A 19 year old female triathlete attends your clinic with right foot pain. An MRI confirms a Navicular stress fracture. Her training volume is 20 hours a week. She has a reduced BMI, a history of overtraining syndrome, iron deficiency and recurrent hamstring tendinopathy. 

Would you routinely ask her about her menstrual cycle during your assessment? 

I put this question out to the physio community on Twitter. The poll had over 1000 responses and showed 75% would ask the athlete about her periods or likely, the lack of. 

Relative Energy Deficiency in Sport (RED-S) or more commonly known as the “female athlete triad” has been a hot topic lately. I’ve openly shared my own experience through my blog “the break in breakthrough”. I know only too well it’s detrimental effects. 

The combination of overtraining and under fuelling through disordered eating/eating disorders puts the athlete into an energy deficit. This negative balance ceases menstruation and reduces the all important bone protecting hormone, oestrogen. 

If prolonged, bone density is lowered and the dreaded stress fractures occur.

The RED-S continuum shows that the energy deficit extends beyond bone health manifesting as other symptoms impacting health and performance (Mountjoy et al, 2014) 



Images from: British Journal of Sports Medicine

This is an issue impacting both female and male athletes in various sports. 

Be proactive, not reactive - early detection & intervention is key. 

As both a physiotherapist and an athlete going through this I have realised the vital role we play in early detection of RED-S. 

Physiotherapists are the first point of call for injured athletes and we are often the gate way to health care. We could prevent the downward spiral into a cascade of recurrent fractures. I have seen too many talented athletes disappear out of sport (quite literally). 

Taboo Topics

A problem is that prior to the athlete breaking down, their performance (although temporary) may not be impacted. In fact, they are probably for a short duration performing better. If they land in your clinic before they fall off the tightrope, are they going to be willing to accept there’s an issue if you address it? 

Furthermore, the subject of periods and eating disorders is somewhat a taboo topic. It’s an uncomfortable subject to approach. Your patient may not be willing to engage in such conversation. 

Could a bone health screening questionnaire be the way forward? 

Physiotherapist, Tom Goom (@RunningPhysio) does exactly this. He uses a bone health questionaire, an excellent way to screen athletes and approach the subject. It makes it easier to approach the awkward questioning of that defensive 15 year old who has not started her periods, which she is embarrassed to talk about. 

See questionnaire here 

Do we need a RED-S flag set of questions for bone health? 

These questions should be asked as part of our assessment and we shouldn’t shy away from these taboo topics.

We routinely use “red flag” and “special questions” to screen for cancer and cauda equina. It’s not unheard of for physio’s being the first to pick up sinister pathology. 

After hearing Bobby Clay’s account of fracturing her foot as she got onto the floor, the issue goes beyond sports performance. It's more about the athletes long term health and well being. 

I would go to the extent of saying that menstrual cycles and energy balance should be a red flag. 

RED-S athletes - what to do? 

This can depend on the resources available to you. 

If you work with SEM consultants, psychologist and dieticians at your fingertips, an MDT approach is essential. 

However, you maybe working in a private clinic or NHS outpatient service where you don't have this luxury. 

Getting the GP onboard is key, however could be challenging. 

The lack of periods isn't usually seen as a concern in general practice. Patients (including me) are often reassured and sent on their way, or simply put on the oral contraceptive pill. 

This is not recommended. The pill masks the menstrual dysfunction but doesn't address the underlying cause. Furthermore, the progesterone only pill can have a negative impact on bone health (Mountjoy, 2015) 

Ideally, some persuasion for the GP to consider: 

-Bone profile - particularly vitamin D and calcium. 

-Hormone profile - Oestradiol, LH, FSH, progesterone, testosterone, prolactin 

*note: need to make sure it's put into context that the patient doesn't have cycles. Hormone ranges will vary across the month. 

-Dexa scan - check bone density 

-Referral to: Sports medicine doctor (there are NHS services), Endocrinologist, dietician and psychologist/eating disorder services if required. 

Primarily, I feel that the role of a physio is establishing that these symptoms are not okay and educating on the potential adverse effects. 

Getting the athlete onboard with longevity rather than short term improvements is essential. 

Being proactive in correcting the energy balance by limiting training volume or withdrawing from play all together should also be considered. 

The RED-S CAT can be a useful tool in helping with the decision making if an athlete should be withdrawn from training (Mountjoy et al, 2015) 

Oh, and of course treat the injury they originally came in for! 

Click here for RED-S CAT and click here for more on medical management.

Male athletes and your gym bunnies - not to be overlooked 

Despite my poll showing encouraging results, I wonder if this is the case across the board of MSK physiotherapists. 

Not all athletes will be treated by physios well versed in sports and exercise medicine. Some will rock up to NHS services and private practices. 

It’s also important to remember, it doesn’t exclusively happen to athletes. The 30 year old busy mum who spends 3 hours in the gym everyday may attend her NHS outpatient department with shin pain. Will she be asked about her periods and her eating habits? and that’s not forgetting about males, where RED-S is even harder to detect. 

So when you get that 19 year old athlete sit on your plinth, be brave and ask the difficult question. 

I wish someone had asked me back then. 

Thank you to everyone who got involved in my poll and to Tom Goom for sharing his screening tool. 

Useful resources

BJSM RED-S Clinical Assessment Tool

Bone Health Questionnaire (with thanks to Tom Goom)  


Clinical tips from Dr. Kathryn Ackerman on how to manage athletes with low energy availability - BJSM Podcast via Soundcloud 

Major Debate about energy deficiency among sportspeople: New RED-S by Dr Margo Mountjoy - BJSM Podcast via Soundcloud  

Optimal health: including female athletes! Part 1 Bones - BJSM blog by Dr Nicky Keay

Relative Energy Deficiency in Sports (RED-S) Practical considerations for endurance athletes by Dr Nicky Keay

The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S) - Dr Margo Mountjoy et al (2014), BJSM.

Triathlons, Endurance Training & Considerations for Female Athletes w/ Dr. Tamsin Lewis MD - Dr Bubbs podcast via Soundcloud  

The Physical Performance Show: Prof Belinda Beck - Bone Health Expert

Male Athletes: the Bare Bones of cyclists by Dr Nicky Keay