19045 Return To Sport Red S Blog 1200×675

Returning To Sport After Energy Deficiency

BY Nicola Keay

The athletic community is becoming more aware of the risks of energy deficiency in sports–but what happens once an athlete has recovered?

There have been encouraging improvements in the athletic community’s awareness and medical management of relative energy deficiency in sport (RED-S). But what happens after an athlete has been “medically cleared” to return to sport? After discussions with athletes and coaches who have dealt with the situation, here are some suggestions on how to help athletes return to healthy practice of sport after dealing with energy deficiency challenges.

RED-S is a situation of low energy availability (LEA), which can lead to adverse health and performance consequences. LEA can be a result of intentional calorie restriction, which can be caused by performance pressure, clinical eating disorders, and many other factors.

Ironically, the original intention of these eating issues may be to improve athletic performance, yet sustained LEA will ultimately lead to stagnation and deterioration in performance.

The desire to return to full fitness can be a powerful incentive to address LEA. Nevertheless, this needs to be carefully structured in collaboration with coaches to prevent injury and avoid regression to the LEA state.

Structured Return to Training

Initially coaches and athletes should start with body weight strength and conditioning. When an athlete’s caloric demand doesn’t match supply, their adaptive responses to training stimuli will be dampened when the hormone networks shut down into an energy saving mode. Once adequate energy availability has been established, hormone networks will be able to respond correctly again.

Muscle Tone

Restoring lost muscle tone and working on proprioception helps mitigate the risk of injury as the athlete increases training volume. Starting with basic strength and conditioning can also help re-establish a healthy routine of fuelling around training (before, during, after). In particular, having recovery nutrition within the critical 30-minute window post-exercise will enable hormonal responses to training. Note that having this recovery nutrition does not mean reducing intake at the next meal!

Athletes should ease into long endurance or high-intensity training after restoring muscle strength and control, in order to prevent injury. This type of training has a high energy requirement, so if adequate energy availability has only recently been restored, too much training too soon can have negative effects.

Bone Health

Injury and soft tissue and bone stress responses are more frequent in RED-S. If an injury has been sustained during a period of LEA, then athletes should put particular emphasis on strength and conditioning. In the case of previous bone stress responses, multi-directional loading is the key to building bone strength before an athlete resumes formal run training.

Even if a bone injury has not occurred, bone turnover is one of the first systems to be adversely impacted by RED-S, so it’s important to include this type of multidirectional bone loading in the initial structured return for all athletes.

Talk with your coach to establish a realistic, attainable goal — this could be something like a low-key race/event several months down the road.


You may have experienced menstrual disruption during your time in LEA. This is a crucial training metric — please use it! If your menstruation becomes irregular or stops, this is a warning sign that your body is not ready to step up training. Male coaches, please be aware of this and don’t be shy about communicating with your female athletes!

Have a Flexible Approach

Don’t ignore injury niggles, illness or fatigue. Discuss these with your coach and back off if necessary. Remember, this process is a marathon, not a sprint.

Try not to put pressure on yourself to return to your previous level. It is important to have a plan, but you can be flexible. Everyone’s physiology is different, so the process of returning to sport does not need to have a rigid timetable.

Recovery and Long Term Outlook

Does anyone fully “recover” from disordered eating or a clinical eating disorder? I don’t think so. To be a successful athlete (or successful in life), you need self-motivation, drive, and determination. These are all admirable qualities, but when taken too far, these can cause unhealthy patterns. Be aware that in times of stress, it may be tempting to revert to old habits of undereating or over-exercise.

It’s also important to be prepared for questions from your teammates and friends. Why haven’t you been training? Why are you not doing a full racing schedule? Whether you share the full story or not is your call.

Good luck with your return to sport after RED-S — if that’s what you want to do. With a balanced approach, a keen eye on metrics and a good attitude, you can come back stronger and healthier for life.


BASEM Educational website www.health4perforamnce.co.uk

IOC consensus statements on RED-S BJSM 2014 and update 2018

RED-S Clinical Assessment Tool BJSM 2014

Avatar1548995272 7
About Nicola Keay

Dr. Nicola Keay BA, MA, MB, BChir (Cantab), MRCP is the author of Health Hormones and Human Potential: A guide to understanding your hormones to optimise your health and performance. Nicky is an Honorary Clinical Lecturer in the Division of Medicine at University College London. She lectures and researches in areas of exercise endocrinology, with publications in this field. Nicky’s clinical endocrine work is mainly with exercisers, dancers and athletes, with a focus on relative energy deficiency in sport (RED-S) and athletes navigating perimenopause/menopause. Nicky works to provide a more personalized approach to female hormone health. Nicky authored the British Association of Sports and Exercise Medicine (BASM) Health4performance.co.uk online resource. Nicky is the medical advisor to Scottish Ballet and a keen dancer herself, taking four ballet classes per week. Follow Nicky on LinkedIn.