Dr Kate Hutchings

• FFSEM
• BASEM- Executive board member (Education)
• MRCGP
• RSM

Relative energy deficiency in sport (RED-S) refers to a diagnosis where a person has insufficient energy intake relative to the amount of training being undertaken. This results in low energy availability for not just exercise, but all physiological systems to maintain health.

The term RED-S has been adapted from a previously recognized condition, the female athlete triad, which comprises three components: low energy availability, menstrual problems (irregular or absent periods) and low bone density.

RED-S was developed to reflect the emerging complexity of the associated health consequences of the condition and to incorporate the understanding that it can affect both men and women alike. It is recognised that it can affect any physically active individual, irrespective of the level of sport or age.

Low energy availability can occur either unintentionally through poor nutritional strategies or intentionally with restrictive eating patterns. Irrespective of the cause, the result is an imbalance between energy intake (nutrition) and energy output (training). In women, low energy availability can affect the menstrual cycle with irregular or absent periods. In recreational sports women, it is important to recognise that loss of menstruation is not a normal part of training and irregular or absent periods need to be evaluated so that any underlying medical problems can be excluded and treated appropriately.

RED-S can have detrimental effects on sports performance, as our hormones are important for driving adaptations to exercise.

Low energy availability can affect muscle strength, co-ordination, concentration, reduce your training response and ultimately put someone at increased risk of injury. In addition, people can feel very fatigued and exhausted with training. If left untreated, energy deficiency also has longer lasting effects on menstrual function and fertility, bone health, metabolic rate, immune function, cardiovascular health, and psychological wellbeing.

Your first appointment

The identification of RED-S can be challenging and requires the expertise of a multidisciplinary team. It is important to know that weight loss is not necessarily a sign of low energy availability.

At your first consultation, we will discuss your symptoms and evaluate your energy balance and menstrual status.

It is important to know about your sporting activities and training schedules, any previous injury history, dietary intake, medications that you may be taking, and whether there is a family history of osteopenia or osteoporosis.

We will undertake screening questionnaires, a physical examination, and in most people, blood tests to assess metabolic and hormone levels. It is then often beneficial to have a nutritional review with one of our specialists.

What treatment modalities can you expect?

The management of RED-S most often requires several clinicians, including a sports medicine doctor, sports nutritionist (or eating disorder specialist), physiotherapist and psychologist. The treatment focuses on reversing the underlying issue of low energy availability by working with specialists on nutritional intake and training plans. This can include addressing any vitamin or mineral deficiencies as outlined in blood tests. Menstrual issues are assessed by a specialist Gynaecologist in this area, and in some patients, further investigations to assess their bone health are required.

It is important to note that oral and injectable contraceptives are not recommended to regulate the menstrual cycle as they have a potential negative effect on bone health and mask any recovery of a women’s normal menstrual cycle.

Patients are encouraged to undertake high impact loading and resistance training at least two to three days per week, especially those in non-weight bearing sports and/or those with low bone density.

What happens after your appointment?

Following your initial appointment and diagnosis, we recommend routine follow up for several months to monitor your recovery, and ultimately, a safe return to your sporting activities.

Bone stress injury represents the inability of a bone to withstand repetitive loading from weight bearing activities, such as running, jogging and jumping sports. Bone is in a constant state of turnover, a process called ‘remodelling’, which means new bone develops and replaces older bone. This enables our bones to adapt and cope with different loads we put them through.

Overuse bone stress injuries occur when excessive load or activities are repeated so often that weight bearing bones to not have enough time to ‘remodel’ between exercise sessions. Examples can be a sudden change in training volume or intensity of running or a lack of recovery between training sessions. This results in an imbalance in the bone remodelling cycle and weakness can develop. 

This can cause a spectrum of injuries, from bone stress to stress fractures which is a small ‘crack’ in the bone. Symptoms are dependent on the degree of injury to the bone, but typically people have pain with weight bearing activities (such as running and jumping) and localised swelling and tenderness over the affected bone. As bone stress injury increases, people can develop pain with walking, as well as at rest.

Lower limb stress fractures are more common than upper limb and the most frequent bones affected are the lower leg (tibia), followed by the weight bearing bones of the foot (metatarsals) and smaller bones of the mid foot. It is important that the symptoms are identified early, as a bone stress injury can recover relatively quickly if it is off loaded as soon as symptoms develop. However, if the affected bone continues to be overloaded (such as with running) and not enough time is given for it to recover, then a stress fracture can develop.

In my clinic, I treat patients of all ages and sporting ability, as these injuries can develop in both recreational and high-level sports men and women alike. It can happen in someone who has started a new exercise or running programme as well as an experienced runner who has increased their mileage and not allowed for adequate recovery between training sessions.

The majority of people who develop bone stress injury do so from overuse and we always need to consider a person’s training regime, and overall general conditioning to understand why they have developed an injury. In addition, there are certain groups of people that can be more prone to developing a problem, including those with low bone density, women with irregular or absent menstrual cycles, those that have suboptimal nutrition for their level of sport and certain medical conditions that can affect bones or lead to reduced absorption of Vitamin D and calcium.

Your first appointment

Typically, patients visit my clinic with activity-related pain and soreness over the affected bone area. During the first appointment, we discuss how your symptoms developed, including any sporting activities or changes in physical activities preceding your symptoms. We then evaluate if you have any risk factors that may make you more likely to develop a bone stress injury.

In the majority of people, we will undertake routine blood tests looking at your bone profile, which includes your calcium and vitamin D levels. In some cases, we will also screen for any associated medical conditions that may be affecting your bones. This can include looking at levels of female hormones of the menstrual cycle.

We undertake a full physical examination, looking at the affected bone, as well as assessing if there are any biomechanical or joint/muscular issues that can predispose to the injury.

Bone stress conditions: what treatment modalities can you expect?

Typically, most people require further imaging, such as an X-ray or MRI scan to assess the degree of bone stress and to evaluate for a stress fracture.  If clinically, a stress fracture is suspected at the first consultation, we will offload the bone using a boot walker (and sometimes crutches) whilst we wait for the scan results.

Once a bone stress injury is confirmed, a period of ‘offloading’ in a boot walker is started. This takes the weight off the bone and allows time for it to heal, the duration of which is dependent on the bone affected and the level of bone stress involved. This can vary considerably from a few weeks to months. However, during this time, we will start physiotherapy rehabilitation, which is progressed gradually as symptoms allow.

Pain is used as a guide for your level of loading and fitness can be maintained with less load-bearing exercise, such as aqua jogging and static cycling. Additional therapies can also be utilised, including hydrotherapy, muscle stimulator machines to maintain strength, and in certain prolonged cases of stress fractures, we can use bone stimulator machines.

Once you are able to begin weight-bearing again out of the boot, we undertake a very progressive return to your sport, often starting on the anti-gravity treadmill, for example. It is important to return to your sport safely and we often work with additional clinicians such as Consultant Orthotists, who will look at your running biomechanics and foot posture.

In addition, if any risk factors are identified, we can work with our sports nutritionist to optimise areas of your bone health, such as Vitamin D deficiency. In some cases, further specialist reviews and investigations are required if there are any underlying menstrual problems that we feel may be affecting your bones.

What happens after your treatment?

Following your initial treatment, we suggest regular follow-up appointments to assess your progress and plan your rehabilitation and return to sport safely. The recovery time is dependent on several factors, including the location of bone and extent of bone stress, how long you have had your symptoms and whether there are any specific underlying risk factors that we need to address.

Tendinopathy is a general term used to describe an overuse injury of a tendon characterised by a combination of symptoms including pain, swelling, and stiffness. This can ultimately affect a person’s ability to undertake physical activity and can be debilitating with daily activities.

Tendons are tough fibres, much like a rope, that connect muscle to bone and are organised in a specific way to provide strength and enable them to adapt to load. The understanding of why tendons change in structure and become painful has changed over the past decade, and we now consider the underlying problem to be a degenerative process (although there is thought to be some inflammation in the early stages).

Tendinopathy can affect all age groups and levels of physically active people. Too much load (known as an ‘abusive load’) through the tendon is primarily the causative factor, but there is a large variation in how much load individuals can endure before developing symptoms. It is recognised that less active people can also suffer from tendinopathy. 

Generally, the incidence increases with age, as the load threshold required to affect the tendon decreases. However, there are certain factors that can contribute to the development of tendinopathy, including any sudden change in the volume or intensity of physical activities, training errors and lack of general physical conditioning, including biomechanical issues. In addition, tendon problems can be associated with medical problems such as diabetes, high cholesterol levels, certain rheumatological conditions and prescribed medications.

Tendinopathy is predominately caused by repetitive activities to the muscle tendon unit and is a result of a failed healing response of the tendon. The strain on the tendon causes micro-tears that can build up over time.

A tendon injury may appear to happen suddenly, but usually is the result of structural changes in the tendon that have developed over many months or years (so-called the degenerative process). Often the more ‘acute’ symptoms of pain and swelling are the result of an excessive load being suddenly applied to the tendon e.g.- hill running, jumping activities.

Tendinopathy causes pain, localised swelling, weakness and often restricted movements of the associated joint. The pain may be worse when you use the tendon and stiff when you first get up in the morning. As symptoms, progress the tendon can be painful with normal activities of daily life.

The relatively new understanding of the underlying causes of tendon problems has resulted in new and novel treatment options.

Your first appointment

In our Sports Medicine clinic, we manage both upper limb and lower limb tendon problems. At your first consultation, we discuss how your symptoms started and whether there were any changes to physical activities prior to the onset of your symptoms. We evaluate whether you have any risk factors for tendon problems and often use symptom questionnaires to assess the severity.

A full clinical examination is performed, looking at not only the affected tendon, but surrounding muscles and joints that may contribute to ongoing problems. We often work with Consultant Orthotists for a biomechanical assessment of the lower limb.

An ultrasound is often recommended as this helps to evaluate the structural changes and guide our management options.

Tendon conditions: what treatment modalities can you expect?

The management of tendinopathy depends on the level of the tendon changes and how long you have had the symptoms. The primary treatment approach is known as ‘load management’, which essentially means an individualised physiotherapy programme whereby the tendon is gradually loaded to facilitate adaptation, healing and strength.

If symptoms are reported relatively early, often only a short period of physiotherapy rehabilitation is required. However, with more chronic long-standing symptoms, it can take several months for the tendon to fully recover.

As the basic science of tendinopathy has evolved, so have the treatment options for these conditions.

In acute cases, we may recommend the use of nonsteroidal anti-inflammatory medication, such as ibuprofen or similar medication. But this has only been found to be beneficial in the early stages of tendinopathy when used for seven to 10 days. There is research to suggest that long term use of these medications can be detrimental to the tendon healing process.

Adjunct treatment modalities offered also include extra-corporeal shock wave therapy (acoustic waves) which helps to stimulate the tendon structure to facilitate repair processes by several different mechanisms.

Injection therapies are also used in some cases and these include high volume injections, sclerosants or platelet rich plasma (blood) with additional dry needling to the tendon. Corticosteroid injections into the tendon are no longer thought to be effective long term and can be detrimental to the tendon structure.

What happens following treatment?

Following your initial appointment, we will discuss your treatment plan with you and monitor your progress over the following months.  We work closely with our physiotherapy team to ensure we can return you to your physical activities safely.

Helping women achieve their fitness potential

Elite-level support for active women of all ages, shapes and abilities

Every day, more women are discovering the benefits of an active lifestyle. While many of us may start some form of exercise initially to improve our fitness and health, and possibly to lose some unwanted excess weight, we often find ourselves appreciating some of the other (unexpected) benefits including:

• More energy throughout the day
• Improved sleep
• Lower stress levels
• Better concentration
• Increased confidence

Whether you’re a high-level athlete, a keen runner, a recreational hockey player or somebody who is just getting started on their fitness journey with a Couch to 5k programme…

…if you are a female, an increased knowledge of your health and training can help to improve your fitness and your sporting performance.

Unfortunately, there is a lot of confusion and incorrect, (often out-dated) information about female health as it relates to sports and exercise. The Active Women’s Clinic at Circle Reading was set up specifically for this reason. We support, educate and tailor treatment for active women of all ages, no matter their current fitness level or health goals.  

Unfortunately, there is a lot of confusion and incorrect, (often out-dated) information about female health as it relates to sports and exercise. The Active Women’s Clinic at Circle Reading was set up specifically for this reason. We support, educate and tailor treatment for active women of all ages, no matter their current fitness level or health goals.  

Our goal is to help every woman achieve their personal fitness goal. Whether that’s winning a Gold medal at the Olympics or being able to keep up with your active child in the local park, we have the expertise to help you.

Women and Sports – differences, issues and specific challenges

Ongoing research continues to teach us more about how females respond to training and exercise. As we learn more, we’re able to better monitor and adjust training patterns and exercise intensity to optimise athletic performance, while also avoiding injury from excessive or incorrect activity.

These are a number of important differences between the sexes regarding the effects of exercise on the body:

• Body composition – Men and women have different genetic attributes and different levels of sex steroid hormones (testosterone, progesterone and oestrogen) which impacts on differences in body composition. For example, in general women will usually have proportionately less muscle and bones mass and a higher percentage of body fat than men.

• Anatomy – The female pelvis is usually wider and has a larger hip width to thigh bone ratio. This helps with pregnancy and childbirth but can affect the way you jump and land. These changes can impact on the risk of sustaining a knee or ankle injury.

• Hormones – A woman’s menstrual cycle is controlled by changes in hormone levels. These changes can affect sporting performance in some women and exercise itself may cause changes in hormone levels. Recent studies have demonstrated how women can feel their performance is negatively affected by their menstrual cycle. Common symptoms include abdominal or back pain, cramps, headaches, breast tenderness and reduced co-ordination difficulties. It’s easy to see how these could affect athletic performance.  

• Women who exercise can experience a higher incidence of menstrual irregularities. It is essential to have the correct nutritional intake for your training or sport, as when we “under fuel”, a negative energy balance can develop (we refer to this as Relative Energy Deficiency in Sport). This problem can not only affect a woman’s menstrual cycle, but if unrecognized and untreated, it can have long lasting effects on health and wellbeing.

• Flexibility – Women tend to be more flexible than men, with less joint stability (this is known as greater joint laxity). While flexibility itself tends to be a good thing, excessive joint mobility can increase your risk of injury, particularly in the knee, ankle and elbow. If you are particularly flexible (hypermobile), you’ll require additional muscle strength to provide the necessary support and stability for your joints.

What to expect when you first visit with us

Your first consultation will run for 40 minutes and be with either Dr Kate Hutchings or Physiotherapist Roz Cooke. They will talk with you about any symptoms you’re experiencing and how they are affecting or limiting your sporting activities. They will also carry out a clinical examination.

Additional investigations may be needed to help confirm a diagnosis and to plan your management. Tests may include:

• Blood tests – helpful for hormonal profile testing and to demonstrate and vitamin or mineral deficiency
• X-ray
• Ultrasound
• MRI
• Bone scan

Some of these tests, such as blood tests, ultrasound or X-rays, can often be done on the same day as your appointment. Other test will need to be booked for another date.

Once the results of any investigations are back, our experienced team will work closely together to plan the optimal treatment plan and will then discuss their recommendations with you. This may involve training and recovery strategies, a rehabilitation programme or additional investigations.

At Circle Reading, you’ll have access to state-of-the-art equipment and technology like Shockwave therapy, a Biodex Isokinetic Dynamometer and an AlterG anti-gravity treadmill.

Depending on your specific symptoms and test results, you may be referred for additional review with specialists in other fields such as nutrition, gynaecology, rheumatology, orthopaedics and psychology. These can all be easily arranged for you if required.

Whatever your unique circumstances, we can provide you with a comprehensive integrated management plan to help you achieve peak performance safely and sustainably. We will closely monitor you throughout your treatment and can make adjustments as needed. Your treatment is tailored to your specific situation and requirements.

Why choose Circle Reading Hospital's sports clinic?

With so many options available to choose from – from personal trainers to fitness apps and exercise equipment - why do so many women continue to trust us with their fitness and sporting health?

Women choose to visit us at the Active Women’s Clinic for a variety of reasons. Some will have been referred by another trusted specialist, such as a sports physiotherapist, rheumatologist or dietitian. Others will have heard about us from one of their friends who we’ve previously helped.   

The overriding reason people trust us is due to the exceptional calibre of the people who run the clinic. Our Clinicians have more than 25 years’ combined experience in working with Olympic female sports women, the FA and professional Ballet.

• Dr Kate Hutchings is a Sports and Exercise Medicine Consultant. Having worked with Olympic and Paralympic athletes, elite athletes and professional sports teams, she has vast experience in ensuring peak sporting performance and in assessing, diagnosing and treating sports injuries to ensure a speedy and full recovery.

• Roz Cooke is a highly experienced physiotherapist. A few of her (many) career highlights include Lead Physiotherapist for England Netball, Senior physiotherapist providing support to British Equestrian Athletes and a Consultant Physiotherapist for Women at the Football Association.  

Previously, access to this level of expertise in sports medicine was restricted to elite athletes. The Active Women’s Clinic at Circle Reading makes it readily available to every woman.

Both Kate and Roz are passionate about bringing the principles of elite sports performance and achievement to women of all fitness levels, helping them to achieve their personal fitness goals safely and free of injury.

The clinic is held at Circle Reading Hospital, a modern private hospital with state-of-the-art facilities and equipment, a team of experienced healthcare professionals, and access (where required) to specialists in other fields. 

For quick, easy access to elite level help, tailored to your personal fitness goals, please contact us to arrange your initial visit.