Back Pain Doctor
Relative Energy Deficiency in Sport (REDs)
Written by Dr Joshua Hatch, Musculoskeletal GP, RACGP Fellow, Diploma in Musculoskeletal Medicine (FSEM UK).
Relative energy deficiency in sport (REDs) was named by the International Olympic Committee in 2014 and updated in a 2023 consensus statement. It describes the range of health and performance problems that follow low energy availability, meaning too little energy left over, after the energy cost of training, for the body to run normally (Mountjoy, Br J Sports Med 2023). It builds on the older “female athlete triad”, recognising that the problem affects men as well and reaches well beyond periods and bones.
Low energy availability is not always deliberate. It can come from a sudden increase in training, a busy schedule that squeezes meals, a low-carbohydrate approach to performance, or pressure around weight and body shape. The consensus describes a spectrum from short-term, manageable low energy availability to a problem that causes real harm, with individual factors deciding who is affected and how much (Burke, Br J Sports Med 2023).
What it does
The effects run across body systems: menstrual disturbance and lower oestrogen, or lower testosterone in men, weaker bones and more bone stress injuries, a slower metabolism, more frequent illness, poorer recovery, low mood and irritability, and stalled performance. Bone is a particular concern in adolescents and young adults, because those are the years when peak bone mass is built.
Why does it turn up in an MSK clinic?
It often presents as a sports injury. A runner with a second bone stress injury, a dancer with a foot stress fracture, a rower whose performance has dropped for no clear reason. Treating the fracture without asking why the bone failed misses the problem.
Assessment
Assessment is a medical history that covers training load, eating patterns, menstrual history, previous injuries, illness and mood, alongside an examination. Blood tests are chosen on the history and help exclude other causes of the same symptoms, such as thyroid disease, coeliac disease or low iron. A bone density scan is considered where there have been repeated bone stress injuries or a long period without periods. The 2023 consensus introduced a clinical assessment tool that grades severity and guides training and competition decisions.
Management
The treatment is restoring energy availability, usually by eating more, adjusting training, or both. That is a team job: a sports dietitian for the nutrition, a doctor for the medical side and any bone injury, a psychologist where eating, body image or pressure are part of the picture, and the coach to adjust the program. Recovery of periods and bone takes time, often months, and training is modified according to severity. It is not stopped by default.
Hormonal contraception does not treat REDs, and a pill bleed is not a natural period, so the pill can mask the very sign that would prompt help (Ryall, Can Fam Physician 2026).
If food or weight has become a struggle, please say so. It is common and treatable. Support is available through the Butterfly Foundation on 1800 33 4673.
For a fuller explanation, including what REDs does to bone and hormones, the warning signs for parents and coaches, how it is assessed and how athletes recover, see the complete guide to relative energy deficiency in sport.
Common symptoms
- Missed or stopped periods, or periods that never started by the expected age
- Bone stress injuries or stress fractures, especially if more than one
- Persistent fatigue, frequent illness and slow recovery from training
- Performance that stalls or falls despite training hard
- In men, low libido or low morning erections
Commonly seen in
Evidence for twelve treatment options in relative energy deficiency in sport (reds)
This is not a fixed ladder or a package of treatments. Every option is assessed independently against this diagnosis, including treatments with limited direct research that may still be reasonable for a clearly defined tissue target. The evidence level, likely benefit, risks, cost and alternatives are weighed at consultation.
Foundation: diagnosis, education and rehabilitation
The part of care with the broadest relevance. For many people it is enough on its own; other options are judged against it, not automatically added after it.
Diagnosis, education and progressive rehabilitation Working out what is driving the pain, explaining what your imaging does and does not mean, and building a graded loading plan you can actually follow. Core care
What it involves
Assessment to identify the likely pain source, an explanation of what the diagnosis means, adjustment of the loads that aggravate it, and a progressive strength and conditioning plan, with weight management where that is clinically relevant.
What the evidence shows
The 2023 International Olympic Committee consensus on relative energy deficiency in sport sets out updated health and performance models, a clinical assessment tool that grades severity with linked training and competition recommendations, and prevention and treatment principles centred on restoring energy availability (Mountjoy, Br J Sports Med 2023). A companion paper describes how the size, duration and cause of low energy availability, and individual factors, shape who is harmed and how (Burke, Br J Sports Med 2023).
Pairing reviewed 2026-10-30.
Where it fits
This is the plan: restoring energy availability with a sports dietitian, adjusting training with your coach, medical review of bone and hormonal health, and psychological support where eating or body image are involved.
Muscle and symptom-modifying options
Useful only when the examination identifies the tissue they target or when short-term pain control creates a useful rehabilitation window.
Wet needling and trigger point injection (trigger point injection) A fine needle into a tender band of muscle, with a small volume of dilute glucose solution injected through it. Not offered for this
What it involves
The needle is placed into the tender muscle band and a small volume of 5% glucose with a very dilute local anaesthetic (0.02-0.08%) is injected. Often done in the same visit as your assessment, and usable where the tender area sits deeper. Dry needling (the same technique with nothing injected) is not offered here.
What the evidence shows
Relative energy deficiency in sport is a problem of energy availability. The 2023 International Olympic Committee consensus presents prevention and treatment principles built around restoring it, with a clinical assessment tool that grades severity and guides training and competition decisions (Mountjoy, Br J Sports Med 2023). Device and injection treatments are not part of that framework.
Pairing reviewed 2026-10-30.
Where it fits
Not offered for REDs. A bone stress injury or other problem that comes with it is managed on its own guide and its own evidence.
Ultrasound-guided injections Guidance means the needle can be seen reaching the target. What goes into the needle depends on the diagnosis. Not offered for this
What it involves
The injection is performed under ultrasound so the needle can be watched into the target structure. What is injected is decided by the diagnosis, and corticosteroid is used sparingly, for the reasons set out below.
What the evidence shows
Relative energy deficiency in sport is a problem of energy availability. The 2023 International Olympic Committee consensus presents prevention and treatment principles built around restoring it, with a clinical assessment tool that grades severity and guides training and competition decisions (Mountjoy, Br J Sports Med 2023). Device and injection treatments are not part of that framework.
Pairing reviewed 2026-10-30.
Where it fits
Not offered for REDs. A bone stress injury or other problem that comes with it is managed on its own guide and its own evidence.
V-ACTOR vibration therapy (vibration therapy) Low-frequency vibration applied over tender muscle. Not a shockwave, despite sharing the machine. Not offered for this
What it involves
A vibration handpiece is moved over the tender muscle and fascia for a few minutes. It runs from the same STORZ MASTERPULS icon console as radial shockwave but is a separate handpiece delivering a different, gentler form of energy. No needles, no anaesthetic, no downtime.
What the evidence shows
Relative energy deficiency in sport is a problem of energy availability. The 2023 International Olympic Committee consensus presents prevention and treatment principles built around restoring it, with a clinical assessment tool that grades severity and guides training and competition decisions (Mountjoy, Br J Sports Med 2023). Device and injection treatments are not part of that framework.
Pairing reviewed 2026-10-30.
Where it fits
Not offered for REDs. A bone stress injury or other problem that comes with it is managed on its own guide and its own evidence.
Energy-based treatment options
Radial pressure wave, focused shockwave and EMTT have different targets and different evidence. They are assessed separately rather than treated as one category.
Radial or focused shockwave? Read the overviewRadial shockwave (radial pressure wave) Broad treatment across tender muscle and fascia, close to the surface. Not offered for this
What it involves
A handpiece is moved over the tender tissue while ballistic pressure pulses are delivered, using a transmitter head chosen for the tissue, including heads shaped for fascia and for the muscle either side of the spine. The pulse is strongest at the skin and weakens with depth, so this is mainly a myofascial treatment, though it can reach deeper in some areas. No anaesthetic, no downtime, usually a course of sessions about a week apart.
What the evidence shows
Relative energy deficiency in sport is a problem of energy availability. The 2023 International Olympic Committee consensus presents prevention and treatment principles built around restoring it, with a clinical assessment tool that grades severity and guides training and competition decisions (Mountjoy, Br J Sports Med 2023). Device and injection treatments are not part of that framework.
Pairing reviewed 2026-10-30.
Where it fits
Not offered for REDs. A bone stress injury or other problem that comes with it is managed on its own guide and its own evidence.
Focused shockwave (ESWT) A true shock wave converging at depth: for tendon, joint, ligament and bone. Not offered for this
What it involves
A focused system generates an acoustic shock wave that converges at a focal point set at a defined depth, concentrating the energy where the target is. This is the form used for tendon, joint, ligament and bone. Typically four to six sessions about a week apart, no anaesthetic and no formal downtime.
What the evidence shows
Relative energy deficiency in sport is a problem of energy availability. The 2023 International Olympic Committee consensus presents prevention and treatment principles built around restoring it, with a clinical assessment tool that grades severity and guides training and competition decisions (Mountjoy, Br J Sports Med 2023). Device and injection treatments are not part of that framework.
Pairing reviewed 2026-10-30.
Where it fits
Not offered for REDs. A bone stress injury or other problem that comes with it is managed on its own guide and its own evidence.
EMTT (magnetotransduction therapy) High-energy magnetic pulses applied over the area. Usually painless, no contact. Not offered for this
What it involves
You sit with the applicator positioned over the area for a short session. It is usually painless and needs no gel or skin contact. It is usually given as a course, commonly alongside shockwave.
What the evidence shows
Relative energy deficiency in sport is a problem of energy availability. The 2023 International Olympic Committee consensus presents prevention and treatment principles built around restoring it, with a clinical assessment tool that grades severity and guides training and competition decisions (Mountjoy, Br J Sports Med 2023). Device and injection treatments are not part of that framework.
Pairing reviewed 2026-10-30.
Where it fits
Not offered for REDs. A bone stress injury or other problem that comes with it is managed on its own guide and its own evidence.
Biologic and joint injection options
Each injection is assessed independently for the named diagnosis. Cost, uncertainty, likely benefit, risks and alternatives are part of the decision.
Platelet-rich plasma (PRP) Your own blood, concentrated and injected under ultrasound guidance. Not offered for this
What it involves
Blood is taken from your arm, spun to concentrate the platelets, and injected into the target under ultrasound guidance in the same appointment.
What the evidence shows
Relative energy deficiency in sport is a problem of energy availability. The 2023 International Olympic Committee consensus presents prevention and treatment principles built around restoring it, with a clinical assessment tool that grades severity and guides training and competition decisions (Mountjoy, Br J Sports Med 2023). Device and injection treatments are not part of that framework.
Pairing reviewed 2026-10-30.
Where it fits
Not offered for REDs. A bone stress injury or other problem that comes with it is managed on its own guide and its own evidence.
Prolotherapy (dextrose) A course of dextrose injections into and around the structure and its attachments. Not offered for this
What it involves
Hypertonic dextrose is injected at the tender ligament and tendon attachments, and into the joint where relevant, usually as a series of treatments a few weeks apart.
What the evidence shows
Relative energy deficiency in sport is a problem of energy availability. The 2023 International Olympic Committee consensus presents prevention and treatment principles built around restoring it, with a clinical assessment tool that grades severity and guides training and competition decisions (Mountjoy, Br J Sports Med 2023). Device and injection treatments are not part of that framework.
Pairing reviewed 2026-10-30.
Where it fits
Not offered for REDs. A bone stress injury or other problem that comes with it is managed on its own guide and its own evidence.
Viscosupplementation (hyaluronic acid) A gel-like injection into an arthritic joint. Widely used, and genuinely contested. Not offered for this
What it involves
One or a short series of hyaluronic acid injections into the joint under ultrasound guidance.
What the evidence shows
Relative energy deficiency in sport is a problem of energy availability. The 2023 International Olympic Committee consensus presents prevention and treatment principles built around restoring it, with a clinical assessment tool that grades severity and guides training and competition decisions (Mountjoy, Br J Sports Med 2023). Device and injection treatments are not part of that framework.
Pairing reviewed 2026-10-30.
Where it fits
Not offered for REDs. A bone stress injury or other problem that comes with it is managed on its own guide and its own evidence.
Nerve-targeted options
Relevant when examination identifies a superficial neuropathic pattern or a compressed peripheral nerve, not simply because pain is present.
Lyftogt perineural therapy (perineural injection therapy) A series of small dilute dextrose injections just under the skin, over tender superficial nerves. Not offered for this
What it involves
Small injections of low-concentration dextrose, usually 5%, placed just beneath the skin along tender superficial nerves. Given as a series of short sessions.
What the evidence shows
Relative energy deficiency in sport is a problem of energy availability. The 2023 International Olympic Committee consensus presents prevention and treatment principles built around restoring it, with a clinical assessment tool that grades severity and guides training and competition decisions (Mountjoy, Br J Sports Med 2023). Device and injection treatments are not part of that framework.
Pairing reviewed 2026-10-30.
Where it fits
Not offered for REDs. A bone stress injury or other problem that comes with it is managed on its own guide and its own evidence.
Ultrasound-guided nerve hydrodissection Fluid placed around a nerve to free it from the surrounding tissue. Not offered for this
What it involves
Under ultrasound, fluid is placed in the plane around the nerve to separate it from the tissue that is tethering or compressing it.
What the evidence shows
Relative energy deficiency in sport is a problem of energy availability. The 2023 International Olympic Committee consensus presents prevention and treatment principles built around restoring it, with a clinical assessment tool that grades severity and guides training and competition decisions (Mountjoy, Br J Sports Med 2023). Device and injection treatments are not part of that framework.
Pairing reviewed 2026-10-30.
Where it fits
Not offered for REDs. A bone stress injury or other problem that comes with it is managed on its own guide and its own evidence.
This is general information only and suitability is assessed individually. Treatments with limited or condition-dependent evidence may still be discussed, but only with clear explanation of the uncertainty, the expected benefit, risks, cost and alternatives. Red flags, progressive neurological symptoms or suspected serious pathology require a different pathway.
Every treatment above is described in full on the non-surgical treatments page, including what each one is used for and what the evidence supports. Ratings apply to the named diagnosis; an adjacent muscle, tendon, joint or nerve problem is assessed as a separate target. The method behind the ratings, and the treatments not offered, are set out on the evidence page.
Corticosteroid injection is reviewed separately for each diagnosis.
Cortisone reliably reduces pain in the short term, and that can be genuinely useful when pain is stopping you sleeping or moving enough to rehabilitate. Beyond that window the picture changes. A systematic review of 41 randomised trials and 2,672 participants found that corticosteroid injection reduced pain in the short term but that the effect reversed at intermediate and long term; in pooled analysis for lateral epicondylalgia the short-term effect was large (SMD 1.44, 95% CI 1.17 to 1.71) while no intervention was favoured at 26 weeks (-0.40, -0.67 to -0.14) and at 52 weeks (-0.31, -0.61 to -0.01) (Coombes, Lancet 2010). In a randomised trial in lateral epicondylalgia, 83 per cent of the corticosteroid group had completely recovered or much improved at one year against 96 per cent given a placebo injection, and recurrence ran at 54 per cent against 12 per cent; adding physiotherapy made no significant difference at one year (Coombes, JAMA 2013). In joints, repeated corticosteroid injections have been associated with cartilage loss. It does not repair anything.
So treatment plans are not built around it. Where an injection is the right call, the specific diagnosis and target are reviewed, what is being injected and why is discussed, the number is kept low, and it is paired with the loading work that changes the longer-term course.
When it might still be considered
- Pain severe enough to block rehabilitation
- A clear inflammatory or bursal target on imaging
- A specific short-term goal: a trip, a procedure, a return to work
- Diagnostic use, where the response shows where the pain is coming from
When a cortisone injection is worth doing, and when it is not
Other general conditions
Pain in the same area can come from more than one source, and the label matters less than what the examination and history point to. These are the other guides for this region.
Related articles
Shorter articles that answer the questions patients ask most often about this.
Frequently asked questions
Isn't missing periods normal for athletes?
Can men get REDs?
Does the contraceptive pill protect against it?
How is REDs treated?
What if food and weight have become a struggle?
Ready for a clearer plan for your back or musculoskeletal pain?
Book an assessment with Dr Joshua Hatch.
Your assessment focuses on understanding the likely source of your pain and the most appropriate non-surgical options for your diagnosis, with the aim of reducing pain and improving function.
You must have your own regular GP before booking. This service works alongside your GP for focused care. Booking requirements.
Book an appointment