tablets may also drive an abberant thirst response: making you want to drink although the body tissue do not need water. This is a known vector for hyponatremia.

      This is why being very measured with salt intake is SO important. "Ply" the system, don't flood it.

      1. Jeff

        Thanks Joe,

        That lines up with my experience – too much salt (more than one S! cap or two NUUN tabs per hour) will make my stomach worse, but I can drink much more with the help of a an occasional salt tablet or bottle of NUUN.

  3. Gary Gellin

    Joe – Cramping caused by overexertion? One has to train harder and get stronger? One can't just order a bottle of magic pills to make the problem go away? No one wants to hear that!

      1. AJW

        OK, I'll bite. Shelly's been making me witch's brew since Vermont in 2008. I start drinking it around 5 hours into the race and take it until the end every couple hours. In a five oz cup she dissolves one full Wyler's Chicken Bullion cube in Coconut Water. Evidentally that provides about 1000 mg of sodium and 500 mg of potassium. To tell you the truth I don't bother asking her about it she just gives it to me and I drink it.

        And, about the cramps I had at Robinson Flat; they started developing about 15 minutes before the Meadow and by the time I stood on the scale I couldn't straighten my leg. The cramps persisted until about a mile before Miller's Defeat. They gradually diminished while I ran the downhill off Little Bald with Bryon Powell. I told him that I was cramping and that I needed to take it slow for about 20 minutes. I didn't cramp again until the River Crossing and, of course, by then pretty much everything was cramping so it didn't matter.

        For my 2 cents I think cramp management is both an art and a science. I completely understand Noakes' research and would never question it. That said, mainlining electrolytes certainly helps speed up the process of eliminating cramps for me. Great column OOJ!

  4. Alex

    A foam roller, used on my calves and IT bands mid-run, has helped me up to 100K. I've not done 100 miles, but if/when I do, that's certainly going in the drop bag.

    1. OOJ

      Alex-

      Thanks for the input. This would satisfy two strategies: the "stretching" (and, as Noakes noted, the soft tissue mobilization) strategy, as well as the "resting"/slowing down strategy.

      My challenge to you: can you use the other (non-stopping) strategies with success, that would allow you finish faster

      1. Alex

        I certainly hope so. Faster is always the goal. To that end, I'm presently focused on aerobic and lactate threshold work, while wearing a HR monitor. The idea is to – along with smart pacing – avoid excessive lactic acid buildup early in races. That, along with form work/awareness and strengthening exercises will, I hope, lead to greater overall speed and efficiency down the road (pun intended). If all of that doesn't make it obvious already, I'm a fan of you work. Thanks for providing informative pieces like this.

        1. OOJ

          Alex-

          Though we don't have the data to back it up, I have a strong feeling that the Central Governor – as measured through heart rate – plays an enormous role in race performance, namely cramping (as well as other malaise: stomach, "quads", brain fog, etc.).

          A worthy examination – that I'm just starting – is looking into low heart rate training by way of Phil Maffetone. He notes that with proper training, we can gradually improve our "fat burning pace" (e.g. for most, a heart-rate of about 150bpm) down to as fast as 5:xx/mile.

          The interesting thing, running that pace is still "hard" (fatiguing, muscle stressing, energy burning), yet the brain does not perceive it to be a threat, since 150 is quite "sustainable" for the heart/brain complex, compared to, say, the 170bpm that I **averaged** for the first 5+hr of Western States this year).

          Therefore, if this theory is valid, two different runners running 15-hour pace (say…me and Tim Olson) would have very different results, based on my HR of 170, versus his of 15x.

          1. OOJ

            Here's an interesting "clinical case study: "purely hypothetical":

            Two runners – let's call them "Tim" and "Hal" – are running a race (say…Western States).

            While UNTRUE, let's assume:

            – They run all the same workouts, easy runs, long runs together

            – They run the same pace

            – Their mechanics are 100% similar to one another.

            – Their "Rate of perceived exertion" is the same for each and every run

            – They're both equally mentally tough (both "cougar winners" in the past)

            – HOWEVER: when Tim runs x:xx/mile, his HR is 150, but Hal's HR is 165 BPM.

            Then:

            – At Western States, they run the exact same splits through Foresthill (62mi), but with very different results: Tim wins without significant medical issues, while Hal suffers from "blown quads" (e.g. fatigue, and Central Governor-related muscle/effort shut down).

            My belief is that the difference in heart-rate at that exact same pace and perceived effort is what caused the malaise and muscle/pace shutdown.

            A worthy area of study, for sure…and fodder for a future StC column!

            1. Alex

              It might also be interesting to consider if substantial race pace work mitigates this somewhat. Let's say your marathon pace puts you around 165-170 BPM. IF you've trained up to 15-20 miles at this pace and HR, your mind may not perceive danger, and thus allow you to work more comfortably. Canova, I think, has his elite Kenyans do marathon pace efforts up to 24 miles. (Of course, ultras are raced at a very "easy" pace, so perhaps all aerobic miles would be "race pace"?)

            2. Darren Young

              Joe,

              Would it be more appropriate to consider their (these purely hypothetical studs) heart rate as a percentage of maximum rather than X BPM? So, for example, Tim runs at 60% while Hal runs at 70% of max (not sure what the MAF equivalent is)?

              Just asking because I have an unusually high max HR and something like 150 is almost never a stretch (even at 42 years old).

              Thanks for your articles! If I'm ever in that state where all these hypothetical runners live I'd love to stop by and get bio-mechanics screening…you do those, correct?

              Darren

  5. Michael Cowart

    thanks for the article… well done.

    I am a chronic cramper in the heat.

    1. I have cramped on a 20 mile run where my average HR was 137. Then cramped the next day when my average HR was 122.

    2. for the most part the cramps don't "attack" until I stop. ( I once DNFed an ultramarathon that I'm convinced I would have finished had I not been convinced to sit down for a while)

    3. Traditionally my cramping problems persist 3 days after which they disappear. (Maybe my brain "gets it")

    4. As to the training harder/slowing down/etc. I am only an experiment of one but I have fallen apart at roughly the same place and time during the same ultramarathon stage race all three times I have attempted the race. Each time I have had different levels of training readiness… different approaches to pace etc.

  6. Martha

    Hmmm…this makes sense. Vermont 100 2010: I spent 20-25 minutes at mile 70 getting my locked-up quads massaged. I left the AS and was able to run again. *(see note). Vermont 100 2011: I didn't take a long break at mile 70, even though my quads were again totally locked up. Had to walk the final 30 miles. In hindsight, it looks like a 20-minute break would have been a good investment. (* Note: In fact, in 2010, i could run so well after the quad massage that I ran myself right into heat exhaustion in the 90-degree, 100% humidity evening air — but that's another lesson learned.)

  7. ATLRB

    Excellent article. Thanks for the information. One question which I don't believe you address directly – since the positive effect depends upon oral receptors should I anticipate no "immediate" positive impact from ingesting a capsule form such as S!caps?

  8. Luke Garten

    Great article! I allmost allways cramp at races. My last 2 50 mile races had two very different results.

    Silver State 50 miler I cramped very early early from miles 18 to 38. My training was exactly the way I had planned it to be and my hydration and fueling went as planned as well. I drank to thirst as I had read from Waterlogged. I took an S cap every hour. My cramping would come on after a climb just as I would start to transition to a downhill. Strangely My hardest effort was my last 11 miles as I was trying to chase down a sub 8 hour finish. No cramps during that charge.

    Marin Ultra Challenge 50 miler a month later went a lot better. I was no longer working overtime at work and I even had to take an 8 day rest period 3 weeks before the race due to work related hip injury. During the race the pace was harder with more climbing. Hydration and fueling was the same but I took no salt or s caps during the race. I actually forgot to take the s caps I had with me from all of the early racing and chating with other racers I completely forgot to take them. I did cramp at the bottom the the last climb but it went away half way up and I was able to continue to run at the upper portion of the climb.

    I think cramping at silver state 50 had nothing to do with salt and was due to lack of rest and not enough taper leading into it (I took a 9 day taper). I think the forced rest period from hip injury helped my performance and maybe some fitness gain from Silver state 50 helped my performance at Marin Ultra Challenge 50.

    I will no longer take salt at races of 50 miles and less.

  9. Daniela

    Wow! This writing comes to me as I'm starting to deal with some cramps on my left hamstring. Never happened before until mile 20 of my last race (PRd by 17min, probably why! Hehe).
    Now the sensation is ever present while I run.
    I'm a bit worried about it, and another runner told me about pickle juice (which I'll try).
    Maybe I need to give my body a break instead of keep training for my first ultra?! I'll keep stretching!

  10. sharon

    Again, wow, your timing is unreal.

    I have been bothered by hamstring cramps on my left leg for the last 3 year, ever since I tore one of the hamstrings during a fast relay race. If I am a good girl and do regular stretching and strength training, then the hamstring is good to go. When spring comes, the snow melts, and I am on the trails, then I do not have time for stretching or strength training, and I am a cramp nightmare waiting to happen. And it did happen just 3 days ago.

    But the amazing thing is 1.5 weeks ago I ran a vertical km race, and stressed the hamstrings pretty good. Two days later I was enjoying a mt marathon at a VERY relaxed pace. Half way in to the marathon, on the wat to the top of a 1000 meter climb my hamstrings started cramping, first with small waves of cramps, then they started to spread. At the top of the mountain there was a bottleneck and everyone stopped. The view was outstanding, there was a musician in the bed of a pickup truck playing and singing french, Muse, karaoke, (how good it that?) Then the guy behind me lost his balance and grabbed my butt to keep from falling. I yelped, and everyone around started laughing. When we started running again my hamstring was one solid cramp, but loosened up within minuets. This has never happened before. The combo of not caring about the outcome of the race, and an absurd situation stopped cramps that have never been stopped before without serious massage.

  11. J.xander

    Your conclusions fit my bill.

    After severe cramping at a marathon last year (and reading one of your awesome articles.) I picked up Noakes book. I also mentioned to my physio the cramping and the book and he gave me the same advice. Maybe it's not the salt at aide stations but the stopping/walking that abates the cramps.

    It has proven true so far.

    I never cramp during training, even intense long mountainous runs. However, put me in a race and Bam!

    I did a marathon this weekend up and over a mountain pass (4000' of climbing). The distance and climb were well within my training zone. However, the excitement of races always pushes me to a faster pace than I train.

    At mile 20 the cramps (medial quad and calf and arch of left foot) started in and threatened to derail the climbing/running. Solution was to slow up. I eased off the pace and, it wasn't instant but, the cramps subsided and I was able to complete the race in a decent time but not at the pace I started (way to fast). Notably, three days later the muscles that cramped are still sore.

    Thanks for writing such great articles!

  12. Brett

    These things always make me laugh. They say there is no scientific evidence that cramping is related to an electrolyte imbalance. But then immediately after they admit the overwhelming anecdotal evidence to the contrary. Nothing is more hilarious than people who are 100% confident about something that they readily admit they don't fully understand. I'm not speaking directly to you here Joe – you will forget more knowledge than I will ever remember. But for tons and tons and tons of people in ultras, not taking salt leads to cramps. Taking salt alleviates them. Period.

  13. Torsten

    Another great post. Thanks!

    Speaking of the Central Governor, there are other reasons to take salt during WS and other ultras. Low sodium creates an osmotic imbalance across the blood-brain barrier that causes rapid water accumulation in the brain, causing various impairments including seizure. Heat is a contributing factor. I'm not sure how that relates to cramping, but presumably it relates to how well the Central Governor works, assuming the brain is part of it. Also, if you just think of salt as sort of a placebo for the Central Governor, and therefore take only minimal amounts, you might be ignoring some potentially dire consequences.

  14. Jeremy C

    Thanks for another fascinating read!

    One question that I can not help but ignore is, IF cramping is CNS related, why does the central governor get salt and think "excellent, I will be better off now, go ahead and run faster". It makes sense that the moment we have calories hit our taste buds, our central governor says "yes, I need those! I will be in better shape… you can run a bit harder now". But IF the cramps are CNS related, AND the electrolyte balance, dehydration etc have no effect on the cramps, then why does the central governor receive salt and say "yes, I needed that"?

  15. KenZ

    As I've noted before, this is right on target with what I've found. Used to think that S-caps reduced my cramping, but then realized (before Noake's book) that what I was really doing when taking the extra S caps during cramping was slowing down just a hair for them to "take effect." Later, tried it with no S caps. Same thing: cramping went away. And funny enough, I do use HR to manage cramping. My last 100k I got an inner thigh cramp, dialed back my speed a hair, and found the magic HR (141) at or below which I would not cramp, but ramp that up to 145/148, and the cramps came on. Ran my last 100 miler with zero electrolytes, zero cramping, and simply managed my speed better within my ability. With a top 10 finish to boot! I don't doubt that the CG has a huge role to play, and perhaps salt, or the taste thereof affects it just like the TASTE of sugar with no calories increases performance in bikers during studies. Perhaps I'll use that info, carry a few S caps again, and simply crack one on the tongue instead of shoving it down my throat.

  16. Tropical John

    Fascinating read, Joe, thanks. I love it when old wives tales are debunked. (but weirdly, I know nothing about this subject – in 138 ultras and 99,800+ miles of running, I've never had a single cramp. Not even after gasping and weezing up Oscar's Pass this morning. Likely one of the very few things I've done right!)

  17. Will

    Great article and I totally bought this argument (and, intellectually, still do) — but at Western States I found myself buying into the "uneducated" story. I have a history of muscle cramps that I have managed reasonably well in recent years, taking electrolytes but not bothering with salt tablets. At States, I was going easy in the heat and doing well until the climb to Devil's Thumb (about 45 miles in). The heat and the climb got to me, and I threw up. Almost immediately, my calves started cramping, which they continued for the rest of the climb and the start of the next descent into El Dorado canyon. At one point they cramped so suddenly and hard that I literally lost my balance and fell over! From there, I started using salt tablets every hour, plus drinking a lot of electrolytes. I came back strongly, and ran most of the final 40 miles, passing over 100 people in the process. So my point is that it seems to me, if they cramps were just related to muscle workload, they should have continued cramping over the second half of the race. Maybe the taste of electrolytes helped, but I feel that the use of salt tablets was very helpful, and my tongue didn't taste them. I'm an empirical scientist by training and careful about extrapolating from a case of one, but I have to say that States gave me an appreciation of salt tablets that I didn't have until now.

    1. OOJ

      Will-

      My devil's advocate:

      – You were worried about the heat, and the canyons

      – How heat *might* contribute to cramping is that it elevates heart rate WITHOUT a *perceived* difference in workload (this could be due to the fact that blood is still oxygenated the same…but it's being diverted to skin – so you're not breathing harder, but muscles are working harder)

      – You have a melt-down at Devil's…possibly due to the elevated HR and heat increase.

      – You start to cramp, due to the *fatigue* and or a *Central Governor response*, saying, "Hey, Will! Danger! This is stupid, please stop running!"

      – After Devil's, you made a significant change in strategy: you drank more, you took "medicine" (the placebo effect of eating a pill) and, invariably, you slowed. You took care of yourself!

      – Your "Central Governor" – previously worried, was now feeling safe, and allowed you to continue.

      Thus, this is my argument that it was NOT salt, you suffered, took stock/fixed yourself, and ran smart.

      Congratulations!!

  18. OOJ

    Here's another fun experiment:

    – Take AJW and sever his hippocampus, so he has no long-term memory

    – Have him run two hundred milers

    – One ultra: he drinks Witch's Brew

    – Other ultra: he drinks it, immediately vomits it out

    – Due to his hippocampal abnormality, he has no memory of the vomiting (or, for that matter, ever drinking the Witch's Brew)

    Research question: is there a difference in cramping?

    My hypothesis: NO.

    There'd be no difference because (1.) the mouth tasting salt and (2.) the aid station break would contribute to the decreased cramp response…NOT the ingestion/digestion of the salt itself.

    But I doubt this experiment would get IRB approval… B-)

  19. OOJ

    One of the messages worth reinforcing here – to not be discounted – is the importance of proper *mechanics* and neuromuscular *efficiency*:

    A noteworthy article I came across today at work:

    http://www.ncbi.nlm.nih.gov/pubmed/20118522

    This athlete was over-using the hamstring and under-using the gluts. Simply put, few of the other techniques beyond efficiency/re-education, would be nearly as successful at cramp treatment…

    This is especially important with unilateral cramping: only one leg = mechanical fault.

  20. OOJ

    Brett-

    There is no "anecdotal evidence" linking cramping to electrolyte imbalance. To reiterate, cramping has been shown to be interrupted by salt (or pickle juice…or, as someone else noted above, a grab in the ass). But is it NOT due to a change in blood serum electrolyte changes.

    I am confident in the numerous studies of cramping and blood values; but the hallmark of a good scientist is to constantly question: both the status quo (and the null hypothesis) and his own beliefs.

    1. Brett

      Hi, that's not exactly what I was saying. What I'm saying is that there are opening statements that science has definitively said that electrolyte imbalances/salt intake have zero to do with cramping. Period. End of Story.

      Then not too long after that we read the opposite, which is to say there is tons of anecdotal evidence to the contrary. That many, many, many people report having troubles with cramps which goes away with increased salt intake. The conclusion that some people make is that it is all mental – there is something going on in the brain. Well honestly, it doesn't matter what happens at that point. The end of story is not the end after all. There simply is too much evidence to contradict the opening statement. Because it is there in black and white for all to see that absolutely salt intake does in fact alleviate cramps. We don't completely know why, so therefore it doesn't matter?

      Salt has an RDA (recommended daily allowance) just like other vitamins. That means your body processes salt and it needs to be consumed in certain amounts each day. So the basic premise that you can exert yourself for several hours without having to replenish something also fails the straight-faced test.

      1. Paul Davis

        Better (or at least more subtle) reading comprehension is required here.

        As already stated, the article claims that electrolyte levels in the blood (or even within tissue) are not the cause of cramping and then ALSO claims that there are ways for the intake of salt via the mouth to have an impact on cramping.

        If you were to believe that in fact electrolyte levels in the blood/tissue are the cause of cramp, then you might conclude that preloading of electrolytes along with continued intake of them during exercise is an effective strategy.

        But if the hypothesis presented here is correct, then preloading is pointless, and the continued intake only has an effect in the same way that the pickle juice study demonstrated. If you believe this, then your approach to minimizing cramping will be very different.

        You haven't cited any study that shows that exertion actually causes changes in electrolyte levels, but giving you the benefit of the doubt that such studies do exist, that still doesn't mean that there is any evidence that a reduction in blood/tissue electrolyte levels is linked to cramping, which is the subject of this article.

  21. OOJ

    Torsten-

    The mounds of research on hyponatremia concludes the *only* way to become "low sodium" -outside a disease process =- is the forced introduction of excessive fluid.

    Heat is not a contributing factor. I encourage you to review the literature and/or read Waterlogged and the large volumes of discussion devoted to heat and hyponatremia.

    Lastly, a review of 34 separate randomized control trials (gold-standard research) on exercise and sodium levels showed that in 33 of those studies, ALL blood sodium values INCREASED.

    In the 34th, the only outlier, the patients were *already hyponatremic* at the onset of the exercise trial.

    Lastly, consider historical context. Prior to circa 1975, the provision of any aid in marathon races was against the rules: no water, no salt, no food. Yet runners continued to perform at extremely high levels…and people were not having seizures.

    1. Torsten

      Is it possible that people, when consuming S-Caps and electrolyte drinks, believe they're getting isotonic or hypertonic solutions, and therefore not going to get hyponatremic? Are they over-thinking and therefore overdrinking?

      I have read a fair amount of Noakes as well as the Science of Sport blog (students of Noakes). They also apply the Central Governor idea to pacing, as I think maybe you have done too. Are we just thinking too much and trumping the Central Governor and outpacing and outdrinking ourselves?

      The Central Governor idea is intriguing and I appreciate your adding the research to the theory.

  22. OOJ

    Jeremy-

    The theory is the same as to why we are so tempted with junk food: we have *primative* dietary urges designed to keep us alive: water, sugar, fat, salt. That said, the provision of one/all of those – especially in situations of duress – may result in relaxation of The Governor.

  23. OOJ

    Perhaps it's because you use that deep baritone to soothe your inner Governor?

    I hear, however, that that baritone wasn't too soothing to some folks camping at the Auburn Fairgrounds a couple weekends ago…. ;-)

    In all seriousness, this is tough to explain, though the cop-out would be "genetic pre-disposition". I will go out on a limb and say, *perhaps*, that an interesting correlation study would be to link cramp incidence with personality type (e.g. are more high-strung runners more prone to cramping?).

    Tropical John is a cool customer…

  24. Jo C

    Thanks for a fascinating article. I am a 5 – time Ironman triathlete (to Hawaii level), and have run 3 marathons and 1 ultra. I had avoided cramps completely until a half – ironman race last year. I had just come off a spell of illness, and had lost fitness and gained weight. I rode the bike to my potential, and set off on the run with confidence – but within 1/4 mile – BOOM! Massive cramps in both my VMO muscles! This stopped me dead! For the next 4-5 miles, I would jog, then have to walk as the cramps returned. Eventually they eased, and I was able to run the rest of the race (slowly!!) This convinced me that cramps originate locally – my VMOs weren't conditioned to ride that hard, and then transition to my "normal" run pace at that time. Your article has just backed up my theory!!

  25. d'Jo D'lig

    Very interesting article. In my case:

    – I rarely get cramps during the race, but as soon as I cross the line, there's a risk of them appearing. I think that reflects that they're brain controlled, when the mental racing stress dissapears, natural physical reflex takes control.

    – After a certain fatigue, my calves always seem to perform some neurotical dances but they have never entirely cramped. My quads don't have this uncontrolled dancing but cramp up suddenly. So I don't see a relation between the "mini-cramps" and the total muscle cramp.

  26. Kevin

    I have two comments, first of all Dr, Noakes own study showed lower sodium concentration in cramping triathletes than in non-cramping triathletes.
    http://www.ncbi.nlm.nih.gov/pubmed/16015122

    He uses the fact they didn't have "clinically" low sodium as an out in this case. but to say there is no link isn't true.

    The other comment that goes to this theory of cramping that I have never seen addressed, why don't marathon swimmers cramp in their shoulders or arms? The central governor theory holds that the muscles undergoing repetitive contractions will cramp. But in 13 years of coaching, training and racing in the sport I've never so much as heard of someone cramping in their primary mover muscles for swimming during an event.

    By contrast, I have heard of many cases of leg cramps in hard races. While your legs certainly move in marathon swimming, for long races and long distance racers, there is very little leg work at all.

  27. JKal

    Severe cramping in right calf at mile 40 of my first 50 miler, took two salt packets (thanks McDonald's you're good for something) and within 30 seconds the cramp was gone. I'd buy the "Brain" theory as that salt had no time to get into my system!!

  28. Matt

    I just want to point out that Dr. Schwellnus' name in English means "swelling nut." Good thing he's a doctor! A certain "Bridesmaids" quote also comes to mind.

    Great article as always!

  29. Heather

    OK, I read most of this article, but started to feel like I was back in grad school reading an empirical research article. And since I'm not having to produce my own research paper on said paper, I skimmed the rest. I just HAVE to say…I don't know exactly WHAT causes the random occasions in a long haul race, where I suddenly feel like my legs and feet are having seizure cramps, a vampire sucked all my life force out, a bowling ball is swishing in my gut, and pretty much poop on a stick. I can tell you that I never used a salt pill until I stumbled upon them in a desperate moment of a 68 miler. I was told I needed salt pills and quite frankly, in the moment, I would have taken pretty much anything. I popped a Salt Stick from my new trail buddy, and I kid you not, I was a new woman in 90 seconds. I went from poop on a stick to dancing on the trail. I'm totally old school and only consume whole foods when I'm running the long haul, I don't go for the latest greatest PUFF THE MAGIC Dragon elixirs on a whim. But in my desperate moment, I gave the Salt Stick a try and it really did work, for whatever my body was depleted of. Pickle juice, bananas, Salt Sticks, jelly beans, whatever works for the individual.

    1. OOJ

      "Ply the Governor with its Favorites!"

      You were told, "You need this!". What if someone told you, "You're only supposed to take this after a race, it's bad for you now", and you still took it. Do you think you'd still have the benefit? I'm not sure…but I would theorize its helpful effect would be less.

      Interestingly: a friend of mine actually *pounded half a Coors Light* from a guy along the trail at Western States. Clearly, all research states that alcohol is a performance-inhibitor. And I think most runners would agree, "OK, this is inappropriate."

      Yet, after walking for 45min, he suddenly ran the entire 2.5 miles/1800' climb thereafter.

      Why?

      I'm not sure, but I feel like, despite the fact that there is scientific evidence to suggest "This is bad", his brain thought it'd be a cool thing to do, and responded accordingly.

      So…"Ply the Governor with its Favorites", but recognize the limitations of the "magic elixers" (especially Coors Light!)

      1. Torsten

        Re/beer. Doesn't alcohol suppress anti-diuretic hormone (ADH)? And isn't ADH implicated in cases of hyponatremia?

        Just making justifications for more beer.

      2. Heather

        Coors Light? I think I recall that being a drink I got back when I was under 21 and had to get a buyer…and didn't know what real beer was. Whatever works Governor.

  30. Brian

    Really one of the best and most useful articles ever posted on IRF. I suffered severely from leg cramps at WS this year and turned a silver-buckle start into a bronze 29-hour sufferfest. I'll be using this advice in all my future races. Thanks!

  31. Tom

    The concept the cramping is "all in yer head" is false. Ultra athletes push ourselves to the limit of muscular endurance and know when we have passed a threshold, based on what our body is doing. We know when we need calories. We know when we need salt. Based on overwhelming experience, I think the science should reconsider the testing Methods. This doesn't make sense.

  32. Loxley Crawshaw

    Interesting article and a lot to take in. Last weekend I ran a relatively short ultra of 33 miles and I was cramping quite badly near the end. It was a hot day (for the UK at least)but there was plenty of water at the AS's. For the start of the race I'd made up a 500ml bottle of electrolyte and I took 3 S'caps during the race. I drank approx. 3.5 litres of water during the race. I don't usually get cramp this severe but I don't usually run in heat either so I automatically thought salt? The thing which goes against your article is the cramps got worse after I finished and rested and didn't get better until I flooded my system with liquid. Another interesting thing happened. Before I set off for the drive home I laid in the shade with my feet up for half and hour and my leg muscles, especially in my calf started randomly firing like crazy. I even took a video of it because it looked weird, no pain just firing and twitching. It lasted about 30 minutes. Was this too much salt or not enough?

    1. OOJ

      Neither. It was likely muscle fatigue, exacerbated by heat.

      Again, note that a strategy for cramp management is active stretching of the muscle into its most elongated state. Therefore, to finish the race and either stand/walk around OR lay around would not accomplish this aim.

      Interesting, regarding heat:

      – The studies looking at heat and cramping measured *internal temperature* of runners who cramped versus those who did not. They failed to find a difference in core temperature.

      But what might be more interesting, would be to take the same runner, do several run trials (same distance/time) at the same pace OR RPE, at various temperatures. Then determine if there is a difference in cramp frequency with each individual runner.

      I think, then, you'd find a difference. My theory: heat robs muscles of blood flow (as it is being diverted to the skin for cooling), but not the oxygenation of the blood. Because of that, breathing rate (a substantial "measure" of effort for runners) does not change, since blood O2 is still sufficient. Therefore, you have a mechanism whereby the muscle IS working harder, but it is difficult for us to consciously perceive.

      Thus, the increased heart rate AND "muscle stress" are both factors that could cause cramping – with distance, effort, and fluid/salt/food intake all being the same.

  33. James

    Great Article thanks.

    I've only ever cramped once in a race (Spartathlon las year after about 50 miles). I felt pretty wasted by then but was taking electrolytes.

    I managed to survive without electrolytes for years as an ultra runner, doing some longer races too (such as the Spartathlon, Marathon Des Sables etc) where heat was an issue. I started taking them before Badwater. Probably just as well as back then I was overiding my thirst mechanism and drinking constantly. I actually put weight on in that race. If that were just pure water I might have ended up as a statistic in this article.

    I do sometimes just cramp after a race, usually in bed the night after. Any clues as to what this is?

    Great stuff again.

  34. Joanne

    Perhaps we need to look at muscle cramping outside of exercise as well to gain an understanding of the causes. I grew up farming in PA. I got up very early every morning and did the basic farm chores before going to school. I took advanced classes and always had a lot of homework. After school it was immediately change clothes and get to the barn and get the basic evening chores done and then tackle whatever seasonal work needed to be completed. I shoveled a lot of manure, threw many hay bales and I often had muscle cramps – even hand cramps and back cramps – total body really and at any time of the day or night they would occur. I could be sitting in German class and my hand would curl up into a painful cramped little ball. We were not able to participate in sports and I would not have called myself a runner at that time. I was not exuding salt but I put in long days and they included a quite a bit of physical activity. We rarely went to a doctor but on a mandatory visit it was mentioned and the advice was to get some rest.

  35. Ethan

    Joe – thanks for your detailed response. I will start by reading Dr. Noakes' book. With regard to the research I mentioned in horses (and I had meant to write hypOcalcemia in my previous post): the distance was 80 km; here's a reference – "Plasma ionized calcium and parathyroid hormone concentrations in horses after endurance rides" by Agiulera-Tejero et al (2001). Electrolyte abnormalities in horses following prolonged exercise are a well-documented phenomenon, a brief bit of poking around the Internet reveals. With regard to the study you propose – coupe thoughts: first, there's no need to clone anyone, you'd just have to round up a sufficiently large number of athletes with a history of cramping as this would mean they all had the required genetic proclivity; second, that study hasn't been done, which is sort of my point. You preface your article by explaining that really what we have are theories and no definitive answer. And I guess at some point when I know more about the existing research, I think it would be cool to do the study and have a more definitive answer.

  36. Joe

    For me, it is simple: If I do a long enough ride or run on a warm day and I fail to take salt, I cramp. Always. If I take salt, I don't cramp. Ever. It doesn't matter how hard/easy I go, if I sweat enough for long enough and I don't take enough salt, those cramps are coming.

    And even since I learned that salt was the key, I've forgotten it enough times to have the lesson taught to me again the hard way

    So I never know what to make of articles like this one. Some expert telling me that my personal experience is not possible.

    I'll stick with practice over theory.

    1. OOJ

      Joe-

      If I can somehow distill 8000 words into about twenty:

      – Salt works, just not how we think it does

      – Because it's not a blood/muscle factor, we need to limit how much we take, AND recognize there are several other factors that influence cramping.

      1. Brett

        "- Salt works, just not how we think it does"

        This is my entire beef with Waterlogged and much of the article above. Because at the very top of the article you say that you can only smile and nod politely when your patients tell you that they combat their cramps by consuming more salt, implying that an electrolyte deficit somehow causes their cramps. And you say it does not.

        You all just cannot have it both ways. I say this respectfully by the way. I hope you can see what I'm trying to say here. It literally reads like 'there is no proof that taking salt alleviates cramps' and 'taking salt alleviates cramps'.

        1. Dean G

          But you can say, "salt on the tongue helps cramps by sending a signal to the brain…

          unfortunately then consuming that salt has other impacts that aren't so positive…

          so thanks to new science we suggest you try a little salt on your tongue instead of a full tablet that you digest."

          That's the way I read Waterlogged. It's about understanding how things work BETTER than we understand them now. So that we get better and better at training the body and helping the body when we ask it to perform these amazing efforts.

          I think we are seeing the same kind of thing across diet. As to when/how to use sugars and fats etc..

        2. Anonymous

          Brett – your beef seems to be that the article (and related studies) argue that lack of salt does not cause cramps, while also offering that added salt helps to fix cramps, seemingly contradicting itself. However, I believe that Joe is saying that lack of salt is not the cause of the problem, even if it is a solution. An extreme analogy would be to say that since metal pins can fix a broken bone, lack of metal pins caused the break in the first place.

  37. Chris H.

    The primary claim seems to be that the tongue, which tastes the salt, has some connection to the brain, which then is connected up with nerves/muscles and whatever. Then, in your response to ATLRB, you said that s caps would appear to have more of a psychological effect (because the salt cannot be tasted by the tongue). Therefore, it would seem that if we just know we're taking in salt, it'll get relayed to the CG. So, according to this hypothesis, it doesn't matter whether we are conscious of the salt intake or not conscious of the salt intake. Am I interpreting this correctly?

    1. OOJ

      The Central Governor processes information that is both conscious and unconscious. The conclusions of the pickle juice study theorized there was a reflex area in the tongue/throat that disrupted the cramp.

      At the same time, there's a "This is a good thing" placebo-effect, as well as the theory that our brains respond positively to water/sugar/fat/salt (the "primative needs" theory). For example, there is a study out there that found improved run performance from runners drinking small volumes of a zero-calorie, sweet drink.

      So, yeah…and interesting experiment would be to somehow remove that psych/placebo effect – perhaps by administering some salt (or sugar) product, yet somehow convincing the subjects that "This is not helpful"…then seeing if they still experienced a benefit.

  38. Evan C

    Two kinds of cramps I experience:

    1) "Seizure cramp" – often comes at the end of a race when I'm pushing hard. Feels like uncontrollable twitching (often in the calves)and can make it my stride feel awkward and off-balance.

    2) "Paralysis Cramp" – these come after I take a fall on a trail run and the entire leg automatically stiffens and becomes extremely painful and immobile for up to 60 seconds. Interesting to note that these occur only after a tumble and that the temporary paralysis brings on anxiety.

    In my experience these can occur regardless of sodium intake.

    If all we need to do is send to our brains the taste of salt – maybe we can just lick the excreted salt from the skin of our arms?

  39. Aaron

    I resolved my cramping issues a few years ago. Sports drinks, bananas, and salt pills had absolutely no effect on my cramping, so I dismissed the electrolyte theory as hogwash and sought my solution in brutally hilly long runs. They worked. Short hill repeats not so much.

    Over the last couple of weeks I've been working on fermenting beet kvass which looks like a useful drink for long distances. I'll have to pay attention to how salty each batch tastes and save it up for low points to see if it has much effect as a pick-me-up.

  40. Gary Gellin

    There are truisms with muscle cramping that almost all of us in this discussion thread are ignoring.

    The biggest is that cramping is related to OVEREXERTION combined with sudden high loading. I can say with absolute certainty after 20 years of persistent cramping during both bicycle and foot races that excessive high intensity loading of a muscle in a single training or racing event will ~eventually~ cause a weak muscle to cramp. I've experienced this in every weather condition possible and with every nutritional experiment one can devise. The body is acting in a defensive way to avoid further damage. If racing FULL GAS on the Quad Dipsea course, whether it is a cold and rainy day or a hot day, I will have onset of muscle cramping at precisely the transition from downhill to uphill at Mile 21.2. If I were completely out of shape but somehow able to run at high intensity, I guarantee that the onset of cramping would be much sooner independent of what was in my water bottle or my breakfast bowl.

    MAGIC ELIXIRS (pickle juice, salt tabs, quinine,..), if they have any affect at all, will not allow you to run at the same effort after the onset of cramping. Has anyone here run anywhere close to even halfway splits at a marathon distance or beyond after cramping (not just minor twinges) more than a few miles out from the finish line?

    The other truism is that cramping is PERSISTENT BUT NOT CONTINUAL. Have you ever been completely immobilized for more than 60 seconds? A cramp can hurt like hell, but it is not like a broken ankle which will take you out completely. The pain subsides, you start off slowly again, you run at a smooth effort (particularly in uphill to downhill transition and vice versa), and you don't sprint. Yes, the cramp will return but it can be held at bay with slow and careful running. Say we are both cramping and you take a magic capsule and I take nothing. We are both running again, albeit a little more slowly than before. What significant difference does that make?

    An interesting anecdote is that a pro bike racer in the 90's, Esteban Fraga, would poke his cramping thigh muscle with a safety pin to stave off cramps. I think I would sooner try a mobile electroshock device – perhaps Ken Z on this forum can fab one up for me to try.

    1. Aaron

      One can continue while managing them, but I'd rather just give up at that point. When I've gone on to finish I've been rewarded with almost a week of swelling and bad DOMS. Chances are pretty good that I was also overloading my kidneys with myoglobin. It just isn't worth it.

    2. KenZ

      Gary, I am more than happy to rig a little high voltage electrostym device for you. Methinks with a simple DC-DC up-converter, capacitor, and a 555 timer we can give you a patch and leads that you can power from your ghetto Garmin backup power pack. You might look like a heart attack patient escaped from the ward, but think of the entertainment value it'd give.

      In all seriousness, and I'd like to hear Joe's thoughts on this, yes there may be a genetic component to how often/if we cramp. There may also be a cascading effect in that we're creating and strengthening neural pathways every time we cramp, in that the body tries the cramp mechanism to get you to slow down, even if for 30 sec to pop an S cap, and it works (to slow you down), thus reinforcing the neural pathway/response. Now, here's the question: I've heard people say that sometimes if you have muscles mis-firing, or not firing enough (quad dominant, or glute inactivity, or whatever) that a good accupuncturist can do a "reset" on you. Never been to one, but I find the resetting/retraining of neural pathways an interesting, albeit unlikely (?) concept. If the first statement is true, could one then somehow reset that pathway response to overexertion? Or should we just shock the crap out of Gary post-occurrence with a rigged electrostym.

    3. OOJ

      Great post, Gary!

      What I will say is that cramping (especially when it comes on with seemingly acceptable efforts) could be an overload secondary to a neuromuscular imbalance: in other words, the brain is over-relying on one muscle group (very commonly seen in the hamstrings vs either gluts AND/OR abdominals).

      That said, from a clinical perspective, a runner/cyclist might benefit from an evaluation from a PT or other movement specialist to be sure ALL muscle groups are firing and doing "their share"!

      An article to argue this point: http://www.ncbi.nlm.nih.gov/pubmed/20118522

  41. Paul Davis

    Not really sure how any of this relates to (e.g.) post-exercise cramping, or the kind of cramping that Joanna describes above.

    It seems very clear to me that cramping is a multi-modal phenomenon, with the only commonality being the basic fiber contraction.

  42. Chris

    I rarely take salt (beyond what's in my sports drink) at any distance. I do, however, occasionally wipe my forehead and lick the salt/sweat on my fingers. Sort of gross, okay, but I think my governor enjoys it becuase it seems so natural during a long run (and I rarely cramp so just this small taste of salt may ward off cramping).

  43. Trisha

    Interesting stuff. I've never taken salt caps (did once during a training run to try it, got a stomach ache, never took them again). I've also never cramped in a race. In ultras I usually have some electrolyte mix in my water, but not a lot. I've always assumed that being hydrated was more important than salt levels in terms of cramping, though I've also found that I can drink very little and still have a very successful run.

    I tend to agree mostly with what you've written. I do have a problem with Noakes's book being the primary source. There have been plenty of discussions regarding issues with things he stated in that book. He is an intelligent man and I trust his work quite a bit, but less so his latest work.

    My main question is how this impacts cramps one gets when not exercising. I've only ever had that kind of cramp and not very often. Certainly it isn't a salt issue nor is it a "working too hard" issue, since those tend to occur when sitting or laying down. Stretching obviously helps, but why do they happen in the first place?

    Thanks for writing about an interesting topic that obviously needs to be looked into further.

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