Why RED-S Matters to Every Podiatrist

Key Takeaways

• RED-S affects more than elite female athletes. Low energy availability can occur in athletes of any gender or sport, particularly those participating in weight-sensitive or appearance-focused activities, increasing the risk of stress fractures, overuse injuries, and delayed healing.
• Podiatrists are often the first clinicians to recognize RED-S. Recurrent stress injuries, persistent foot and ankle pain, delayed recovery, and concerning behavioral patterns around exercise or nutrition should prompt clinicians to consider an underlying systemic cause rather than focusing solely on biomechanics.
• Early recognition supports better long-term outcomes. Identifying RED-S and coordinating care with nutrition, mental health, and sports medicine professionals can help optimize injury recovery, protect long-term bone and metabolic health, and support safe return to sport.

Please note: This content is a direct transcript, capturing the authentic conversation without edits. Some language may reflect the flow of live discussion rather than polished text. 

Transcript

Jennifer Spector, DPM: Hello and welcome to Podiatry Today Podcasts. I'm your host, Dr. Jennifer Spector, Podiatry Today’s Associate Editorial Director. Today's episode will explore an increasingly important topic that every podiatrist should understand, which is relative energy deficiency in sport or RED-S. We've talked about this before in Podiatry Today and while many of us were trained to recognize the female athlete triad, our understanding of how low energy availability affects athletic performance, injury, risk, healing, and overall health has evolved significantly since then. Joining me today is Dr. Savannah Santiago. Dr. Santiago is an incoming third-year resident at Ascension St. Vincent Hospital in Indianapolis, Indiana, where she's completing her podiatric surgical residency under our editorial board member, Dr. Patrick DeHeer. She's an active speaker, educator, mentor, and columnist, and she already plans to continue her surgical training as a foot and ankle fellow with Illinois Bone and Joint Institute under the mentorship of Dr. Brian Burgess.

In this episode, we'll discuss a recent session from the APMA National on how that conversation has evolved beyond the female athlete triad, what foot and ankle findings may signal an underlying energy deficiency and the important role that podiatrists can play as a part of the multidisciplinary team caring for these athletes. Dr. Santiago, congratulations on your session at the APMA National and welcome to the podcast.

Savannah Santiago, DPM: Thank you so much. I'm so excited to be here and this is my absolute favorite topic to get to talk about.

Jennifer Spector, DPM: It's been really interesting learning more about this concept through some of our contributors and I'm just so excited to touch down with you today. In our training, a lot of us were trained to recognize the female athlete triad. How is the conversation different with RED-S?

Savannah Santiago, DPM: Yeah, so I think one of the most important things, I was actually a college cross-country and track and field athlete, so this topic's near and dear to my own heart. But one of the most important things about RED-S is that it involves both our female and male patients and everything in between. So for our female patients, it was initially with the female athlete triad. We were just looking at female athletes that were losing their period or amenorrhea, but with the change to RED-S is actually looking at the athlete as a whole and how those symptoms manifest. And it's not only looking at female athletes, but also our male athletes and specifically types of athletics that have a large promotion on appearance or on weight. So I always give the example of my little brother wrestled in college. So especially when you're having to make weight, when you're in these types of sports that have weigh-ins that have certain aesthetics associated with them, men can also have eating disorders and can have problems with their health due to improper fueling.

Additionally, RED-S looks at the lack of proper energy consumption and the impact on athletes, whereas the female athlete triad was more so just looking at the lack of a period and stress fractures.

Jennifer Spector, DPM: And it seems like we're missing a lot if we're only thinking in terms of that female athlete triad.

Savannah Santiago, DPM: And we were looking at only a certain type of athlete. We were looking at the super tiny ballerinas or the marathon runners that were as big as my pinky finger. And when we're talking about relative energy deficiency in sports, it can happen to anyone who's training very hard, is pushing their body hard and isn't consuming enough for the energy output that their body is asking for.

Jennifer Spector, DPM: Right. So for the everyday podiatrist, are there foot and ankle complaints like stress injuries or delayed healing perhaps that should prompt us to think beyond just the biomechanics and consider that underlying energy deficiency as a possibility?

Savannah Santiago, DPM: Absolutely. I think the biggest sign is your interactions with the patient themselves. The type of patient that generally speaking suffers from RED-S is someone who's a perfectionist. They have almost OCD or compulsive-like habits when it comes to exercise, when it comes to food consumption, when it comes to talking about exercise or the importance of exercise. And we have to keep in mind for a lot of these athletes, I mean, their entire world revolves around their ability to work out, their ability to perform, especially our professional or amateur athletes. So it's a patient that comes in, they just seem really desperate. They're really clinging on. They're just really emphasizing how they can't work out or they can't meet this metric. They're compulsively talking about how important it is, how they have to get back on this. They are talking about food. They seem very food focused of like, "Well, if I can't work out, then I can't consume this or I can't do that.”

Additionally, it's going to be an athlete that presents with stress fractures, overuse injuries, chronic problems. It's the athlete that presents very often to your clinic. And when you talk to them about their exercise, they're very regimented of, "I exercise this much, I do this and X, Y, and Z." And while discipline is absolutely so important, especially for a serious athlete, it kind of comes to that more pathological sense of something just seems off when you're talking to this patient about what's going on. If you mention having to take any time off, it is the absolute end of the world. They don't feel that they're able to take time off. They're resistant to the idea of slowing down or not doing anything else. And with especially a child athlete, if the parent is speaking in a way that seems like, well, they can't take any time off, they're being pushed really hard, it might also be time to ask the parent to take a step out, please.

I had a situation in clinic where it was a female gymnast and after we asked the patient to step out, the child began to cry saying how much she hated her sport and that she couldn't do it anymore because she felt like her body was breaking down. And so looking at all of those things, also talking to our athletes about the classic symptoms. If they're a female, are they getting their period? Are they having aches and pains that just aren't going away? How's our healing process going? If you notice that they have abnormal hair growth, anything like that, just the appearance of the patient as well.

Jennifer Spector, DPM: It seems like such an impactful and such a complex interaction. When you identify a patient that potentially is dealing with RED-S, what role do you think we play as podiatrists in that larger care team and how do you start some of these difficult conversations?

Savannah Santiago, DPM: I mean, I think that we play a huge role. When people are getting these types of sports-related injuries, often the podiatrist is one of the first doctors that they're seeing about it. And it is important for us to be screening for this criteria to have an eye open that, "Hey, this is their third overuse injury this year. This is the third time I've seen them for a stress fracture in the last couple of months." Or I asked the patient to take a break from running, rowing, swimming, whatever they're doing and they kept going full speed, didn't take any time off and now their injury's worsening. Or the way that I talk to them, their reaction to the idea of taking any time off or when I talk to them about their nutrition, they're very defensive, noticing all of these little red flags and potentially prompting them and making sure that they know that mental health services may need to also be on board, that we want to work with them, getting them connected with nutritional services.

If a patient has a BMI under 18, that is always a red flag and telling them like, "Hey, with how your health currently is and where your BMI currently is, we can to operate on you, or we can't do X, Y, and Z," and making sure that we're getting an entire team of people involved to help support the athlete the best we can.

Jennifer Spector, DPM: Thank you so much for sharing this. I think we've learned a lot about a different view on how podiatrists can be part of a multidisciplinary team. We're very familiar with it in other types of pathology like the diabetic limb, but in this type of sports medicine environment, it's a really interesting point of view to see where we fit in the bigger picture.

Savannah Santiago, DPM: Yeah, of course. This is one of my favorite topics to talk about, and I promise I have so much more to say and I look forward to interacting with everyone on it.

Jennifer Spector, DPM: Well, I'm sure it's going to be a great session and as we've discussed today, foot and ankle injuries can sometimes be the first clue to a much larger systemic issue. Recognizing those signs of RED-S and understanding when to engage a multidisciplinary care team can help us as podiatrists to both improve athletic performance and long-term patient health. Thank you to the listeners for joining us for this episode. Be sure to subscribe so you don't miss future conversations on clinical, surgical and professional issues shaping podiatric medicine today. Thank you so much, Dr. Santiago for being with us.