CAQ REVIEW
Overtraining Syndrome
Nathan Cardoos, MD
Definitions
Functional overreaching (FOR): intensified training results
in a temporary decline in performance. When appropriate pe-
riods of recovery are provided, a positive ‘‘supercompensation’’
effect occurs, with the athlete exhibiting enhanced performance.
Nonfunctional overreaching (NFOR): an accumulation
of training and/or nontraining stress resulting in short-term
decrement in performance capacity with or without related
physiological and psychological signs and symptoms of
maladaptation in which restoration of performance capac-
ity may take from several days to several weeks.
Overtraining syndrome (OTS): same as NFOR, except
decrement is long-term and restoration takes several weeks
or months.
Key point: the difference between NFOR and OTS is
the amount of time needed for performance restoration;
therefore, the diagnosis of OTS can often only be made
retrospectively (3).
Pathophysiology
& Unknown, biochemical/hormonal hypotheses include
the following: glycogen depletion, central fatigue/branched
chain fatty acid depletion, glutamine depletion/immune dys-
function, autonomic imbalance, oxidative stress, hypotha-
lamic dysregulation, and cytokine release/inflammation (1,2).
& The mechanism triggering these changes often in-
volves a training error that results in imbalance between
energy expenditure load and recovery. This typically oc-
curs in combination with a complex set of psychological
factors and environmental stressors (e.g., monotony of
training, excessive competitions, sleep disturbances, in-
terpersonal difficulties, academic/occupational stressors,
illness, altitude exposure, heat or cold injury, etc.).
Epidemiology
& Most commonly seen in endurance events such as
swimming, cycling, or running
& Prevalence and incidence data for true OTS are lack-
ing; the lifetime prevalence of NFOR/OTS is estimated
to be approximately 30% for nonelite endurance athletes
and 60% for elite athletes (2,3).
Address for correspondence: Nathan Cardoos, MD, 119 Belmont St.,
Jaquith Building G, Worcester, MA 01605; E-mail: ncardoos@gmail.com.
Column Editor: John R. Hatzenbuehler, MD; E-mail: HATZEJ@mmc.org.
1537-890X/1403/157Y158
Current Sports Medicine Reports
Copyright * 2015 by the American College of Sports Medicine
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Copyright © 2015 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
Important Differential Diagnoses
& NFOR/OTS is a diagnosis of exclusion (1).
& Common: caffeine withdrawal, environmental aller-
gies, exercise-induced bronchospasm, infectious mononu-
cleosis, insufficient sleep, anemia, performance anxiety,
inadequate carbohydrate or protein intake, mood disor-
der, psychosocial stress, upper respiratory infection.
& Less common: dehydration, diabetes mellitus, eating
disorder, hepatitis, hypothyroidism, lower respiratory in-
fection, medication side effect (antidepressant, anxiolytic,
antihistamine, A-blocker), post-concussive syndrome, preg-
nancy, substance abuse.
& Rare but important: adrenocortical insufficiency or
excess, congenital or acquired heart disease, arrhythmia,
bacterial endocarditis, congestive heart failure, coronary
heart disease, human immunodeficiency virus, malabsorp-
tion syndrome, chronic lung disease, Lyme disease, ma-
laria, malignancy, neuromuscular disorder, chronic renal
disease, syphilis.
Evaluation
& Thorough history including chief complaint, training
program, diet, medications, nutrition, illness, review of
systems, and assessment of training goals.
& Hallmark feature in history: athletes with NFOR/
OTS are usually able to start a normal training sequence
or a race at their normal pace but are not able to complete
the training load they are given or race as usual (3).
& Initial laboratory examinations: complete blood count,
complete metabolic panel, Erythrocyte Sedimentation Rate/
C-reactive protein, thyroid-stimulating hormone, iron
studies, creatine kinase, urinalysis, and beta-human cho-
rionic gonadotropin. Consider monospot, hepatitis panel,
Lyme titer, toxicology screen, and chest x-ray.
& Prescribe absolute rest for 2 wk.
) If mood is adversely affected with full rest, con-
sider relative rest with well-defined expectations.
& If improved at follow-up, focus on adjustments to
training and prevention (as follows).
& If no improvement, consider NFOR/OTS:
) Will require prolonged training rest and further
workup
) Consider consulting with a sports psychologist
and nutritionist.
) Sequence of advancing activity should focus on
frequency, then duration, then intensity (1,2).
Current Sports Medicine Reports 157
Monitoring
& Monitor performance in time trials and standard
exercise challenges.
& There are currently no good practical biomarkers for
NFOR/OTS (2).
& Psychiatric indicators may be most useful. Examples
include the Profile of Mood States and Recovery-Stress
Questionnaire for Athletes (1).
& A two-bout maximal exercise protocol has shown differ-
ences in hypothalamic-pituitary-adrenal response for athletes
with FOR, NFOR, and OTS and may have prognostic value (2).
Prevention
Considerations for coaches, athletic trainers, and health
care providers (2,3):
& Maintain accurate records of performance and en-
courage athletes to keep a diary of training load.
& Emphasize adequate rest and ‘‘time out’’ periods when
performance declines, when an athlete complains of fa-
tigue, or after illness or injury.
158 Volume 14 & Number 3 & May/June 2015
Copyright © 2015 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
& Individualize and supervise training program.
& Avoid monotony of training.
& Encourage and reinforce optimal nutrition, hydra-
tion, and sleep.
& Be aware of life stressors, and communicate with
athletes about physical, mental, and emotional concerns.
Consider regular psychological questionnaires.
& Schedule regular health checks with a multidiscip-
linary team.
References
1. Gannon E, Howard TM. Overtraining syndrome. In: O’Connor FG, Casa
DJ, Davis BA, St. Pierre P, Sallis RE, Wilder RP, editors. ACSM’s Sports
Medicine: A Comprehensive Review. Philadelphia (PA): Lippincott Williams
& Wilkins; 2013. p. 265Y8.
2. Kreher JB, Schwartz JB. Overtraining syndrome: a practical guide. Sports
Health. 2012; 4:128Y38.
3. 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; 45:186Y205.
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