The Sneaky Reason Why Recovery Seems Elusive: Relative Energy Deficiency in Sport (REDS)

Relative Energy Deficiency in Sport (REDS) is a syndrome that is often seen in female (and sometimes male) athletes where there is a low energy availability (not enough calories in or too many calories burned). This decreased energy availability leads to varying physiological consequences including injury risk, menstrual disturbances, and difficulties with mood and bone health.

As a physical therapy clinic, it may seem a bit weird that we’re talking about what appears to be a psychological problem. However, here’s the thing – while some examples of REDS are obvious (clinical eating disorders, excessive overtraining) – the ones we see in the clinic sometimes occur unknowingly.

In fact, I’d argue the accidental version of REDS is more common than you think. It can be the reason individuals land in our clinic in the first place. Because of REDS, individuals can struggle with recurring injuries, frequent bone stress fractures, or have difficulty healing after an injury. This is a syndrome that leads to injuries that are miserable and difficult to work through. These injuries are also 100% preventable with proper education and psychological support.

Firsthand REDS Experience

I (Dr. Sarah) experienced this firsthand. I’ve had REDS. It came about from an eating disorder that progressed to “normal” so I was “healthy” in my doctor’s eyes. It eventually reversed as I started to have less anxiety with eating. During this process, I partnered with a nutritionist who showed me how little I was eating compared to what I needed to properly fuel my body. The results were life-changing.

It astounded me how I was no longer cold all the time, wasn’t continually getting injured, and didn’t get sick multiple times each winter. This motivated me to dig into the science behind my experience. I discovered an entire population of individuals that had similar experiences. In talking with these people I learned they weren’t appropriately fueling themselves and were also struggling with frequent injuries.

As I dove into this with the clients I work with, I realized there’s simply not enough material out there regarding REDS. Because of this, I wanted to highlight what REDS can look like and how it can occur accidentally. I’ve intertwined my experience with REDS as we go along, to better illustrate what it looks like as it is different for different individuals.

What REDS Looks Like

On a very simple level, REDS means you aren’t eating enough for your body to do what it needs to do. Your heart needs calories to pump blood through the body, your brain needs calories to think, and your digestive system needs calories to process food. Your body takes care of these functions first, because they are vital to you staying alive.

In an individual with REDS, there aren’t enough calories left to repair muscles, bones, tendons, and ligaments from the stress of exercise. This results in tissues that don’t fully repair. When tissues are consistently unable to fully repair, injury is often the result. These injuries are most commonly but not necessarily stress fractures. There are a few indicators on a musculoskeletal level that prompt us to look for REDS in the clinic –

  • Stress fractures: tibia, metatarsals, fibula, & navicular bone
  • Frequent muscle or tendon injuries
  • Injuries that happen concurrently with period abnormalities
  • Limited muscle mass despite significant strength training and exercise
  • Urinary incontinence

We also observe for other changes such as

  • Difficulty with body temperature regulation
  • Lack of 3 consecutive periods
  • Constipation or feeling bloated
  • Poor recovery between training sessions
  • Overtraining or difficulty taking a rest day
  • Poor sleep patterns
  • Restricting or strict control of food
  • Preoccupation with or constantly talking about food
  • Anxiety
  • Withdrawal and reclusivity
  • Irrational behavior
  • Fear of food and weight increases

REDS – the WHY

There are so many reasons why relative energy deficiency in sport can happen. It’s a nuanced and complicated topic. I’d like to dive into the three things I’ve seen contribute the most to this.

  1. Our society has merged the definitions of skinny and athletic
  2. There’s a lot of contradicting and poor information surrounding nutrition
  3. We have been taught to base our worth on our appearance, achievements, and our possessions

Skinny & Athletic are NOT the Same Thing

It’s actually fairly easy to underestimate how much food you truly need to fuel your body. In a world full of calorie counting, macro-tracking, and food weighing, the focus is typically on how little you should eat, not how much you should eat. Most nutritional programs focus on losing weight, not eating healthy. As a society, our focus is on how little you should eat.

What our society largely ignores is how much you need to eat in order to be healthy. Our world’s focus on skinny – not healthy – has caused a large majority of individuals to be worse for the wear. Somehow we have merged the definitions of skinny and athletic, thinking that they are one in the same.

Here’s the thing – skinny and athletic are not the same. Skinny means not having much of anything on your bones – not much fat, not much muscle. To be a high-performing (or even just a recreational) athlete, you need muscle. And, yes, you also need fat.

If you Google photos of the best athletes, they are not the individuals with the smallest body fat percentage (unless, of course, they do physique competitions or a sport that relies on body weight). They are individuals who have muscle and fat. In order to have one, you must have the other. It’s also near impossible to gain muscle unless you gain fat with it.

Head Knowledge Becomes Practical Experience

This was an incredibly difficult idea for me to wrap my head around. After spending multiple years banging my head against the wall and refusing to eat more, but wanting my performance to improve, I bit the bullet. I started eating more. If I was hungry, I ate. I intentionally made larger meals and incorporated more snacks. What I found was I started feeling better.

I also gained weight – muscle and fat. In about a 50/50 ratio, which I learned was actually pretty good. I put on 27.8 pounds over the course of 2 years. 13.6 of that was muscle and 14.2 pounds was fat. My PRs went up – a 150# deadlift and frequent back pain turned into 270#, a back squat that consistently gave me adductor injuries turned into 225#, and a hamstring that prevented me from running turned into regularly running without issues.

The hardest part of the switch was the mental transformation. I had always known that different people work better at different body weights. But, I was convinced that my 12% body fat (a fairly lean number for a female) was healthy enough and should allow my body to do what I wanted it to. In reality, I had to learn to accept that my body performs better when it’s closer to 20% body fat. How can people know that different people work differently? Also, how do you sort through all the misinformation?

Combating Misinformation

Sorting out misinformation and figuring out how much food is enough can be very difficult. This is a topic where science and feelings intersect. There are some absolute truths – yet – there is also nuance when applying the information to your life.

While I can speak to generalizations, this isn’t my area of expertise. I know enough to know when to refer out and this is one of those cases. If you suspect you have REDS, I am more than happy to talk with you about what you are experiencing and help discern if it’s something that needs to be addressed. If we do find something, I can provide you with the resources that you need to pursue treatment.

What I don’t recommend is scouring the internet, trying to find answers, and implementing solutions on your own. I did that for a long time and still ended up needing to see someone for help. Ironically, if I would have sought guidance 10 years sooner, I would have saved myself many injuries and lots of frustration. Sometimes, the best way to get to where you want to go is to let someone else guide you.


Our Worth and Our Bodies

This is an incredibly hard topic to address and discuss because of how firmly the relationship between our physical appearance and our worth is entrenched in our culture. The messaging we receive starting from the time we are born revolves around how what we are worth is based on how we look, what we do, and/or what we have. This couldn’t be further from the truth, but yet almost everyone grows up believing this lie. This is a multifaceted problem. Uncovering one aspect of it will not completely change our perspective, but it is a start.

REDS In A Nutshell

On a very basic level, REDS is when your body doesn’t have enough fuel. When there is not enough fuel, it is easier for the body to break. Breaking down can look like many things. In a physical therapy setting, it can appear in the form of frequent injuries.

Acknowledging the nutritional and psychological aspects of injuries are incredibly important. In those with REDS, addressing those needs is even more important. If you are continually reinjuring something or feel like you are unable to heal from an injury, you may want to consider scheduling a Discovery Visit to discuss whether or not you could have REDS.

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