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Episode #69

Injury Prevention & RED-S

with Emily Kraus

15 Mar, 2022

VIS Expert, Clinical Assistant Professor at Stanford University, Dr. Emily Kraus, shares injury prevention tips, ways to prevent RED-S & the female athlete triad, and the gap in medicine research between male and female athletes.

Voice In Sport
Episode 69. Emily Kraus
00:00 | 00:00


Episode #69

Expert: Emily Kraus

“Injury Prevention & RED-S”

Stef On today's episode, we're speaking with Dr. Emily Kraus VIS expert and current clinical assistant professor at Stanford Children's Orthopedic and Sports Medicine Center. Dr. Kraus is board certified in physical medicine and rehabilitation and takes a unique approach to the diagnosis, treatment and prevention of sports injuries. She is also super involved in the athletic community. Dr. Kraus proudly grew up as a three sport high school athlete in a small town in Nebraska, and now is an avid runner and cyclist. She has competed across nine marathons, including Boston marathon twice, in California international marathon in 2019 with a personal best of two hours and 50 minutes.

As an athlete herself, she recognizes how sport participation plays a valuable role in the physical, emotional, professional, and social development of an individual. She's committed to maintaining these ideals for the future generations of athletes. She's involved in multiple Stanford IRB approved research projects that focus on female athletes. Her clinical interests lie in endurance sports medicine, bone health, running, biomechanics, adaptive sports, and overall supportive female athletes.

In this episode, she shares tips with us on how we can prevent RED-S, the female athlete triad and bone health issues by improving our nutrition and recovery habits. We also dive deep into and discuss her newly launched FASTR program at Stanford.

Stef Welcome to the Voice In Sport podcast, Emily. We're so excited to have you here with us today.

Emily Thank you for having me Stef and Voice in Sport.

Stef I mean, I'm so excited to talk to you about so many things today, your background as an athlete, as a doctor, and somebody who's part of the VIS community. You have so much knowledge to share with us. So can't wait to get into it, and we're really gonna go deep in female athlete triad, RED-S, bone health, and injury prevention.

So, I want to start though with your own personal experience, you know, you, you grew up in a state as well, it's a little bit off the radar, like mine, Nebraska, not Alaska. So but you were also a three sport athlete, and I want to kind of go back to your personal experience as an athlete at a younger age.

How did you get into sports, and why did you pick those three sports?

Emily Yes. I love going back to my roots, first of all, and I, um, yes, I'm a Nebraskan at heart. I was probably born in a small town in Nebraska called Holdridge, and I actually spent the first 26 years of my life in that state. I feel really lucky to have been exposed to a lot of different sports growing up.

 I actually just looked up this old photo of my T-ball team, and I have this photo of me rounding the bases, like it's with these jorts on and this oversized cotton t-shirt, and I am just beaming ear to ear, and I feel like that should be how everyone's first experience with sports should be like

Where it's fun, it's a team, there are popsicles at the end of each game and practice, and it's, I think there is a way to. Kind of carry that through as the sport evolves and as the athlete grows up. And my, my main sports that I played in high school were cross country, basketball, and tennis, which was a lot of different, lots of different sports. Some individuals, some team sports, and I loved them all.

I played golf in the summertime too, and we were a very active family, and so every day we would be playing tennis as a, as a family, or we're going out on the golf course or shooting hoops with my dad and the early mornings. And I learned a lot about myself through that about self-discipline, and there was something to be said about living in a small town where I was able to play all those sports all four years of high school, and really be able to dedicate that time to that sport.

And now, as I'm working as a physician at Stanford children's and seeing a lot of athletes who come into my clinic, it's a little bit of a different story where there might be a single sport that they play all year round. And that dynamic has changed to some degree.

So I make a point of really encouraging athletes to consider diversifying their sports and continuing to experiment and sample. I think that may help with some of those questions of burnout and those overuse injuries and some of the other injuries that we may see when they do kind of take that moment to sample in other sport, because they may have a lot of fun playing tennis or picking up a golf club and swinging it around for awhile.

Stef I love that. So you're in the office all the time, seeing young athletes come into your clinic. I think that must give you such a great perspective on what these young athletes are facing every day. So, for the girls that are listening to the podcast today, what do you wish you could whisper to like all of those young athletes that come into your office, you know, something consistent that you wish you could tell them about their journey, you know, to have a positive impact on them.

Cause I'm sure, you know, you would have parents coming in there with the kids. You don't always get to like, just say, Hey, you know, like stick with it. So if you share with our audience, what is one thing that you wish you would whisper to all of those young athletes that come into your office.

Emily Oh, just one thing. Oh man, it's hard to just narrow it down to one, but I think it's important for those athletes to realize that tomorrow is one day, but we need to think about the future and the next year, the next five years, the next 10 years of their active life, and what habits they're doing now actually can have an effect in 10 years.

And that's hard for that athlete to really process because they're thinking about tomorrow's game they may not be able to participate in, but there are going to be more games, and if this injury is handled properly and if we can really get to the root of the problem, which sometimes requires peeling the onion quite a bit, they'll get back and they'll get back stronger.

So, it's really hard because I think sometimes when an athlete comes in with an injury, they've got these walls up, they're upset, they're frustrated. They're either angry at me or angry at their parent for bringing them into the clinic to get that diagnosis. But it's the long game that we really want to focus on and we want to keep these athletes in sports.

So that's I guess one piece of advice is it's not just about that next game or tomorrow, it's about the future of their athletic life.

Stef I love it. It's so important. Well, you talked about something so critical, which is trying different sports when you're younger and, you know, exploring, I mean, some of the best Olympians that we have on the podcast, maybe didn't even get into their sport until they were like 20 or into college. So, I think that there's so much power in trying different sports and seeing the benefit across doing multiple.

And you're actually a good example. I mean, you didn't go on to the Olympics and win a medal, but you are still an active runner yourself, ultra distance, and you're super into cycling. You know, how do you think, being involved in the three different sports that you have essentially sort of created as your craft and how do you think it has affected your body in the long-term?

Because I would imagine being in three sports is positive on one side, cause we get to work on different muscles groups and stuff like that, but then it could probably be pretty tough on your body, too. So, you know, I'm just kinda curious on, if you noticed the sports that you're in and how it has affected your body.

Emily I forgot to even mention one of the earlier activities that I did, which was ballet. I did ballet for a few years, and I remember my mom commenting that when I would run down the basketball court, I would like bound like a ballet dancer. So, I will say that all of those different sports can help influence and in a positive way each other.

And for example, I believe strongly about some degree of participation in sports that involve multi-directional movement patterns. So, I think, like playing basketball and playing tennis helped build my bones for kind of long-term bone health, potentially more than just running and the more repetitive impact of running.

And I think there was a protective component, even though I don't play a lot of basketball and I wish I played more tennis now. But, I now run pretty consistently, and so the bone building effects of that multi-sport participation was really helpful and protective. And another thing just as far as just my love of running, I would say my first love for sports is running, but I really do enjoy all sorts of cycling, gravel, mountain bike road, but my love of running, I think I was able to hold on to that and really kind of grow that love throughout high school, college, med school, through kind of this gradual build and increase in, in running. So, I participated in running for a season in high school, and then I went to a different sport, and I think it really protected me from some of the overuse injuries that I do see in the year round runners that come into my clinic. And I know it's really hard because these athletes, they, they love to run, and so me telling them to run less is just almost like nails on the chalkboard as far as delivery. And I think that they could really try other sports that can compliment. I have an athlete who does some rock climbing. I've another athlete too. Um, Some swimming just to really kind of build that kind of full body strength and that core strength and endurance.

Stef I love that. So how did being involved in running or just sport in general impact your career decisions, and how did you eventually end up deciding to focus on female athletes in sports science?

Emily Yeah. So I was one of those rare birds who knew they wanted to go into medicine at a pretty young age. By the time I think it was seventh or eighth grade, one of my science teachers really struck me as someone that I wanted to be like. And she and Mrs. Bricker shout out to Mrs. Bricker if she's listening to the Voice in Sport podcast.

So I, I loved the sciences. I knew that I loved being active. I was a very active child and teenager, and so I wanted to find this way to combine the science and physical activity. And in high school, I started to shadow a lot of the primary care doctors and family medicine doctors in my hometown. And I really appreciated the ability of their practice and what they could do to impact the lives of the patients that they saw.

And there was a continuity there that I really appreciated as well, where they could see that that patient grow. And so I wanted to be able to make that type of impact. And so my love of athletics really motivated my pursuit to explore more of a sports medicine direction.

And I actually thought I wanted to be an orthopedic surgeon for quite a while. So during high school, through college, through three years of my med school, I was on this track to become an orthopedic surgeon. And I thought that I wanted to be a team physician for a professional football team, specifically the Denver Broncos, because that was one of the closest football teams to, to Nebraska.

 And I thought that was kind of the, the way that I treated athletes. My mind wasn't even broadened out enough to really see the delivery of care to female athletes like myself. And I had a couple of injuries where I would see physicians, but I didn't put it together that I could be in that type of a role in the future.

So I eventually realized that I didn't want to be an orthopedic surgeon, I wanted to hold more of a comprehensive type position to treat athletes. So, really look at all the different factors that could be contributing, including nutrition, training habits, what's your shoe wear? Are you doing any strength training? What's your sleep like? And I took the approach of pursuing a field called physical medicine and rehabilitation or physiatry that really takes that comprehensive approach to the care of all patients. And that's where I really fell in love with exploring and trying to ask both the right clinical question, but also then study that through research and through that got involved in some research studies, which I think we'll talk about that really opened my mind to the need to care and better understand the female athlete.

And through that, I started to do more clinical care for the female athlete and more research for the female athlete. So, it's kind of this very kind of circuit as tangential way to get to this field, but it started at a pretty young age and my exposure to sports and athletics during those times really made me understand the impact of physical activity and sports participation, both for just kind of the health benefits, but also just like life skills and overall career direction.

Stef I love that. Well, now we have another thing in common because I also wanted to go to school to study sports medicine, but once I got to school and had my first organic chemistry class, I realized, you know, not so much. So I want to ask you about what is the, you know, skills . And education that you really feel like you need to be successful or good in this field?

Because, you know, I'm a good example where I took one class and I was like, oh, I'm going a different direction and it probably was the right call for me, but for young women today who are in college, and they're thinking about getting into sports, science, and research, or even the medical field specifically for sports, what would you say to those girls are the most important aspects they need to be considering?

Emily Yeah, organic chemistry that will get you. I still have, have some post traumatic stress from some of those organic chemistry tests, but I survived, I'm here. I would say, I think you had it like this really deep interest and passion to pursue this field. And I think you need to have that fire.

You need to have a strong desire to really commit to a bit of a long-term, longer track. And I think I was fortunate to not really have blinders on because I still explored other careers throughout that time. But, I knew in my gut that this was something that I would continue to love and be good at.

And I had the knowledge and the background and the experience and kind of that mindset and determination to get through those painful organic chemistry classes and some of those other classes, even during med school where you really, you kind of hit some low points that can almost break you and not to scare people, because I think you learn a lot about yourself during those moments, too, where you're like, okay, how can I get through this with performing at my best while still maintaining my sanity.

And so I think that my coping mechanism was running and my outlet was to go on runs to kind of process or just completely escape from the stress of an exam and take that brain break and get out some of those nervous jitters or pre-test jitters, and that helps me kind of level out as far as just being prepared and being organized.

So I think having that balance and that drive are important pieces. I mean, really having a love of the science and a love of those topics that you're going to be getting exposed to and learning about for hours and hours on end and being willing to kind of commit to the long haul for a longer career track where the rewards are going to be different than maybe the compensation or adult job. That adult job is going to come a little bit later than, than it maybe in other careers.

Stef Well, I love that full circle. I didn't continue on that track, but you did. And now here we are trying to solve really the same problem, but from a different angle, right. I'm creating a company to support it. I ended up going the sport business route and you went the sport medicine route.

And I think what's really cool is when you then find partners like we have in ourselves and the other women involved at VIS to then figure out how do you make something great that will help these young girls in their journey. So, although I sucked at organic chemistry, I'm proud to say that I was okay on some of the business classes.

Here we are, you know, making something great together. So, I want to talk a little bit about some incredible projects you're working on at Stanford. Specifically focusing on female athletes and the gender gap, which is still very much real. The gender gap is real in sports science. The gender gap is real in sports.

 So I think that in this area of sports, science and research for women in particular, we have a lot of room to, to really grow and to accelerate. So, can you explain to us what the FASTR program is and the goal of the program?

Emily Yes. Also Stef, I wanted to just share that if you were willing to teach some business classes, some sports business classes, I am all ears. So, I'll be first row in the classroom taking all the notes, asking you all the questions.

Stef Amazing. Well, we can swap, we can have exchange classes.

Emily Perfect. All right, so FASTR. This is new. This is program that I'm so excited to introduce to the world. And it's really been fun to get involved with over the past year. And so FASTR, first of all, stands for Female Athlete Science in Translational Research, and, Stef, as you mentioned, we focus on addressing this gender gap.

That's still peasants and human performance and research today and women in sports. Our main focus at the beginning is really talking about early identification and interventions to treat the female athlete triad and prevent the female athlete triad, and also relative energy deficiency in sport or RED-S.

And we're really trying to find ways to improve the health of girls and women. Of all abilities through both athletic participation and performance. We're really also hoping to translate this research and information and get it into the hands of athletes, coaches, other practitioners in the community, so they can really learn and help spread this good information.

 So this program is a research program that's at Stanford and we are in close collaboration with Harvard. Harvard has an amazing female athlete program led by Dr. Kate Ackerman. And it's been really rewarding to be able to work with her more consistently on these projects and find ways to collaborate.

And I really just soak up her mentorship. She has a lot of experience in both the clinical care and research of women in sport. And it's been a journey that's just beginning and I'm excited to just continue to pursue these projects and this learning and growing with her.

Stef I love that two different universities came together to create this program. I always think when you can partner with the right folks across different organizations, it can really accelerate the change. And I want to talk a little bit about that change and that gap, like why do you think that gap exists in the first place? And what brought the two organizations together to get after this. .

Emily Yes, I'm so glad you mentioned this because I would not be directing this FASTR program and I wouldn't be collaborating with Harvard if it wasn't for this bigger initiative from the Wu Tsai Human Performance Alliance. So there is a multicenter effort or initiative to really look at answering questions on health and human performance of all athletes.

We are so fortunate to have been included in this larger initiative and through this FASTR program and the Harvard program. So big shout out, and you can check out Wu Tsai Human Performance Alliance and learn a lot more about some of the other projects and innovation hubs that they're also really trying to tap into and better understand for athletes of all ages.

But specifically with female athletes, there has been a gradual then rapid increase in female sports participation, especially around the time of Title IX. And, so with that increase in female sports participation, there's been this need to better understand these physiological differences between sexes so we can better understand the injuries, treat those injuries, and both improve health and performance and longevity in sport. And, unfortunately, a lot of the research out there still on athletes is primarily about male experiences. And we are really working on trying to close that gap as far as knowing how those injuries present, how we should diagnose them differently, treat them differently and really understand the unique risk profile of a male or female athlete.

 And how that differs between sport, how that differs among the ages, so, an adolescent athlete or a pre-pubertal athlete is going to present differently and going to need different management than an adults athlete or a masters athlete. So, we really need to close that gender gap in all those different levels.

And I mean, there are so many different areas and research questions that we can ask. And I think one of the challenges that I have right now, Where do we start? Who do we collaborate with? And it's been super exciting and, challenging to kind of narrow that focus to really get to the important questions early and then kind of build on those.

Stef Well, I think it's amazing. And it's also a big reason why we started the Voice In Sport foundation, because I think we need more focus and we need to accelerate these areas. So, we're really excited to support any of the work that you guys do there. And hopefully with the research that you guys are going to be doing that gap will become smaller and smaller and smaller in the future.

So if you take a step back and think, okay, five years from now, what is the impact that you hope the FASTR program will have on female athletes?

Emily Yeah, the big five-year, ten-year vision would really be that we have a system in place to translate this information and the fundamentals is already in the hands of coaches, parents, athletic trainers, athletes. And now we're starting to get to more of those specific research questions revolving around the menstrual cycle revolving around how to really screen an athlete from just an early age to prevent these more devastating injuries such as a bone stress injury, or overuse injury to the bone, stress reaction, and stress fracture, or even an ACL injury, both pretty much seasoned ending or a year ending or even career ending in certain athletes.

So those are big goals. So starting with really getting that information out in a way that's very systematic and accurate and efficiently delivered. So, we don't expect coaches or parents or athletes to read all of the manuscripts that we're writing, but it's our obligation to continue to translate that just as much as it is to do the research too.


Elizabeth Thank you for listening to the Voice in Sport podcast. My name is Elizabeth Martin, a soccer player at Emory University and producer of this week's episode. If you enjoy hearing from Emily Kraus and would like to get the chance to talk to experts like her, go to to sign up for a free membership and gain access to exclusive episodes, mentorship sessions and other weekly content.

Don't forget to follow us on Instagram, Twitter, and Tik Tok @voiceinsport. Now, let's get back to the episode.

Stef I love that. I think it's so important. So let's talk a little bit about the athletes specifically. I mean, you're a runner yourself, I know you worked on a project, The Healthy Runner Project that interviewed quite a few collegiate athletes and high school athletes. So can you explain the why behind The Healthy Runner Project and what you learned?

Emily So Healthy Runner Project is a project that's very near and dear to my heart because it was my first project when I got to Stanford from Nebraska. And it was at that stage, we were doing these retrospective chart reviews to fuel the research for the actual study and Dr. Fredricson, who's the principal investigator as well as Dr. Really in a T that UCLA Dr. Fredricson's at Stanford. He trusted me to be the research coordinator as a resident. And I'm lucky to still be involved with it now. So this was back in 2016 when this started and The Healthy Runner Project is a four year prospective study at Stanford and UCLA looking at whether a nutritional intervention to increase energy availability could help improve overall bone health, specifically bone mineral density, and prevent overuse injuries on bone stress injuries. And so through that, we did these pre-seasoned screens that were pretty comprehensive.

We did questionnaires in addition to the questions that the athletes would fill out through their pre-participation physicals. And we got extensive menstrual cycle history. Did the athlete have a period, not a period. Are they on any oral contraceptive pills or any other type of hormonal replacement?

 Did they have any on their injury history specifically or especially bone stress injuries and any other disordered of eating history, which was really obtained from a sports dietician with experience and accreditation? Asking those types of nutritional related questions. And then we would categorize an athlete as low, moderate, or high risk based on the female athlete triad cumulative risk assessment.

And that would help us understand the degree of nutrition intervention that that athlete may need over the course of that season. And so the study is to determine whether that nutritional intervention actually reduces the incidents of bone, stress injuries, and stress fractures. But some of our preliminary research did find that those scoring tools that we use, those pre-season scoring tools, which were still at the time of implementation.

 They did actually predict future bone stress, injury risks. So the screening tool was important. And now the question is how do we use that screening tool to prevent those consequences from happening or manifesting down the road.

Stef That's amazing. Well, some of our athletes at VIS we're part of that study at UCLA. So, when we were preparing for this podcast, they were all excited about that. They're like, wait a minute. I was there. I was in that study.

Emily Thank you for participating.

Stef Yes, it's amazing. It's so important. Well, and I want to talk a little bit about bone health, because this is an area I think that we don't talk enough about until it breaks so just at the highest level, you know, what do female athletes need to know about their bones? Before they get in a place where they get a stress facture, what would you say highest level of female athletes need to know about their bones.

Emily Well I may be biased, but I think understanding bone health and bones are important for our livelihood and they keep us upright. We're sitting with, because of our bones, we are walking, we're running, we're active because we have healthy, strong bones that are keeping us upright. And we have hundreds of them in our body.

They are continuously remodeling, so they're, they're breaking down and they're rebuilding. And that's part of this beautiful process that allows our bones to continue to grow and allows us to get taller. And break down every time we exercise and we run. But I think it's important to also realize that there is a fine balance between that bone building and bone breakdown, and that evolves over time.

And especially in the adolescent athlete, these are their peak bone building years. And, and so we need to do everything possible to optimize that time and so that's one of our big focuses both in my clinic, and in our research. Make sure athletes realize that if they come in with a broken bone it may not just because they landed wrong or they trained too hard. It could be related to other factors such as their nutrition.

Stef Well, I think it's really important to note that, especially in an area that you're really passionate about running and ultra marathoning that a third of ultra marathon women, so that's roughly 37% have had major stress fractures.

So, you know, unfortunately this is an area for runners that is just really prevalent. And I think that I want to help these young girls understand what they can do to prevent this from happening. And we're going to talk about RED-S and female athlete triad.

But if we can just fo focus for one minute on three tips that a female athlete can take today to ensure they have good bone health?

Emily You got to fuel your body. You got to think about what you're putting into your body and not just overall intake, but think about some of those micronutrients too, and think about the calcium, the vitamin D, and there are a lot of different diets out there, and I'm not going to preach one diet over the other but I do think that understanding how to get the optimal nutrients to allow those bones to build with the right minerals and those nutrients is super important.

And then I talked about previously the multi-directional activities and another reason to diversify sports and sample other sports that might be different than just running or swimming.

So participation in ball sports has been shown to have a protective effect on future bone stress injury risk, or stress fracture, stress reaction, risk. So I do encourage that and maybe an athlete it's like, I don't like ball sports. I'm not going to be forced into it. There are other things, different plyometric activities and other activities they can do to help build that bone strength.

And I also think that weight training and strength training is a great way to continue to optimize bone health through every decade of life. And that may look a little differently in high school compared to an athlete in her forties, but I still think it's super important.

Stef I love it. Thank you. I think it's so critical. I wish I would have had these tips when I was younger. So I appreciate, I appreciate that. So let's go into one of the areas that you guys are really going to go deep in with the FASTR program and that's RED-S and the female athlete triad.

I just want to start at the highest level. Are they the same thing? Is there differences? I heard that, you know, a female athlete triad is sort of the old way to talk about it. Red-S is the new way to talk about it. So can you break down those two for us and help us understand just what exactly they both are.

Emily I'm so glad we're talking about this. I wanted to take one more step back, or I guess a broader look and talk about low energy availability cause that's really at the foundation of both. So low energy availability occurs when athletes don't consume enough energy to account for the exercise and the body's natural processes such as metabolism as well as growth and development and especially in adolescents. So, over time, if that low energy availability becomes more of a chronic issue, that can cause these two conditions that are very similar to each other, the female athlete triad and relative energy deficiency in sport.

So starting with the female athlete triad that's includes low energy availability. And this may or may not include an eating disorder, impaired bone health, whether that's low bone mineral density or bone stress injuries, and then menstrual dysfunction, which may mean delayed or irregular periods.

 So, the concept of the female athlete triad started back in the 1980s and the term was actually coined in the 1990s. Then in 2014, the International Olympic committee put out a consensus statement on relative energy deficiency in sport. And so at that time they expanded the triad further on and really included other negative physiologic and performance consequences from that low energy availability beyond just that reproductive hormones, depression seen in the triad. And so those effects can include impaired metabolism, recovery, immunosuppression, and many other different systems, both from a health and performance effect.

So another thing I think it's important to realize is just how low energy availability can present. I'd mentioned a couple of different mechanisms from either inadequate energy intake that can then be done intentionally with restrictive energy intake or unintentionally with maybe an athlete's over-training.

Or I see it in these transitions. When an athlete maybe goes from middle school to high school, JV to Varsity, high school to college, where the intensity and the volume of their sports increases. Maybe they start to feel more pressure. Maybe they start to compare their body to another athlete's body.

And that's where these more subtle subclinical behaviors start to take place. And I think what worries me the most. And what's hardest to see is when an athlete who is maybe unintentionally taking in food or over-training flips to intentionally restrict because that athlete thinks she's getting a competitive edge and she's going to run faster or make the team, or maybe there is an aesthetic component too.

So that's where it's really hard. And I think it's really important to recognize those trends, both as a coach, both an as a, as a physician, during annual physicals, as a parent or even just as a teammate.

Stef Well, thank you for breaking that down. Like that's incredible. And now I think just really easy to understand. I think educating ourselves is one of the most important things to do. And that's super clear. So I want to know since you're a researcher and you're at Stanford, like what's the cutting edge research on female athlete triad and RED-S today. What is the most important research that has been done that female athletes, all female athletes should know today.

Emily Ooh. Oh man. I think there's so much out there. So, I mean, that's like the nerd in me, there's a lot of research going on at different levels. And whether it's that PAC-12 study or The Healthy Runner Project, I will say that they're expanding that project to other institutions now, which is really exciting.

And seeing if that nutrition intervention can be feasibly done at other schools. There has been a lot of research done to help compare RED-S I had mentioned that cumulative risk assessment tool with a similar risk assessment tool called the RED-S CAT, RED-S cumulative assessment tool. And so there's been work both to compare the two, to see how much they're similar and how much they're different.

But there's also work to really kind of take it to the next level. And one of the challenges with the, the triad tool is that some of those risk factors are non-modifiable. So we can't change the number of bone stress injuries in our past. We can't change the year that we first had our period.

And so finding that way to create a risk screening tool with more modifiable risk factors in it that can allow us to really work on addressing those risk factors to take that screening tool or screening system or scoring system down.

Stef Amazing. So what are, what are the most important things that female athletes should be paying attention to, to ensure that they don't get down a path where they do end up having RED-S or the female athlete triad experiences? Like what are the signs, the most important signs they need to be paying attention to.

Emily That's a really good question. I think it's challenging because I mentioned that a missed period is one example or one sign, but oftentimes the missed period is the later presentation. And we can recognize this earlier and pick up on these signs earlier. So an athlete may still have to some degree, regular periods, but still have some degree of reproductive suppression.

So they may have lighter periods or a period of shorter duration. They may have lost some of their other menstrual cycle symptoms such as cramping or mood variability. So those are signs that could mean that they're on that trend towards more hormonal and reproductive suppression and a lot of athletes they're on some degree of hormonal replacement for contraception, and, so, their periods are either very regular through taking the oral contraceptive pill, or they may have an IUD where they don't get a period at all. And so what what, what did those athletes do? I'm not going to tell an athlete to stop taking birth control. If they're taking it for reasons for birth control, but I do think they need to be more aware of some of those other symptoms that could be presenting as.

And those are a little bit more general, like fatigue, despite feeling adequately rested and having appropriate training and training load. Maybe just a plateau and performance in general, despite having a great coach and a great training plan. If they're in the clinic, we can get certain blood markers that can show signs of thyroid suppression or other sex hormone, suppression which can be still difficult to measure.

 If it's more at a chronic stage, they may even have increased inflammatory markers, not very specific, but it's another sign. There could be weight changes that happen as far as fluctuations in weight, especially if it's more extreme restriction, but it doesn't have to be, I think sometimes there's this idea that, oh, I don't have an eating disorder, so I don't have triad or RED-S, but it doesn't have to the degree of an eating disorder or weight loss to experience a lot of those effects of the hormonal suppression. And I don't want to try and scare people into thinking they all have RED-S or triad, but I think it's important to look internally. And if things are a little off you're more irritable or maybe your cycle is different, take a step back and look at the last month and be like, what could be a contributor?

Oh, I moved to college and I've been really stressed and I've been moving all the time and now I'm eating cafeteria food and I don't like any of the cafeteria food, so I've been eating salads two meals a day. Or I am still training the same amount and eating the same amount, but I'm walking a couple more miles a day or riding my bike around campus.

Or I'm super stressed about my organic chemistry test that's next week and I'm not sleeping and I'm studying a lot and that stress level, all of those things can start to overlap and play a role. And that's really hard to study. So I'm kind of talking more clinically now and kind of anecdotally, but all those pieces can be contributors to triad and RED-S and just injury risk.

Stef So what happens if you do start noticing a shift like that, whether it's a shift in your, in your period flow or fatigue or the plateau, any of those indicators you just met? What should you do? What is your first step to take? If you're a female athlete out there right now, and you're concerned about your body and sort of where it's at.

Emily So best case scenario would be if there is a, a dietician or somebody that is already within your team. Having a conversation with that, with that sports dietician and say, Hey, these are what I'm feeling. And it could be something like an iron deficiency or another mineral deficiency that has been subtly overlooked, or maybe just through a change in diet or a change in environment.

But they may be able to tease out pretty quickly that there is an under fueling pattern happening and that can really help alleviate any bigger stressors down the road with injury or kind of increases in severity of those symptoms. If it gets to a point where there are a couple of months of missed periods, I think having that conversation with a sports medicine physician or a physician who specializes in the female athlete is a really good next step.

 I think looking internally, like I said, at past training habits and other stressors and trying to address that piece as best as that athlete can and, and really maybe chatting with peers too, cause they may all be like, you know, I am, I'm experiencing a lot of these same symptoms and maybe there is some type of culture or theme within that team, whether it's through restricting intake or like just rapid increase in training load that they don't realize they're doing. That can be through communication, both within the team and with the coach to help address at an earlier stage. And I think that you need to create that environment to allow for those conversations to happen in a natural form or natural way before it gets too severe?

Stef Yeah. Well, let's talk about that a little bit. Cause I think culture is so important in teams and you know, often we can help each other out, but it's one of those subjects that maybe you don't want to bring up or you notice something and it's hard to speak up. What advice would you have for the girls that may be notice patterns and their teammates and they're concerned about them. You know, what's a good way to approach a teammate either about yourself like that you're struggling or that you notice, and you're worried or concerned about a teammate.

Emily Yeah. So let's say, well, first of all, I think it's really helpful if coaches are listening to have these conversations at the beginning of the season, like, Hey, this is what the triad and RED-S are. These are some signs, menstrual cycles are great. You want them periods are powerful, don't lose them.

And if you do we want to know about it, but that wasn't the case. And we're just kind of working with a one-on-one with a couple of athletes on the team. I think it's helpful if, you're concerned about another athlete and finding ways to almost find a way to relate to the situation and be like, gosh, I feel like there's just been a lot of pressure this season to perform and The can to get more strict with fueling and, and training and I'm feeling this pressure.

And I'm worried about the team and worried about you and how you're experiencing or coping with this. And hopefully that allows for this open dialogue between the two. I will say that I'm sure there are mental health specialists out there that can do a really good job or find some of that right wording or help finesse the wording to make it a conversation that doesn't come off as so direct and put that athlete on the defense. But I think that we all can do our part to help change this culture and things like this Voice In Sport podcast and the social media posts and what you're doing on Instagram and Twitter to help spread the good word are steps in the right direction, but we just gotta get it to those athletes, get it to the coaches to disseminate.

Stef That's right. And it's so important that we all are comfortable having conversations like this. Right. Cause that's what I, well, it will enable more girls to speak up. So I really appreciate you saying that. And there are a lot of ways you can do it, but at least start with a conversation and start with asking for help.

 And sometimes it takes a while to find the right fit, too, that's why, you know, on our platform, we have so many different options. You can try the sports psychology that sport dietician until you find somebody you feel comfortable with, because if you don't feel comfortable with the person, it's hard to have these really intimate conversations about your body.

 Which is why I think sometimes coaches avoid bringing it up in the first place, but we need to, like you said, shift that and make it part of a start of every season. I love that.

Emily Yes.

Stef Okay. So let's talk about some of the long-term impacts. You know, when you let RED-S go too long how is that correlated to injury and sort of then long-term effects for female athletes and what should we know about that.

Emily Yeah. So unfortunately as far as long-term impacts from RED-S it's still so early in its infancy the idea of RED-S that we don't see like decade long impacts. I like to take a step back and say low energy availability, what are those impacts from kind of chronic low energy availability. And I think the big impact that we see is in overall bone health. So those bone health effects can really affect our maximum bone building potential, especially in women. And like I said earlier, those adolescent years are peak bone building years. So, that can lead to future fracture risk or bone stress injury risk.

 There is some research out there that looks at the relationship of female athlete triad with overuse injuries, just general overuse injuries like tendonitis and knee pain. And so there are some studies that show an increased risk of those types of overuse injuries in the triad and female athlete triad population.

And then we also think about the questions with fertility and the ability to have babies and build a family. And we do see issues with athletes and endurance athletes with their ability to have children and how quickly that timeline happens.

And the research gap there is still pretty significant. And I think it's an important area to explore for future studies and prospective studies. And then there's also a question as far as kind of immunological and even just cardiac effects of this chronic low energy availability state.

And some of those are still to be explored as far as what is the impact and long-term impact. And in general, I think that we just, we know that there's an optimal fueling that just allows all of our bodily systems and organ systems to function at full capacity.

Stef Amazing. Well, not only are you working on the FASTR project and the program, but you're also involved in several other programs at Stanford. So I just want to talk about some of those is it leads into injury. So that includes you're involved in the adaptive sports injury prevention program in Stanford Runs Safe Injury Prevention. So can you talk to me a little bit about your role on both of those programs and why you're also involved there.

Emily Yes, in academics, we wear lots of different hats and I do have a lot of passions and my background in physiatry, physical medicine and rehab one of my areas of interest and passion is in the adaptive athlete. So an athlete who sustains a spinal cord injury or a traumatic brain injury or a stroke, and wants to get back into being active after that devastating injury.

This role is primarily at the Palo Alto VA, and we're trying to build a program there to find ways to get those athletes back safely and a number of different sports adaptive cycling to adaptive climbing. And there's an adaptive mountain biking event this Friday and for doing a intro to adaptive sports next Tuesday.

So it's, it's an important area and I think that it's, it's growing and really rewarding. And then the, the run safe is one of my other interest is in running mechanics and biomechanics, and we have emotion analysis and sports performance lab here at our Sunnyvale location. And so a lot of these athletes that are coming into my clinic, if they have an overuse injury, especially bone stress injury, I kind of think about the nutrition piece, I think about the training piece, but I also think about how are they running what's what are their landing patterns? Could they be loading differently on one leg versus the other leg? And could that be enough to contribute to this repetitive load? And like I talked about back to that bone remodeling, are we overloading that bone to keep it from really fully recovering and leading it to that injury. So we do run any value running evaluations led by our motion analysis lab.

 There's a physical therapist, Selinda Chan biomechanist, Sam Lyons and Jeff Morgan, and they do 3D motion capture and then deliver that information back to me, I reviewed that with the athlete and try to provide good exercise prescription and maybe some gait retraining to get them back to their sport safely.

So those are a couple of other areas of interest and we are doing some research within those fields too.

Stef That's super inspiring. I love, I love it. I mean, you're, you've got a lot going on. But incredible work. I'd love to know a little bit more about the running biomechanics, because it seems that this conversation around bone health and stress fractures and RED-S it happens much more with women than it does with men.

And I know there's not the component of menstruation for men. But, when you look at the biomechanics and the work that you're doing over there, are there learnings that all female athletes should know about their bodies when it comes to the biomechanics?

And does any of that contribute to the increase in stress fractures that runners typically see or is primarily it, you know, when we talk about RED-S and the bone fractures that happen, or the stress fractures that happen is that primarily from that, you know, not eating correctly and over-training, and has nothing to do with our biomechanics.

Emily Oh, yeah, it's hard for me to like, just put a hard stop and separate them because for me it's like, it's, I think it's all kind of there. They can be related and there can be some contributions from both. So I like to take this comprehensive approach to the athlete and I kind of think about. Injury risk in this bucket.

Irene Davis. I remember she did a presentation. She's a biomechanistic at Harvard and Harvard Spalding, and she had this injury threshold bucket. And so if you have this bucket and you have this line and maybe this athlete has low triad, this female athlete has low triad RED-S risk. So there's maybe a couple of drops in the bucket for that one.

However, maybe there's a bit more of a training load in that bucket. So you can add maybe a cup of injury risk to that. And then there is some faulty running mechanics where that female athlete is really just kind of dropping her knee in when she lands.

And there's just a lot of extra load in that area. And so we do see some increases kind of valgus moment. And certain running and landing mechanics and female athletes, especially, and maybe that's really contributing to that bucket and add in maybe a little bit of a low vitamin D and a dash of poor sleep.

And maybe that athlete has surpassed that threshold and has some degree of risk. And I would love to quantify that bucket and create a nice risk stratification tool. So we actually have a scoring system for it, but right now it's me kind of theorizing and trying to put it all together.

So kind of when we talk about males versus females this is a really interesting area that needs a lot more research, especially in adolescent female athletes. So I think my big interests are in bone stress injuries and ACL tears. And especially in female athletes, the ACL ACL tear risk is higher, especially in the adolescent female athlete.

And, and so why is that? Is that hormonal? Is that like strength? Is that a combination and how can we use biomechanical analyses to help prevent future risk and how can we really make biomechanical analysis more cost effective so it can be done. And there's some cool technology out there where they're trying to do some different screening tools just through iPads or through iPhones.

 But I think we really need to study that well to understand how we can use that effectively and accurately and really make sure that it's kind of a scientifically sound.

Stef Well, I love the bucket. I'm like Voice In Sport graphic right now of how we're going to talk about this bucket for all of the female athletes, because I think it's so important. I want to go back to the ACL though, because I tore my ACL and in high school and it was devastating and I know that it is higher risk for female athletes. So have we figured out why yet, or is that still in process?

Emily Yeah, there are a couple of theories out there with like anatomic alignment, hormonal profiles, and how maybe at different stages of a hormonal cycle an athlete may be at greater or lesser risk. And then also just some other kind of landing mechanics. I'm really interested in the landing mechanics piece because I think that's something that can be really addressed easily.

I mean, you can't change an athlete's anatomy but the strength is something that a lot of athletes can really work on. So, I would say hip glute strength and in both static and dynamic form are great ways to start are ways that can be done in a community setting can be done with your peers.

And I think can be standardized more. Think we're still figuring out what the best injury . Prevention program looks like and what that looks like in males versus females. And there are a lot of researchers like Greg Myers doing some good research on this and a number of others out there.

And we hope to also do some studies that really explore some of those underlying risk factors and how to address those impairments too. But yeah, I didn't really answer your question. I think we're still figuring it out, but hormonal anatomy and strength are big things.

Stef Interesting. Okay. So let's, let's kind of wrap up, I guess on how do you deal with being in this state of whether you have RED-S and you're trying to recover, or you have a bone injury and you're trying to get back. There is definitely a relationship to mental health there, right? Cause it's hard for athletes not to be playing their sport.

So I know you conducted a survey, a study that looked into the relationship between RED-S and mental health issues and, and how that led to depression and anxiety. I want to talk a little bit about, I guess, what led you to do that study and what was the outcome? What can we teach these young girls, I guess to benefit and take away from that study as they're going through recovering today.

Emily Yeah, Stef, I think the mental health piece is a really important one to talk about, and it can be really difficult for an athlete to talk about or express that they're struggling with some degree of anxiety or depression. So, the research study that we did and we conducted during the pandemic, which is, is a challenging time because there are other factors and contributing factors that can be at play during a pandemic that can cause anxiety and depression just beyond what revolves around sport.

But we did try to ask the question at the time that they took the survey and then prior to the pandemic to just make sure that we weren't really kind of confounded or having other confounding variables on potentially contribute to that increased anxiety and depression.

But we distributed a survey via Instagram, Twitter, and kind of distributed through some of our local schools as well looking at the relationship between the female athlete triad and anxiety and depression symptoms.

So we had 780 women complete the survey of all ages. And then about probably 10 or 11% of those were less than 18. But we did see this interesting relationship between female athlete, triad risk, especially that low energy availability disordered eating component with anxiety and depression symptoms.

So I think it's important to clarify that we don't know if the triad RED-S caused anxiety and depression or did the anxiety and depression symptoms lead to greater risk of triad and RED-S, but either way, I think it's important to have this discussion on mental health. And when an athlete does present with some signs and symptoms of the triad and RED-S that we can think about how to incorporate or talk about some of those mental health questions and how to study that in the future. I feel like this would just kind of scratch the surface of really exploring ways to manage and treat the triad RED-S in a multidisciplinary way. And I've been super lucky to have some great conversations with Kim O'Brien, she's a VIS expert and a number of other psychologists and mental health specialists that's part of their passion and career to explore these issues.

Stef Well, you've had so much amazing work already in play, and I can't wait to see what comes out of this next program. I'm sure it's going to be incredible. You know, you've met with so many young athletes that have had injuries and seen so many women recover and go through RED-S what do you think is just one piece of advice you'd give any athlete out there that is currently struggling with an injury.

Emily Oh, I think I actually gave this advice either yesterday or today. Like respect the process that this injury is frustrating and hard right now. But if you approach your recovery correctly you can get back stronger. And healthier and smarter and performing better in her sport.

Because I think when an athlete comes in they're so frustrated. And I had an athlete today with a hamstring injury. That's just been chronic and she's so frustrated. She just wants to play soccer. And she is really bummed about taking a month or two off.

And I will say I had a, I had a med student with me who was a prior collegiate and professional athlete and male that he was like, you know, one month, two months, isn't going to break you, so, dedicate that time to following the guidance and the instructions. Trust the process. If you have questions, ask them and we will do our best to get you back safely.

But, we need your help we need the athletes' help, too, to be on board with this plan.

Stef Such good advice. Thank you. We end all of our podcasts with the same question, because the women that we bring on this podcast, whether they're experts or they're athletes, they all want to change the game for women in sport. And you're doing it through sports science and research, which is really incredible.

 Definitely something that I couldn't do since I didn't have, well, I passed, but I didn't do a great job in organic chemistry. So, you know, what is one thing you would like to see changed for the future of women?

Emily I mean, I think it comes back to closing that gap and empowering more women in sport through closing that gap and getting more consistent education out there on female athlete health.

Stef Amazing. Well, I'm sure you guys are going to do that with your new program and we're excited to see the work and support it. So thank you, Emily, for joining us.

Emily Thank you for having me Stef and Voice in Sport.

Stef This week's episode was produced and edited by VIS creator Elizabeth Martin, a soccer player from Emory University. Emily's expertise reminds us the role of nutrition, training, and recovery and how important they are to play in our overall. As female athletes, we often struggle with bone health, RED-S and the female athlete triad.

And we thank Emily for sharing her tips on how we as athletes can prevent these injuries and improve our overall health. At Voice in Sport we are dedicated to providing the resources and expertise to better educate female athletes. Emily reminds us on how to handle our injuries properly advises us with methods on how to avoid overuse and the importance of female athlete participation in scientific research.

We are beyond grateful that Emily shared all her wisdom with us today. And we are so excited to see all the incredible things she will achieve in sports science and research for female athletes, you can follow Emily on Instagram or Twitter @emilykrausmd. Or head to the community page and sign up for a session with her.

Please subscribe to the Voice in Sport podcast. Give us a rating and review on apple podcasts and send this episode to a friend in our community that you think might enjoy the conversation. You can follow us on Instagram, Facebook, Twitter, and Tik Tok @voiceinsport. See you next week on the Voice in Sport podcast.

Host: Stef Strack

Producer: VIS Creators™ Elizabeth Martin and Zosia Bulhak 

VIS Expert, Clinical Assistant Professor at Stanford University, Dr. Emily Kraus, shares injury prevention tips, ways to prevent RED-S & the female athlete triad, and the gap in medicine research between male and female athletes.