Dr Kate Hutchings
Consultant in Sports and Exercise Medicine
MBCHB, DCH, DRCOG, MSc, MRCGP, FFSEM
Practices at: Circle Reading Hospital
Having worked in Sydney during the 2000 Games, she returned to the UK to work in Sports and Exercise Medicine (SEM) and gained her Masters with distinction in 2004 from University College, London. She has also held a GP position in South West London from 2003 to 2010.
She completed her Specialist training in SEM from Oxford University Hospitals NHS Trust and is on the General Medical Council Specialist Register. She has trained in a variety of disciplines including Orthopaedics, Rheumatology, Exercise Medicine, Public Health and Emergency Medicine and is skilled in the use of diagnostic ultrasound and ultrasound guided injections.
Kate is also involved in promoting the importance of physical activity in chronic disease management and is co-author of the NHS document 'A fresh approach'.
Kate has experience in working with both professional and recreational teams from a wide variety of sports. Her previous positions include working for the English National Ballet as company doctor and she is experienced in looking after the female athlete and related medical issues. She has also held positions at Chelsea Football Club academy division, Oxford University Rugby Team and has travelled with both UK Athletics and the GB synchronized swimming team to world championships.
She has developed and led NHS musculoskeletal clinics at Crystal Palace, London for a number of years looking after recreational sports men and women. During the London 2012 Olympic Games, Kate worked as a Sports Physician at the Aquatic Centre as part of the medical team looking after swimming and diving. She also worked for Team GB medical headquarters for the Tokyo 2020 Olympic Games.
In 2018, Kate was part of the medical head quarters looking after the England Olympic Team at the Commonwealth Games in Australia.
She is a fellow of the Royal College of Sports and Exercise Medicine and held a position on the Executive board of the British Association of Sports and Exercise Medicine. In addition, Kate has previously held the position of Medical advisor to the Royal Ballet.
- All aspects of general SEM
- The female athlete and bone health
- Foot and ankle
- Exercise Prescription
- BASEM- Executive board member (Education)
The term RED-S has been adapted from a previously recognized condition, the female athlete triad, which comprises three components: low energy availability, menstrual problems (irregular or absent periods) and low bone density.
RED-S was developed to reflect the emerging complexity of the associated health consequences of the condition and to incorporate the understanding that it can affect both men and women alike. It is recognised that it can affect any physically active individual, irrespective of the level of sport or age.
Low energy availability can occur either unintentionally through poor nutritional strategies or intentionally with restrictive eating patterns. Irrespective of the cause, the result is an imbalance between energy intake (nutrition) and energy output (training). In women, low energy availability can affect the menstrual cycle with irregular or absent periods. In recreational sports women, it is important to recognise that loss of menstruation is not a normal part of training and irregular or absent periods need to be evaluated so that any underlying medical problems can be excluded and treated appropriately.
RED-S can have detrimental effects on sports performance, as our hormones are important for driving adaptations to exercise.
Low energy availability can affect muscle strength, co-ordination, concentration, reduce your training response and ultimately put someone at increased risk of injury. In addition, people can feel very fatigued and exhausted with training. If left untreated, energy deficiency also has longer lasting effects on menstrual function and fertility, bone health, metabolic rate, immune function, cardiovascular health, and psychological wellbeing.
Your first appointment
The identification of RED-S can be challenging and requires the expertise of a multidisciplinary team. It is important to know that weight loss is not necessarily a sign of low energy availability.
At your first consultation, we will discuss your symptoms and evaluate your energy balance and menstrual status.
It is important to know about your sporting activities and training schedules, any previous injury history, dietary intake, medications that you may be taking, and whether there is a family history of osteopenia or osteoporosis.
We will undertake screening questionnaires, a physical examination, and in most people, blood tests to assess metabolic and hormone levels. It is then often beneficial to have a nutritional review with one of our specialists.
What treatment modalities can you expect?
The management of RED-S most often requires several clinicians, including a sports medicine doctor, sports nutritionist (or eating disorder specialist), physiotherapist and psychologist. The treatment focuses on reversing the underlying issue of low energy availability by working with specialists on nutritional intake and training plans. This can include addressing any vitamin or mineral deficiencies as outlined in blood tests. Menstrual issues are assessed by a specialist Gynaecologist in this area, and in some patients, further investigations to assess their bone health are required.
It is important to note that oral and injectable contraceptives are not recommended to regulate the menstrual cycle as they have a potential negative effect on bone health and mask any recovery of a women’s normal menstrual cycle.
Patients are encouraged to undertake high impact loading and resistance training at least two to three days per week, especially those in non-weight bearing sports and/or those with low bone density.
What happens after your appointment?
Following your initial appointment and diagnosis, we recommend routine follow up for several months to monitor your recovery, and ultimately, a safe return to your sporting activities.
Overuse bone stress injuries occur when excessive load or activities are repeated so often that weight bearing bones to not have enough time to ‘remodel’ between exercise sessions. Examples can be a sudden change in training volume or intensity of running or a lack of recovery between training sessions. This results in an imbalance in the bone remodelling cycle and weakness can develop.
This can cause a spectrum of injuries, from bone stress to stress fractures which is a small ‘crack’ in the bone. Symptoms are dependent on the degree of injury to the bone, but typically people have pain with weight bearing activities (such as running and jumping) and localised swelling and tenderness over the affected bone. As bone stress injury increases, people can develop pain with walking, as well as at rest.
Lower limb stress fractures are more common than upper limb and the most frequent bones affected are the lower leg (tibia), followed by the weight bearing bones of the foot (metatarsals) and smaller bones of the mid foot. It is important that the symptoms are identified early, as a bone stress injury can recover relatively quickly if it is off loaded as soon as symptoms develop. However, if the affected bone continues to be overloaded (such as with running) and not enough time is given for it to recover, then a stress fracture can develop.
In my clinic, I treat patients of all ages and sporting ability, as these injuries can develop in both recreational and high-level sports men and women alike. It can happen in someone who has started a new exercise or running programme as well as an experienced runner who has increased their mileage and not allowed for adequate recovery between training sessions.
The majority of people who develop bone stress injury do so from overuse and we always need to consider a person’s training regime, and overall general conditioning to understand why they have developed an injury. In addition, there are certain groups of people that can be more prone to developing a problem, including those with low bone density, women with irregular or absent menstrual cycles, those that have suboptimal nutrition for their level of sport and certain medical conditions that can affect bones or lead to reduced absorption of Vitamin D and calcium.
Your first appointment
Typically, patients visit my clinic with activity-related pain and soreness over the affected bone area. During the first appointment, we discuss how your symptoms developed, including any sporting activities or changes in physical activities preceding your symptoms. We then evaluate if you have any risk factors that may make you more likely to develop a bone stress injury.
In the majority of people, we will undertake routine blood tests looking at your bone profile, which includes your calcium and vitamin D levels. In some cases, we will also screen for any associated medical conditions that may be affecting your bones. This can include looking at levels of female hormones of the menstrual cycle.
We undertake a full physical examination, looking at the affected bone, as well as assessing if there are any biomechanical or joint/muscular issues that can predispose to the injury.
Bone stress conditions: what treatment modalities can you expect?
Typically, most people require further imaging, such as an X-ray or MRI scan to assess the degree of bone stress and to evaluate for a stress fracture. If clinically, a stress fracture is suspected at the first consultation, we will offload the bone using a boot walker (and sometimes crutches) whilst we wait for the scan results.
Once a bone stress injury is confirmed, a period of ‘offloading’ in a boot walker is started. This takes the weight off the bone and allows time for it to heal, the duration of which is dependent on the bone affected and the level of bone stress involved. This can vary considerably from a few weeks to months. However, during this time, we will start physiotherapy rehabilitation, which is progressed gradually as symptoms allow.
Pain is used as a guide for your level of loading and fitness can be maintained with less load-bearing exercise, such as aqua jogging and static cycling. Additional therapies can also be utilised, including hydrotherapy, muscle stimulator machines to maintain strength, and in certain prolonged cases of stress fractures, we can use bone stimulator machines.
Once you are able to begin weight-bearing again out of the boot, we undertake a very progressive return to your sport, often starting on the anti-gravity treadmill, for example. It is important to return to your sport safely and we often work with additional clinicians such as Consultant Orthotists, who will look at your running biomechanics and foot posture.
In addition, if any risk factors are identified, we can work with our sports nutritionist to optimise areas of your bone health, such as Vitamin D deficiency. In some cases, further specialist reviews and investigations are required if there are any underlying menstrual problems that we feel may be affecting your bones.
What happens after your treatment?
Following your initial treatment, we suggest regular follow-up appointments to assess your progress and plan your rehabilitation and return to sport safely. The recovery time is dependent on several factors, including the location of bone and extent of bone stress, how long you have had your symptoms and whether there are any specific underlying risk factors that we need to address.
Tendons are tough fibres, much like a rope, that connect muscle to bone and are organised in a specific way to provide strength and enable them to adapt to load. The understanding of why tendons change in structure and become painful has changed over the past decade, and we now consider the underlying problem to be a degenerative process (although there is thought to be some inflammation in the early stages).
Tendinopathy can affect all age groups and levels of physically active people. Too much load (known as an ‘abusive load’) through the tendon is primarily the causative factor, but there is a large variation in how much load individuals can endure before developing symptoms. It is recognised that less active people can also suffer from tendinopathy.
Generally, the incidence increases with age, as the load threshold required to affect the tendon decreases. However, there are certain factors that can contribute to the development of tendinopathy, including any sudden change in the volume or intensity of physical activities, training errors and lack of general physical conditioning, including biomechanical issues. In addition, tendon problems can be associated with medical problems such as diabetes, high cholesterol levels, certain rheumatological conditions and prescribed medications.
Tendinopathy is predominately caused by repetitive activities to the muscle tendon unit and is a result of a failed healing response of the tendon. The strain on the tendon causes micro-tears that can build up over time.
A tendon injury may appear to happen suddenly, but usually is the result of structural changes in the tendon that have developed over many months or years (so-called the degenerative process). Often the more ‘acute’ symptoms of pain and swelling are the result of an excessive load being suddenly applied to the tendon e.g.- hill running, jumping activities.
Tendinopathy causes pain, localised swelling, weakness and often restricted movements of the associated joint. The pain may be worse when you use the tendon and stiff when you first get up in the morning. As symptoms, progress the tendon can be painful with normal activities of daily life.
The relatively new understanding of the underlying causes of tendon problems has resulted in new and novel treatment options.
Your first appointment
In our Sports Medicine clinic, we manage both upper limb and lower limb tendon problems. At your first consultation, we discuss how your symptoms started and whether there were any changes to physical activities prior to the onset of your symptoms. We evaluate whether you have any risk factors for tendon problems and often use symptom questionnaires to assess the severity.
A full clinical examination is performed, looking at not only the affected tendon, but surrounding muscles and joints that may contribute to ongoing problems. We often work with Consultant Orthotists for a biomechanical assessment of the lower limb.
An ultrasound is often recommended as this helps to evaluate the structural changes and guide our management options.
Tendon conditions: what treatment modalities can you expect?
The management of tendinopathy depends on the level of the tendon changes and how long you have had the symptoms. The primary treatment approach is known as ‘load management’, which essentially means an individualised physiotherapy programme whereby the tendon is gradually loaded to facilitate adaptation, healing and strength.
If symptoms are reported relatively early, often only a short period of physiotherapy rehabilitation is required. However, with more chronic long-standing symptoms, it can take several months for the tendon to fully recover.
As the basic science of tendinopathy has evolved, so have the treatment options for these conditions.
In acute cases, we may recommend the use of nonsteroidal anti-inflammatory medication, such as ibuprofen or similar medication. But this has only been found to be beneficial in the early stages of tendinopathy when used for seven to 10 days. There is research to suggest that long term use of these medications can be detrimental to the tendon healing process.
Adjunct treatment modalities offered also include extra-corporeal shock wave therapy (acoustic waves) which helps to stimulate the tendon structure to facilitate repair processes by several different mechanisms.
Injection therapies are also used in some cases and these include high volume injections, sclerosants or platelet rich plasma (blood) with additional dry needling to the tendon. Corticosteroid injections into the tendon are no longer thought to be effective long term and can be detrimental to the tendon structure.
What happens following treatment?
Following your initial appointment, we will discuss your treatment plan with you and monitor your progress over the following months. We work closely with our physiotherapy team to ensure we can return you to your physical activities safely.
Ways to pay
Pay for yourself
Pay for yourself with our fixed price packages. This includes your pre-assessment, treatment, follow-ups and six months of aftercare.
Pay with health insurance
We are widely recognised by health insurers. Ask your insurer about your cover and for an insurer pre-authorisation code.
Spread the cost
Pay for yourself with monthly repayments spread over 12 months, interest-free (terms and conditions apply)