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Young athletes’ optimal health: Part 3 Consequences of Relative Energy Deficiency in sports

12 Apr, 17 | by BJSM

Part-3 of the blog mini-series on RED-S

By Dr Nicky Keay

In my previous blogs, I  described the adverse effects of Relative Energy Deficiency in sports (RED-S) in both female and male athletes- current health and sport performance and potential long term health problems.

What about young aspiring athletes?

There is concern that early sport specialisation, imbalances in training not covering the full range of the components of fitness, together with reduced sleep, all combine to increase injury risk. Young athletes are particularly vulnerable to developing RED-S during a period of growth and development accompanied by a high training load.

Sufficient energy availability and diet quality, including micronutrients, is especially important in young athletes. To investigate further I undertook a three year longitudinal study involving 87 pre- and post-pubertal girls, spread across control pupils at day school together with students in vocational training in both musical theatre and ballet streams. There was a gradation in hours of physical exercise training per week ranging from controls with least, followed by musical theatre, through to ballet stream with the most.

In all girls dietary, training, and menstrual history were recorded and collected every six months. At the same visit anthropometric measurements were performed by an experienced Paediatric nurse and bloods were taken for Endocrine markers of bone metabolism and leptin. Annual DEXA scans measured body composition, total body bone mineral density (BMD) and BMD at lumbar spine (including volumetric) and BMD at femoral neck.

The key findings included a correlation between hours of training and the age of menarche and subsequent frequency of periods. In turn, any menstrual dysfunction was associated with low age-matched (Z score) BMD at the lumbar spine. There were significant differences between groups for age-matched (Z score) of BMD at lumbar spine, with musical theatre students having the highest and ballet students the lowest. There were no significant differences in dietary intake between the three groups of students, yet the energy expenditure from training would be very different. In other words, if there is balance between energy availability and energy expenditure from training, resulting in concurrent normal menstrual function, then such a level of exercise has a beneficial effect on BMD accrual in young athletes, as demonstrated in musical theatre students. Conversely if there is a mismatch between energy intake and output due to high training volume, this leads to menstrual dysfunction, which in turn adversely impacts BMD accrual, as shown in the ballet students.

I was fortunate to have two sets of identical twins in my study. One girl in each twin pair in the ballet stream at vocational school had a twin at a non-dance school. So in each twin set, there would be identical genetic programming for age of menarche and accumulation of peak bone mass (PBM). However the environmental influence of training had the dominant effect, as shown by a much later age of menarche and decreased final BMD at the lumbar spine in the ballet dancing girl in each identical twin pair.

After stratification for months either side of menarche, the peak rate of change for BMD at the lumbar spine was found to be just before menarche, declining rapidly to no change by 60 months post menarche. These findings suggest that optimal PBM and hence optimal adult BMD would not be attained if menarche is delayed due to environmental factors such as low energy density diet. If young athletes such as these go on to enter professional companies, or become professional athletes then optimal, age-matched BMD may never be attained as continued low energy density diet and menstrual dysfunction associated with RED-S may persist. Associated low levels of vital hormones such as insulin like growth factor 1 (IGF-1) and sex steroids impair bone microarchitecture and mineralisation. Thus increasing risk of injury such as stress fracture and other long term health problems. The crucial importance of attaining peak potential during childhood and puberty was described at a recent conference at the Royal Society of Medicine based on life course studies. For example, delay in puberty results in 20% reduction of bone mass.

It is concerning that RED-S continues to occur in young athletes, with potential current and long term adverse consequences for health. Young people should certainly be encouraged to exercise but with guidance to avoid any potential pitfalls where at all possible. In my next blog I will delve into the Endocrine mechanisms involved in RED-S: the aetiology and the outcomes .


Optimal Health: including female athletes! Part 1 Bones British Journal of Sport Medicine

Optimal health: including male athletes! Part 2 Relative Energy Deficiency in sports

Keay N. The modifiable factors affecting bone mineral accumulation in girls: the paradoxical effect of exercise on bone. Nutrition Bulletin 2000, vol 25, no 3. 219-222.

Keay N The effects of exercise training on bone mineral accumulation in adolescent girls. Journal of Bone and Mineral Research. Vol 15, suppl 1 2000.

Keay N, Frost M, Blake G, Patel R, Fogelman I. Study of the factors influencing the accumulation of bone mineral density in girls. Osteoporosis International. 2000 vol 11, suppl 1. S31.

New S, Samuel A, Lowe S, Keay N. Nutrient intake and bone health in ballet dancers and healthy age matched controls: preliminary findings from a longitudinal study on peak bone mass development in adolescent females, Proceedings of the Nutrition Society, 1998

Keay N, Dancing through adolescence. Editorial, British Journal of Sports Medicine, vol 32 no 3 196-7, September 1998.

Bone health and fractures in children. National Osteoporosis Society

Lifetime influences on musculoskeletal ageing and body composition. Lecture by Professor Diana Kuh, Director of MRC Unit for Lifelong Healthy Ageing, at Royal Society of Medicine, conference on Sports Injuries and sports orthopaedics. 17/1/17

Relative Energy Deficiency in sport (REDs) Lecture by Professor Jorum Sundgot-Borgen, IOC working group on female athlete triad and IOC working group on body composition, health and performance. BAEM Spring Conference 2015.

Health and fitness in young people

Optimal health: including female athletes! Part 1 Bones

26 Mar, 17 | by BJSM

Part-1 of the blog mini-series on RED-S

By Dr Nicky Keay

It is hard to dispute that women are underrepresented in medical research and certainly there are not many studies that include female athletes. Does this matter? After all whatever your gender, the same physiological and metabolic processes occur. However, the Endocrine system is where there are distinct differences in sex steroid production, which in turn have different responses in multiple target cells.

Although studies on changes in exercise performance in response to various dietary interventions and training regimes are often very interesting and well described, I am left feeling slightly uneasy when the subjects are all males. The cause for my concern is that the female hypothalamus-pituitary-ovarian axis is a particularly sensitive system with complex feedback loops and interacting networks.

Menstrual disturbance is not unusual amongst women in sport/dance where low body weight is an advantage. When a ballet dancer performs pointe work, putting full body weight through the big toe is hard enough, without extra load! Some women might consider it a convenience to be spared the hassle of menstruation. At age 24, I was perfectly fine never having had a period (primary amenorrhoea), or so I thought, being no more tired than other hospital medical colleagues working full time, studying for postgraduate medical exams and also involved in exercise training.

While working as a SHO at Northwick Park Hospital, I volunteered to be included in a study at the British Olympic Medical Association. The study was of female lightweight rowers and ballet dancers to look at VO2 max, percentage body fat and bone mineral density (BMD). I had been doing Ballet intensively (and obsessively) from a very young age, together with restricted fat and carbohydrate intake. Sounds a familiar scenario? Although I looked perfectly healthy (and I did not fit into a clinical condition requiring treatment), worked and danced well, my bone density was worryingly low. So if you are a female doing weight-bearing exercise or resistance training which loads the skeleton, these activities promoting osteogenesis will be negated if you are not ovulating and producing adequate oestrogens. The female athlete triad composed of disordered eating, amenorrhoea and low BMD was originally described by Drinkwater in 1984. However, once pathological states causing amenorrhoea have been excluded, in medical terms the female athlete triad did not necessarily constitute a disease state requiring intervention, rather subset of the “normal population”.

How significant is having low BMD compared to the age-matched population during your 20s? Could this even be viewed as a reversible adaptation to training, reflected in site specific differences in BMD according to sport? After all, when female athletes retire with decreased training “stress” and more “relaxed” diet, menses often resume and therefore does BMD also improve? This was the question I sought to answer in my study on 57 premenopausal retired professional dancers. Even with return of menses, if these athletes had experienced previous amenorrhoea of more than 6 month duration, then bone loss was irrecoverable. Current low BMD was also correlated to lowest body weight (independent of amenorrhoea) during dance career and later age of menarche. There did not appear to be any protective effect of being on the oral contraceptive pill. Constructing a model of BMD using multiple regression 33.6% of total variation in z (age matched) score for BMD at lumbar spine was accounted for by duration of amenorrhea, age at menarche and lowest body weight during dance career. So “athletic” hypothalamic amenorrhea rather than being a reversible, adaptive response has long term, irreversible effects on BMD.

Apart from bone metabolism, what other systems are impacted by mismatch of energy intake and expenditure in overtly healthy athletes? Are the endocrine and metabolic systems in male athletes also affected by subtle imbalances in training energy expenditure and dietary intake? What about young athletes? In my next blog I will explore the rationale behind the original female athlete triad now being described as part of Relative Energy Deficiency in sports (REDs). The implications for current health and sports performance, as well as long term health in both adult men and women and young athletes.


Keay N, Fogelman I, Blake G. Bone mineral density in professional female dancers. British Journal of Sports Medicine, vol 31 no2, 143-7, June 1997.

Keay N. Bone mineral density in professional female dancers. IOC World Congress on Sports Sciences. October 1997.

Keay N, Bone Mineral Density in Professional Female Dancers, Journal of Endocrinology, November 1996, volume 151, supplement p5.

Keay N, Bone Mineral Density in Female Dancers, abstract Clinical Science, Volume 91, no1, July 1996, 20p.

Keay N, Dancers, Periods and Osteoporosis, Dancing Times, September 1995, 1187-1189

Keay N, A study of Dancers, Periods and Osteoporosis, Dance Gazette, Issue 3, 1996, 47

Fit to Dance? Report of National inquiry into dancers’ health

Fit but fragile. National Osteoporosis Society

Your body your risk. Dance UK

From population based norms to personalised medicine: Health, Fitness, Sports Performance

IOC Consensus Statement concludes little evidence of negative outcomes associated with strenuous exercise in pregnancy

13 Oct, 16 | by BJSM

By Professor Gregory Davies, MD

But the overall quality of the available evidence on the impact of intense exercise is not strong, with few studies carried out in elite athletes, the statement warns.


Alysia Montano, 34 weeks pregnant (photo: Getty Images)

The statement is the second in a series of five issued by the IOC on exercise and pregnancy, focusing on elite athletes. It draws on a systematic review of the available published evidence, presented by an international panel of experts at a three day meeting in Lausanne, Switzerland, last September.

Traditionally, there has been concern that strenuous exercise during pregnancy may divert critical oxygen flow to skeletal muscles rather than to the uterus and developing fetus. The systematic review evaluated an extensive list of pregnancy outcomes and reached the following conclusions:

  • Elite athletes planning pregnancy may consider reducing high impact training routines in the week after ovulation and refraining from repetitive heavy lifting regimens during the first trimester as some evidence suggests increased miscarriage risk.
  • There is little risk of abnormal fetal heart rate response when elite athletes exercise at <90% of their maximal heart rates in the second and third trimesters.
  • Baby birthweights of exercising women are less likely to be excessively large (>4000g) and not at increased risk of being excessively small (<2500g).
  • Exercise does not increase the risk of preterm birth.
  • Exercise during pregnancy does not increase the risk of induction of labour, epidural anesthesia, episiotomy or perineal tears, forceps or vacuum deliveries.
  • There is some encouraging evidence that the first stage of labour (before full dilatation) is shorter in exercising women.
  • There is also some encouraging evidence that exercise throughout pregnancy may reduce the need for caesarean section.

The IOC Committee identified the need for more research around these issues, specifically in elite athletes.

You can find the first of the five IOC statements on Exercise in Pregnancy here:

All 5 IOC statements will be Open Access.




Gregory Davies, MD, Professor and Chair, Maternal-Fetal Medicine
Queen’s University, ON


Cutting sporting Australians to their knees: time for more investment in sports injury prevention

29 Jun, 16 | by BJSM

By David Hunter, Florance and Cope Professor of Rheumatology

Australia flagAustralians’ passion for their favourite sporting pursuits is almost unmatched by any other country throughout the world. We pride ourselves on our sporting heritage and the records that our minnow sized population has been able to achieve in an ever expanding sporting world. Not detracting from the importance of physical activity, our love for sport is counterposed by the risks inherent in not practising sport safely.

How common is this problem?

Every year approximately 20,000 Australians tear the main ligament in their knee and about half of those require reconstruction. The major burden of these injuries is amongst our young adults (15 to 25-year-olds) and this appears to be rising at about 5 to 6% each year. These injuries appear to be more common in females potentially as a consequence of anatomical and physiological differences. They are so common they now lead to five times more hospital admissions than road injuries.

What are the consequences?

Separate from the pain and diminished sports participation, knee injuries can also lead to reconstructive surgery, osteoarthritis and potentially, joint replacement. Thirty to forty per cent of participants experiencing a major sports-related injury will discontinue playing sport and/or will significantly reduce their physical activity levels. Approximately 60% of young persons who sustain a knee injury will develop osteoarthritis within 10 to 15 years.

This can be prevented

Robust evidence supports that over half of these injuries could be prevented if young people received appropriate balance and agility training. This training teaches them how to land properly on their knee and move so that the potential for injury is not sustained. A preventive training program should include exercises that are done 2-3 times a week over the course of the entire season, take no more than 15 minutes to complete, and can be incorporated by coaches into regular training sessions. Many forward thinking countries around the world have implemented such training programs with great success. An Australian sports injury prevention program targeting all 12 to 17-year-olds and high risk 17 to 25 – year -olds would cost $1 million per year and cut future public health costs by $120 million over four years.

An effective response to sports injury prevention is now needed in order to make sport safe for all participants and reduce the later community burden of osteoarthritis. Sport has many salutary benefits and we strongly encourage increased “safe” participation in sport. The major sporting codes are all on board and we need funding to ensure the Australian sports commission can train coaches and trainers properly in implementing these sports injury prevention programs. Discussions have been had with the respective federal sports/health ministers of successive Labor and conservative governments without success. Will Smith’s recent movie appropriately highlighted concerns related to concussion and the threat of litigation for the NFL. Young sporting Australians deserve the right to practice sport safely-our mutual love for sport supports that wish.


Running injuries and how to prevent them: BJSM article (by Irene S. Davis et al.) featured in the NY-Times

13 Feb, 16 | by BJSM


Running is a low barrier activity with ongoing popular appeal. Running injury prevention is therefore an (unfortunately) important related area of study, with practical – day to day- training implications for many individuals. Therefore it is no surprise that Irene S. Davis et al.’s BJSM publication Greater vertical impact loading in female runners with medically diagnosed injuries: a prospective investigation” sparked public interest. The authors’ work was recently featured, by author Gretchen Reynolds, in The New York Times:

Athlete running at sunset on beach

“…Running injuries are extremely common, with some statistics estimating that as many as 90 percent of runners miss training time every year due to injury.

But the underlying cause of many of these injuries remains in question. Past studies and popular opinion have blamed increased mileage, excess body weight, over-striding, modern running shoes, going barefoot, weak hips, diet, and rough pavement or trails. But most often, studies have found that the best indicator of a future injury is a past one, which, frankly, is not a helpful conclusion for runners hoping not to get hurt.

So for the new study, which was published in December in the British Journal of Sports Medicine, researchers at Harvard Medical School and other universities decided to look at running injuries, one of the more obvious but surprisingly understudied aspects of running, and to focus their attention, in part, on those rare long-time runners who have never been hurt.

Specifically, they set out to look at pounding, or impact loading, which means the amount of force that we create when we strike the ground. Pounding is, of course, inevitable during a run. But runners with similar body types and running styles can experience wildly different amounts of impact loading, and it hasn’t been clear to what extent these differences directly contribute to injuries…

During that time, more than 100 of the runners reported sustaining an injury that was serious enough to require medical attention. Another 40 or so reported minor injuries, while the rest remained uninjured.

More remarkably, in the minds of the researchers, 21 of the runners not only did not become injured during the two-year study but also had not had a prior injury. They remained long-term running-injury virgins, the athletic equivalent of unicorns…

…The never-injured runners, as a group, landed far more lightly than those who had been seriously hurt, the scientists found, even when the researchers controlled for running mileage, body weight and other variables.

That finding refutes the widely held belief that a runner cannot land lightly on her heels.

“One of the runners we studied, a woman who has run multiple marathons and never been hurt, had some of the lowest rates of loading that we’ve ever seen,” said Irene Davis, a Harvard professor who led the study. She pounded far less than many runners who land near the front of their feet, Dr. Davis said. “When you watched her run, it was like seeing an insect running across water. It was beautiful…”

Read the full NY-Times article HERE

Potential association between the current recommendations for ski binding adjustment and the high prevalence of knee injuries in female skiers?

16 Dec, 15 | by BJSM

By Gerhard Ruedl and Martin Burtscher

Department of Sport Science, University of Innsbruck, Austria

Take home message: Are women’s bindings set 15% too high – and increasing risk of knee injury?

Are you one of the over 200 million recreational skiers practicing this fascinating sport on snow covered ski slopes during the winter months? You might know that the injury risk among recreational skiers halved during the past 20 years.

It’s true that release bindings largely prevented tibia and ankle fractures, at least in adult skiers, knee injuries still represent the major injury type — about 1/3 of all ski injuries [1,2]. Female skiers have twice the knee injury risk and an about  three times the ACL rupture risk compared to males. Importanty, knee injured females still report an about 20 percent points higher failure of binding to release when compared to males [1,3].

man and women skiing

According to the official ski standards (ISO 11088 standard) [4] for binding values, skiers have to differentiate between skiing speed (slow to moderate vs. fast), terrain (gentle to moderate vs. steep) and skiing style (cautious vs. aggressive) to classify themselves into one out of three skiing types without considering any sex-specific differences.[4]

Assume a male and a female skier of equal age, height, and weight and of equal ski shoe sole length, and both classifying themselves as type-3 skier (fast speed, steep terrain, aggressive style). They both would get the same binding setting values without considering any sex factor. However, there are at least two potential sources of error which could represent an explanation for the higher number of failure of binding release among female skiers.

First, a recent study by Brunner et al.[5] found that males, more skilled skiers, and risky skiers perceived their actual speed as fast, moderate and slow when skiing up to 10 km/h  faster compared to females, less skilled and cautious skiers. Therefore, one might suspect that compared to a ‘slow to moderate’ or ‘fast’ male skier the binding setting for a ‘slow to moderate’ or ‘fast’ skiing female is too high resulting in a higher number of failure of binding release as sexes seem not to differ neither with regard to the date of last binding adjustment,[6] nor with regard to not correctly adjusted bindings,[7] nor with regard to self-reported types of falling in the case of an ACL injury.[1,6]

Second, a study by Werner and Willis[8] found that muscle strength is highly correlated with the ability to release the ski binding in a self-release test. Due to the equal weight of the male and female skier in the aforementioned example it has to be considered that the weight-to-strength ratio is negatively influenced by the higher fat mass in females[9] maybe partly explaining the sex difference in the lack of binding release due to less muscular strength among females.

Although the ISO 11088 standard[4] does not consider female sex, it is important to know, especially for female recreational skiers, that according to ISO 11088 standard point B.4 the binding setting may be lowered by 15% upon request of the skier in the following cases:

  1. a) Skiers who have satisfactory experience with lower settings regarding the manufacturer’s recommendations may request settings based on their experience;
  2. b) Skiers who have skiing experience without inadvertent releases may request a setting up to 15% lower than recommended by the manufacturer, approximately achieved by moving one line up in the Table B 1;
  3. c) Skiers having certain characteristics such as neutral skiing technique, defensive attitude, high degree of control, may request a setting up to 15% lower than recommended by the manufacturer, approximately achieved by moving one line up in the Table B 1.

Regarding point B.4 c), the terms “neutral skiing technique” and “defensive attitude” are very subjective and therefore may strongly vary between individuals and sex. When assuming that the terms “neutral skiing technique” and “defensive attitude” are – according to the ISO 11088 determination of skier type[4] – largely synonymous with a cautious (or smooth) skiing style in contrast to an aggressive (or risky) skiing style, our findings of an earlier study[10] that self-reported risk taking behaviour on ski slopes is independently associated with male sex (OR: 1.99) and a higher mean skiing speed (53 vs 45 km/h) are gaining in importance. In other words that means that a cautious behaviour on ski slopes is associated with female sex and a lower mean skiing speed.

In a second study[11] we demonstrated that mean skiing speed (measured with a radar speed gun) of more than 2100 skiers and snowboarders is significantly lower among female compared to male skiers and snowboarders (40 vs. 47 km/h).  In addition, we interviewed a subgroup of about 550 skiers and snowboarders and divided these persons into a faster (59 km/h mean speed) and slower skiing group (36 km/h mean speed).[11] The slower group was independently associated with female sex, higher age, lower skill level, snowboarding (vs. skiing) and cautious behaviour.[11] In a third study we evaluated whether self-reported risk taking behaviour on ski slopes was associated with the personality trait sensation seeking.[12] Again, self-reported cautious behaviour was associated with female sex, higher age, lower skill level, and less mean score of Sensation Seeking.[12]

Taken together, our results clearly highlight that female sex is associated with a more cautious behaviour and a less mean skiing speed on ski slopes indicating that the terms “neutral skiing technique” and “defensive attitude” may especially apply to female skiers.

Therefore, keeping in mind the clearly higher failure of binding to release among female skiers suffering from knee injuries, a 15% lower ski binding setting would likely be appropriate for the majority of female recreational skiers.


  1. Ruedl G, Helle K, Tecklenburg K, et al. Factors associated with self-reported failure of binding release among ACL injured male and female recreational skiers: A catalyst to change ISO binding standards? Br J Sports Medicine (in press)
  2. Burtscher M, Ruedl G. Favourable Changes of the Risk-Benefit Ratio in Alpine Skiing. Int. J. Environ. Res. Public Health 2015; 12 (86): 6092-6097. doi: 10.3390/ijerph12060000x
  3. Greenwald RM, Toelcke T. Gender differences in alpine skiing injuries: a profile of the knee-injured skier. In: Johnson RJ, Mote CD, Ekeland E, eds. Skiing Trauma and Safety, 11th J. ASTM Intl. 1997, Balitmore:111-21.
  4. International Organization for Standardization. Assembly, adjustment and inspection of an alpine ski/binding/boot (S-B-B) system ISO 11088, Geneva, Switzerland, 2013
  5. Brunner F, Ruedl G, Kopp M, et al. Factors associated with the perception of speeds among recreational skiers. PloS One. 2015 Jun 29; 10(6):e0132002. doi: 10.1371/journal.pone.0132002. eCollection 2015.
  6. Ruedl G, Webhofer M, Linortner I, et al. ACL injury mechanisms and related factors in male and female carving skiers: a retrospective study. Int J Sports Med. 2011;32: 801-6.
  7.  Ruedl G, Pocecco E, Sommersacher R, et al. Differences between actual and recommended binding z-values. In: Müller E, Lindinger S, Stöggl T, Pfusterschmied S, eds. 5th ICSS-Congress, 14.-19. Dec. 2010, St. Christoph, Austria. Book of abstracts: 141.
  8. Werner S, Willis K. Self-release of ski-binding. Int J Sports Med. 2002;23:530-35.
  9. Sinning WE. Body composition and athletic performance. In: Clarke DH, Eckert HM, eds. Limits of human performance. The academy papers. Champaign, 1985: 45-56.
  10. Ruedl G, Pocecco E, Sommersacher R, et al. Factors associated with self reported risk taking behaviour on ski slopes. British Journal of Sports Medicine 2010, 44 (3): 204-206. 11.   Ruedl G, Sommersacher R, Woldrich T, et al. [Mean speed of winter sport participants depending on various factors]. Sportverletz Sportschaden. 2010;24:150-53.
  11. Ruedl G, Abart M, Ledochowski L, et al. Self-reported risk taking and risk compensation in skiers and snowboarders are associated with sensation seeking. Accid Anal Prev. 2012;48:292-96.


Gerhard Ruedl  is a Senior Assistant Professor, Department of Sport Science, University of Innsbruck, Austria. His research interests include: risk factors (e.g. risk-taking behavior) leading to injuries and use of protective equipment (e.g. helmets) among alpine skiers and development of motor performance and weight status among school children

Martin Burtscher is a Full Professor at the Department of Sport Science, University of Innsbruck, Austria. His research interests include: exercise physiology with emphasis on mountain sports activities; physiological and pathophysiological effects of altitude and hypoxia; epidemiology and prevention of accidents and emergencies in skiing and mountaineering; life-style interventions in health and disease mainly focusing on exercise, environmental and nutritional aspects.

Highlights from the Female Athlete, BASEM Spring Conference 2015

14 May, 15 | by BJSM

Undergraduate perspective on Sports & Exercise Medicine – a BJSM blog series

By Sean Carmody (@seancarmody1)

“Too often in sport, doctors are men and they don’t understand”

That was the opinion of Paula Radcliffe last January in reference to the effects of menstruation on athletic performance. Clearly a challenge had been laid down to Sport and Exercise Medicine (SEM) as a discipline to deliver better care, that pays attention to sex and gender, to female athletes. With that in mind, the recent BASEM Spring Conference on the theme of The Female Athlete was particularly timely. Key themes and sub-topics from the conference are highlighted below.

tired-athletesThe Relative-Energy Deficiency in Sport – Professor Sundgot-Borgen

  • The Female Athlete Triad doesn’t account for effects of reduced energy availability among male athletes.
  • Relative Energy Deficiency in Sport (RED-S) recognises the importance of energy availability for optimal health and performance but presents a more comprehensive approach than the triad’s limited triangular view.
  • Risk factors for developing relative energy deficiency include; restrictive eating, injuries and illness, specialisation, decline in performance level, casual misinformed comments by coaches on physical appearance.
  • Risk of developing RED-S can be minimised by: educational programs for athletes and coaches, re-emphasising weight as a performance parameter, avoid critical comments about body shape, increase athlete awareness of effect of optimal energy intake on performance, open communication to encourage discussion around eating problems.
  • Further research is required to examine energy deficiency among male athletes and Paralympians.

See also: IOC Consensus Statement on Relative Energy Deficiency in Sport.

Bone Health in Athletes – Dr Julia Newton

  • Bone is a biological machine and adapts to load and function.
  • 7% of maternal bone is lost to the fetus during pregnancy.
  • The adolescent period is key- bone mass increases by 25-40% in puberty.
  • Factors which can affect the attainment of peak bone mass include; exercise, endogenous hormone profile, energy deficiency associated amenorrhoea, timing of puberty, smoking, teenage pregnancy, anorexia, exogenous hormones whilst still accruing bone.
  • Factors which lead to bone loss include; low oestrogen or testosterone, increasing age, corticosteroids, decreased weight or muscle mass, smoking and alcohol.
  • There is a 2-4 fold increased risk of stress fractures in amenorrhoeic athletes.
  • Vitamin D deficiency is an independent risk factor for stress fractures.
  • Treatment options for low bone mineral density include; calcium and vitamin D supplements, impact exercise, addressing contributory lifestyle factors.

Ballet: The Vitamin D and Bone Mineral Density Story – Professor Matthew Wyon

  • Ballet dancers undertake rigorous training; 38 hours per week at least.
  • They are considered prime candidates for developing the female athlete triad.
  • The research examining the prevalence of low BMD among ballet dancers is limited, however initial studies suggest 40% have low bone mineral density.
  • The average ballet career ends at 24, so it is important to keep long term health of the athlete in mind.
  • Ballet dancers are commonly deficient in Vitamin D. They train and perform indoors, have restricted diet practices and do not commonly supplement.
  • Diet has poor effect in restoring Vitamin D levels apart from a few exceptions (eg oily fish).
  • There is a potential link between vitamin D deficiency and increased incidence of injury.

To Bleed or not to Bleed – Mr Michael Dooley

  • A sports gynaecologist concerns themselves with the effects of the menstrual cycle on performance, amenorrhoea and relative energy deficiency in sport, contraception and infertility.
  • The percentage of women participating in the Olympics has increased from 11.5% in 1960 to 44.5% in 2012, meaning that understanding the effects of the menstrual cycle on performance is a relatively new issue.
  • Women have won gold medals, and broken world records at all stages of the menstrual cycle.
  • Swimmers have demonstrated a premenstrual worsening of performance with improvement during the menstrual cycle.
  • ACL rupture is 4-8 times higher in women, and appears to occur more often in the ovulatory phase of the cycle.
  • Amenorrhoea leads to an increased risk of stress fractures.
  • Athlete quote; “Having a carefully prepared plan to manipulate my cycle to avoid competition has helped my mental preparation, performance and enjoyment”.

Gymnastics – Dr Chris Tomlinson

  • Gymnastics is a weight-dependent sport demanding intensive training regimes.
  • Gymnastics involves young, skeletally immature athletes who are at risk of overuse and traumatic injuries.
  • Common injuries in gymnastics include shoulder impingement, osteochondral defects in the elbow, lumbar spine stress fractures, and ACL rupture.
  • Physicians take a twice-yearly menstrual history from gymnasts, and a once yearly SCAT score as a baseline, DEXA scan twice annually to examine body composition.
  • Daily weighing in gyms is common and can lead to public shaming. 20% of gymnasts show evidence of an eating disorder.
  • Weighing should be carried out in a private setting (eg in a clinical consultation room away from coaches and other athletes).
  • Retiring gymnasts should be equipped with the skills to cope, and the appropriate social support structures should be put in place.

The Female Elite Athlete: A practical approach to the medical issues – Dr Anita Biswas

  • Common problems among female athletes include stress fractures, ACL rupture, low energy availability and mental health issues.
  • All support staff should be aware of issues surrounding training load and menstrual cycle.
  • The EIS Vitamin D strategy includes: screening for deficiency and supplementing accordingly.
  • Faddy diets such as carbohydrate restriction are often practiced by female athletes.
  • The EIS carry out annual medical screening including questions around menstruation and eating habits.
  • Information sharing between sports will improve athlete care.

Sean Carmody is a final year medical student at the Hull York Medical School. He tweets regularly on subjects relating to sports medicine and performance @seancarmody1.

Dr. Liam West BSc (Hons) MBBCh PGCert SEM (@Liam_West) is a graduate of Cardiff Medical School and now works as a junior doctor at the John Radcliffe Hospital, Oxford. In addition to his role as an associate editor for BJSM he also coordinates the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series.

If you would like to contribute to the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series please email LIAMWESTSEM@HOTMAIL.CO.UK for further information.

The delegate view of 6th London School of SEM Conference– What lessons were learnt?

1 Apr, 15 | by BJSM

Undergraduate perspective on Sports & Exercise Medicine – a BJSM blog series

By Jonathan Shurlock (@J_Shurlock)

Reading the recent BJSM blog on the 6th annual London Deanery Sports and Exercise Medicine (SEM) Conference written by the event organisers, inspired me to give the delegate view of the important lessons learnt by those in attendance, and add in some links to related BJSM material.

Tales from the ballet: common problems encountered with performing athletes and dancers – Dr Roger Wolman

  • Dancers are often lumped as a single group, however movement patterns vary significantly between forms of dance
  • Injury risk factors – Poor nutrition. The movements desired by dance coaches require demanding biomechanics. Aesthetic requirements of low body weight and knee hyper-flexion
  • Demands – Highly competitive environment means that dancers do not reveal injuries for fear of being held back. Tours are often long, with inadequate rest
  • Support – Limited financial resources, therefore there is inadequate medical and scientific support. The first NHS specialist dance injury clinics were set up in 2012. There is often an on-going battle between dance teachers and sports therapists and a balance must be met to ensure protection of athlete’s health and performance capability

Mental health in sport – Dr Justin Yeoh

  • The true incidence of depression in sport is uncertain, due to limited research. There is a higher incidence in aesthetic sports (e.g. dance, gymnastics)
  • If exercise is effective in the treatment of depression, so why do athletes get depressed? à Athletes are perceived to be superhuman. However, they have the same risk factors as the general population, and a long list of additional risk factors (e.g. recurrent injuries)
  • Athletes will not necessarily discuss their symptoms, so awareness is needed of the common signs, including:
  • Consistent poor or inconsistent performance (reduced work rate, poor motivation)
  • Increased apathy or irritability
  • Medical issues (recurrent illness or injury, excessive fatigue)
  • Stigma and lack of education are still prevalent issues. Good examples of schemes to improve awareness and reduce stigma from PFA, Rugby Union, and Rugby League
  • See recent BJSM blog

Rehabilitation considerations in the older athlete – Mr Bruce Paton

  • Increasing age impacts on oxygen transfer (reduced V02 max), maximum heart rate and muscle physiology (reduced number and size of muscle fibres, and change in muscle fibre types)
  • The V02 max requirement to retain independence is thought to be above 15-18 litres/min/kg
  • A substantial drop in performance is seen with most sports at around 70 years of age, event with chronic exercise
  • Eccentric or isometric loading is very useful for older athletes
  • See previous BJSM blog

The challenges of managing an athlete with a disability – Dr Richard Weiler

  • The general level of evidence for the implementation and effectiveness of prevention strategies and treatments in disability sport is poor
  • “You must unlearn what you have learned” à observe and understand the different abilities that these athletes possess
  • Humour can be critical when working with individuals in disability sport

Keynote; How to increase exercise in sedentary people – Dr William Bird

  • Low cardiorespiratory fitness has a much greater impact on all cause mortality than obesity. (See evidence here)
  • A huge number of deaths from disease such as breast and bowel cancer are attributable to physical inactivity (See evidence here)
  • You cannot isolate physical activity and throw it on top of a busy, stressful life. To promote physical activity, we need to identify patient values and end goals, to provide a gateway to a better life
  • Promotion of physical activity requires changes to infrastructure and strong partnerships and leadership from the health sector
  • See open access article and BJSM podcast

To delivery and beyond: Exercise in pregnancy – Dr Eleanor Tillet

  • Physical activity guidelines are modified during pregnancy (See here)
  • Exercise in pregnancy should be encouraged, as long as you ensure your patient is aware of the following:

–   Contraindications to physical activity during pregnancy

–   Injury risk with increased ROM

–   Avoidance of exercise where there is risk of abdominal trauma

–   The aim during pregnancy is not to gain fitness, but to maintain

Paediatric sports medicine: Top tips for managing the child and adolescent athlete – Dr GB Ajayi

  • Children are not little adults! Their injury risks are not the same as the adult population
  • Increasing height = modified centre of mass = reduced muscular control = increased injury risk (Testosterone mitigates against this)
  • Ossification centres are areas of weakness therefore children can get injuries not often seen in adults (e.g. supracondylar fractures)
  • You need to be aware of the increased risk of acute avulsion injuries and chronic overuse osteochondroses
  • See these systematic reviews (1 & 2) for a good summary of injury considerations in children

How the medical team prepares for an international tournament – Dr Ian Beasley

  • The multidisciplinary team (MDT) is central in tournament preparation. The team must agree realistic aims and plan logistics
  • An emergency action plan is needed at every stage
  • Where is your defibrillator? This should always be immediately accessible, not ‘under the bus’
  • When traveling for competition endemic problems need to be assessed, such as local communicable disease, temperature and humidity
  • During international competition, the host country hosts a meeting of all team medical officers to discuss specifics. This is vital to ensure effective medical care throughout the competition


Jonathan ShurlockBSc (Hons), is a fourth year medical student. He sits on the european College of Sport & Exercise Physicians (ECOSEP) student committee, in addition to the London Sports and Exercise Medicine Committee. He has a passion for clean sport, and as such works as a research assistant at The Centre for Sport and Exercise Science and Medicine (SESAME) in Eastbourne, working on various WADA funded anti-doping projects. His twitter handle is @J_Shurlock.

Dr. Liam West BSc (Hons) MBBCh PGCert SEM (@Liam_West) is a graduate of Cardiff Medical School and now works as a junior doctor at the John Radcliffe Hospital, Oxford. In addition to his role as an associate editor for BJSM he also coordinates the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series.

If you would like to contribute to the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series please email LIAMWESTSEM@HOTMAIL.CO.UK for further information.

‘The fatigued athlete’ and RED-S: Lessons from the field and the BASEM spring conference

16 Apr, 14 | by Karim Khan

Sport and Exercise Medicine: The UK trainee perspective, a monthly blog series

athlete fatigue

By Dr Khine Swe Win

I recently attended the British Association of Sport and Exercise Medicine (BASEM) spring conference, “The fatigued athlete” in Manchester. It provided the latest evidence in diagnosis, prevention and management of underperformance syndromes.

Unsurprisingly, the new IOC consensus statement on Relative Energy Deficiency in Sport (RED-S) was a discussion topic of interest at the conference. The RED-S replaces the previous term “female athletes triad” (a medical condition often observed in physically active girls and women, that involves three components: (1) low energy availability with or without disordered eating, (2) menstrual dysfunction and (3) low bone mineral density, (Mary Jane De Souza et al 2013)).

The new term recognizes the complexity of the condition’s pathophysiology and multisystem involvement, affecting both men and women. The background theory of RED-S is the imbalance in the energy availability and the energy expenditure, or misbalance between training load and recovery. Low energy availability can have serious implications for many body systems such as nutrient deficiencies, low immunity, risk of infections and illnesses, and chronic fatigue, resulting in short-term and long-term compromise of optimal health and performance.

Multiple monitoring tools have been used to detect early signs of fatigue and health decline in athletes. A good monitoring tool should be reliable, reproducible, standardized, sport-specific and provide immediate feedback. Of the many monitoring models, here are some examples that I have come across:

  • Daily monitoring of rated perception of exertion (RPE), sleep hygiene, muscle soreness, fatigue level, readiness to train, attractiveness of training day, general health, mental wellbeing (POMS).
  • Physical tests and examination such as range of movement, adductor squeeze test, FABER test, Functional movement assessment (SFMA), counter movement jump (CMJ).
  • GPS data on duration, covered distance, speed, acceleration, total work, metabolic power.
  • Physiological markers such as heart rate, heart rate recovery, heart rate variability.
  • Monitoring by blood tests and biochemical markers.

The key is to effectively analyze data and utilize it to boost performance. Multiple factors enhance team performance. The sum of many little improvements or marginal gains can provide a big leap in performance.

Further points to highlight from the conference discussion include:

  • Load can influence performance and hence, appropriate load management is crucial. Athletes should be exposed to different stimuli on a day-to-day basic and should avoid monotony of training.
  • Establishment of recovery strategies within the team is important.
  • It is essential that athletes have a balanced nutritious intake with a mixture of macro and micronutrients.
  • Nutritional interventions can be considered for low immune athletes, such as Vitamin D
level, high carbohydrate, whey protein, open window theory (post exercise recovery shakes),
probiotics (illness prone athletes)
and Colostrum (influencing the gut barrier).
  • Sleep efficiency is slowly gaining its popularity in maximizing performance. The issue of sleep and its impact on performance was discussed recently by Dr Andy Franklyn-Miller in his research review blog (HERE)
  • Athletes’ personal, environmental and emotional issues should be addressed efficiently.
  • Dr John Roger discussed that the athletes should be “Happy, Healthy (heart rates normal), Hungry (appetite excellent)
and Horny (libido in good working order) (4Hs)
  • There are also other multiple factors that can influence performance, such as time zone transition, jetlag and altitude exposure.

I conclude by sharing Tom Lancashire’s thoughts, from an athlete’s perspective, that as core staff we should “know the athletes, understand the sport, and communicate and co-ordinate effectively within the team.”

Read more in BJSM:


Dr Khine Swe Win is a final year sport and exercise medicine registrar, undertaking her training in West Midlands deanery. 

Dr James Thing co-ordinates “Sport and Exercise Medicine: The UK trainee perspective” monthly blog series.

‘Care of the Female Athlete’ special theme issue: AMSSM call for manuscripts

25 Jul, 13 | by Karim Khan

The American Medical Society for Sports Medicine (AMSSM) is soliciting submissions for publication in the February 2014 issue of the BJSM. This AMSSM themed issue will focus on the broad topic of “Care of the Female Athlete”. (See the cover of the 2013 AMSSM special issue of BJSM at right). 


Manuscript submissions can be in any area of sports medicine as it pertains to women in sport. Submission ideas can include but are not limited to those manuscripts that are cutting edge, highlight current areas of significant clinical interest or debate, focus on a novel treatment or training regimen.

Deadline for original manuscripts  is  September 15, 2013

They must be submitted to the BJSM Editorial office by this date to be considered. Instructions to authors can be found HERE . Submissions should be sent to

In your cover letter, reference that the paper is being submitted for the AMSSMease also send an email with the title of the paper you’re submitting to both Dr. Joy ( and Dr. Logan (, and copy BJSM Editor Karim Khan, MD, PhD (

Submission of a manuscript for the themed issue does not guarantee acceptance. All manuscripts will be peer-reviewed.

The AMSSM (@TheAMSSM), one of BJSM’s 13 member societies, is excited to have this opportunity to highlight “Care of the Female Athlete” in this BJSM issue. We are confident that we can have exceptional representation from our AMSSM membership and from other contributors.

Yours in sport and exercise medicine,

Elizabeth Joy, MD, MPH

Kelsey Logan, MD

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