Relative Energy Deficit in Sport (RED-S)

Relative Energy Deficit in Sport (RED-S)

Article by Zoe Russell

Relative Energy Deficiency in Sport (RED-S)

What is RED-S?

Relative Energy Deficiency in Sport (RED-S) is a condition that is defined as ‘impaired physiological functioning caused by relative energy deficiency. In plain English, this means a state of being in your body which means there’s not enough energy supply for the demands you’re asking your body to perform, leading to weakening or injury in the system. The relative deficiency of energy has negative consequences for bone health, menstrual health, metabolic rate, immunity, protein synthesis, immunity, cardiovascular health and performance outcomes. 

Historically, RED-S was called the ‘Female Athlete Triad’. Research in the last decade or so has increased our understanding of this phenomenon and its far-reaching consequences. Previously, the medical community was aware of the three main ‘symptoms’ of the Triad – high demands of physical activity, impaired menstrual function and decreased bone health. Health professionals believed that this condition was only occurring in females. As the research has uncovered more facets to RED-S, the name and definition had to be expanded to accurately reflect our new ways of measuring Low Energy Availability (LEA), the recognition of males with RED-S, identifying many other health parameters that are affected, and to highlight to the sporting community the negative ramifications for athlete performance.  (Mountjoy, et al., 2018)

What Causes RED-S?

RED-S is caused by a prolonged state of Low Energy Availability (LEA). This is where the balance between energy (i.e. food) is tipped out of balance with energy out (i.e. activity). This can occur in many ways and is not always a sudden change, making identifying the causes difficult without help from trained medical professionals and coaches. Some examples might be an increase in sport or training load, decreased food intake or type of foods eaten, increased stress to the body through a lack of sleep, growth spurt, illness, or psychological stress. 

What Are RED-S Symptoms?

Symptoms of RED-S are broad and cross over with many other conditions and illnesses. This can make it tricky to recognise and diagnose.   (Mountjoy, et al., 2018)

Symptoms and other associated conditions your health professional might ask you about when they suspect RED-S might include: 

  • Recent weight loss 
  • Loss of appetite, disordered eating, or a history of eating disorders 
  • Participation in high demand, weight or aesthetically driven sport (e.g. dance, gymnastics, jockeys, boxing etc.) 
  • Slow or stunted growth in children and adolescents 
  • Recurrent coughs, colds and cases of flu 
  • Recent irritability, mood swings, or a history of mental illness or increased stress 
  • Poor judgement, poor coordination, decreased athletic performance 
  • Low iron or anaemia 
  • Changes in or absence of a menstrual cycle in adults or a delayed or absent onset of puberty in adolescents 
  • History of stress fractures 
  • Recurrent or unhealed injuries 
  • Feeling tired, run-down or exhausted
  • Difficulty sleeping or concentrating 

How Is RED-S Diagnosed?

Diagnosis can be tricky for RED-S as symptoms vary, and everyone’s body responds differently to LEA. Energy availability is a sliding scale that constantly changes as we eat, move, rest and challenge ourselves. (Couanis, 2017) 

Diagnosis can also be made tricky by an athlete’s coping skills and their motivations for revealing or minimising their symptoms to their coaches, trainers, family, friends, and themselves. Generally, the person feels and looks pretty run down because the body isn’t getting enough fuel to perform all the activity. 

Often, athletes are recognised as being in an energy deficient state when it leads to them becoming injured or developing other conditions for seeking medical treatment. It is then up to the medical professional they seek help from to recognise the signs and symptoms and get the athlete the appropriate type of help they need to heal well and stay well. Most often, these treatments need to be multifactorial and involve a few different types of practitioners. 

What Are Your RED-S Treatment Options?

Treatment options are based on the signs and symptoms each individual has, what their greatest concerns are, and the results of any tests or investigations. A mix usually delivers treatments of professionals, which might include:

  • Sports Dieticians, to address food-related behaviours 
  • Physiotherapists, for injury management and rehabilitation advice 
  • Exercise Physiologists, for reconditioning and modification of training/performance tasks 
  • GPs and Team Doctors, to manage symptoms, prescribe medication and order tests, and clear for return to sport 
  • Sports Psychologists and Psychiatrists, to help develop coping skills and address the thinking and beliefs around the current behaviours which led to RED-S 
  • Endocrinologists, to help address hormonal imbalances 
  • Gynaecologists and fertility specialists, to address hormonal and reproductive concerns 
  • Cardiologists, where heart function has changed 
  • Immunologist, to assist with the immune system and allergy concerns

Not everyone who has RED-S will require intervention from every single type of medical professional. Everyone is different, but most people who have RED-S have at least 3-4 professionals involved in their treatment team based on their needs. 

This team of experts works very closely with the athlete, their family, teammates, coaches and trainers to ensure that the factors influencing energy availability are the most beneficial ones possible for the entire team or club. The best tool we have to reduce further injury and illness risk is education and advising everyone involved about training load, nutrition, coping strategies and sleep hygiene to get the most out of the athletes in a healthy, sustainable way. 

Screening and prevention programs are becoming more popular throughout the sporting world. We know that early detection of RED-S is crucial for preventing long-term health consequences. 

What Results Can You Expect?

Results for RED-S vary widely, dependent on which symptoms an athlete presents with and their severity and complexity. Each treatment plan is bespoke and will require the collaboration of many professionals.

If RED-S is a result of simply unintentional undereating or over-training, a little bit of knowledge and guidance can resolve RED-S quite quickly. However, if RED-S hasn’t been recognised and other health conditions have developed, treatment timeframes will vary depending on those conditions. 

If you suspect that you or your child might be suffering from Relative Energy Deficiency in Sport (RED-S), you can book a consultation with your PhysioWorks physiotherapist. 


Couanis, G. (2017). Relative Energy Deficiency in Sport (RED-S). Retrieved from on the 28/05/2020. 

Fede, C., Pirri, C., Fan, C., Albertin, G., Porzionato, A., Macchi, V. … Stecco, C. (2019). Sensitivity of the fasciae to sex hormone levels: Modulation of collagen-I, collagen-III and fibrillin production. PLoS ONE 14(9): e0223195. 10.1371/journal.pone.0223195 

Mountjoy, M. Sundgot-Borgen, J. K., Burke, L. M., Carter, S., Constantini, N., Lebrun, C. … Ackerman, K. (2015). The IOC relative energy deficiency in sport clinical assessment tool (RED-S CAT). British Journal of Sports Medicine. 2015;49:1354

Mountjoy, M., Sundgot-Borgen, J. K., Burke, L. M., Ackerman, K. E., Blauwet, C., Constantini, N. … Budgett, R. (2018). IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update British Journal of Sports Medicine 2018;52:687-697

British Journal of Sports Medicine. (2015) Relative Energy Deficiency in Sport (RED-S) Clinical Assessment Tool (CAT). British Journal of Sports Medicine. Retrieved from on 28/05/2020 

Acute Injury Signs

Acute Injury Management.

Here are some warning signs that you have an injury. While some injuries are immediately evident, others can creep up slowly and progressively get worse. If you don't pay attention to both types of injuries, chronic problems can develop.

For detailed information on specific injuries, check out the injury by body part section.

Don't Ignore these Injury Warning Signs

Joint Pain

Joint pain, particularly in the knee, ankle, elbow, and wrist joints, should never be ignored. Because these joints are not covered by muscle, pain here is rarely of muscular origin. Joint pain that lasts more than 48 hours requires a professional diagnosis.


If you can elicit pain at a specific point in a bone, muscle, or joint, you may have a significant injury by pressing your finger into it. If the same spot on the other side of the body does not produce the same pain, you should probably see your health professional.  


Nearly all sports or musculoskeletal injuries cause swelling. Swelling is usually quite obvious and can be seen, but occasionally you may feel as though something is swollen or "full" even though it looks normal. Swelling usually goes along with pain, redness and heat.

Reduced Range of Motion

If the swelling isn't obvious, you can usually find it by checking for a reduced range of motion in a joint. If there is significant swelling within a joint, you will lose range of motion. Compare one side of the body with the other to identify major differences. If there are any, you probably have an injury that needs attention.


Compare sides for weakness by performing the same task. One way to tell is to lift the same weight with the right and left sides and look at the result. Or try to place body weight on one leg and then the other. A difference in your ability to support your weight is another suggestion of an injury that requires attention.

Immediate Injury Treatment: Step-by-Step Guidelines

  • Stop the activity immediately.
  • Wrap the injured part in a compression bandage.
  • Apply ice to the injured part (use a bag of crushed ice or a bag of frozen vegetables).
  • Elevate the injured part to reduce swelling.
  • Consult your health practitioner for a proper diagnosis of any serious injury.
  • Rehabilitate your injury under professional guidance.
  • Seek a second opinion if you are not improving.

Article by John Miller

Elite Sports Injury Management

You probably already know that a sports injury can affect not only your performance but also your lifestyle. The latest research continues to change sports injury management considerably.  Our challenge is to keep up to date with the latest research and put them to work for you.

How we treated you last year could vary significantly from how we treat you this year. The good news is that you can benefit considerably from our professional knowledge.

What Should You Do When You Suffer a Sports Injury?


Rest from painful exercise or a movement is essential in the early injury stage. "No pain. No gain." does not apply in most cases.  The rule of thumb is - don't do anything that reproduces your pain for the initial two or three days.  After that, you need to get it moving, or other problems will develop.

Ice or Heat?

We usually recommend avoiding heat (and heat rubs) in the first 48 hours of injury. The heat encourages bleeding, which could be detrimental if used too early. In traumatic injuries, such as ligament sprains, muscle tears or bruising, ice should help reduce your pain and swelling.

Once the "heat" has come out of your injury, you can use heat packs. We recommend 20-minute applications a few times a day to increase the blood flow and hasten your healing rate. The heat will also help your muscles relax and ease your pain. If you're not sure what to do, please call us to discuss your situation specifically.

Should You Use a Compressive Bandage?

Yes. A compressive bandage will help to control swelling and bleeding in the first few days.  In most cases, the compressive dressing will also help support the injury as you lay down the new scar tissue. This early healing should help to reduce your pain. Some injuries will benefit from more rigid support, such as a brace or strapping tape. Would you please ask us if you are uncertain about what to do next?


Gravity will encourage swelling to settle at the lowest point.  Elevation of an injury in the first few days is beneficial, especially for ankle or hand injuries.  Think where your damage is and where your heart is. Try to rest your injury above your heart.

What Medication Should You Use?

Your Doctor or Pharmacist may recommend pain killers or an anti-inflammatory drug. It is best to seek professional advice as certain medications can interfere with other health conditions, especially asthmatics.

When Should You Commence Physio?

sports injury

In most cases, "the early bird gets the worm".  Researchers have found that the intervention of physiotherapy treatment within a few days has many benefits.  These include:

  • Relieving your pain quicker via joint mobility techniques, massage and electrotherapy
  • Improving your scar tissue using techniques to guide the direction it forms
  • Getting you back to sport or work quicker through faster healing rates
  • Loosening or strengthening of your injured region with individually prescribed exercises
  • Improving your performance when you return to sport - we'll detect and help you correct any biomechanical faults that may affect your technique or predispose you to injury.

What If You Do Nothing?

Research tells us that injuries left untreated take longer to heal and have lingering pain.  They are also more likely to recur and leave you with either joint stiffness or muscle weakness. It's important to remember that symptoms lasting longer than three months become habitual and are much harder to solve.  The sooner you get on top of your symptoms, the better your outcome.

What About Arthritis?

Previously injured joints can prematurely become arthritic through neglect. Generally, there are four main reasons why you develop arthritis:

  • An inappropriately treated previous injury (e.g. old joint or ligament sprains)
  • Poor joint positioning (biomechanical faults)
  • Stiff joints (lack of movement diminishes joint nutrition)
  • Loose joints (excessive sloppiness causes joint damage through poor control)

What About Your Return to Sport?

Your physiotherapist will guide you safely back to the level of sport at which you wish to participate.  If you need guidance, ask us.

What If You Need Surgery or X-rays?

Not only will your physio diagnose your sports injury and give you the "peace of mind" associated, but they'll also refer you elsewhere if that's what's best for you. Think about it. You could be suffering needlessly from a sports injury.  Would you please use our advice to guide you out of pain quicker? And for a lot longer.

If you have any questions regarding your sports injury (or any other condition), don't hesitate to get in touch with your physiotherapist to discuss. You'll find our friendly staff happy to point you in the right direction.