Overtraining: prevention, diagnosis and when to see a doctor

Overtraining syndrome can take a whole season from an athlete, and sometimes more. The good news is that its development can mostly be prevented, and the early stages spotted in time. The editorial team explains how to build up prevention, how doctors make this diagnosis and when medical help cannot be done without.

Prevention: periodisation and recovery

The main tool of prevention is periodisation, that is, planning the training process in waves. Periods of high load alternate with unloading weeks, and the season is divided into preparatory, competitive and transitional stages. This approach allows one to gain the benefit of functional overreaching and to prevent its transition into non-functional.

Among its practical recommendations, the ECSS/ACSM consensus names individualisation of load, reduction of monotony, obligatory rest after hard blocks and competitions, and adequate nutrition and sleep (Meeusen et al., 2013). Rigid "standard" plans that do not account for the reaction of the specific athlete increase the risk.

As far back as the 1990s, C. Foster showed that not only total load but also its monotony and so-called training "strain" are linked to episodes of illness and worsening of athletes' condition (Foster, 1998). The practical conclusion is simple: a week should have genuinely easy days.

Finally, prevention includes managing non-sporting stress. During periods of exams, work deadlines or family events it is worth deliberately reducing training volume. The coach should know about such circumstances in order to adjust the plan.

Monitoring: questionnaires, tests, a diary

Monitoring is needed in order to notice the moment when adaptation stops occurring. The most accessible method is a daily assessment of wellbeing: sleep quality, level of fatigue, muscle soreness, mood, motivation. Systematic reviews confirm that such self-reports respond sensitively to changes in load (Saw et al., 2016).

In sports psychology, validated questionnaires are used, for example the Profile of Mood States (POMS) or the RESTQ-Sport stress and recovery questionnaire. They allow one to quantify the balance between stress and recovery and to track it over time (Kellmann, 2010).

Objective indicators — resting heart rate, heart-rate variability, recovery heart rate after a standard load — are useful as a supplement. They must be compared with the athlete's own "norm", not with average values.

Regular control tests give the most important information: whether performance is rising. If results in standard tests fall for several weeks in a row despite training and rest, that is a weighty reason to review the programme.

• daily wellbeing questionnaires (sleep, fatigue, mood, soreness);
• perceived exertion and duration of each workout;
• the trend of resting heart rate and heart-rate variability;
• control tests of performance every few weeks.

Diagnosis as the exclusion of other causes

There is no specific test for overtraining syndrome. The consensus states directly that it is a diagnosis of exclusion: the doctor must first rule out other illnesses that could explain the drop in performance and the fatigue (Meeusen et al., 2013).

The consensus offers a step-by-step list of questions: is there an unexplained decline in performance, does it persist despite rest, are there mood disorders, is it not linked to infection, anaemia, endocrine disorders, eating disorders, medication or alcohol. Only after these causes have been ruled out can one speak of overtraining.

The basic examination includes a complete blood count, ferritin, function of the thyroid, liver and kidneys, markers of inflammation, and as indicated — serology for viral infections and a hormonal profile. It is also important to assess energy balance and the presence of signs of relative energy deficiency.

The doctor will always ask about medications, supplements and drugs. Withdrawal from anabolic steroids, the use of thyroid hormones or stimulants can produce a picture very similar to overtraining but require a different approach.

Special tests and markers: possibilities and limits

Researchers have long searched for a hormonal "marker of overtraining". The testosterone-to-cortisol ratio, levels of catecholamines, glutamine, cytokines — all these indicators have been studied, but none proved reliable enough for individual diagnosis (Cadegiani & Kater, 2017).

One of the most interesting ideas is a protocol of two maximal exercise bouts separated by several hours of rest. In athletes with non-functional overreaching or overtraining, the hormonal response (in particular ACTH and prolactin) to the second bout differed from the norm (Meeusen et al., 2004). However, this test is complex, expensive and used mainly in research centres.

Heart-rate variability and other indicators of autonomic regulation are useful for monitoring, but their changes in overtraining are heterogeneous: in some athletes sympathetic tone predominates, in others parasympathetic.

Thus, in practice the diagnosis is based on a combination of history, the dynamics of performance, questionnaires and the exclusion of other illnesses, rather than on a single laboratory indicator.

When to see a doctor and how to return

You should see a sports doctor if results fall for more than two or three weeks despite reduced load, if persistent sleep disturbances, low mood, loss of motivation, frequent infections or menstrual-cycle disturbances have appeared.

Urgent examination is required for chest pain, fainting, heart irregularities, pronounced shortness of breath, and also for symptoms occurring while taking hormonal drugs or stimulants. Such cases cannot be explained by "just overtraining" without an examination.

Treatment of confirmed overtraining syndrome is rest and a gradual return to load, not drugs. At first the athlete performs only light activity, then gradually restores volume, and adds intensity last of all. The process can last for months, and haste often leads to a relapse.

During recovery it is worth continuing to monitor wellbeing and to work on the causes: sleep, nutrition, stress, the structure of training. Support from a psychologist can be useful, especially for professional athletes.

Editorial conclusions

Overtraining is much easier to prevent than to treat: periodisation, easy days, unloading weeks, sleep and nutrition are the basis of prevention.

Regular monitoring of wellbeing and control tests allow non-functional overreaching to be spotted at an early stage.

The diagnosis is made by excluding other causes, and a reliable laboratory marker still does not exist; treatment consists of rest and a phased return to training.

We also recommend reading our materials on the causes of overtraining, on chronic fatigue in athletes and on heart-rate variability as a monitoring tool.

References

1. Meeusen R, Duclos M, Foster C, et al. Prevention, diagnosis, and treatment of the overtraining syndrome: joint consensus statement of the European College of Sport Science and the American College of Sports Medicine. Med Sci Sports Exerc. 2013;45(1):186–205.
2. Foster C. Monitoring training in athletes with reference to overtraining syndrome. Med Sci Sports Exerc. 1998;30(7):1164–1168.
3. Kellmann M. Preventing overtraining in athletes in high-intensity sports and stress/recovery monitoring. Scand J Med Sci Sports. 2010;20(Suppl 2):95–102.
4. Saw AE, Main LC, Gastin PB. Monitoring the athlete training response: subjective self-reported measures trump commonly used objective measures: a systematic review. Br J Sports Med. 2016;50(5):281–291.
5. Meeusen R, Piacentini MF, Busschaert B, et al. Hormonal responses in athletes: the use of a two bout exercise protocol to detect subtle differences in (over)training status. Eur J Appl Physiol. 2004;91(2–3):140–146.
6. Cadegiani FA, Kater CE. Hormonal aspects of overtraining syndrome: a systematic review. BMC Sports Sci Med Rehabil. 2017;9:14.