Is Creatine Causing Your Shin Pain? + Splitting Training, Endometriosis for Lifters | Direct Line · May 2026

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3:17What you're hearing right now is the free preview. Three questions from this month's episode. First up, a mid-30s woman with bilateral shin pain wants to know if her creatine is causing it. We walk through the compartment syndrome literature, the case report that's getting passed around online and mostly misinterpreted, and what we would actually do if we saw this person in clinic. Then we cover whether splitting your resistance training sessions across the day changes anything for strength and hypertrophy outcomes. And we close with endometriosis for the lifter, including what the evidence says about exercise, nutrition, and the anti-inflammatory diet claims.

3:49The full episode covers a lot more and it lives on Barbell Medicine Plus, which also gets you ad-free listening on every episode, early access to every episode, bonus podcasts, and discounts on all of our products. It's$9.95 a month and you can get a 30-day trial for just a dollar. Links in the description. Here's the free preview.

4:18and help us work through it all it's the second most handsome doctor in north america dr austin baracki what's going on dude that was uh quite a preamble a lot of setup there a lot of setup a lot of alliteration for everyone yeah something yeah something the whole family can enjoy that's what we do here on the farball lesson podcast all right let's start off with this creatine question um some more alliteration there uh and we're gonna talk about compartment syndrome. So I should have said creatine question compartment syndrome and maybe just get it all in there. This question asks, I started taking five grams of creatine about a month ago.

4:52And recently when I run within the first 10 to 15 minutes, I'm getting terrible calf and shin pain and pressure in one or both legs. Sometimes my foot will even go numb. I've been lifting weights and running regularly prior to this. I'm mid thirties woman, if that matters. I've read that this has been reported with creatine supplementation due to increased water retention inside the muscles. Do I have to totally stop taking creatine or would it be worth trying a lower dose? So this is something we actually talked about yesterday in another episode that will be being released shortly. But there is a published case report linking creatine to a clinical diagnosis of the condition this woman probably has.

5:32It's called chronic exertional compartment syndrome. I'm not trying to diagnose anybody here over the air, but it does sound like that. This condition, the way it works is that running sort of pressurizes the muscular compartments in the lower leg, the sleeves of connective tissue that hold each muscle group in place, basically it tight. And as pressure inside those sleeves goes up, it compresses the nerves and the small blood vessels running through them. So you experience pain, and in this case, the foot can go numb. Unstopping the activity usually makes the symptoms resolve, and the pain and numbness go away.

6:08Then it comes back the next time you run. I have this not in my legs, but in my arms when I race motorcycles, particularly if I've spent a bunch of time off, my hands will go numb, which is problematic when you're trying to operate a motor vehicle at speed. interestingly she also fits the demographic that this happens in most often a study from 2013 by waterman looked at 8.3 million u.s active duty military uh person years that's a fancy way of saying look a bunch of a bunch of people in the military over a long period of time and found 4100 chronic exertional compartment syndrome cases female sex was an independent risk factor and so was being between the ages of 17 and 40.

6:51So she does fit the demographic. It does kind of sound like that. And I think what we want to walk through here is what creatine actually does to like water in the body. Mainly, not to say, look, creatine has no possible influence here, but just that that's not probably where I'd start, where we would start. Although you may feel differently, Dr. Brockie. We'll see. So when we look at the data on what creatine does to body water, A lot of this comes from loading phases where people are taking like 20 grams of creatine per day for usually a week. And the idea is that you would load creatine such that it saturates your cells faster.

7:31So, for example, if you just started taking three to five grams of creatine per day versus doing a loading phase for one week first, the loading phase gets you, you know, saturated with a bunch of creatine in your muscles faster by a significant period of time. In this case, significant being a couple of weeks. Now, what happens during the loading phase is total body water goes up. But the ratio of the water that's inside the cells compared to the water that's outside the cells does not change. The author's own conclusion from one of these landmark papers, there's no evidence that creatine shifts fluid in a way that would cause problems, which we can maybe end this question here and just move on.

8:10But this has been repeated in a number of position stands by the International Society for Sports Nutrition in 2021 and 2024. or it doesn't really increase total body water, doesn't really shift the fluid significantly, and doesn't really cause dehydration or cramping. There have been studies on compartment pressures where we actually measure what's going on inside the different muscular compartments. Four studies here, three in healthy men on loading doses again or higher, the compartment pressures tend to go up. some subjects reported tightness and burning with activity, but none met diagnostic criteria for this chronic exertional compartment syndrome.

8:52The fourth study, and this is the one that's getting the most airplayed, probably because it's the newest, is from 2025. It's a case report on a runner who started creatine and developed chronic exertional compartment syndrome about a month later. It required surgery, which is a fasciotomy. Basically, you take the fascia that covers the muscle, you cut a hole in it or long relief in it so that muscle has room to expand. The case report, The authors there call it an association, not a causation, but the internet usually doesn't have access to these papers for whatever reason. When I see a case report behind a paywall, I also get a little miffed because I'm like, guys, if anything should be free in academic literature, it should be case reports.

9:28But in any case, they also didn't disclose her exact dose, the pressures of the lower limb if they were measured, or her training history. Just one case, but yeah, people have taken this and kind of run with it. And the mechanistic story does sound reasonable to me if creatine causes some sort of water retention, particularly with loading. And water can raise pressures, perhaps pressures in the compartments that could cause chronic exertional compartment syndrome. But again, there's a lot of logical leaps in there like that ultimately don't pan out. Creatine doesn't really increase total body water outside of maybe a loading phase.

10:03the compartment pressures are, they vary significantly amongst individuals and none of them have met chronic exertional compartment syndrome sort of criteria. So like kind of just a big red X at every, every leap there. So to me, I don't know that stopping creatine is the move here. If this is something that happens every time you run, I think actually getting a workup by an actual sports medicine physician is a good idea. You know I wouldn't want to change anything prior just to sort of diagnosis accurately, if that makes sense. It could be a tibial stress fracture, something like that, or could it actually be chronic exertional compartment syndrome, in which case you'd want to measure those sort of things.

10:44I don't know that DIY in this has a big risk though, either. Like if you just stop taking the creatine, it goes away like, okay. I don't know that I would blame the creatine. Although again, sussing that out would require some additional diagnostic steps. I don't think that dropping the dose is necessarily the greatest idea, but that's more of a mechanistic sort of hedge because we think that creatine typically has a general washout period of about a week, but the creatine saturation can stay elevated for up to four weeks. So you would need some time for that to resolve. So Austin, in a person like this, you know, bilateral shin pain, four weeks into taking creatine and gets this sort of foot numbness 10 to 15 minutes in, would you say, Hey, just stop the creatine and move on with your life or would you go further with that?

11:30Yeah, the context matters here quite a bit. Here we have a person who is pretty young, does not disclose any other associated medical history. And I'd really want to characterize very specifically both the nature of the symptoms and the timing of the symptoms. And so if the symptoms are really localized to the shin, that is different than if the symptoms are a little bit more localized to the calf, which is different than if they're localized to like just foot numbness. Like all of those things send me in very different directions also the fact that it is bilateral seemingly pretty symmetric and both sides onset at the same time uh you know like overall in her training course not just like at the same time with activity that also changes the way i think about this compared with if it was unilateral right so like to your point about a stress fracture like what is what's the likelihood of a bilateral symmetric uh you know temporarily uh you know simultaneous stress fractures becoming symptomatic on both sides that lowers that probability quite a bit if it's more in the shins, then I'm more questioning like, what's the running history like?

12:27How do we ramp up to this? Is this just like run of the mill, shin splint type scenario? She said in her question that she's been lifting and running for a long time. So assuming that there have been no dramatic changes in training load, which would be one of the questions I would get at, have we, you know, changed something? Have we started doing something more, introducing sprints, much more distance, change in footwear, all sorts of other things that can be like shorter term variables that could impact this. And if the symptoms are much more, you know, calf specific and like this kind of foot numbness that tends to raise more concerns about well could there be a vascular phenomenon so any kind of like exertional symptom the no misdiagnosis is going to be something vascular and then the neurological symptom seemingly is more of like a consequence of what else the other aspect here which could be maybe something compressive like a you know transient exertional compressive neuropathy of some kind which could fit with a diagnosis of chronic exertional compartment syndrome so it's possible but i'd want some more background history about like hey other medical history any vascular risk factors and then when it comes to the the history about creatine i agree with you like the the idea that this is like a do not pass go go directly to a physician and get a diagnosis i'm not sensing this is like an ultra immediate short-term red flag if it's something that we don't seemingly are not able to to get better then that would be a reason to definitely get checked out on a shorter time frame but you're right that diying it isn't the riskiest thing either and what i mean by that is a like discontinuation and re-challenge is a pretty reasonable way that even somebody who leans skeptical which i think that like both of us just like up front don't typically associate creatine with this sort of a manifestation we might tend skeptical on that but if somebody says look i was running and lifting doing everything fine i kept doing the same thing i introduced creatine this came on we're like ah okay tough to say for sure then like then i stopped it and it went away then i started taking again and the same thing came back it's like okay i relent i don't have a full explanation for why some of these things are plausible even though there's not like this super compelling like so much more you know intracellular or extracellular fluid accumulation you know specific to creatine but you've given me enough of a reason and it's like ultimately do i care more about your ability to do the conditioning that you like to do running or being on a couple grams of creatine a day the benefits of creatine are modest to arguably trivial for most the benefits of uh even running a couple you know a little bit probably already outweigh the benefits you're getting from creatine so i'd rather you be able to run and i would just like lean in that direction yeah yeah i mean i think about if somebody's vulnerable to a like a compartment syndrome type experience right perhaps a subtle shift in fluid maybe does that or other changes that co-occur when somebody takes creatine perhaps dietary pattern changes their training load i'm you know there's obviously a lot of variables here but ultimately like if someone's like i'm just going to quit the creatine and see what happens i'd be like fine that's fine but when somebody tells me the story and i start thinking about what could it be i'm like okay it kind of smells like sounds like compartment syndrome but what if there's an orthopedic issue or what if there's a vascular issue or a neurological issue and i'm like well i don't wouldn't want to miss those totally so to the extent delaying the diagnosis versus with the like a withdrawal and re-challenge thing i'm like oh that outside of the vascular thing is like the no miss and then i don't really want to say that on air because it does seem like really risky like so much of so much of that you know thought process and response was based on the the context that we know about this person uh you know otherwise uh assumedly healthy 30 year old woman if you turn this into like a 60 year old whether they smoked or not i'm like nah we need to get you checked out because this could be like a claudication manifestation you need a more thorough vascular eval or something like that it's not to say that younger people can't have some kind of like vascular disease that can manifest with claudication or like neurogenic pseudo claudication or something like that like any of those are possible just not very likely um and so i would first you know probably trial discontinuation see what happens and if it persists then it's like okay that wasn't it now we can dig a little deeper that's a i think from what i'm sensing here probably a reasonable way to go but if somebody said i want to get checked out sooner also fine uh this is for infotainment purposes only we are We are your doctors.

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23:00Spots are limited. So if you wanna learn more and register today, head over to barbellmedicine.com and look for the Bozeman Pain and Rehab Seminar. We also have a link in the show notes below. All right, next question is about splitting up resistance training sessions. So the question is, if I have three resistance training movements planned for the day, but due to certain logistical issues, I split them up hours apart sometimes. Does that affect strength and hypertrophy over the long run? I would assume maybe you are getting less fatigue resistance adaptations. But if I'm doing the three sets for my bench press, I would assume that doing the leg press two hours later is not impacting strength and size for either of them.

23:37Yeah, it's fine. We'll just move on to the next question. But I actually think, though, we don't need to do a deep dive on this per se. But I do think some, you know, insight into my general heuristic, our general heuristics about training may be useful just to like answer these sorts of questions going forward. You know, I think you would agree that our role as coaches or our programming, like our templates, like what they're designed to do is maximize training load. We want people to do as much physical activity as possible, including formal exercise. And the idea is because there's a dose response relationship between the amount of exercise that people do and the benefits from it.

24:18Not only health benefits, but also performance benefits, obviously. In this case, frequency is a tool to distribute that training load. So you could jam a given amount of training. Again, if you just had this list of 20 exercises you needed to do, you could put it on one day, two days, three days, four days, five days, seven days. Split it up however you want. We think frequency is a tool to distribute that based on your preferences, logistical constraints, et cetera. When you look at the evidence on frequency as its own like sort of independent variable here, it almost disappears entirely when you look at training adaptations that we care about.

24:56Strength, hypertrophy, power, cardiorespiratory fitness. In fact, the majority of the time when it does show up as an individual variable, it's because they have not corrected per volume, total amount of training that gets done. And so a prime example of this is one of Schoenfeld's initial meta-analyses on this from 2016. It's 10 studies. And they said that the weekly volume was equated, and the higher frequency groups grew about 3 % more on average. Now, as it turns out, the volume was not actually equated. And when they updated the meta-analysis in 2019, this time with 25 studies, the volume was better equated, and everything disappeared.

25:36The hypertrophy difference disappeared. See the same thing in Gurgic's 2022 study on strength. Mainly there was a signal when people went from one time per week of doing strength training to multiple times per week. Their strength seemed to improve because they were doing more training. I do think, though, this is maybe where I go against the evidence. And I recall back to like a 2018 seminar that we did when that somebody was like, what opinion do you hold or belief that you hold is like not evidence based. I actually do think there's something maybe to an increased frequency because – not just from adherence.

26:10I do think that's probably the number one use case. It's like, look, if I can split it up seven days a week and that's better for me, adherence, that's number one. Maximize the training load. Fits with the heuristic. But imagine a scenario where I took all of your deadlift volume. I don't know how many sets per week you're deadlifting right now. Let's just say it's 10. Nice and neat. And I put that all on one day versus I split that up over two days. or three days, I suspect that your actual training load is going to be higher. The more I split that up due to intro workout fatigue, right, you're going to be able to lift a little more weight, a little more reps at a given RPE if I split it up.

26:46And so the training load, yeah, on a one week basis is not that much different, but it's a little different. Two weeks, you know, total, if we summed it together, a little bit more different, eight weeks, 16 weeks, that sort of difference grows, right? And so the training load that you're able to accumulate over a year, for example, is potentially much greater. And also to the extent that you're training these things in a more fresh state might allow for some additional skill development. I feel like it's not an evidence-based take. I mean, I can harangue the data and try to come up with a rationalization, but I don't know.