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RED-S Part 2 : Returning to Sport

If you, a teammate, friend, or family member has been diagnosed with or suspects Relative Energy Deficiency in Sport (RED-S_, you may be wondering, “what’s next”?

When you look at the entirety of body systems that can be affected by RED-S, it may feel overwhelming! That’s why overcoming RED-S is often overseen by multiple professionals who can monitor your progress in different areas. A recovery team may include a physician, dietician, physiologist, endocrinologist, physical therapist, athletic trainer and more.

As discussed in RED-S: More Than a Triad, RED-S stems from an athlete being in a state of Low Energy Availability (LEA), meaning that the energy (food) that is taken in, does not meet the athlete’s energy demands for physiologic needs and physical demands of sport. Therefore, the key to overcoming RED-S is getting out of energy debt. Working with a sports dietician will help you determine the cause of LEA (unintentional under fueling, or disordered or restrictive eating habits) and how to get the proper amount of nutrients that you need to establish adequate energy availability to overcome RED-S.

In female athletes, a primary goal in the return from RED-S is often to re-establish a menstrual period that comes regularly (every 23-35 days), since the menstrual cycle is often disrupted in a LEA state. Tracking your menstrual cycle can be a helpful tool to help dictate training progression – if an athlete loses their period or it becomes irregular, training should not be progressed (1).

From a physical activity standpoint, it is important to return to your activities gradually. Remember that Energy Availability = Energy Intake – Energy for Physiologic Function – Energy for Sports etc. Therefore, we don’t want to jump back into the full amount of training. In an energy available state, your body will be able to properly adapt to training, however It will be a gradual increase in activity – think marathon, not a sprint!

A physical therapist can work with you to help you build up to your optimal performance level, in a healthy and safe way, which is especially important if you sustained an injury during your RED-S journey. Athletes who have been in a LEA state have reported decreased neuromuscular control such as impaired balance or sense of body in space (2). Impaired neuromuscular control is high predictor of injury, and a physical therapist can help improve motor patterns and motor control to reduce injury risk as you gradually increase activity volume and intensity. Since bone density is adversely affected in RED-S, it is also imperative to provide multidirectional loading to increase bone density and reduce of bone injury.

During the return from RED-S, it is important to be in tune with your body, and tell your coach or someone on your recovery team if you notice any nagging pains or increased fatigue. The professionals overseeing your return to sport will likely have a broad plan but give yourself some grace and flexibility in the schedule. Sometimes progress may take longer (or shorter!) than expected. Every person has their own unique journey overcoming RED-S and there is no formula to calculate an exact timeline. Being patient with this process can be difficult, but with a supportive team behind you, and the desire to get back to activity you love, you can come back from RED-S stronger than ever!

Thanks for reading!

Dr. Elizabeth


(2) Reduced Neuromuscular Performance in Amenorrheic Elite Endurance Athletes. Tornberg Å Melin A Koivula F Johansson A Skouby S et. al.Medicine and science in sports and exercise 2017 vol: 49 (12) pp: 2478-2485


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