Starting all Over Again

When runners develop an injury they often take a break from the impact of running but keep up their fitness by crosstraining, whether it be on the bike, in the gym or in the pool. Unfortunately, although I had tried to do a bit of crosstraining (mainly to try to hold onto my sanity as well as some fitness) I found that it was neither fixing my RED-S nor my stress fracture. Going back to the drawing board for a last ditch "kill or cure" solution, I stopped all exercise completely. For about 6 weeks, I did no running, no cycling, no swimming, no aquajogging, no visits to the gym and in fact hardly walked more than a mile or two. After that I spent the 4 weeks gradually reintroducing some exercise, though still making sure there was no impact. I went on a few bike rides (nothing fast, but a couple of "sportives" for the endurance aspect of it.....well actually, just for the cake at the feed stations, swam a couple of times and did some hiking. All through this time I kept up my food intake (yeay) and actually managed to put on weight and fix the RED-S, so that eventually I could restart running (though I did check with my orthopaedic consultant friend, William Hage (www.williamhage.com) that this was the right thing to do).

A sportive finishes with beer...

I have to admit that it has been a struggle - I used to run for the love of running (hence why crosstraining in a gym has never held any appeal for me) but suddenly I didn't love it. It was hard. My short "easy" run loop that started and finished at my front door would take at least 50% longer and have to incorporate a couple of breaks (not due to leg pain, but lack of fitness). I feel that in some ways I've had to go back to the beginning of my running career and start from scratch all over again....building up the distance, never mind the speed. I would have to force myself out the door, as it isn't exactly pleasant to find yourself struggling to breathe when going a much slower pace than you can ever remember running before.

Or a medal....I'd rather have cake
than either!!

I've also had to maintain my calorific intake (and keep reminding myself that I'm "healthy" rather than "heavy") to ensure my hormone cycles don't go awry again. This has led me to discover the benefits of wearing capris or tights......as shorts tend to cause more chafe these days (nice) !!!



My new mantra!!!

After a few weeks, I realised that I was starting to enjoy it a bit more again - OK, so I'm not back to where I was before, but I could make it all the way round my easy loop without stopping, and then started to increase the distance or the pace on occasions. I was very reluctant to run any set distance as I knew I would find myself comparing "current me" to "former me". I decided to give myself a good talking to and get over it - no-one would care (or even notice) except myself, so I started out with a parkrun. At the end of the first one, I was bent double, gasping for air, shattered, so I thought I must have set a fast time......and then realised that I'd just about managed to run 1.5 minutes/mile slower than my best time!! Still, at least I was running again....and that was something that I'd thought I might never do again.

"Enjoying" a race again (although
maybe not breaking any records)

Since then, I find that I still have to give myself a few stern chats.....but I have done a couple more parkruns, and 2 other races. Each time I have to try to remember where I am NOW, not where I was when I stopped (though to be fair it would only take a few hundred metres of me not remembering before I would be bent over double and gasping for air again). My injuries seem to be holding up, so I'm hoping that I can now gradually regain some level of fitness in order to enjoy my running again, and so that I can travel and hang out with all my running friends again (I admit that I had been avoiding some catch-ups and races so that everyone didn't get sick of my constant moaning and grumpiness!).

When 24 people of differing ages and
abilities turn up to your track session
it can be rather intimidating!!

In the meantime, I have managed to keep up my British Athletics coaching course with trips to Birmingham and Loughborough, and am actually really enjoying designing sessions and programmes now - with some of the local runners being used as willing guinea pigs - so here's to spending a bit of time on both sides of the fence :-)

RED-S

I have never really considered myself to be a "proper" runner, still less an athlete. Don't get me wrong, I am in awe of those that have the commitment and determination to put themselves through the mill by training really hard, being strict with their diet and sacrificing a lot of their "social" life, but I see myself as more of a fun runner....running for the love of being outdoors, being fit, and discovering new cafes to run to "just to check out their cake selections". I would look at some (rather) slim runners and wonder how they had the energy to do what they did and why they didn't break. I honestly never expected to be one of those "broken" people. However, a nonhealing stress fracture, a DEXA scan showing osteopenia and a diagnosis of RED-S made me take my head out of the sand and investigate further.

I feel like I have been talking about RED-S for a while now, but I fully admit that when I first heard of it (ie when I was diagnosed with it) I did not know much about it. It is good to raise the profile of this condition as a lot more people are affected by it than realise it, so spreading the word is vital for diagnosis and treatment..

On chatting to a friend last weekend, she admitted to (very sensibly) googling RED-S when I mentioned the condition, but other people seem to think I'm talking about anaemia and red blood cells, so I thought I'd give you a little bit more information about it.

RED-S is a condition caused by low energy availability, where nutritional intake is insufficient to cover the energy demands of both exercise training and normal physiological function.

Unintentional low energy availability can arise with an increase in training load not matched with an appropriately timed increased of nutritional intake or an underestimation of energy expenditure from exercise outside of training schedule, for example active transport (eg cycling) to/from training sessions, study or work.

Intentional low energy availability is more prevalent in sport where low body weight confers a performance or aesthetic advantage, eg endurance running, cycling, dance, gymnastics.

The Relative Energy Deficiency in Sport (RED-S) model was first described by the International Olympic Committee in 2014, and published in the British Journal of Sports and Exercise Medicine. Prior to this, there had been a lot of research in female exercisers, with what was known as the female athlete triad (low energy availability, menstrual disruption and impaired bone health). It is now recognised that this triad is a clinical spectrum, reflecting varying degrees and time scales of energy availability, menstrual function and bone health.

Energy availability can range from adequate, with healthy eating patterns matched to requirement, through to low  due to disordered eating and severe energy deficit with an eating disorder involving a psychological aspect. Menstrual functional can vary from regular menstruation, to lack of periods (amenorrhoea) and bone health from normal for age, through to weak bones (osteoporosis). The female athlete triad model evolved into the RED-S model as  growing evidence showed that the consequences of low energy availability can affect males as well as females, and at all ages and levels of exerciser from recreational to elite.

Presentation

• RED-S involves multiple systems and hence bone stress injury may not necessarily be the presentation; particularly in acute low EA and/or in non-weight bearing sports.
• Recurrent illness, fatigue, athletic underperformance and psychological issues rather than injury can be presenting features.
• In young athletes, RED-S may present as delayed puberty, fall off growth centiles for height and/or weight
• In any woman of reproductive age in the absence of pregnancy, whether exercising or not, if menstrual cycles are not regular then this requires medical investigation, as RED-S is a diagnosis of exclusion. The Royal College of Obstetrics and Gynaecology (RCOG) defines primary amenorrhoea as no menarche by 16 years of age, secondary amenorrhoea as cessation of periods for >6 months in a previously regular menstruating woman and oligomenorrhoea is defined as less than 9 cycles per calendar year. this does not include withdrawal bleeds from hormonal contraceptives.
• The equivalent of normal menstrual cycles in men, is morning erections indicating reproductive endocrine axis function with adequate testosterone levels.
• Athletes with RED-S may first present with injury to a physio, eg a bone stress response, including stress fracture typically of the lower limb/pelvis.
• Recurrent soft tissue injury could also be a presenting feature of RED-S.

Management

RED-S is a diagnosis of exclusion presenting a multi-system dysfunction caused by a disrupted periodisation of nutrition, training and recovery. For an athlete to reach their full athletic potential, they must address these imbalances - reaching this potential is compromised in RED-S.

Drugs are not recommended as first line management in amenorrhoeic athletes. Oral contraception (OCP) masks amenorrhoea with withdrawal bleeds. OCP does not support bone health and indeed may exacerbate bone loss by suppressing further IGF-1 (a growth factor). Although transdermal oestrogen, combined with cyclic progesterone does not down regulate IGF-1, any hormonal intervention cannot be a long term solution, as bone loss will continue if energy availability is not addressed as a priority.

So clearly, the mainstay of management is to deal with the energy availability imbalance in terms of increasing the intake/type of nutrition or decreasing the expenditure, or a combination of both.

And finally, re me...

As for myself, I naively thought "it could never happen to me" as I've never restricted my diet, love my food, have a normal BMI and although I love running, I've never taken my training that seriously. Yes, I became amenorrhoeic about 6 years ago, but I hadn't lost really lost weight or increased my training. I do remember going away for a few days with a group of running friends at this time, but I wasn't actually running at the time as I had PF (I was helping time their sessions instead), but even so, after eating meals with all of them, I found I was still hungry and so I would go and eat extra food by myself in my room. I guess this shows that I wasn't getting enough nutrition, but I didn't realise what longterm damage might be occurring. I've previously had horrendous problems with my menstrual cycle, having been admitted to a gynae ward while a junior doctor due to pain and heaviness so I was actually happy when they seemed to stop. Since the stress fracture and the DEXA scan, I have done a lot more research on the matter and now realise that I need to be "healthier". I've been told that my fracture may never heal, but at least I have managed to treat the RED-S with a combination of eating (even more than before) and a total break from any exercise. I am no longer amenorrhoeic (humbug to remembering how horrendous periods can be all over again) and am now teaching myself that I am not so much "heavy" as "healthy"......onwards and upwards...and if I can help others learn more in advance of having to deal with fractures and osteopenia then I've achieved something!

For more information, have a look at this open access educational resource on RED-S
http://health4performance.co.uk/