What is RED-S?

There is a lot of discussion in the news lately about Relative Energy Deficiency in Sport (RED-S) and it is a topic that we at Adams Sports Medicine and Physical Therapy talk a lot about. Dr. Hannah DePaul and Dr. Katie Noble spend time educating high school cross country and track teams about how to be healthy and fast. We respect and admire Mary Cain and other women who have come forward with their personal struggles with RED-S. RED-S has dangerous, long-term consequences to the health of both female and male athletes. As Mary Cain highlights, in order to navigate the complexities of sport, body image and self-worth – the support and guidance an athlete has is critical to avoid the disorder. 

So what is RED-S? It’s having an inadequate amount of energy to support bodily functions for optimal health and performance, which can lead to serious health and performance consequences (see diagram below).1 When runners don’t eat or recover enough to support training, an energy deficit is created. When this energy deficit persists, an athlete will experience decreased performance, strength, and endurance and has increased risk of depression and physical injury. In a culture that often glamorizes #norestdays, young athletes need to be protected from developing habits that feed this disorder.

For women, RED-S can lead to menstrual dysfunction, which weakens bones and can lead to fractures. This is especially concerning in young athletes, as teens are developing peak bone mass that they will rely on for the rest of their lives. Periods are a barometer of overall health and if it’s lost, an athlete should seek medical help. Losing a period from training is never normal. For men, low testosterone can lead to thinning bones. While the signs of low testosterone aren’t as obvious as a lost menstrual cycle, knowing the risk factors for RED-S can help male athletes stay ahead of it. 

Historically, the culture of distance running has included a “thinner is faster” ideal. Research now proves that this thinking is dangerous to health and performance. A recent study found that male runners who responded “yes” to the statement “being thinner means being faster” were more likely to have low bone mineral density and an increased risk of fractures.2 A runner’s thoughts and beliefs about body image has real effects on physical health. There is no truth that the lightest runner is the best runner. The best runner is well-supported, well-rested, well-fueled, and wisely trained. 

Nutrition and sleep also play a huge role in preventing RED-S. A study found that women who consumed less than 800 mg of calcium per day had nearly 6x the rate of stress fracture than women who consumed more than 1500 mg of calcium.2   It’s shown that sleep deprivation can lead to bone loss.3 

RED-S isn’t just a physical health issue, it’s a cultural problem with sport. The culture of a sport and team can bring out the best in a runner or can be toxic to well-being. Breakthrough performances elevate sport and inspire humanity. The future of the sport lies within young athletes. Coaches, health care providers, parents, and everyone within an athlete’s support system has a responsibility to foster performance without sacrificing an athlete’s long-term physical and mental health. 

  1. De Souza MJ, Nattiv A, Joy E, et al. Br J Sports Med 2014;48:289.
  2. Tenforde, Adam & Fredericson, Michael & Sayres, Lauren & Cutti, Phil & Sainani, Kristin. (2015). Identifying Sex-Specific Risk Factors for Low Bone Mineral Density in Adolescent Runners. The American journal of sports medicine. 43. 10.1177/0363546515572142. 
  3. Tenforde AS, Sayres LC, Sainani KL, Fredericson M. Evaluating the relationship of calcium and vitamin D in the prevention of stress fracture injuries in the young athlete: a review of the literature.” PM R. 2010;2(10):945-949. Article Summary on PubMed. (http://www.ncbi.nlm.nih.gov/pubmed/20970764)
  4. Ben-Sasson, et al. Extended duration of vertical position might impair bone metabolism. Eur J Clin Invest, 1994

Running With Knee Osteoarthritis

Have you ever heard someone say, or even said yourself, “I shouldn’t run because I have arthritis in my knees?” Although this may seem like sound decision making when managing this diagnosis, the research begs to differ.

Osteoarthritis (OA) is a common type of arthritis that occurs as individuals get older. It is the breakdown of the cartilage “cap” on the end of the bonds. It can cause pain and loss of function. Many of our patients love to run and race… and they do not want age/pain to hold them back from doing what they love. Often times people think this diagnosis, especially in their knees, means the end of their running career.

A recent study debunks the “rest is better” myth. Lo et al. (2017)1 found that individuals 50 years old and over with knee OA and who performed self-selected running actually did at least one of the following: decreased their knee pain, did not worsen their pain, or did not progress their structural symptoms in the knee. This means that runners diagnosed with OA should not automatically go into retirement. They are safe to continue running based on how they are feeling and being conservative with their progression. This study supports that movement is key in treating pain and providing the appropriate stress on the knee cartilage to aide in regeneration.

If you are experiencing pain with running or have more questions about your running – schedule an evaluation or running gait analysis to help get you back on track to your goals!

Kaylee Pobocik, SPT, ATC

1 H. Lo, Grace & M. Musa, Sarra & Driban, Jeffrey & M. Kriska, Andrea & E. McAlindon, Timothy & Souza, Richard & J. Petersen, Nancy & Storti, Kristi & Eaton, Charles & C. Hochberg, Marc & Jackson, Rebecca & Kent Kwoh, C & C. Nevitt, Michael & Suarez-Almazor, Maria. (2018). Running does not increase symptoms or structural progression in people with knee osteoarthritis: data from the osteoarthritis initiative. Clinical Rheumatology. 37. 10.1007/s10067-018-4121-3.

Bone Health

Healthy bones are the foundation to healthy running. Bones are strong, sturdy, and designed to tolerate a great amount of stress. In fact, bones get stronger from weight bearing. This is good news for runners, who put cumulative stress through their bones with each foot fall.

However, bones have their limits and require proper care. Here are key things all runners should know about their bone health.

Energy availability is a pillar of bone health. Energy availability (EA) is a measure of energy burned versus energy replenished per day. You have to eat enough calories to not only support the miles you put in, but to support your brain and bodily functions. If EA is chronically low from underfueling or overtraining, your body will start to drain your bones to get the nutrients it needs to keep you alive and moving. If you’re underfueling or overtraining, bones become weaker. EA can be quantified with this calculator (www.femaleathletetriad.org/calculators). Daily EA should be around 45 kcal/kg FFM/day and athletes should be eating a MINIMUM of 30 kcal/FFM/day for optimal bone health. Along with weaker bones, low EA can lead to fatigue, decreased performance, and increased risk of injury.

Sleep is by far the most important aspect of recovery an athlete can utilize, as lack of sleep is associated with weakened bones. Sleep deprivation can have significant negative effects on performance in endurance tasks and may also influence learning, memory, pain perception, cognition, immunity and inflammation. In a study of military recruits who were purposefully sleep deprived, it was found that they had a 5% reduction in bone mineral density in just seven days.1 Sleep is the time your body takes to replenish and repair tissue that was stressed during the day. If your sleep is disturbed, your bones are at a greater risk of injury.

Nutrition is about quality and quantity. Runners need to eat enough food each day. (Remember EA?). Some runners find benefit in an individualized consultation with a registered dietician. (We can recommend some good ones!) Specifically, all runners should pay attention to daily calcium intake. Calcium is a major building block that keeps bones strong. Recent studies show that women who consumed less than 800 mg of calcium per day had nearly 6 times the rate of stress fracture than women who consumed more than 1500 mg of calcium.2 Furthermore, fracture risk in runners is decreased by 62% for every additional cup of skim milk consumed per day.2 Calcium’s best friend, Vitamin D, is responsible for calcium absorption. The worse a runner’s vitamin D intake, the longer it takes to recover from stress fracture.3 Thus, increasing daily calcium and vitamin D is a simple way to reduce fracture risk.

Listen up, ladies. Your menstrual cycle is a vital sign. That’s right: put it right up there with heart rate and blood pressure. A healthy, regular cycle is the cardinal sign that you are maintaining an appropriate EA, getting adequate nutrition, and protecting your bones. Female runners who have stopped menstruating are at a 4.5-fold increased risk of injury compared to regularly menstruating women.4 This is because monthly estrogen spikes with each cycle help protect bones against break down. Your period is a monthly signal of your health. If your periods become irregular or stop, talk to your healthcare provider for strategies to regain your cycle.

When it comes to bone health, prevention of fractures is best. If a fracture does happen, the road to recovery doesn’t have to be so bumpy when you’re armed with the right information to help prevent future bone health issues. Most importantly, the road ahead has the potential to be better than before. If you have questions about bone health or would like to be evaluated for a bone stress injury, don’t hesitate to reach out to our therapists.

  1. Ben-Sasson, et al. Extended duration of vertical position might impair bone metabolism. Eur J Clin Invest, 1994
  2. Nieves et al. Nutritional Factors That Influence Change in Bone Density and Stress Fracture Risk Among Young Female Cross-Country Runners
  3. Serum Vitamin D Levels Are Inversely Associated With Time Lost to Bone Stress Injury in a Cohort of NCAA Division I Distance Runners
  4. Heikura I. 2018

IRONMAN Weekend!!!!

Our clinic specializes in the education and treatment of endurance athletes. This weekend is a “double whammy” of endurance events, with the Ironman World Championships in Kona, HI taking place today (October 13th) and Ironman Louisville taking place tomorrow, October 14th.  (click the links to find out more info about the events, search athletes and track their results)

We have multiple athletes participating in both events, and our staff understands all the hard work, heartache and sacrifices you have endured to get to this day. Best of luck, apply your training, but most of all….enjoy the journey.

Ironman Traverse City 70.3

Well, that happened quickly. Ironman Traverse City 70.3 SOLD OUT in the first hours of general registration. Hoping to see a ton of our friends, colleagues and athletes training and prepping for the first year of this event, scheduled for August 25, 2019.

Dr. Katie Noble Collaborates with Fellow PTs to Discuss Women’s Distance Running

In this blog post, Dr. Katie Noble shows her passion for running, and specifically the education surrounding women’s distance running. All three PTs – Katie, Sam Gerutta, and Amy Yorke – examine challenges female runners face, important aspects of health to consider, and even some of their own experiences as runners/clinicians.



Race Tip #5: Taper

With less activity, athletes run the risk of defeating themselves mentally. A taper period is a crucial part of training that can make or break your upcoming race. Dr. Hannah DePaul reflects on her time swimming at the University of Michigan where she learned a lot about taper.

Two things that resonated with her: “The hay is in the barn and “Control the controllables.” Her coach would preach that all the hard you have put in is done, and now is the time to recover. Let the mind and body prepare for race day. You will not gain any fitness in the last couple of weeks leading up to your big race.

Some things are out of your control, such as who else is racing or what the weather will be like. Do not waste mental energy on those factors. Control what you have the ability to control…your mindset, attitude, and preparation. Focus on your race, trust your training, and good things will come. Having strategies in place ahead of time will help keep you mentally focused. So acknowledge the taper and embrace it!

Race Tip #4: Sleep

A typical response we hear from athletes – when asked how much sleep they are getting a night – is, “not as much as I would like.” Athletes are great at working hard, but sometimes the importance of sleep is neglected. It’s not just the work you put in, but the amount of recovery you give your body. As an athlete, sleep is the most effective recovery strategy that we can utilize. Lack of sleep can increase risk for injury and affect physical and mental performance. A recent systematic review from Bonnar et al. (2018) found that extending sleep had the most beneficial effects on subsequent performance compared to napping, sleep hygiene, and post-exercise recovery strategies. Also, 7-9 hours of sleep per night is recommended for healthy adults but athletes need 9-10 hours to reach their full potential. Make sleep a priority. Set a regular bed time, avoid caffeine late in the day, and limit screen time before bed. Improving sleep can be difficult, but stick with it! It’s worth it. Train hard and rest harder!

Bonnar, D., Bartel, K., Kakoschke, N. et al. Sports Med (2018) 48: 683.

Race Tip #3: Advice From Us

The Bayshore Marathon provided an opportunity for Dr. Hannah DePaul and Dr. Katie Noble to pull from their own experiences and share some advice with our patients and fellow athletes.

Katie advises that instead of concentrating on the outcome of a race, focus on the process. Set small goals during the race to make the task more mentally manageable. Not every race goes to plan, but stay calm and do what you can in the moment. Every race is a learning opportunity that you can benefit from in races to come!

Hannah found that many endurance athletes put so much focus on just the long workouts (example the 20+ mile marathon prep run), but neglect the consistency and frequency in their training to nail the full race. The hero workouts can contribute to injuries and require prolonged recovery time. Instead, she recommends focusing on consistent training rather than hero workouts. Putting in the work week after week will give you confidence and put you in the right mindset to meet your race day goals!

Tweak and Level Multisport

Tweak is a swimming facility that focuses on athletes’ biomechanics and overall fitness in order to help them be more efficient in the water. During a swim analysis you will get into an endless pool and their coaches will capture live video. When going over the footage, they will look at your form, point out aspects to improve and give you feedback that you can immediately work on and integrate into your stroke. It is akin to what we do for runners with a running gait analysis, but for swimmers in the water. You can schedule your swim analysis online or call the facility and talk to the staff! 


Level Multisport is a triathlon store that we have heard so much about from our patients. Since 2011, they have been proudly serving the triathlon and fitness community. Their knowledgeable and friendly team are deeply involved with the multisport lifestyle themselves, giving them an edge on helping you find exactly what you want and need for your training. They specialize in shoe fitting and bike fitting and also offer elite swimwear. Feel free to attend their Saturday morning Spin Lab or just stop in to grab some gear and meet the crew!