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Running and Running related Injuries – RED-s

Part 1 of Our Series On Running-related Injuries

RED-S: The Invisible Risk for Athletes – Understanding, Identifying, and Treating It

The passion for sports drives many athletes to train harder, whether to achieve peak performance or improve personal fitness. But what happens when energy intake doesn’t keep up with energy expenditure? The result could be Relative Energy Deficiency in Sport (RED-S).

Relative Energy Deficiency in Sport (RED-S) – a complex syndrome with serious health and performance-related consequences. This article explores what RED-S is, how it develops, the associated risks, and how physiotherapy can help prevent and treat it.

What is RED-S? A Definition

According to the 2023 International Olympic Committee (IOC) Consensus Statement, RED-S refers to a condition that affects both female and male athletes. It results from low energy availability (LEA), meaning the body doesn’t receive enough energy to support essential functions and athletic performance【1】.

How Does an Energy Deficit Develop?

An energy deficit can arise in several ways:

Inadequate food intake: Many athletes unintentionally consume too little food, often due to skipping meals, poor meal planning, or simply being unaware of their actual energy needs【2】.
Intentional restriction: Some athletes deliberately limit their calorie intake to achieve certain aesthetic or performance goals【6】.
Increased energy expenditure: Without adjusting dietary intake accordingly, a high training volume can quickly lead to an energy deficit【4】.

Common Consequences of RED-S

RED-S affects both physical and mental health. The most significant health consequences include:

Reduced metabolic rate and hormonal disturbances, such as amenorrhea in women or low testosterone levels in men【1, 2】
Decreased bone density, increasing the risk of stress fractures【2, 4】
Weakened immune function, leading to a higher risk of infections【1】
Elevated cardiovascular risk factors, such as high cholesterol【3】

Psychologically, an energy deficit can lead to increased stress, dissatisfaction with body image, and disordered eating behaviors【7, 8】.

Impact on Athletic Performance

RED-S not only compromises health but also significantly affects athletic performance. Common performance-related issues include:

Reduced endurance, as energy stores are insufficient to sustain prolonged activity【1】
Higher injury risk, especially stress fractures due to weakened bones【4】
Diminished training adaptations, meaning athletes fail to improve despite hard training【1】
Decreased muscle strength and overall fatigue【1】

Psychological Factors in RED-S

Psychological factors play a crucial role in the development and persistence of RED-S. Key contributors include:

Disordered eating behaviors
Athletes may develop an unhealthy relationship with food, becoming overly concerned with calorie intake and body weight. This can lead to intentional calorie restriction and persistent energy deficits【6】.
Poor nutritional planning
In high-pressure training phases, nutrition is often overlooked. A lack of proper meal planning or insufficient knowledge about the required energy intake can exacerbate the problem【2】.
Exercise addiction as a contributing factor
While exercise addiction (also known as compulsive exercise) isn’t the primary cause of RED-S, it can worsen the condition. Exercise addiction refers to a compulsive need to train excessively, even when it poses health risks. This behavior increases energy expenditure and complicates recovery【7, 9】.

Diagnosis and Screening: Early Detection is Key

A major challenge in managing RED-S is late diagnosis. The syndrome is often identified only after severe health consequences have already developed. Several tools can aid in early detection【5】:

Screening Tools

The IOC recommends specific questionnaires such as the LEAF-Q (Low Energy Availability in Females Questionnaire) and the LEAM-Q (for males). Medical evaluations, including assessments of bone density and hormone levels, are also crucial for detecting early signs of RED-S【5, 6】.

Treatment and Prevention: A Multidisciplinary Approach

Treating RED-S requires a multidisciplinary team consisting of sports physicians, nutritionists, psychologists, and physiotherapists. The goal is to restore energy balance and promote a healthy relationship with training and nutrition【3, 6】.

Steps in Treatment

Nutritional adjustments: Ensuring adequate energy intake with a balanced mix of carbohydrates, proteins, and fats【2】.
Reducing training volume: Temporarily decreasing training intensity and volume to promote recovery【6】.
Psychological support:
Psychological intervention focuses on addressing disordered eating and eating disorders as well as helping athletes to develop a balanced approach for training and nutrition. Key aspects include: Cognitive behavioral therapy (CBT) to identify and modify compulsive thought patterns【7, 9】Encouraging alternative hobbies and social activities to shift focus away from training and Developing sustainable training plans in collaboration with coaches and physiotherapists【7, 9】.

The Role of Physiotherapy in Managing RED-S

Physiotherapists play a vital role in both the treatment and prevention of RED-S. They support athletes in gradually rebuilding physical capacity and help prevent future injuries【6】.

Physiotherapy Interventions

Education on overtraining and energy balance to help athletes understand how to prevent future energy deficits【1, 5】

Strength and stability training to improve bone density, reduce muscle weakness and increase capacity to mechanical loading【4】
Monitoring of workload to manage the return to training【6】

Conclusion: Raising Awareness and Minimizing Risks

RED-S is a serious syndrome that can severely impair both health and athletic performance. An energy deficit can result not only from intentional calorie restriction but also from inadequate nutritional planning or the increased demands of high-intensity training phases. Psychological factors, such as disordered eating behaviors and compulsive exercise, can exacerbate the problem and hinder recovery.

A holistic approach involving early detection, tailored nutritional and training adjustments, and professional support – particularly through physiotherapy – is essential to mitigate the effects of RED-S and ensure long-term performance sustainability.

Have you experienced RED-S, disordered eating, or related challenges? Share this article on social media and let us know your thoughts. We look forward to your feedback!