Abstract & Commentary
Synopsis: Dietary creatine supplementation significantly increases the resting and postexercise anterior compartment pressure of the leg compared to presupplementation levels.
Source: Potteiger JA, et al. Changes in lower leg anterior compartment pressure before, during, and after creatine supplementation. Journal of Athletic Training. 2002;37(2):157-163.
There has been widespread acceptance of the use of dietary creatine supplementation to enhance muscle bulk and athletic performance. One common problem noted has been increased rates of muscle cramping with fluid shifts. Potteiger and colleagues from the University of Kansas had previously shown that creatine use also was associated with increases in lower leg anterior compartment pressure. The present study went a step further.
Sixteen athletically active males served as somewhat heroic volunteers for an elaborate set of experiments. They had not been prior users of creatine or had a history of lower leg problems. The subjects were divided into a low-dose creatine group of .03 g creatine/ kg/d, and a high-dose supplementation group of .3 g creatine/kg/d for 7 days followed by .03 g creatine/kg/d until 35 days. Both groups underwent extensive testing to include determination of body mass, body composition, blood pressures, lower leg volume, and muscle biopsies. Anterior compartment pressure measurements were performed prior to exercise, immediately after exercise, and then 1, 5, 10, and 15 minutes post exercise. All of these measurements were performed prior to creatine use and then after 7 days and 35 days of supplementation as well as 28 days after stopping the supplements.
As expected, body mass and lower leg volume showed increases with creatine supplementation. Also of note there was an elevation of blood pressure, especially in the high-dose group with creatine supplementation. Muscle biopsies showed elevated creatine amounts that normalized after supplementation was discontinued.
Because no differences were seen between the groups in terms of compartment pressures, but only with time, the 2 groups were combined for the data analysis. Creatine use showed a rather dramatic increase in anterior compartment pressure measurements both resting and after exercise. The numbers were quite striking with an increase from baseline at rest of 18 mm Hg to 26 mm Hg after just 7 days of creatine. Immediately after exercise the pressures increased from 52 for the controls to 77 with the creatine supplementation. At 5 minutes post-exercise, when the pressure should be diminished, they were down to 24 for the control group but remained elevated at 41 for the creatine supplementation group. When patients were measured after being off the creatine for approximately 1 month, these numbers were still elevated at about 33 mm Hg. All pressure measurements both at rest and after exercise were significantly elevated from baseline for the creatine supplementation groups.
Potteiger et al note that creatine elevates compartment pressures to the point that athletes are at risk for exertional compartment syndrome symptoms. Indeed, complaints of tightness and burning in the anterior compartments were common among the participants in this study.
Comment by David R. Diduch, MS, MD
Pedowitz has established formal criteria to diagnose patients with exertional compartment syndrome.1 This is based on elevated compartment pressures 1 minute after exercise of greater than 30 mm, or 5 minutes after exercise greater than 20 mm of mercury. The mean pressure measurements for the subjects in both the high- and low- dose creatine groups were all elevated above these established criteria. Furthermore, pressures were slow to return to normal levels even after 28 days of being off of creatine. Interestingly, many of the athletes in the study had symptoms compatible with exertional compartment syndrome.
I believe Potteiger et al were successful in proving their hypothesis. Creatine supplementation can significantly increase resting and postexercise anterior compartment pressures above presupplementation levels, and there is a slow normalization of these pressure measurements after stopping creatine use. This study was well conducted, organized, and written and should heighten our awareness for exertional compartment syndromes for athletes with a history of creatine use. It should also prompt us to question athletes who present with exertional compartment syndrome symptoms as to whether they are using creatine. It would certainly be simpler and less risky to have athletes stop creatine use rather than undergoing surgical decompression.
The mechanism behind the elevated compartment pressures is less clear and could be an excellent source of further research. Potteiger et al contend that increased protein synthesis as a result of creatine supplementation may increase volume within a fixed muscular compartment. Another factor is that creatine uptake by the muscle occurs in conjunction with an influx of sodium with associated water uptake by the muscle with swelling that also would increase volume within the fixed compartment. Both of these would likely result in higher compartment pressures both at rest and after exercise due to the rigidity of the anterior compartment of the lower leg. Indeed, there has even been a previous case report of acute quadriceps compartment syndrome with rhabdomyolysis in a weight-lifter using high-dose creatine.2 Sports medicine care providers need to have a heightened awareness for this potential problem with creatine use.
Dr. Diduch, Associate Professor, Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA, is Editor of Sports Medicine Reports.
References
1. Pedowitz RA, et al. Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Med. 2000;18:35-40.
2. Robinson SJ. Acute quadriceps compartment syndrome and rhabdomyolysis in a weight lifter using high dose creatine supplementation. J Am Board Fam Pract. 2000;13:134-137.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content