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RED-S: Relative Energy Deficiency in Sport - What is it, and how does it affect me?

Updated: Sep 29, 2021

by Jonny Sumner, Specialist MSK & Sports Physiotherapist and Clinical Director

RED-S is a condition that is gaining more awareness across elite and recreational sportspersons and the reality is that increasing numbers of us are unknowingly putting ourselves at risk of developing it. Over-training combined with under eating, pressures on body image in society with the need for being lean are some explanations but they don’t just stop there. A recent boom in running since the Covid-19 lockdown was enforced this Spring has likely been a contributing factor why we are seeing more people in our Physiotherapy and specialist RED-S clinic with this diagnosis.

The underpinning cause of RED-S is a long-term mismatch in our energy intake and the energy we expend through exercise and daily life processes. Essentially it is when we don’t eat enough (and possibly not eating the right food groups) and we over exercise. This leads to multiple parts of the body becoming affected. The result is an impact on our health, but most importantly to our athletes, performing artists (dancers) and runners, is the significant negative impact on training and performance.


There are health implications but also performance consequences of developing RED-S. In fact, quite often the exact opposite expected outcome someone hopes to achieve with their training regime occurs. For example, trying to shed the weight by increasing training can cause the body’s metabolic rate to slow, the body to retain the visceral (belly) fat you might be trying to shift and overall resulting in you not having the energy to train as much. This is also seen in dieting where people try to shed weight by restricting their food intake and it can have the opposite effects. Some other performance effects are:

· Reduced muscle strength

· Decreased endurance

· Increased injury risk

· Decreased recovery rate

· Impairments in judgement and concentration

· Decreased coordination

· Anxiety and depression – both primarily due to chemical imbalances but also can result from pressures of under-performing and being out ill or injured.

· Irritability and decreased engagement in activity and sports


Physical symptoms or possible signs of RED-S can include:

· Amenorrhea (irregular or loss of a women’s monthly period)

· Stress fractures and other soft tissue overuse injuries

· Significant weight loss

· Fatigue, muscle cramps and general weakness

· Dehydration

· Stomach and gut related problems (gastrointestinal)

· Dizziness when changing postures (orthostasis)

· Becoming more frequently unwell or finding it hard to shake off common illnesses or infections

Psychological signs are often overlooked in clinics that do not specialise in this area of Sports Medicine. Our RED-S team are uniquely equipped to identify and help you manage any of these psychological problems. For more severe psychological effects LDN PHYSIO’s Clinical Sports Psychologist Melanie Rendall is on board to support our RED-S clients. Some psychological problems that are often experienced:

· Generalised anxiety or depression and also anxiety related to one’s sport or performance

· Body dysmorphia which is being certain that you are over-weight of ‘fat’ despite being clinically a healthy weight or under-weight

· Excessive exercise, including not allowing yourself regular periods of rest

· Perfectionism with exercise or diet

· Difficulty concentrating

· Becoming tempered or angered easily

· Avoiding eating pre or post exercise (fasting) with a belief this will be beneficial

· Exercising beyond your capabilities

· Preoccupation with weight and eating[AH2]

Why does RED-S effect so many processes in the body?

Our body goes into somewhat of a power saving mode, limiting the energy we have for vital tasks that keep us alive and not having the reserves for other parts. This is represented below with the previously named ‘Female Athlete Triad’ a feature of RED-S.

The science behind this is vast but a major part of the condition is the dysfunction of the endocrine (hormonal) systems. The impact the endocrine system has on most parts of the body is so significant that a specialist trained Physiotherapist or Sports Doctor is often needed to spot the early signs before things can develop, become chronic and become harder to treat.


RED-S can have a profound effect on a women’s ovulation resulting in loss of period, loss of fertility (short and long term effects), there are also considerable longer term psychological impact of effects to a women’s fertility. There can be other significant effects, from negatively impact on stress levels, to poor bone health from the resulting decreased oestrogen levels. Bones can become weaker and more prone to fractures and stress fractures, whilst recovery from injury can often be delayed.


A reduction in male hormonal level is represented as a decrease in testosterone. The negative impact this can cause is reduction in muscle mass, decreased libido, impotence, increased fracture and stress fracture risk and also has been show to link with an increase in visceral fat. The latter may come as a surprise to some - a reduction is visceral fat is a common fitness goal for those embarking on a training program, but incorrectly approaching exercise to the point of RED-S may have the entirely opposite effect.

There is not a one-size-fits-all approach for RED-S and there is currently no specific test for the diagnosis. Our unique and specialist RED-S clinic at LDN PHYSIO covers all bases from your exercise history, recurrent and current injuries, relationship with food and psychological behaviours. Our Sports Medicine Consultant can address the medical aspects of complex cases whilst our Nutritional expertise and Clinical Sports Psychologist are positioned perfectly to provide the right support to those in need.

If you feel you may have some of the symptoms or tendencies pointing to RED-S, The RED-S clinic is our specialist clinic and can be found at Alternatively you can simply book a Physiotherapy appointment with one of our specialists can support with your diagnosis and tailored treatment and training plan.

Booking in could not be easier, visit or contact us directly at or via WhatsApp on our home page.

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