REDs: the silent threat to female athletes
As a chiropractor working with active women weekly, I see the physical consequences of under-fuelling more than most people realise. Stress fractures that won’t heal. Recurring injuries that won’t resolve. Persistent fatigue that rest doesn’t fix. These aren’t just training problems. They’re often signs of something much bigger = Relative Energy Deficiency in Sport (REDs). What Is REDs? RED-S (Relative Energy Deficiency in Sport) occurs when an athlete doesn’t consume enough energy to meet the combined demands of exercise and normal body function. Over time, this low energy availability can affect health, recovery and athletic performance. This leaves your body without enough fuel to support both your performance and normal physiological function, so it starts shutting things down. REDs don’t only affect elite athletes. It affects recreational runners, gym-goers, dancers, and active women who are simply trying to be healthy but have inadvertently created a chronic energy deficit. Why does REDs happen? Most athletes experiencing REDs aren’t intentionally restricting food. They’re: This is what makes REDs so insidious. Energy availability is the amount of energy your body has left after accounting for exercise. Historically, around 45 kcal per kilogram of fat-free mass per day has been used as a reference for adequate energy availability, while levels around or below 30 kcal/kg FFM/day have been associated with physiological disruption in research. However, the 2023 IOC consensus emphasises that there is no single cut-off that determines whether an individual will develop RED-S — the amount of energy required varies between people. In simple terms, energy availability is the amount of energy your body has left after exercise. For example, if someone has 60 kg of fat-free mass, optimal energy availability is around 45 calories per kilogram, which equals about 2,700 calories left over for the body each day. If that person burns 800 calories through exercise, they would need to eat roughly 3,500 calories that day to maintain that level. Once energy availability drops toward 30 calories per kilogram of fat-free mass — around 1,800 calories left over in this example — the body may start struggling to adequately support things like hormones, bone health, recovery, immunity and normal metabolic function. How do you know if you have REDs? The 2023 IOC consensus statement significantly expanded our understanding of REDs – moving far beyond the original “Female Athlete Triad” to recognise a much broader spectrum of consequences. Signs to watch for: Physical: Performance: Psychological: The menstrual cycle is particularly important. Hormonal disruption is one of the earliest and most reliable indicators of REDs – and the bone health consequences of prolonged hormonal suppression can be irreversible, particularly in younger athletes. What can help with REDs? REDs requires a multidisciplinary approach: REDs is not a niche problem for elite athletes. It’s a real, clinically significant condition that I encounter regularly in active people of all levels. Please seek assessment from a sports medicine physician or healthcare practitioner familiar with REDs. Early intervention dramatically improves outcomes.
Understanding Achilles Tendinopathy: How to Recover
Achilles tendinopathy is a common issue among active people and notoriously slow to heal. Whether you’re a runner, on your feet all day, or pushing through workouts, pain and stiffness at the back of your ankle can be frustrating. But with the right approach, recovery is possible. What Is the Achilles Tendon, a Tendinopathy — and Why Does It Matter? The Achilles is a unique tendon. It’s built to store and release energy during walking, running, and jumping. Because it constantly manages high loads, its tissue turns over slowly. This makes it prone to breakdown under stress and slower to recover than muscle tissue. Achilles tendinopathy isn’t just inflammation—it’s a degenerative process. The tendon’s collagen fibers lose their healthy alignment and become disorganized. The tissue often becomes waterlogged, stiff, and less responsive to stress. This change occurs due to chronic overload, poor biomechanics, or underlying health factors. The Role of Overuse and Load Tendinopathy usually builds over time. Repeated strain without proper recovery leads to small microtraumas that the tendon can’t fully repair. On the other hand, tendon rupture is often the result of a sudden, forceful load—typically on a tendon that’s already been weakened. Load Stimulates Repair—But It Has to Be the Right Kind Tendons respond positively to mechanical loading. Research shows that all contraction types—concentric, eccentric, and isometric—can stimulate tendon adaptation, provided the load is sufficient. Heavier loads and longer times under tension are especially effective. Simply put: it’s not just what you do, but how you do it that matters. Inflammation Isn’t Always the Enemy Acute inflammation plays an essential role in healing. It increases blood flow and kickstarts collagen production. Suppressing this inflammation too early (e.g., with NSAIDs) can interfere with tendon recovery, especially beyond the first 24–48 hours post-injury. Tendons Are Slow to Change—But They Do Because tendons are metabolically slow, full remodeling after injury can take 6–12 months. That’s why consistent, progressive loading is key. Think of it as building tendon resilience over time—not looking for a quick fix. Risk Factors Beyond Training Your rehab should address more than just movement patterns. Factors like body composition, diet, and health history matter: Medications can also play a role: Age and Tendon Health As we age, our tendons lose water content and become less elastic. Collagen turnover slows, which means healing takes longer. After age 30, tendon rupture risk increases. But exercise can help offset these changes. In fact, studies show that heavy resistance training in older adults leads to measurable improvements in tendon structure and strength. How Tendons Adapt Over Time Tendons, like muscles and bones, respond to long-term loading. Studies show that: What About Eccentric vs Concentric vs Isometric? Good news: the contraction type matters less than how much load you’re using and how you apply it. All types can be beneficial as long as the load is appropriate. Instead of focusing on movement type, prioritize heavy, slow, controlled exercise with progressive overload. A Thoughtful, Individualised Rehab Approach Effective rehab for Achilles tendinopathy isn’t one-size-fits-all. It needs to: General rehab tips include: Final Thoughts Achilles tendinopathy is complex. It involves tissue changes, systemic health factors, and load management. But tendons do respond to the right kind of load. Recovery may be slow, but it’s absolutely achievable. If you’re dealing with Achilles pain or just want to future-proof your body, I can help. Let’s build a plan backed by science and tailored to your life. References
Don’t Tread on Me
Can your shoes be causing you pain? Dr Braeden Melmer Choosing a shoe can be difficult, especially when it comes to exercise. Many factors can influence the type of shoe we choose, such as the shape of the foot, the brand of shoe, walking/ running style, and the form of exercise. If you find yourself getting pain or discomfort when walking or exercising in the following body parts (foot, toes, heel, calf, knee, hip, or low back), there is a good chance you may be wearing the wrong shoe, or the shoe needs to be modified for your feet. Although there has been a shift in shoe design in the last 5-10 years due to foot mechanics research, most traditional shoes do not support natural foot mechanics. This is due to a modernised design of style, which creates a narrow toe box. This inhibits natural foot mechanics in a few ways. Imagine you’re at the beach, walking on the sand or in the yard, walking on the grass barefoot, and you feel the sand and grass between your toes. We put weight on our foot and push off. Our toes spread apart before we push off. With most shoes, a narrow toe box prevents this and causes our toes to compress up against each other. This can change the toe off-angle, which resultantly can increased shear forces through the knee and hip, which over time leads to dysfunction. Continuing off the last point, most formal shoes or dress shoes and women’s heels have a heel lift, which causes the forefoot to drop, respectively. A rise as little as a 2-5cm increase in heel lift shortens the Achilles tendon and prevents the foot from naturally flexing. At this heel elevation, shear forces increase through the forefoot and knee up to a 23% increase in body weight. If we were to increase that to a 7.5 cm heel, which can be quite a common height, the forces shoot up to 76% body weight felt through the foot and knee. These are quite large increases in forces that the lower limb will not withstand for long. Long-term effects that can come from such dysfunction are: Choosing the Right Shoes for You The three main shoes we typically look at are: Minimalist shoes have become a more popular choice for exercise, and I do advocate for this type of shoe, in most circumstances, and for day-to-day movement. However, they may not always be appropriate, as I will highlight. Minimalist shoes usually have a wide toe box, and as the name suggests, “minimal” cushion support allows for the foot to act naturally while walking and the toes to splay as they should. These shoes also have minimal to zero heel raise, which takes the pressure off the knee and changes gait from a heel strike to a mid to forefoot strike. This type of strike allows the calf to absorb more forces, but because of this, an increase in stress on the shin, Achilles, and calf can occur, increasing the chances of overuse injury during long periods of running or walking. In the case of running, we may want to consider a shoe with a typical or maximal cushioned support, depending on the individual’s foot shape and ground strike, particularly if you are a heel striker. A maximal shoe has quite large midfoot support with a slight slope towards the toe. And although this shoe may seem like a good option for running, the evidence is mixed and minimal. The idea is they reduce forces through the foot and Achilles but still seem to aggravate what they are helping, along with the knee. My advice would be to start on a typical/neutral running shoe first before jumping to a maximal. Some other factors we must consider are as follows, which become tricky: Summary Regardless of the shoe, we should always still seek out one that has a wide enough toe box for our feet. It is important to have your foot mechanics assessed along with gait and running style, as this will help decide which shoe is best for you with the type of exercise being done. At the end of the day, every foot is different, so different styles that are good for one may not be so for another. Therefore, it is important to always ask a professional with a biomechanical background who can help choose the right shoe for you! References: J.J. Hannigan and C.D. Pollard. Differences in running biomechanics between a maximal, traditional, and minimal running shoe. Journal of Science and Medicine in Sport 23(2020) 15-19 E. James.2014. Born to Walk: Myofascial Efficiency and the Body in Movement.
