RED-S and overuse injuries that will not heal in runners

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Hey, everyone. This is your guest host, Mandy Riehl, for the Restoring Human Movement podcast. Thank you for joining the Movement Movement. If this is your first time joining us, welcome. We have well over 200 episodes now that cover nearly every part of the body. Maybe some afflictions you've heard of, maybe some afflictions you've heard of, or have been Googling a lot. So feel free to check those out as well. Today, we're going to be talking about something called REDS, and how that relates to overuse injuries and recovery, especially in endurance athletes or athletes that have a lot of training time per day or per week.

So this topic is very near and dear to my heart. I'm an endurance athlete. I do ultra marathons and trail running. I was in the NCAA for four years doing cross-country and track, and I kept seeing these things pop up where people were getting overuse injuries and not figuring out why they occurred in the first place. I think we always hear the almost cliche now, you did too much too soon, but that actually isn't the full equation. We've found out a lot more in the last 10 years with some new research that's been released by the IOC, the International Olympic Committee, about this topic, REDS. So we're going to get into it in this podcast, and if this sounds like you, you may get some new information from this, so stick around.

So first off, we need a general understanding of what REDS is, and it's simple in essence, but it gets complicated the more you get into the research, so we'll summarize it here. REDS stands for Relative Energy Deficiency in Sports, and it is somewhat of an update on the old model called the Female Athlete Triad, and in part of this update, they included people who are not female. So this is relevant for all athletes, but the basic premise of REDS is that you are expending more energy than you are taking in, whether that is through exercise or activities of daily living or both, and taking in energy pretty much comes down to caloric intake.

Now, I think the knee-jerk reaction for most people is, well, I don't have an eating disorder, so I must be getting enough fuel, and this is not always the case. REDS does describe a lot of instances where people are unintentionally under fueling, so I was actually one of those people back in the NCAA where I never suffered an eating disorder or disordered eating in general, but I was just not eating enough for the amount of activity I was doing as a cross-country and track athlete, simply because it was college, I didn't have time to go to the dining commons as much as I should have, things like that.

So this does not require that you have an eating disorder, but folks who do experience eating disorders or disordered eating do more commonly experience REDS symptoms if they are doing a sport or a high activity like this. So REDS is really common in endurance athletes, super, super common in runners, triathletes, and in sports where look or figure, body image is a big concern. So things like rowing, weight class sports, wrestling, gymnastics as well, dance. These are the main culprits for REDS, but really for endurance athletes, it comes down to body image and more than anything, this old adage that lighter is faster.

And I could talk about that whole cliche for hours and hours, but suffice to say REDS is basically a disparity between your energy intake and your energy expenditure. Now, what happens when that is off balance? For a day, for a couple days, for a week, nothing really happens. I think we've all experienced, people who work out often, I think we've all experienced the quote-unquote bonk of not having enough energy on the day to complete tasks either during or after your workout. And that is part of training, that's somewhat normal, I think, but this is more of a chronic thing. So if the days and weeks and months or even years stack up where you are under-fueling, whether intentionally or not, and expending more energy than your body has to spend, your body has to look for that energy in other places.

This is when we start getting into the overuse injury realm, among other things. So overuse injuries is a huge part of this, especially bony injuries like stress fractures or stress reactions, muscle strains, tendon injuries. Your healing time goes up, so you won't recover as quickly if you do experience an injury, whether that's from your sport or elsewhere. I remember a teammate way back when who sprained her ankle, doing something completely unrelated to running, sprained her ankle, and was somebody who suspects that she was in reds for a long time. And her ankle sprain didn't heal for, I want to say, something like six months.

So this can affect more than just your sport-specific injuries as well. And on top of that, if you're in chronic energy deficiency and in a reds realm here, you can experience other changes like psychological changes, endocrine changes. There's GI changes that come along with that, and a lot of the research now is delving into these areas and finding out that when you spend too much energy chronically that your body doesn't have to spend, your whole body has to pitch in to help keep that energy at bay. So it really is quite wide-ranging. I think the most common things that I've seen on the kind of helping end of this is psychological changes that can happen, but moreover, bone stress injuries and lack of recovery from other soft tissue injuries.

Tendinitis, tenosynovitis, tendinopathy, those types of things can come up more quickly with less training load and heal slower. And then bone injuries, especially if we're talking about bone injuries in the femur or in the fifth metatarsal in the foot, so the outside bone of your foot or in the sacrum. Those seem to be very tied to relative energy deficiency in sport. And I can't think of off the top of my head anybody who I've met or worked with that has had a stress fracture or stress reaction in one of those that was not related to reds. So really important, especially in endurance sports.

And it kind of refutes the claim that the only way that you get an overuse injury is you did too much too soon. So too much too soon is definitely still valid. If you've never run a step in your life and all of a sudden you're like, I'm going to run a marathon and you run 10 miles that day and your foot hurts. Yeah, okay, you did too much too soon. That's probably not reds related. And yes, that is an overuse injury because you very literally overused the tissues that were not trained to handle that type of load. That is too much too soon. Too much too soon is not, I've been running for 15 years.

I run approximately 40 miles a week and I decided to run 45 miles this week and all of a sudden my shins hurt. That's not too much too soon. That's a trained individual who has the tissue tolerance and the training in their body to be able to handle that load. But for whatever reason, it's not handling it. So that you need to look at the other side of the equation. If that's energy expenditure, what about our energy intake? If that same runner has been operating right on the line of maybe a little bit of a deficit and all of a sudden they increase their training load just enough to tip that scale into too much energy expenditure for what they're taking in, that can trigger a chain of events that would cause an overuse injury rather than going the other way around where too much training caused it.

Rather, it's more a lack of recovery rather than too much training. So you can think of it as a classic scale, right, with a little fulcrum in the middle. If you have energy intake on one side and energy expenditure on the other side, they need to balance or else you'll have fallout. And a lot of times that does look like overuse injuries. Now, immediately, some of you may be thinking, oh, my God, what if I'm in reds right now? And I don't know. And there are some markers. It's usually easier to track in females or people of menstrual age. For females, if you've had your period for a while, so this is not your I just started my period and it went away for a while.

But somebody who's had menstruation cycles that are regular for some time, you can track if they start going away. That's a sign that you may be in reds. So reds often affects our reproductive hormones first. If your body goes into, quote unquote, starvation mode of, hey, I'm using too much energy that I don't actually have. So I need to get my energy from somewhere else. You go into a semi starvation mode. And one of the first things to go is reproductive hormones. And there are plenty of podcasts and things like that out there that can get in the nitty gritty for you on the endocrine and the hormone side.

I am not as trained in that. But I do know that when reproductive hormones go, you have downstream effects of bone health going, especially in females. So estrogen is really, really tied in with how we are able to metabolize our bones. And that doesn't mean eat your bones, but that means the normal cycle of bone destruction and rebuilding that happens within our bodies. There's usually, there's a normal timeline of that. And in general, as long as you're fueling your body and there's no underlying conditions there, your bones destroy and rebuild themselves over time regularly, just like all the other tissues in your body.

If you have a disruption in estrogen or some of your other reproductive hormones, that is super tied to bone health. And it means that your bones actually can't put down more bone. So the destruction part that normally happens happens, but the rebuilding part does not. So this is where we get into stress fractures or stress reactions or bone stress injuries, especially in places that they are not common. So the reds, classic reds, bone stress injury spots, again, are femoral neck, so femur up in your hip or your sacrum in your low back or the fifth metatarsal. So the outside kind of just below your pinky toes.

And for whatever reason, those are higher risk fractures, but they do seem very tied to reds. And again, this goes back to hormones and why our body is shutting down because it's not getting enough energy. And then for men, obviously, you don't really have a period to track from, but there are some things out there about libido and sex drive that you can track. And if you notice that those are going down for no apparent reason, that's a good sign. And there's a lot of research going in right now about testosterone levels and how that may be in play with reds as well in terms of low testosterone.

But I think they're still trying to find a consensus on that. I haven't seen any research yet that comes to a good conclusion on how we should track that. So for women, we can track this mostly using our menstrual cycles if they're regular. So if you find that you're suddenly skipping menstrual cycles or they have become way lighter for no apparent other reason, especially if you've been missing menstrual cycles for multiple months at a time, my rule of thumb, if there's no other signs of reds, if you've been missing your period for two or three months, that's a sign that we need to dig in and make sure that we're not in a red zone.

That's a good marker for most people that are menstrual. So for men, it has more to do with sex drive and libido, and researchers are doing more work on trying to find markers for men. But usually, right now, the recommendation is if you find that you have a different sex drive than normal, it's going down. And again, there's no other apparent reason for it. And you feel like you're training a lot and maybe under fueling. That's a sign that you need to do some thinking about if you're in this relative energy deficiency realm here. Here's one of the catches about reds and why I think it's important that all athletes, especially athletes that are in an endurance sport, know about this at a young age.

Bone health and bone density peak at a certain age. So for females, I think that is right around age 21. And for males, we're talking more like age 23, obviously plus or minus a few years for each individual case. And when you hit that bone density peak, you can't exceed it without pharmacological intervention. But if you have a condition that affects your bone density when you're younger, say like reds, and you don't hit that peak, it can be really, really hard, if not impossible, to come back from that to where your normal physiological range would be if you weren't experiencing that condition.

So this is something I see. I coached high school cross-country and track, and I see it especially in the freshmen and the younger kids who come in where they have been running, say, club cross-country or youth sports in general for a long time, and they're under eating or overtraining or both, and their bone health is not good. So they come in as freshmen in high school already having experienced stress fractures. And that automatically puts up a flag in my head of, oh, my God, are they going to be okay later in life? So this is not just a, well, I need to pay attention to reds so I can do well in my sport.

Obviously, that's important. But this is much more wide-ranging of, I need to pay attention to reds so that I don't have osteopenia at 40 or osteoporosis at 40 or younger. I've seen people who have fallen into this unintentionally before. Most of the time, it's people who have disordered eating or an eating disorder. But it doesn't have to be that egregious. It can still affect your bone density later in life. And we're finding more and more and more that this is a long-term problem. Even if you are not in a deficient zone anymore, the effects can last quite long. This can also potentially affect fertility for women and men.

And again, this is one of the things that they're doing research on now. This was only described officially in 2014, I believe. There was an International Olympic Committee consensus that was released. But prior to that, we didn't really know that men could experience things like this. We thought it was just a female problem. And we didn't know that it had these wide-ranging effects. So this is a really important topic for everybody to know. Not just if you are experiencing an injury, but for your general health and making sure that you're living a life that you can stay active until older age.

We know that that helps with injuries and pain and psychological function and a huge variety of other things. That you're able to stay active in your older age, keeping muscle tone up to decrease falls and things like that. And it can come all the way back to reds and bone density in your younger years, even in adolescence. Hey everyone, it's Sebastian. I'm going to hijack the show just for a second here to tell you about an opportunity that we have called the Discovery Session. A lot of people over the years have reached out to us from our YouTube channel because we have 150,000 YouTube subscribers at this point in time.

Probably more by the time you're listening to this. And we have a lot of people listen to this show and read our articles online. They're frustrated. People are frustrated about not being able to get back to full activity. They're frustrated they can't really trust their body. They're frustrated that they have not found any long-term answers or things to make them happy. And so we're here to help. We may not be the ones to actually help you and we're okay with that. But we're hoping that if you are able to speak with us that we can maybe give you some insight of things that you potentially haven't tried yet.

And if we know people, we'll suggest those people too. So if you want to take advantage of the Discovery Session, all you need to do is go to p2sportscare.com and find the Book Now button. It's all in there. We have virtual or in-person options. You can go to the show notes for this show and find a link that will directly connect you to us. Or you can call us, 714-502-4243. We'd love to help you the best that we can and we're always here to serve. Now back to the show. In the short term, though, we're talking mostly about overuse injuries and recovery. So overuse injuries can come about a ton of different ways.

We touched on too much too soon. And if that's not you, we may be talking about a REDS situation. And like I said before, REDS can affect more than just energy, like how you feel throughout the day. Do I have enough energy to create, to perform a task at hand? But has endocrine fallout, has GI fallout, psychological fallout, physiological fallout in a wide variety of ways. But the physiological fallout, kind of if you dissect through it, you're looking at decreased muscle strength. Your endurance performance will go down. You have less glycogen stores. So when you are trying to create energy in your body, you need blood sugar in order to fuel your muscles.

So glycogen is basically a storage form of blood sugar. And when you don't have glycogen stores, you may find that you're bonking more often. So maybe you're in the middle of a run or a ride or whatever your sport is. And you find that, oh my God, all of a sudden it feels like I've hit the wall. It feels like I'm at mile 20 of a marathon, but I'm only two miles into a run. You feel super sluggish, like you're trying to perform your task underwater. Even if your training doesn't really line up with that. But with all those three, so again, decreased endurance performance, decreased muscle strength, and decreased glycogen stores, that does put your body at higher risk for injury.

So especially decreased muscle strength, if you are trying to perform something maybe at your maximum effort, so say a race or a competition, and you don't have the muscle strength to actually perform the task, that's where you get your tendon injuries, your quote unquote overuse injuries, soft tissue injuries that usually classically would come up from doing too much too soon. But in this case is actually from under recovering rather than overdoing. So moving on to more of the overuse injury specific side of things, for those of you who have gone through rehab for any sort of soft tissue injury, so most commonly we're talking about tendinitis or tendinopathy, you know that there's usually exercise involved and it's usually relatively hard exercise.

It may make you sore the next day, and it feels a little bit like training. In order to actually get any quote unquote gains from this, any benefit from it, you actually have to have the energy for your body to put down the tissue where it needs to be healed, to be able to send blood flow to that area, and to be out of starvation mode. So you need to have enough energy stores in order to actually recover. Folks who are in reds during an injury, commonly you see that they feel like they're not running or training or cycling or whatever it is enough so that they're actually going to pull back on their eating so that they don't quote unquote overeat.

And this is a total fallacy, you actually need fuel to recover your body from whatever injury you're experiencing, even if you are not training at the same level that you were before the injury. But you can see that when you pull back on energy, you're not able to recover as quickly. And then we get in a situation like my teammate from years ago who sprained her ankle and had a sprained ankle for six months when, in theory, it should really only take probably between four and 12 weeks for complete tissue healing to do on its own without even any intervention. That's called natural history. But four to 12 weeks is a pretty wide range, but that's usually what we're looking at for healing of soft tissue injuries without intervention.

So if you're somebody who's been experiencing soft tissue injuries and it's been months or years even, I know people who have had Achilles tendonitis for years, we're missing something. And whether that's reds or something else, you know, that's why you come to a movement expert who understands both of these things, both reds and, say, biomechanics of what your sport is. But if you've been experiencing overuse injuries for months or years and they're not getting better, you're missing some piece of the puzzle here. A lot of times that can be reds. It can be as simple as, okay, go eat more or go to this registered dietitian who's sport-informed so that they can give you some better information about what you should be fueling with and how many calories you actually do need to intake throughout the day.

Or it can be something but biomechanical still that you're just pissing off over and over again. And if you're in a red state, yes, you won't recover as quickly, but there can also legitimately be just a biomechanical influence on overuse injuries as well. That's a different realm. We have a ton of podcasts on things like that, so you can check that out in other sections of this show. So to kind of recap these last few minutes here, if you are in relative energy deficiency in sport or REDS, where you feel like you're not intaking enough calories for the amount that you are spending in daily life and your sport combined, you're not only putting yourself at risk for acquiring new injuries, especially bone stress injuries and soft tissue injuries, but you're also putting yourself at risk for under-recovering both in your training and in any pre-existing or underlying injuries that you may have been dealing with before you were even in REDS in the first place.

So not only are you recovering worse, but you're also putting yourself at risk for an injury to start. So it's not a good combination, no matter what side of the equation of injured versus not injured you happen to be on at any given time. Now, again, we may be thinking like, am I in REDS right now? And we've talked about our markers of your menstrual cycle and your libido for men, but also the people who are most at risk are people with a history of or a current eating disorder or disordered eating. There's a slight difference there. And folks who are adolescent, so teenagers, especially female teenagers in endurance sports that have a body image component.

So we're talking your gymnasts who are high school age roughly, your cross-country runners, your distance runners, people who are girls who are getting into cycling or triathlon, less so in swim. I'm not entirely sure why, but it seems like swim is not as body image focused as these other sports. But dance is another one and rowing where there's weight classes, wrestling as well. I know I've talked some with Allie of Align Fitness by Allie. She works with a lot of dancers and she has found a lot of especially bone injuries in her dancers, her female dancers. Again, usually younger, high school age-ish that seem to be Reds related in part one because of the demands of the sport.

They are rehearsing just an ungodly amount of time per day. I frankly, I don't know how they do it, but they're rehearsing a lot per day. And there is that body image component of feeling like they need to be thinner or more flexible or look a certain way that can cause disordered eating, even if it's not technically qualified into a full-on eating disorder. But all those things kind of combine into Reds and it falls out in the way of bone stress injuries for them. So the big question that I like to pose to people I work with who are going through an injury, so what and now what? So what? We know that Reds has some pretty wide-ranging effects on the body and it can be both short and long-term.

But now what? What do you do if you think that you are in Reds, especially if you are injured and trying to get out of an injury cycle? What's the next steps? One of the next steps, obviously, we're going to do a shameless plug here. I know a lot about Reds. I don't claim to be an expert about it, but I am familiar with it. And I know how it can affect overuse injuries and recovery timelines. How that plays in with biomechanics as well gets pretty complicated pretty quickly. But moreover, you should be finding a practitioner who is familiar with Reds. They are rarer than you think they are right now in 2024.

Again, because the research is only about 10 years old and there's usually about a 10-year lag, at least what I've heard. There's about a 10-year lag between research hitting PubMed or the internet or whatever, the journals, and it actually starting to get into mainstream health sciences here. So you need to find somebody who is familiar with Reds. If you are currently injured, ideally, you're finding a movement expert that is familiar with Reds and familiar with the sport that you do. And if you have an eating component here where you think you're under-fueling, whether intentionally or not, that may require going to a registered dietitian who is sport-informed and, again, knows about Reds.

This is very important to screen that before you commit to a plan with them. If you think you're in Reds and you can do some research on it on Google, it's out there. You spell it Red-S. If you think that you're in that boat, you need to make sure that whoever you're working with knows what that is. So I have experienced Reds. I was in it for several years. I had one stress fracture that tipped me off to it. And I did some hormone testing and found out, wow, I have no reproductive hormones. And that's weird for this age. I think it was 19 at the time or something like that. And we found out that, yes, I was in Reds.

And I can't tell you how many times I have gone to get follow-up blood tests at different doctor's offices. And they have no idea what I'm talking about, which can be really frustrating as a patient because I've been diagnosed with this. Or at least at the time, I was informally told, yes, you are in relative energy deficiency in sport. And when you go to somebody who's supposed to be a health expert, it's really frustrating to say, hey, I have Reds or I've experienced Reds. And they're like, what is that? And it's nothing wrong on them. There's so much research that goes out there. And especially general doctors have to have such a breadth of knowledge that it's really hard to get into the nitty-gritty like this on a regular basis.

But there are some great resources online of how to talk to your doctor about Reds, especially if they are not familiar with it. I believe the website is called Reds Project. And there's a good handout there that says that you can actually give your doctor that says, hey, this is what Reds is. I think I'm experiencing it. What do you think I should do? And even if the doctor doesn't have off the top of their head knowledge of what Reds is, they may be able to read a handout like that and create a treatment plan for you going forward. But obviously, it's going to be easier if you go to somebody who knows what Reds is, and especially the case on the registered dietitian side.

I've worked a little bit with a registered dietitian around here, Joy Shen, who has some sport-informed knowledge about this. And the treatment effects that I have seen from people that she's worked with are notably different than effects from people who go to registered dietitians that are not sport-informed. So I do think that's very important that your practitioner knows what this is and knows how this can fit into the puzzle of whatever's going on for you. Also, if we're talking about the simple equation of energy expenditure versus energy intake, and you think that that is tipped too far on the energy expenditure side, you have two options to do something on your own.

You can increase your energy intake, usually by a lot, to try and make up for that deficit. Or you can decrease your energy expenditure. So what that looks like is, I'm either going to eat way more, especially calorie-dense foods, so we like fats here, avocado, things like that. Whatever you like eating, eat more of it. That would address the energy intake side of things. Or you can decrease your energy expenditure, so train less, less training hours. That includes cross-training. For all of you people, especially runners, I'm going to pick on you because I am one. You people who say, okay, I'm going to train less, which means I'm going to run less mileage, but I'm going to hop in the pool for an hour or two.

That's still training. Energy expenditure is all day. That is all of your activities. So I'm not talking about like, okay, go sit on the couch and do nothing. But you need to keep in mind that cross-training or doing sports that aren't your sport of focus is still energy expenditure. So you can play it on that side where you're doing less energy expenditure, so training less or doing less sport. Or on the side of energy intake where you're eating more. And ideally, if you're somebody who's very concerned about this or you're in a bone stress injury state or you're trying to recover from an injury, you do both at the same time.

So you eat more and you do less, bottom line. And lastly, for those of you who have been experiencing soft tissue injuries due to REDS or overuse injuries in this regard, and you're trying to recover from it, it is important that your practitioner knows what REDS is, but also knows the biomechanics and the demands of your activity. So this goes back to just knowing that whoever you're going to, movement expert, needs to be able to treat you as both an athlete and somebody experiencing REDS and understand how those two play off of each other in your recovery process. If you are treated as somebody who is not in REDS, it may be confusing and frustrating even to hear a timeline from your practitioner that says, hey, yeah, you should be good in like two weeks and all of a sudden you're six weeks in and you're not recovered and everybody's confused.

Whereas if you go to somebody who has the knowledge of the biomechanics and the injury influences that don't have to do with REDS, as well as having a working knowledge of what REDS is and how it affects recovery and injury recovery specifically, you're going to get a much more realistic timeline and you're going to get much more tailored advice into how you need to recover not only your specific injury, but your whole body from this affliction. To be honest, y'all, I can only think of maybe six practitioners off the top of my head that are sport informed enough to know what REDS is and how it relates to their field.

One of them is a registered dietitian, another an MD, two others are chiropractors and medical exercise specialists. And myself, I'm a chiropractor and medical exercise specialist as well. If you would like to talk one-on-one and get some specific advice about your situation and what the next steps need to be for you, please go ahead and click that link in the description. It will take you to a booking site where we can talk in a discovery visit. So it's 30 minutes. We'll talk one-on-one and figure out what the path forward for you looks like. I think it's really important, like I said again, that you guys all get advice from somebody who knows what's going on in your full body.

That way, we're looking at it at a more holistic view rather than just focusing on exactly where your injury is and looking at nothing else. So go ahead and click that link in the description. As you guys might be able to tell, I am very passionate about this subject, so I'm happy to chat with any of you. Set up a discovery visit with myself, a Mandy Riehl, for 30 minutes, and we will figure out what the next best steps are for you. In the meantime, take care, and we'll see you in the next one.