You may be reading this because a health professional has suggested that you could be experiencing Relative Energy Deficiency in Sport (RED-S). If so, you may be wondering what it actually means. Here is everything you need to know about what RED-S is, why it matters, and what you can do to break the cycle.
What is RED-S?
Relative Energy Deficiency in Sport (RED-S) happens when your body does not have enough energy to cope with exercise alongside its normal physiological functions, such as digestion, breathing, maintaining body temperature, hormone production, immune function and tissue repair.
This is called low energy availability—when the energy you consume through food is insufficient to meet both the demands of training and the body's essential functions.
The cycle often begins when training volume increases in an effort to improve performance, but food intake doesn't increase to match. Many active people unknowingly fall into this pattern. Over time, the body begins to prioritise essential survival processes, reducing the energy available for recovery, bone health and athletic performance.
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Why does RED-S matter?
Recovery and adaptation rely on adequate energy. Cell repair is essential to maintain muscle, keep us strong and allow our bodies to adapt to training. Without enough energy, muscles repair slowly, bones become vulnerable to stress injuries and the immune system is compromised.
You may notice:
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Poor recovery between training sessions
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Frequent illness or fatigue
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Difficulty gaining or maintaining weight
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Reduced training performance
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Hormonal changes, including menstrual disturbances in females or reduced libido in males
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Delayed puberty in adolescents
As your body attempts to conserve energy, RED-S can also affect reproductive hormones, bone health and fertility. Importantly, signs can be particularly difficult to recognise in male athletes and post-menopausal athletes, where hormonal symptoms may be more subtle.
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Who can develop RED-S?
RED-S can affect active individuals of any age, gender, body size or sporting level.
Maybe you're a lightweight athlete, have low bone density, digestive issues or a previous eating disorder. Perhaps you're new to running, have recently increased your training mileage, or maybe you're simply not progressing through your rehabilitation as expected.
Although anyone can develop RED-S, it is more commonly seen in sports with high training loads or weight considerations, including running, cycling, rowing, gymnastics, horse racing (jockeys).
If RED-S has been raised as a possibility, your healthcare team is looking beyond your immediate symptoms to understand the bigger picture and provide the most holistic care possible.
RED-S and bone stress injuries
One of the most significant long-term consequences of RED-S is an increased risk of bone stress injuries.
Unlike an acute fracture, bone stress injuries develop gradually when bone is repeatedly loaded faster than it can repair itself. Early symptoms often include pain that worsens with impact, pain at night, or pain that persists despite rest or anti-inflammatory medication. Standard X-rays and ultrasounds may appear normal in the early stages, making these injuries easy to miss.
In adolescents, persistent back pain should never be dismissed as "normal." Children and adolescents generally heal quickly, so ongoing low back pain warrants further investigation for a stress injury of the pars interarticularis (a small section of bone in the lower spine). These injuries are particularly common during periods of rapid growth and in sports involving repetitive spinal extension and rotation, such as gymnastics, cricket, football, diving, dance, tennis and athletics.
Early recognition is essential because bone stress reactions identified before progressing to a complete fracture have a much greater capacity to heal.
Could RED-S be affecting you?
Ask yourself:
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Have you had a stress fracture before?
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Have you been told you have low bone density?
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Do you avoid certain foods or entire food groups?
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Do you experience gastrointestinal symptoms?
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Have you noticed changes to your menstrual cycle or a reduction in libido?
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Are you recovering well from training?
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Have you experienced recurrent injuries or frequent illness?
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Are you not progressing as expected within your rehabilitation plan?
Answering "yes" to one or more of these questions doesn't necessarily mean you have RED-S, but it does warrant further discussion with your healthcare team.
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How can a sports dietitian help?
Having a dietitian appointment never hurt anyone!
It can be surprisingly difficult to recognise whether you're over-training or under-fuelling, and addressing this mismatch is often one of the simplest and most effective ways to prevent injuries and improve performance.
A sports dietitian can:
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Assess whether your energy intake matches your training demands
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Identify factors contributing to low energy availability
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Optimise nutrition to support bone health, recovery and performance
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Ensure your fuelling practices support your goals
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Work alongside your physiotherapist, podiatrist and sports physician as part of a multidisciplinary team
Medical management may also include addressing menopause, nutritional deficiencies or other contributing factors where appropriate.
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The main takeaway
A common misconception is that more training always leads to better results. In reality, you cannot out-exercise under-fuelling or a bone stress response.
If you have persistent niggles, recurrent injuries or feel like your rehabilitation has stalled, you're in good hands. Our physiotherapists, podiatrists, sports physicians and sports dietitians work together to identify the underlying causes of persistent pain, delayed recovery and bone stress injuries that might otherwise be missed.
Treat this as an opportunity to learn how best to fuel, recover and perform at your best. Addressing low energy availability early can significantly reduce your future injury risk while improving your health, recovery and sporting performance!
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Learn how our Melbourne Sports Physio team can help you?
At Melbourne Sports Physiotherapy our goal is to get you moving pain free as soon as possible.
But, we also want you to actually move better and live a healthier, more active and fulfilling life!
If your sports, fitness training or work has been wearing your body down, book in with one of our expert massage therapists so we can help you reduce your pain or stiffness.
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