Could post-COVID-19 complications such as Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) or Postural Orthostatic Tachycardia Syndrome (POTS) be causing my muscle fatigue, cramps, and twitches, particularly in the forearms and hands, following a recent COVID-19 infection?

Post-COVID Muscle Cramps and Twitches: POTS and ME/CFS Evaluation

Yes, your muscle fatigue, cramps, and twitches in the forearms and hands could be manifestations of post-COVID complications, specifically POTS or ME/CFS, and you should be evaluated for these conditions if symptoms persist beyond 4 weeks after your COVID-19 infection. 1, 2

Understanding Your Symptoms

Your symptoms align with post-acute sequelae of SARS-CoV-2 infection (PASC), which affects 10-30% of individuals following COVID-19. 2 The muscle-related symptoms you're experiencing have several potential mechanisms:

Direct Neuromuscular Effects

• SARS-CoV-2 directly damages skeletal muscle through inflammatory effects, cytokine storm, and muscle catabolism, as the virus targets ACE2 receptors present in muscle tissue. 3
• Muscle fatigue persists long-term in COVID-19 survivors, with severe cases showing reduced torque generation and impaired electrical neuromuscular function even one year post-infection. 4
• Neuromuscular limitations including pathological reflexes and restricted range of motion have been documented in young adults with post-COVID ME/CFS. 5

Systemic Deconditioning

• Profound cardiac deconditioning occurs rapidly (within 20 hours of bedrest), causing reduced plasma volume, decreased stroke volume, and compensatory tachycardia that worsens muscle fatigue. 1
• Alterations in immune activity and metabolism create exercise intolerance that standard diagnostic tests may not detect. 1, 2

Two Key Conditions to Consider

Postural Orthostatic Tachycardia Syndrome (POTS)

POTS is characterized by heart rate increase >30 beats per minute after 5-10 minutes of standing without blood pressure drop, accompanied by palpitations, lightheadedness, weakness, and exercise intolerance. 1, 6 Critically, 42% of POTS cases are preceded by viral infections, making this a highly relevant diagnosis post-COVID. 1, 6

Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS)

ME/CFS requires three core features: (1) substantial functional impairment lasting >6 months with profound fatigue not relieved by rest; (2) postexertional malaise (worsening after physical/cognitive exertion); and (3) unrefreshing sleep, plus either orthostatic intolerance or cognitive impairment. 1, 7 About half of long COVID patients meet criteria for ME/CFS. 7

Diagnostic Approach

Consider PASC evaluation when symptoms persist beyond 4 weeks after mild COVID-19, rather than waiting 12 weeks. 1, 2 Your initial workup should include:

• Complete blood count, basic metabolic panel, troponin, C-reactive protein 1
• ECG and echocardiogram 1
• Ambulatory rhythm monitor 1
• 10-minute active stand test: Measure heart rate supine, then after standing for 10 minutes to assess for POTS (≥30 bpm increase) 1, 6
• Assessment for postexertional malaise: Do your symptoms worsen 24-48 hours after physical or mental activity? 7

Treatment Strategy

Immediate Non-Pharmacologic Interventions

Start these measures now, as they form the foundation of treatment:

• Aggressive hydration: 3 liters of water or electrolyte-balanced fluids daily 2, 6
• Increase salt intake to 5-10 grams (1-2 teaspoons) per day through liberalized dietary sodium 2, 6
• Waist-high compression stockings to support central blood volume 2, 6
• Elevate head of bed with 4-6 inch blocks to maintain plasma volume 2, 6
• Minimize upright activity during symptom flares to reduce orthostatic stress 2, 6

Pharmacologic Options (If Non-Pharmacologic Measures Insufficient)

• Low-dose beta-blockers (bisoprolol, metoprolol, propranolol) or nondihydropyridine calcium-channel blockers (diltiazem, verapamil) titrated to control excessive tachycardia 2, 6, 8
• Fludrocortisone up to 0.2 mg at night combined with salt loading to increase blood volume (monitor potassium levels) 2, 6
• Midodrine 2.5-10 mg with first dose before rising and last dose no later than 4 PM for orthostatic intolerance 2, 6

Critical Exercise Considerations

Exercise therapy is crucial for recovery, BUT standard upright exercise (walking, jogging) may worsen your symptoms. 1, 2 This is a critical distinction:

• Do NOT use graded exercise therapy if you have postexertional malaise, as physical activity worsened the condition in 75% of long COVID patients. 2
• Avoid complete bedrest, as this worsens deconditioning. 2, 6
• Start with recumbent exercises (lying down or semi-reclined) to avoid orthostatic stress while preventing further deconditioning. 1

Common Pitfalls to Avoid

• Do not dismiss symptoms as simple deconditioning – ME/CFS involves complex immune, metabolic, and neurological pathophysiology beyond mere physical deconditioning. 7
• Do not push through fatigue – this distinguishes post-COVID complications from depression or anxiety, where activity typically improves symptoms. 7
• Do not allow complete bedrest during acute flares – maintain some recumbent activity when possible. 6

When to Seek Cardiology Consultation

Seek cardiology evaluation if you have:

• Abnormal cardiac test results 1
• Known cardiovascular disease with worsening symptoms 1
• Persistent cardiopulmonary symptoms not otherwise explained 1
• Documented cardiac complications during your COVID-19 infection 1