Relative Energy Deficit in Sport (RED-S)
Relative Energy Deficiency in Sport (RED-S)
What is RED-S?
Relative Energy Deficiency in Sport (RED-S) is a condition which 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. It was 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 in (ie food) is tipped out of balance with energy out (ie activity). This can occur in many ways and is not always a sudden change, which can make identifying the causes difficult without help from trained medical professionals and coaches. Some examples might be an increase in sport or training load, a decrease in 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 are so varied, and everyone’s body responds differently to LEA. Energy availability is a sliding scale that changes constantly 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 either revealing or minimising their symptoms to their coaches, trainers, family, friends and to themselves. Generally, the person feels and looks pretty run down, because the body isn’t getting enough fuel to complete all the activity being performed.
Often, athletes are recognised as being in an energy deficient state when it leads to them becoming injured, or developing other conditions, for which they seek 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, and what their greatest concerns are, as well as the results of any tests or investigations. Treatments are usually delivered by a mix 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 make sure 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 a 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 https://www.perthsportsmedicine.com.au/relative-energy-deficiency-in-sport-perth-claremont-cockburn-wa.html 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. https://doi.org/ 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 https://bjsm.bmj.com/content/bjsports/49/7/421.full.pdf on 28/05/2020
FAQS About Sports Physiotherapy
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 to how we treat you this year. The good news is that you can benefit considerably from our 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. 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 their professional advice as certain medications can interfere with other health conditions, especially asthmatics.
When Should You Commence Physio?
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. 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), please contact your physiotherapist to discuss. You'll find our friendly staff happy to point you in the right direction.
Acute Sports Injury Clinic
How to Best Care for Your Sports Injury?
There is never an excellent time for an injury. But we do know that most sports injuries occur over the weekend! That's why at PhysioWorks, we have established an Acute Sports Injury Clinic at a selection of our clinics on a Monday and Tuesday.
The acute sports injury consultation fee is significantly lower than a routine assessment and treatment consultation. In most cases, your private health will cover the full cost of your full acute injury physio assessment fee.
Why Use an Acute Sports Injury Clinic?
Your Acute Sports Injury Assessment Consultation allows us to provide you with:
- A quick and accurate diagnosis. One of our Sports Physiotherapist's or an experienced sports injury-focused Physiotherapist will confidently guide your new injury management.
- Early acute sports injury care, professional advice and education. What to do this week?
- Fast referral for X-rays, ultrasound or MRI scans to confirm your diagnosis.
- Prompt referral to Sports Physicians, GPs or Surgeons with whom we work if required.
- Immediate supply of walking boots, braces and rental crutches if needed.
- Low-cost professional service.
For more friendly advice or guidance, please call your nearest clinic to discuss your specific needs.
Who is a Sports Physiotherapist?
Sports Physiotherapy is the specialised branch of physiotherapy which deals with injuries and issues related to spokespeople. Practitioners with additional formal training within Australia are Sports & Exercise Physiotherapists.
What is Sports Physiotherapy?
Sports injuries do differ from common everyday injuries. Athletes usually require high-level performance and demand placed upon their body, which stresses their muscles, joints and bones to the limit. Sports physiotherapists help athletes recover from sporting injuries, and provide education and resources to prevent problems.
Each sports physiotherapist usually has sport-specific knowledge that addresses acute, chronic and overuse injuries. Their services are generally available to sportsmen and women of all ages engaged in sports at any level of competition.
Members of Sports Physiotherapy Australia (SPA) have experience and knowledge of the latest evidence-based practice, skilled assessment and diagnosis of sports injuries, and use effective 'hands-on' management techniques and exercise protocols to assist recovery and prevent future damage. SPA members have access to the most recent advances in sports physiotherapy. You'll be pleased to know that most of PhysioWorks physiotherapists and massage therapists have a particular interest in sports injury management.
What is the PhysioWorks Difference?You'll be impressed with the experienced physiotherapists, massage therapists and reception staff who represent PhysioWorks. To ensure that we remain highly qualified, we are committed to participating in continuing education to provide optimal care. If you've been searching for health practitioners with a serious interest in your rehabilitation or injury prevention program, our staff have either participated or are still participating in competitive sports at a representative level. We also currently provide physiotherapy and massage services for numerous sports clubs. Our experience helps us understand what you need to do to safely and quickly return to youryouryour sporting field, home duties, or employment.
How You'll Benefit from the PhysioWorks Difference?At PhysioWorks physiotherapy and massage clinics, we strive to offer our clients quick, effective and long-lasting results by providing high-quality treatment. We aim to get you better quicker in a friendly and caring environment conducive to successful healing. With many years of clinical experience, our friendly service and quality treatment is a benchmark not only in Brisbane but Australia-wide.
What are Some of the BIG Differences?Our therapists pride themselves on keeping up to date with the latest research and treatment skills to ensure that they provide you with the most advantageous treatment methods. They are continually updating their knowledge via seminars, conferences, workshops, scientific journals etc. Not only will you receive a detailed consultation, but we offer long-term solutions, not just quick fixes that in reality, only last for a short time. We attempt to treat the cause, not just the symptoms. PhysioWorks clinics are modern thinking. Not only in their appearance but in the equipment we use and in our therapists' knowledge. Our staff care about you! We are always willing to go that 'extra mile' to guarantee that we cater to our clients' unique needs. All in all, we feel that your chances of the correct diagnosis, the most effective treatment and the best outcomes are all the better at PhysioWorks.
Sports Physiotherapy BrisbaneUltimately, your safe return to sport will be determined by your sports physiotherapist, doctor or surgeon. They will take into consideration your tissue healing and how well you have progressed in your rehabilitation. Returning to sport too early can delay healing and prolong recovery and pain. Your physiotherapist will aim to speed up the process via some hands-on treatment techniques, exercises, electrical modalities, plus most importantly, strength and agility exercises to replicate your sport. Sometimes bracing or taping may allow an early return to sport. As a general rule, most soft tissue injuries and bone injuries will take at least six weeks for scar tissue to mature or your bone to strengthen. Therefore, caution is required and is best discussed with your sports physiotherapist, doctor and coach.
FAQsCommon Physiotherapy Treatment Techniques What is Pain? Physiotherapy & Exercise What Causes Post-Exercise Muscular Pain? What are the Best Core Exercises? Barefoot Running: Your MUST READ Guide to the Pro's and Con's. Can Kinesiology Taping Reduce Your Swelling and Bruising? Heat Packs. Why does heat feel so good? How Can You Prevent a Future Leg Injury? How Do You Improve Your Balance? How Does an Exercise Ball Help Back Pain? Post-Operative Physiotherapy Rotator Cuff: What is it? Sports Injury? What to do? When? What are Common Adolescent / Children Leg Injuries? What are the Early Warning Signs of an Injury? What are the Signs of an Unsupportive Pillow? What is a TENS Machine? What is Chronic Pain? What is Nerve Pain? What is Sports Physiotherapy? What to expect when you visit PhysioWorks? What's the Benefit of Stretching Exercises? When is the Best Time for a Pre-Event Massage? Why do your Joints Click? Why Kinesiology Tape Helps Reduce Swelling and Bruising Quicker
Why Do Physiotherapists Prescribe You Exercises?The prescription of exercise appropriate to you and your injury or fitness level is one of the many professional skills of a physiotherapist. Whether you have suffered an acute injury, chronic deconditioning or are recovering from surgery, the correct exercise prescription is essential. That's why your physiotherapist's knowledge and skills will personalise your exercise dose. Your physiotherapist not only is educated in injury diagnosis but also exercise physiology or the science of exercise. This training enables your physiotherapist to assess and diagnose your injury, plus also to prescribe injury, fitness or age-appropriate activities targeted to you now.
What Exercises Should You Do?Your exercises shouldn't be painful. Please take caution with some overzealous exercise prescribers who believe that the more painful the activity, the better. Thus simply isn't true—notably, the frail, immunosuppressed, deconditioned or post-operative person. You'll find that your physiotherapist will thoroughly examine you and prescribe a series of exercises suitable for you in quantities that will not injure you further. Please seek an exercise expert, such as your physiotherapist, when you are planning your rehabilitation.
What Happens When You Stop Exercises?Without some simple exercises, we know that specific muscles can become weak. When these supporting muscles are weak, your injured structures are inadequately supported and predispose you to linger symptoms or further injury. You can also over-activate adjacent muscles that may lead to further damage. It is also essential to understand that even if you are "in good shape", you may have crucial but weak localised or stability muscles. When you have an injury, you should perform specific exercises that specifically strengthen the muscles around your injury and the adjacent joints. Your physiotherapist will assess your muscle function and prescribe the right exercises specific for your needs. The exercises prescribed will usually be relatively simple, and do not require any special weights equipment, and can be performed safely at home.
Would You Stop Your Daily Prescription Drugs?Your physiotherapist will prescribe your individualised dose or exercises. They are using their professional expertise to optimise your exercise dose. Would you just stop taking your regular blood pressure medication because you were too busy or didn't think it was working? We would hope not! Exercise, when prescribed by an expert such as your physiotherapist, should be treated as your recommended dose. Just like when you don't take your blood pressure medication, you can't expect the drugs to work of you don't take it as prescribed by your health professional. So, next time you skip your "exercise dose" just remember that you are not putting your health first. If you have any questions, please contact your Physio Works physiotherapist for your best care.
Olympic InjuriesThe Olympic games are the pinnacle of an athlete's career, where the fastest, strongest and elite compete for the podium finish. But just like you and me, they too suffer injuries, both career-ending and career limiting. How do they recover? In the 2008 Beijing Olympic games, out of the 9572 athletes, 1055 injuries were reported with the most common place of injury at the knee. The table below shows a grasp of the injuries sustained by athletes at the 2008 Olympic games and 2010 Winter Olympic games. Let's focus on the summer sports for the purpose of this article. If you guessed soccer, taekwondo, field hockey, handball and weightlifting as your top 5, you win the GOLD! Source: Scientific American, 2012
What're the Safest Olympics Sports?For the risk adverse, you top 5 sports to get you to and from the Olympics are Sailing, Canoeing/Kayaking, Rowing, Synchronised swimming and diving. Having said that, I've seen all of those sportsmen and women with injuries at PhysioWorks! But the injury is not necessarily the end of your Olympic aspirations. You can see from the chart above that most athletes were able to recover and compete.
How Do Olympians Recover So Quickly?When you’re at the elite level, you generally have an overabundance of medical assistance. You are closely monitored in terms of your daily health and any “niggles” are seen to immediately - not to mention the multiple physiotherapy sessions they can have in one day! Furthermore, they have access to state of the art medical technology which can assist diagnosis and speed up recovery. So what would be a 6-week injury for the local athlete (“Elite”) could potentially be under 4 weeks for the Olympian. They are also well in-sync with their bodies and consistently perform the recovery tasks mentioned below to ensure they are ready for their events and speed up their recovery.
What Do Olympians Do to Recover Quicker?As mentioned earlier, a considerable portion of the Olympic athlete's recovery can be attributed to their access to medical assistance. The athlete does the training, has a natural talent, but there is also a proactive and readily available medical team behind them ensuring they stay at the top. We cannot undermine the athlete’s proactivity in performing their own recovery - regular stretching, not ignoring “niggles”, performing rehabilitation and “prehab” as prescribed. These are done so consistently but also with technical precision - not accepting poor quality.
How Do Olympians Prevent Injuries Between Events?Competing at the Olympics isn’t a one-off event. More often than not, each sport has heats followed by a final series - sometimes even on the same day! To ensure the athletes are in their finest form to compete, they implement all the tricks of the trade - most of which we have access to! Compression gear, physiotherapy, massages, stretching, foam rollers, adequate nutrition and active recovery. Active recovery is often overlooked by the local sporting athlete but can so easily be the difference between being 80% and 100% recovered for your event. This can be done by a simple warm down jog/walk, stretching, pool recovery (water walking, light swimming) and nutrition. As the name suggests, the warm down is the opposite to the warm-up, we aim to gradually lower the heart rate and body temperature following physical activity. Simultaneously, it removes waste products created during exercise, including the dreaded Lactic Acid - which can cause cramping and tightness in muscles if it is not effectively removed. Inevitably, the tightness and soreness in muscles restricts movement and can limit the athlete's ability to perform at their top level.
What Does PhysioWorks offer that the Olympic Athletes have access to?At Physioworks, we believe that every athlete whether competing in 5th-grade rugby or premier grade netball should have access to the same medical team services that elite athletes do. A team approach, with you at the centre, ensures your recovery from injury or event is undertaken effectively and efficiently. By offering access to physiotherapists, dietitians, massage therapists, exercise physiologists, hand therapists, acupuncturists etc as well as supplying products to potentially speed your recovery (protective equipment, compression garments, Tens machines and many other products), we are giving our patients every opportunity to ensure their quick and safe recovery. Of course, there is the body’s natural healing ability but, if we can place it in the optimal healing environment, you too can heal like an Olympian. GO AUSTRALIA!!
Private Health Insurance Rebates
PhysioWorks Physiotherapy and Remedial Massage are more affordable than you think. Your Private Health Insurance (PHI) usually pays for the majority of your treatment fees, leaving you with only a small gap payment.
However, Private Health Funds do vary their rebates payable depending upon the level of cover that you have taken. Some funds have kept up with the costs of modern medicine whereas, sadly others haven't, with rebates similar to what they were a decade ago.
HICAPS - Instant Health Fund Claims
Most health funds are members of the HICAPS instant claims system. Swipe your health insurance card at our reception counter, and you can instantly claim your physiotherapy treatment via our online Hicaps System. Remedial Massage is claimable via Hicaps for some but not all funds. For more information, please visit Hicaps for the latest funds which can use their instant claiming system.
Private health insurance rebates are available for all of our physiotherapists. Instant claims are possible via our in-practice Hicaps system.
- All Private Health Insurance Funds including BUPA, Medibank Private, HCF
- For a full list of Hicaps instant claim funds see here: Hicaps Funds
- HCF More for Muscles Program
PhysioWorks practitioners are registered providers for government, Workcover and insurance companies including:
- Australia Post; Coles Myer; Woolworths
- Department of Veterans' Affairs
- CTP & Sports Insurers