RED-s (The Female Athlete Triad)

There is a need to understand the underlying causes of what drives RED-s, how it can affect elite performance artists and sportspeople, and what can be done to help people at risk of developing this problem

Originally RED-S (Relative Energy Deficiency in Sport) was know as The Female Triad which referenced the pathology in female athletes which leads to three things: Disordered Eating, Amenorrhea (lack of menstruation) and Loss of Bone Density (Osteoporosis). This disorder can also have an impact on the hormonal, renal, immune, reproductive and cardiovascular system over time.

Athletes can fall along this spectrum with not all these clinical conditions arising at the same time. The basis of this disorder as suggested by its name is energy deficiency. So simply put, energy availability. This is energy intake minus the energy cost of exercise, mechanisms the body uses internally to maintain functioning, and activities of daily living. 

Restrictive eating practised by women and girls in sports and physical activities that emphasise leanness such as dancing or long distance running are of special concern. That being said in male athletes, especially those who compete in long distance or endurance sports, RED-s is on the rise. This is due to their need to be lean but also to have stores of energy for maintaining energy output over long periods of time. RED-s is also seen in recreational athletes and performing artists. Risk factors for developing this disorder include; restrictive eating, injuries and illness, specialisation, decline in performance level, and casual misinformed comments by coaches on physical appearance. 

The chances of developing RED-s can be minimised by athletes, coaches and administrators understanding warning signs and adhering to International Olympic Committee parameters for management and reintroduction to activity after treatment for severe RED-s. Also having an understanding of avoiding critical comments about body shape, educating athletes on the necessity for adequate energy intake for performance and open discussion about eating problems. Athletes often respond when the effect of the disorder is explained in terms of decreased performance. Low glycogen stores inevitably lead to lack of concentration, decreased strength, decreased endurance, decreased improvement with training and increased risk of injury. All of these have a significant negative effect on performance. 

Ballets dancers who undertake rigorous training and have body shape demands are prime candidates for developing RED-s. Some research has shown that as many as 40% of ballet dancers have low bone mineral density. Due to their training indoors for hours they also often have low Vitamin D which can contribute to low calcium and injuries. Given that the average ballet dancers’ career often ends at 24 it is extremely important to keep their long term health in mind.

Although it is tempting to partake in these practices and many athletes are not even aware that they are not taking in sufficient energy to match their output it is crucial to note the long term repercussions of continuing this behaviour. 


1.Medicine & Science in Sports & Exercise:

October 2007 - Volume 39 - Issue 10 - pp 1867-1882

2. Barrack, Michelle T., et al. "Higher Incidence of Bone Stress Injuries With Increasing Female Athlete Triad–Related Risk Factors: A Prospective Multisite Study of Exercising Girls and Women." The American journal of sports medicine 42.4 (2014): 949-958.

3.Highlights from the Female Athlete, BASEM Spring Conference 2015

14 May, 15 | by BJSM 151 Undergraduate perspective on Sports & Exercise Medicine – a BJSM blog series

4. Lecture Series by Margo Mountjoy MD on The Body Matters (edx course McGill University)

Surfs Up - Exercises for Surfing on Dry Land

There are an estimated 2.5 million recreational surfers in Australia. An online survey to try and pinpoint what kinds of injuries amateur surfers sustain was carried out in 2015. This survey found that shoulder, ankle and head/face injuries were the most common acute injuries. Injuries were particularly high for surfers that performed aerial manoeuvres. 

The action of surfing can be divided into three main groups: 

The endurance paddle out 

The high power paddle into the wave

Riding the wave.

Paddling puts strain on the shoulder joints but also because of holding the head for visibility and arching the upper back to allow arm clearance in the water it also puts strain on the neck and upper back. Riding the wave requires lots of twisting and flexing forward through the lower back. This strains the lower back and puts high torsion strain on the knees and ankles. 

Surfing requires extreme levels of of aerobic endurance as well as fast muscle power output. For this reason it is really important to train endurance, strength and core balance. Not everyone can get to the water every day so here are some suggestions for dry land exercises to prepare you for the surf.


Strength Exercises (8-12 repetitions in 3 sets): 

1. Bent over dumbbell rows

2. Dead lifts

3. Squats on a bosu ball

4. Planks on a bosu ball

5. Reverse cable woodchops

6. Alternating sandbag lunges


Plyometric Exercises (these help with the power component):

These are best done on a soft surface like grass. Make sure you are warmed up and light on your feet and avoid landing on your heels. Make sure you rest for at least a minute between sets. 

Squat thrusts into a pop-up (30-60 seconds, 3 sets)

Box jumps (30-60 seconds, 3 sets)


Aerobic exercises: 

Swimming is the best for obvious reasons. But, running and cycling will also improve endurance. 


For those wanting to get a bit adventurous the Indo Board allows you to do exercises that help train the movements you do surfing but without leaving dry land. You can perform exercises like lunges, squats and planks on the board which makes them harder and also engages stabilisers in the knees and ankles. Surfset is also a good form of training. 

For those of you on a budget you can train by putting your board on two inflatable stability discs. If you are going to give this a try make sure you protect your board’s fin. These exercises will also test your stability and unlike surfing, if you fall off, the landing is harder so be careful. 


Check out ProSurf Training, a great app developed by Joel Parkinson and his trainer Berg. 

Top Exercises for Orchestral Musicians

By Dr Susan Tyfield (M.Tech.Chiropractic)

National and international surveys show that the lifetime prevalence of performance-related musculoskeletal disorders (PRMDs) in professional orchestral musicians ranges from 39-87%.

Over time professional musicians develop very specific patterns of how their nerves control their muscles. This is also called mapping. 

The cumulative effect of this can lead to adaptive changes which can include postural imbalances and asymmetrical strength and mobility. Despite this, very little research has been done to develop a targeted strength and rehabilitation program for professional orchestral musicians. For this reason a study was done by Chan C, Driscoll T and Ackerman B to develop and assess a specific exercise program for musicians. 

This program included neck, shoulder, back, abdominal and hip exercises and is very in depth with 5 stages of progression. 

Here are a few exercises from the first stage and we will cover the more complicated ones in future blog posts:

Warm up: 1. Standing with your weight even on both feet and do deep diaphragmatic breathing. Place one hand on your chest and the other on your abdomen. As you take a deep breath in you should feel your abdomen raise up followed by the hand on your chest.

                     Do this 6-8 times slowly.

                  2. Roll your neck and shoulders for 30 seconds.

                  3. Gently reach to touch your toes

                  4. Do gentle controlled rotations for you upper and lower back.

Stage 1: Neck - Deep neck flexor exercise

              Shoulders - Middle and Lower Trapezius Activation

              Spine - Prone leg lift

              Abdomen - Single leg fall out

              Hip -  Deep hip external rotator activation (clam exercise) do without exercise band

Cool down: Same as warm up

These exercises are designed to target supporting muscles that are under-activated during playing. During the research study musicians voiced concern that the exercises would lead to fatigue and affect their practice but this didn't prove to be the case as the exercises are designed to work under activated muscles. 

Always remember the big self care habits, rest, hydrate, and a healthy diet. 


Chan, C., Driscoll, T., & Ackermann, B. (2013). Development of a specific exercise programme for professional orchestral musicians. Injury Prevention19(4), 257-263.

To Stretch or Not To Stretch

By Dr Susan Tyfield (M.Tech.Chiropractic)

Does stretching prevent injuries? This has been a very contentious issue in sports. There are a lot of theories and different evidence on this topic. Let’s take a look at some of the research we do have.

Firstly, keep in mind that stretching before exercise and at other times has been mixed up by many people and we will see that they are different things.

Research has shown that in a series of stretches, after the first stretch, on the next stretch you can actually go further because you feel less pain. This is called stretch tolerance. This can be useful in certain situations to give you pain relief, such as when muscles are in spasm. But in terms of injury prevention, masking pain in this way has the potential to lead to injury. 

Another factor to take into account is that our ability to resist injury is also related to the amount of force that a muscle can absorb or generate. For instance, research was done using a machine similar to a Cybex machine, which gives resistance equal to the force that you put out so that muscle strength can be measured. This research found that after stretching, muscle output was actually weaker or less than previously. Similar results were found with both static and dynamic stretching. This may not correlate to injury risk directly, but what athlete would want to be weaker when they head out to train? 

It would also seem that eccentric (resistance) contraction of muscles - such as when your hamstring tightens to resist your knee straightening when you’re running - is actually stronger when the muscle is cold (more stiff), rather than warm. Muscles have, in fact, been shown to tear at the same length whether warm or cold. 

Don’t get excited though. This doesn’t mean you can abandon your stretching completely, you just need to think about it a bit differently. Instead of only stretching before you exercise, evidence shows that a regular stretching regime in and of itself does seem to increase muscle strength long term. So perhaps yoga can be viewed as weight training after all!



Magnusson, S. P., Simonsen, E. B., Aagaard, P., & Kjaer, M. (1996). Biomechanical responses to repeated stretches in human hamstring muscle in vivo. The American Journal of Sports Medicine, 24(5), 622-628. doi: 10.1177/036354659602400510

Shrier, I. (2004). Does stretching improve performance? A systematic and critical review of the literature. Clinical Journal of Sport Medicine, 14(5), 267-273.

Simic, L., Sarabon, N., & Markovic, G. (2013). Does pre-exercise static stretching inhibit maximal muscular performance? A meta-analytical review. Scandinavian Journal of Medicine and Science in Sports, 23(2), 131-148. doi: 10.1111/j.1600-0838.2012.01444.x

Siu, P. M., & Alway, S. E. (2005). Subcellular responses of p53 and Id2 in fast and slow skeletal muscle in response to stretch-induced overload. Journal of Applied Physiology, 99(5), 1897-1904. doi: 10.1152/japplphysiol.00374.2005

Preventing Pain in Young Musicians

by Dr Susan Tyfield (M.Tech.Chiropractic)

The field of performing arts medicine is fairly young. Which means that little research has been done to examine it and there are few medical specialists trained in the special needs of this group. Despite this, it is becoming more and more apparent that unhealthy behaviours in early technique and body maintenance can become life-long problems.

Musicians are often compared with athletes because much physical exertion and long hours of practice are required when playing an instrument. Unfortunately, until recently both the medical community and performing arts community didn’t treat them as such. This has led to a bad foundation of care for musicians’ musculoskeletal needs, and many of these bad postural habits begin early in their playing careers. In Australia, the teaching of instrumental music performance lags behind elite sport with regard to producing optimal performance to ensure the least amount of stress on the body.

The University of Western Australia has just instituted a collaborative project which aims to reduce the risk of injury for young musicians, by filling a gap in teaching at tertiary schools of music. This is, however, aimed at older music students, still leaving a gap for child and adolescent performers during the time when they are beginning the foundation of how they play and care for themselves

An article in the European Journal of Pain found that there appears to be a connection between the reporting of pain in childhood and those children having more experiences of reported pain into adulthood. If pain is not addressed and treated early on, it can greatly impact a child’s quality of life, by interfering with mood, sleep, appetite, school attendance, academic performance, and participation in sports and other extra-curricular activities. And in fact, if unrelieved, childhood pain can increase a child’s vulnerability to pain later in life.

For example, in research done to see how often adolescent string instrumentalists experienced muscle or joint pain in the preceding month, researchers found that 73.5% of the children had experienced some playing-related pain.

Given that often children and adolescents don’t tell parents or caregivers that they are in pain, it is of even greater importance to start an early care plan for those who might be vulnerable. 



1. Ackermann, B. J. (2016). From Stats to Stage--Translational Research in Performing Arts Medicine. Medical Problems of Performing Artists, 31(4), 246.

2. Brattberg, G. (2004). Do pain problems in young school children persist into early adulthood? A 13‐year follow‐up. European Journal of Pain, 8(3), 187-199.

3. Mathews, L. (2011). Pain in children: neglected, unaddressed and mismanaged. Indian Journal of Palliative Care, 17(Suppl), S70.

4. Vinci, S., Smith, A., & Ranelli, S. (2015). Selected Physical Characteristics and Playing-Related Musculoskeletal Problems in Adolescent String Instrumentalists. Medical Problems of Performing Artists, 30(3), 143.