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Musculoskeletal clinical topic of the month – RED-S

Background to Relative Energy Deficiency

Musculoskeletal clinicians are becoming increasingly aware about recognising and treating patients with relative energy deficiency syndrome (RED-S). The term was introduced in 2014 by the International Olympic Committee (IOC) Consensus Statement, and was previously called the Female Athlete Triad [1]. Our understanding around the condition has increased significantly and we now know it affects both male and female of all ages.

Although well recognised in the athletic population, there are still large cohorts of patients where this diagnosis is either being missed, or not even considered. In its most simplest form, energy deficiency occurs when energy availability does not meet expenditure, across a sustained period of time. This eventually leads to multi-system disruption and a wide array of metabolic, endocrinological and hormonal manifestations.

Part of the difficultly in recognising RED-S can be explained by following factors;

  • Huge variety of clinical presentation. This may include musculoskeletal injury, body physiological disruption, illness and poor mental health.
  • Lack of time in consultation to consider or calculate energy availability or energy expenditure, formally or informally.
  • Lack of knowledge around RED-S or feeling it is ‘out of scope’ for the practitioner.
  • Absence of appropriate screening tools.
  • Limited access to diagnostic and investigatory tools, e.g. imaging, blood tests
  • Speciality silo working, where inter and intra-collaborative working as an MDT is not possible or feasible.

Inter-speciality collaboration takes time, effort and efficient communication. Development of new and existing pathways between clinicians is a key component to providing good patient care.

Who is at risk of RED-S

Although RED-S can occur in anyone, certain cohorts of people are at higher risk. These high risk groups include;

  • Athletes
  • Women between the ages of 15-40
  • Elderly people
  • Those recovering from injury, illness or after an operation
  • Patients with mental health conditions such as disordered eating, body dysmorphia
  • Patient with medical conditions that affect absorption of food and nutrients e.g. coeliac disease

Varying presentations of RED-S

In order to detect RED-S more effectively, it is vital to keep an open mind and be vigilant for the large variety of potential presentation. Most of RED-S presenting symptoms can be picked up in a good systems review history. Below, we describe some of ways RED-S presents to our clinic.

Musculoskeletal symptoms

Stress injury, fracture
Delayed or poor injury healing
Recurrent injuries
Poor bone quality

Poor mental health

Anxiety and depression
Disordered eating

Gastrointestinal disruption

Altered bowel habit

Growth and development issues

Weight loss or weight gain
Delayed Menarche
Delayed growth

Neurological symptoms

Nerve palsy
Neuromuscular disruption

Hormonal and metabolic imbalance

Menses disruption
Hair loss
Loss of sexual function and libido

RED-S case presentations

reds Musculoskeletal clinical topic of the month - RED-S

Case 1

This 25 year old female runner has been treated for recurrent “groin strains” for 3 months. Her pain continues to escalate so she is unable to weight bear. X-rays organised by her GP are normal. MRI scanning (top left image) revealed a stress fracture of the neck of femur surrounding oedema. She has multiple risk factors for energy deficiency including disordered eating, poor sleep and poor body perception. On systems review screening she also has had secondary amenorrhia for the past 6 months. She made a full medical recovery with the correct psychological therapy and nutritional support.

Case 2

This 18 year old female climber presented with lateral foot pain but no acute injury. She went to A+E and was given crutches and RICE advice but no investigation at the time. This x-ray (top right image) was taken 12 weeks after the injury and shows evidence of poor bony healing. Her energy deficient state reduced her ability to heal and she ended up requiring surgical fixation. With proper consideration to her energy availability from the outset, her chances for bony healing could have been optimised, surgery avoided with a much faster recovery time.

Case 3

This 42 year old male endurance cyclist presented with foot weakness and inability to dorsiflex his foot (bottom right image). Initially thought to be a biomechanical issue with his bike, his presented to clinic with common peroneal palsy and a BMI of 19. He had a good nutritional plan in place but was vastly overtraining with regards to mileage on the bike. This highlights the importance of taking a thorough training history and gaining objective measures of load whenever possible. Often, patients such as this will be able to provide you with detailed description of their training and recovery regimes. He recovered over a period of 3-6 months with MSK rehabilitation for his weakness and a complete restructure of his training regime.

Case 4

This 78 year old widower presented with pain and difficultly moving his right upper arm. He did not sustain a trauma or fall. He sustained a pathological fracture of his humerus (bottom left image). He was found to be osteoporotic and extremely energy deficient due to his social circumstances, as he now lived alone without care since the passing of his wife. It is important to remember that the elderly are particular vulnerable to becoming energy deficient, and that elderly men, like women, have a high prevalence of poor bone health and mineralisation.

Screening for RED-S

Alongside a thorough history, screening questionnaires can be a useful tool to detect energy deficiency and associated symptoms. Due to the sensitive nature of the questions, any clinical screening needs to be delivered compassionately with full consent from the patient.

At London Bridge Sports Medicine, our patients complete an initial screening questionnaire to detect at risk patients. Feel free to download the LBSM screening tool for Energy Availability in Women. If any responses raise concerns, it is always best to seek advice of an appropriately qualified medical professional.

What to do if you suspect relative energy deficiency?

If you suspect or discover RED-S in a patient, it is important they are treated holistically and with a full multidisciplinary team approach. Medical expertise is often required at the outset to ensure the health and wellbeing of the person is not at risk. Communication between practitioners is vital so that the patient’s care plan is aligned and flexible to their needs.

We of course are happy to assist via referral or informal discussion around any client/patient that you suspect may be suffering for RED-S.


IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update. Margo Mountjoy et al., British Journal of Sports Medicine, 2018

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