Episode #392: Overtraining Syndrome: Causes, Diagnosis, and What’s Actually Going On

Summary

In 2022, researchers conducted the most rigorous systematic review ever performed on overtraining syndrome — looking specifically for controlled studies that documented a human transitioning from a healthy training state to an overtrained state. Zero studies met those criteria.

The word “overtrained” appears in coaching certifications, wearable device dashboards, and clinical sports medicine guidelines — and in each context it means something different. That definitional chaos has consequences: it delays real diagnoses, produces nocebo effects with measurable physiological outcomes, and leads athletes to reduce training they didn’t need to reduce.

In this episode, Drs. Jordan Feigenbaum and Austin Baraki work through the full evidence base on overtraining syndrome — the taxonomy, the attempted studies, the six competing mechanistic theories, the biomarker failures, and what’s actually happening when a lifter can’t make progress.

Full episode for Barbell Medicine Plus subscribers at https://barbellmedicine.supercast.com/

🎧 Listen on Apple Podcasts: https://podcasts.apple.com/au/podcast/overtraining-syndrome-causes-diagnosis-and-whats/id1199780143?i=1000758456757

Key Takeaways

• The definition problem — why a single word is doing four incompatible jobs simultaneously, and why that matters clinically and practically.
• The taxonomy — functional overreaching, nonfunctional overreaching, and overtraining syndrome as points on a continuous variable that can only be identified after the fact, not at presentation.
• The supercompensation model — where it came from, why it fails to describe how resistance training adaptation actually works, and how applying it too literally produces both overloading and underloading errors at the same time.
• Austin’s clinical differential — what a physician actually works through when a patient presents with fatigue and declining performance, and where overtraining syndrome actually sits on that list.
• What resistance training research shows — including 140 maximal singles, 90 working sets per week, and daily 1-rep max attempts. No study has cleanly induced overtraining syndrome through resistance training. The hormonal data went in the opposite direction from what the endurance overtraining model predicts.
• Six mechanistic theories — glycogen depletion, serotonin/BCAA, autonomic imbalance, central governor, HPA axis dysregulation, and Armstrong’s complex systems framework. Each one is partially supported and each falls short.
• The biomarker problem — resting cortisol is normal in 75%+ of OTS cases, the testosterone to cortisol ratio has never been validated against clinical outcomes as an individual diagnostic, and HRV recovery in strength training lags physical recovery by up to 30 hours.
• Austin on wearables — including a clinical pattern he’s seeing with GLP-1 receptor agonists: wearable scores indicating deterioration when the clinical picture is actually fine.
• Session RPE as the real tool — why session RPE trending upward at stable training load is a more reliable signal of load-recovery mismatch than any biomarker currently used.
• Prevalence and confounders — the 60% figure, why it almost certainly captures all three FOR/NFOR/OTS categories plus REDS, depression, and illness, and why the residual true training-load-induced OTS in an otherwise healthy athlete may be vanishingly rare.
• Three failure modes — the three things Jordan actually sees in practice when lifters present saying they feel overtrained, and how to distinguish between them using session RPE.
• The medical workup — Austin’s practical walkthrough of what to assess when programming and lifestyle changes don’t move the needle, including iron deficiency (ferritin testing caveats, lab reference range problems), sleep apnea, post-viral syndromes, and hormone panels done correctly.

Episode Timestamps

• 0:00 Cold open — the zero-studies finding
• 1:21 Why “overtrained” does four different jobs simultaneously
• 16:10 The FOR / NFOR / OTS taxonomy
• 19:43 The supercompensation model — borrowed from endurance, never validated for resistance training
• 32:28 Austin’s clinical differential for fatigue and declining performance
• 36:17 RT evidence — what happens when researchers try to induce OTS through lifting
• 43:19 Austin — what actually drives the complaints he sees in practice
• 47:30 Six theories for what causes overtraining syndrome
• 1:01:09 The biomarker problem — why the T:C ratio and cortisol don’t work
• 1:05:09 What your wearable is actually measuring (and what it isn’t)
• 1:09:28 Austin — testosterone levels in trained athletes and when to act
• 1:13:40 Heart rate variability — limitations for strength training
• 1:15:36 Session RPE — the monitoring tool that actually works
• 1:17:31 How common is overtraining syndrome, really?
• 1:23:04 Three failure modes — what’s actually happening when lifters say they feel overtrained
• 1:32:14 Austin — what a proper medical workup looks like
• 1:34:22 Outro

Clinical Pearls

References

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Transcript

00:00:00:06 – 00:00:21:04

Unknown

There’s a word that gets applied to a tired marathon runner, a burned out cross fitter and a powerlifter who has missed their working set weights for multiple weeks. That word is overtrained. The assumption embedded in that word is that these three people share the same underlying condition. Though this is almost certainly wrong. In 2022, researchers conducted the most rigorous systematic review ever performed on overtraining syndrome.

00:00:21:05 – 00:00:44:12

Unknown

They were looking specifically for studies that could objectively document a human being transitioning from a healthy training state to an overtrained state under controlled experimental conditions. Zero studies met those criteria. Now, this isn’t an argument that something real isn’t happening to these athletes. There’s substantial observational, retrospective, and case based evidence that athletes experience something during periods of prolonged, excessive training load.

00:00:44:14 – 00:01:01:06

Unknown

But what that finally does tell us is that overtraining syndrome as a concept has been built on observation in retrospect, not the kind of controlled experimental evidence we need to confidently explain what it is, how to identify it, or even what to do about it. And as we argue today, the problem may not just be that we lack good studies.

00:01:01:12 – 00:01:21:09

Unknown

It may be that the concept itself is pointing in the wrong direction. Today we’re going to pull apart what the evidence actually shows, where it ends and what that means practically, for how you train and how you recover. I’m Doctor Jordan Feigenbaum and this is the Barbell Medicine podcast.

00:01:21:11 – 00:01:28:06

Unknown

I’m.

00:01:28:08 – 00:01:46:07

Unknown

And to help me manage today’s training load within appropriate recovery resources. It’s the second most handsome doctor North America, doctor Austin Baraki. What’s going on, man? We, doing all right? Just finished some training this morning myself. Despite my best efforts, I still have not yet found a way to do too much. But here we are. But you’re trying.

00:01:46:10 – 00:02:11:01

Unknown

Okay, so let’s start. Why? This is actually a difficult problem to solve. Because. Very simple. Somebody would have done it already. And I think it starts with the labeling. Like the word overtraining appears in coaching certifications, wearable device dashboards on social media, and also even in like clinical sports medicine guidelines. And in each of those different contexts it means something different.

00:02:11:03 – 00:02:38:17

Unknown

So the same word overtraining is doing at least four different jobs at the same time. Within a coaching certifications text, it can mean a deliberate training stimulus you’re supposed to apply to drive a fitness adaptation, which is also called overreaching. Or it could also be a dangerous failure state that you’re supposed to avoid at all costs. But the same manual sometimes uses the same word for both, without acknowledging that these are distinctly different things on like wearable tech go watch or something like that.

00:02:38:17 – 00:03:06:04

Unknown

It can mean whatever the algorithm, that device was trained on, senses that you’re overtrained without having anything to do with the clinical definition. In social media, it means I trained a lot, and now I feel bad, which is decidedly vague. Yeah. And in the sports medicine literature, it refers to a specific diagnosis of exclusion that requires ruling out things like thyroid dysfunction, anemia, low energy availability, depression, illness, etc. before you can apply the label.

00:03:06:06 – 00:03:26:17

Unknown

Now, these aren’t minor variations of the same concept, they’re just different phenomena that imply different sort of management. So if a coach tells an athlete they are overtrained compared to when a sports medicine physician uses the same word, they mean different things. And so it’s understandable. Like this confusion around overtraining not only what it is, but what to do about it.

00:03:26:19 – 00:03:47:18

Unknown

At least four different definitions. And I think this is not a unique problem to sports medicine or exercise science. This happens all the time. Austin, have you seen this in medicine where, like, the same word is used across maybe different, to mean different things in, in medicine. Yeah. It’s hard to think of a ton of examples just off the top of my head.

00:03:47:18 – 00:04:15:15

Unknown

But sometimes, like, lay person language slips into clinical conversations. And that leads to, like, imprecision around things. One that immediately comes to mind, now is, that the claim or describing somebody is being dehydrated. And so, if we have any like, nephrologists in the audience, they will know what I’m talking about. Because when you say that somebody is dehydrated from a medical physiologic, nephrologists perspective, it means they don’t have enough, like, free water in their body.

00:04:15:15 – 00:04:39:05

Unknown

And they should be like hyper and they Tremec and things like that. Whereas if somebody is hypovolemic, that has a different implication. But people use those words interchangeably and so it is the they actually have quite different management strategies. And so that imprecision leads to confusion, when the terms are applied vaguely, although in practice, a lot of the time when I hear somebody use the term dehydration, they often I recognize that they really mean hypokalemia.

00:04:39:05 – 00:04:53:16

Unknown

And I’m like, yeah, I know what you mean. But, sometimes when I’m feeling a little spicy, I’ll, I’ll pick on him for it, but yeah, it happens in a lot of contexts, you see all the time. Also in the like the wellness industry, you know, gut health, spine health, brain health. And it’s like, all right, what are we talking about exactly.

00:04:53:18 – 00:05:19:23

Unknown

Yeah. Yeah. And so that you know, there’s more, of an issue than just the terminology, it’s kind of like what the origin story, the villain arc of overtraining syndrome. How did it become a diagnosis in the first place? It’s kind of just retrospective in nature. The actual science field, sports medicine field, observed a pattern. Some individuals, after periods of high training loads, experienced prolonged performance decrements.

00:05:20:03 – 00:05:40:22

Unknown

They also had mood disturbances and, hormonal changes. Sometimes that did not resolve with a reduction in training load. And so they call that overtraining syndrome. And then and this is the step that matters. They started treating the name as though it identified a specific disease or pathology with a specific mechanism. And then their diagnostic criteria were built around the label.

00:05:40:22 – 00:06:10:22

Unknown

Decades of research follow that study. The label, rather than kind of the underlying biology. We should state that, you know, naming something a pattern is not the same as identifying a disease. Naming a syndrome is not the same as identifying a disease. The athletes or individuals are experience something real, for sure, but whether those symptoms share a single underlying cause or whether or overtraining syndrome is, several different problems producing similar presentations, it’s never really been established.

00:06:10:22 – 00:06:39:15

Unknown

In the opener, I stated, you know, we’ve been trying to identify like, how do you cause overtraining syndrome, right? And like, how do you take somebody from a, you know, healthy, right. Normally training, you know, with the given training load and then generate overtraining. And it was never it’s never been done. So the concept of overtraining syndrome may be pointing in the wrong direction, which has consequences for how we ultimately kind of diagnose people and manage people, who supposedly have overtraining syndrome.

00:06:39:17 – 00:06:58:15

Unknown

Yeah. Part of the challenge is how what we’ll get to, I’m sure generally like quote unquote nonspecific. The symptoms are here. And so when you collect a bunch of nonspecific symptoms and you put them into a syndrome, then yeah, you can probably end up with a whole bunch of different ways that you could get there. So it’s not fundamentally going to be like one thing.

00:06:58:17 – 00:07:19:17

Unknown

Additionally, is it reasonable to think that, you know, if you had different athletes in different sports training in different ways, that there, that each of them could have the same overtraining syndrome? No, it’s all going to be different based on the sport, the training and the person. But again, the non specificity of symptoms leaves the door open for a lot of other possible causes and contributors.

00:07:19:19 – 00:07:37:07

Unknown

And so if all you know is overtraining syndrome then you’re going to miss a lot of other potential causes contributors risk factors, things that might be might be, treatable, and easily resolved in other ways to a point where maybe the person can ultimately tolerate that level of training. I mean, when the training itself wasn’t the underlying problem at all.

00:07:37:09 – 00:08:05:16

Unknown

Yeah, yeah, but there’s a problem with labeling, you know, somebody with overtraining syndrome, especially if it’s used maybe to aggressively, you know, rather than with restraint. You know, people will say your CNS is fried, your adrenals are cooked or fatigued, your nervous system, you know, needs to recover. Not only are these phrases not supported by science, but ultimately they can produce a negative effect on the individual curing them.

00:08:05:18 – 00:08:28:00

Unknown

They go from, you know, I have a set of solvable input problems that the training load maybe to I have a broken system that needs protecting, which can produce a fear of training load. Might cause somebody to prematurely load or reduce how much exercise they’re doing and, otherwise attribute, you know, normal training induced fatigue to a syndrome that almost certainly doesn’t apply.

00:08:28:01 – 00:08:48:12

Unknown

And actually, there’s been a recent systematic review that found that nocebo effects in sport and exercise, had approximately twice the magnitude of effect as placebo effects when it came to performance. This is based on 20 studies of varying quality. But the mechanism it’s not really hard to explain language about fatigue states. And negative sort of outcomes.

00:08:48:18 – 00:09:10:17

Unknown

They have physiological consequences. The word overtrained, if it’s applied imprecisely, is not neutral. It’s not just a throw away word. So, Austan, can you walk us through the nocebo mechanism here? How how you think about it? Because the claim that a coaching phrase produces a physiological consequence gets dismissed as purely psychological, and it isn’t what’s actually going on here.

00:09:10:18 – 00:09:30:13

Unknown

Yeah, well, I would say that in the same way that when we talk about the quote unquote placebo effect, it’s actually not just referring to a single thing. There are numerous different placebo effects that have been kind of characterized mechanistically. If somebody really wants to nerd out on this, there’s a book by, a well-known Italian guy in the space.

00:09:30:17 – 00:09:56:23

Unknown

Benedetti I think his first name is Fabrizio. Fabrizio Benedetti. The book titled Placebo Effect, where he goes into great detail, characterizing the and summarizing the research that has characterized the different, mechanisms of placebo type effects. There are some that proceed by way of, like endogenous opioid related pathways, for example, for placebo mediated pain relief. Others through other signaling mechanisms, including some of the interesting stuff, for example, around like dopamine signaling.

00:09:56:23 – 00:10:19:13

Unknown

And there’s the placebo effect, even in like treating parkinsonism and things like that, which is all super interesting. And so I would be unsurprised, to learn that, nocebo, different, effects, perceived by way of various different mechanisms, whether it relates to increasing pain intensity, increasing the experience of, you know, anxiety, fear, all sorts of other things that can ultimately play into this.

00:10:19:18 – 00:10:40:05

Unknown

But I think the problem here is when people try to silo out psychology as some sort of, separate process that is not intimately linked with biology. Ultimately, if we wanted to be ultra reductionist, everything is biology one way or another. And that, well, then there’s going to be the chemists who argue everything’s chemistry, and then the physicists who argue everything’s physics, and then the mathematicians where everything is math.

00:10:40:05 – 00:11:00:11

Unknown

I think there was a there’s an old comic strip that, that, that I remember that, that made that argument. But there is biology underlying all of these things. Psychology is like an emergent property of the underlying biological processes. And so I would not say that it is fair to dismiss nocebo as purely psychological in the same way, I would say it’s unfair to dismiss placebo as purely psychological.

00:11:00:11 – 00:11:35:01

Unknown

There are interactions between the psychological aspects and underlying neurology, biology, immunology, all sorts of other things. There’s a whole field, dedicated to, to this, branch of study. And so when somebody does receive those sorts of external cues, whether more favorable in the context of placebo or negative in the context that nocebo, there are underlying biological impacts of that that can lead to changes in attention as well as, changes in kind of underlying biology that can lead to variations in how people might experience the same subsequent event, either more favorably or more negatively.

00:11:35:02 – 00:11:55:23

Unknown

Yeah. Imagine if you walk into a gym, you’re CrossFit or right, and the class in front of you is just getting done. And you know, there’s all 25 people who took the previous class are on the ground panting, writhing, or whatever. Maybe they’re missing blood. Yeah, exactly right. Your expectation, your alert system is going to be elevated, most likely.

00:11:56:01 – 00:12:13:01

Unknown

And so you’re going to subsequently experience that workout differently. And so it’s all connected, you know, just you can’t reduce it. And I think, your expectations, your mood state, how you’ve been primed in a way to, to experience what’s coming next or what what the intervention is. Yet it all it all kind of makes sense.

00:12:13:01 – 00:12:34:11

Unknown

And the idea that, you know, humans experience a negative sort of effect more prominently than a positive one. I mean, I think it’s that been some well-established, psychiatric research where we tend to identify things that are negative more easily. And perhaps that’s a, you know, evolutionary response on some level to, like, protect us. But anyway, it’s not it wasn’t surprising for me to learn this.

00:12:34:16 – 00:13:06:17

Unknown

It was surprising for me to see that this was still well studied in sport, because often there’s a gap there. So that was kind of interesting to me. Yeah. All right. And the last thing I want to talk about before we get into the labeling or the taxonomy of, of this, overtraining syndrome, is that this is, you know, most importantly, a diagnosis of exclusion, because when we label somebody or when somebody is labeled with overtraining syndrome, that means that effectively, no other condition or underlying cause, has been identified.

00:13:06:19 – 00:13:39:17

Unknown

You think about the prevalence of anemia of hypothyroidism or thyroid disorders of, low energy availability, not only in sport but also just in the general population. And their presentations are very similar to overtraining syndrome, but they’re far more likely to be, to have happen then and overtraining syndrome. And so if you just label somebody and you’re you have overtraining syndrome, we got to reduce your training load and failed to account for any of these other possibilities that delays diagnosis, which could be, a problem here.

00:13:39:19 – 00:14:01:12

Unknown

And again, I just think about, you know, what is the prevalence of anemia just in the general population. It’s like, okay, you know, when you hear Hoofbeats think, think, horses, not zebras. To me, overtraining syndrome is like, definitive zebra. You’re even in, you know, people who train a lot, compared to disease, run of the mill, I’ve, you know, not dismissed.

00:14:01:12 – 00:14:30:03

Unknown

Somebody is inexperienced, but these more common sort of medical conditions that ring true to you or that seem right. Yes. And it also gives me an opportunity to step back onto a familiar soapbox. But ultimately, what you’re describing is that these, nonspecific symptoms are common for a variety of reasons. Just because somebody trains and even if they train, what seems to be a fair amount does not automatically mean that they’re not collection of nonspecific symptoms that we call this syndrome is being driven by the training.

00:14:30:05 – 00:15:07:08

Unknown

Now, the training itself might be poorly matched to the person for a variety of reasons. And so if that is the basis on which you are concluding that they are overtraining, that’s a little bit of an odd way to frame it. But I kind of see how you get there. It’s just that more so that this is not a good fit for them at this moment in time, because of the other variable that has yet to be identified and a common, common, common example, is going to be what you mentioned with iron deficiency, the prevalence of iron deficiency in like reproductive age women in the United States, 40% have iron deficiency.

00:15:07:08 – 00:15:28:17

Unknown

Now prevalence is impacted by where you set your cutoffs on lab testing. And I have, you know, ranted about this at length in public and with individual patients. When you measure a ferritin level and the reference range is like the lower limit of normal is 15, that is, an incorrect lower limit of normal. And it should be at least 30 in my opinion, closer to 50, would be the appropriate lower limit of normal.

00:15:28:17 – 00:15:48:09

Unknown

So depending on where you set your target, that’ll define the prevalence. But almost half of women in that demographic are iron deficient. And so if they train and they say I’m tired and you conclude they’re overtrained, it’s like, well, if I just got their ferritin up to 75 and they tolerate training just fine, were they overtrained or was it just a poor fit for their iron deficient state.

00:15:48:09 – 00:16:10:11

Unknown

And so you know, what’s the is this purely semantics or is there something more meaningful underlying. And I think that’s what we’re getting at here. Yeah. Yeah. Maybe we’ll keep returning to this sort of, mystery symptom or mystery cause or hidden cause. We’ll come back to that. But before we get into the science of overtraining, we need to get the vocabulary right, because a single word is being used to describe at least three distinct states.

00:16:10:13 – 00:16:49:22

Unknown

And without that information in place, everything that follows is ambiguous. So let’s start with the definitions. First up is functional overreaching. This is defined as short term performance decrease that resolves in days to approximately two weeks, after which performance returns to or exceeds baseline. This is, quote, super compensation. Working as designed, people get fitness adaptations from their training, but most people listen as podcasts, have experience when they’ve done workouts and gotten stronger, improve their cardiorespiratory fitness, increased muscle size, etc. nonfunctional overreaching is when the decrease in performance extends for weeks to months.

00:16:50:00 – 00:17:16:13

Unknown

The super compensation effect is lost. Effectively, no fitness adaptation is realized. Mood disturbances and measurable neuroendocrine changes are also present some of the time, recovery is expected, but the timeline is challenging to predict in advance. It’s defined retrospectively by how long resolution takes. And now, when we get into this sort of, definition, it seems squished, more squishy than the functional, overreaching one.

00:17:16:13 – 00:17:45:18

Unknown

And it gets worse from here, because overtraining syndrome is when the decrement in performance persists for months to potentially years. Sometimes there are significant hormonal abnormalities that are observed. Sometimes you also see psychological, conditions that, happen alongside of this. And by definition, in the consensus statement on these definitions themselves, it is a diagnosis of exclusion. You can only arrive to it after systematically ruling out everything else that produces the same presentation.

00:17:45:20 – 00:18:12:01

Unknown

And in fact, quoting directly here one of the guidelines related articles says you can only differentiate between nonfunctional overreaching and overtraining syndrome only after a period of complete rest. So at the moment, an athlete presents with fatigue and declining performance, you can’t determine if they are nonfunctional overreaching, then, or if they’re overtrained. They just have to rest and then you’ve got to monitor them, which Austin’s already shaking his head.

00:18:12:01 – 00:18:31:10

Unknown

He’s like, that’s what’s the point of all? That’s right. Yeah, it’s a great question. What is the point of all this now if you want to name it, if you think that helps your management or at least how you think about it, that’s one thing. And, maybe, burying the lead here. I don’t think this is helpful, but, and there’s another problem here.

00:18:31:11 – 00:19:01:10

Unknown

After any sufficiently hard workout force, production performance is measurably reduced using the strict functional overreaching definition, every athlete is technically functionally overreaching until they recover. The boundaries between these categories are squishy again, and the retrospective labels assign based on recovery duration, which is itself a function of training. History, nutrition, sleep, life, stress, genetics, etc. and measurement timing. All of that contributes here.

00:19:01:11 – 00:19:20:01

Unknown

We can’t use functional overreaching versus nonfunctional overreaching to make a different clinical decision. At the time of presentation. You just don’t know, right? What if somebody’s you know, their force production goes down after a workout, they’re functionally overreached. And then weeks go by and they never get stronger. And it turns out you’re a nonfunctional overreach. We we don’t know how does that affect your your management here.

00:19:20:03 – 00:19:43:10

Unknown

It kind of just, you know, whether they just, you know, weren’t training in an intelligent way that led to the adaptations that you were looking for, like, oh, yeah, there’s this distinction of like where you training appropriately for the goal that we had in mind, you know. Yeah, exactly. And so this taxonomy that we just described is built on a model of training adaptation that we should probably examine directly, because the model has a flaw.

00:19:43:10 – 00:20:06:21

Unknown

That explains most of the confusion, in my opinion. And this is this stress recovery adaptation model. And Austin, I’d like you to walk us through this, at least to start of it, because, you know, it all starts with this Hans Selye’s general stress physiology work from the 1950s. How do you use that or apply that when you’re with your own programing logic, like when you’re either designing a training program or assessing your own response?

00:20:06:21 – 00:20:27:18

Unknown

Do you use, you know, stress recovery, adaptation and maybe define it for the audience at home? I have not this is this is a topic. It’s been some years, I think, since we’ve, you know, launched some launched some attacks at this. And so I think we’re, we’re overdue to, to come back to it. It is a model based on his original research that I believe originated in rats.

00:20:27:18 – 00:20:53:21

Unknown

Just to be clear, not unlike human subjects who were performing training. And so it is a, I would say, a pretty distant extrapolation from that. And as we like to say, it’s one of those models or those explanations that, make sense if you don’t think about it, at least too hard. And but it does lead to a set of nice, neat, tidy, you know, downstream implications and conclusions that, that feel.

00:20:53:21 – 00:21:20:13

Unknown

Right. And leads to nice, simplistic ways to arrange training and things like that, that at least in the early stages of somebody’s training career, might seem to be working out as you would predict, but tend to break down relatively quickly. Beyond that. So the core logic of this, paradigm, we’ll call it, is that you initially apply some form of a physiologic or we’ll call it a psycho physiologic stressor to the organism.

00:21:20:15 – 00:21:43:17

Unknown

This disrupts the organism from homeostasis. And then you recover from that stimulus. And in the course of recovery, you have, we’ll say, built up additional defenses and resilience and ability to tolerate that same stressor in the future. And that adaptation leads you to end up kind of above the starting point. And that’s where that term of quote unquote, super compensation kind of, came from.

00:21:43:19 – 00:22:20:16

Unknown

And so when this paradigm is applied to training and to programing, it really suggests it as a neat, linear, punctuated and very predictable process where there’s this like discrete stressor, this dip, when you are, you know, stressed and thereby recovering, and then when you return to baseline and then when you kind of, compound your adaptations above the baseline, and then you have to time the next stressor, perfectly during that subsequent kind of super compensated phase so that you can repeat it, and then you just kind of oscillate back and forth with a gradual trend upwards, over time.

00:22:20:18 – 00:22:46:04

Unknown

So, yeah, when somebody enters the gym for the first time and they do a workout and then they’re like, oh, I came back a couple days later and I could add weight. That is like almost like a confirmatory experience of this, of this model for them. And it leads it to be pretty compelling. Again, if you train long enough, then it requires increasing mental gymnastics to, keep that model as the as the central paradigm of your of your training approach.

00:22:46:08 – 00:23:04:07

Unknown

How does that. Yeah. How does that sound to you? Yeah, it sounds to me it’s kind of like you’re describing this, like, you know, process is one clean wave. You know, where where it all happens in this predictable manner. You got to catch the wave at the right time. And if you miss it, well, now you’re you’ve missed out on gains from from exercise.

00:23:04:07 – 00:23:29:09

Unknown

Right. What’s really happening though, under the hood is that the body is running multiple systems simultaneously on completely different timescales. So for example, neural adaptations with respect to how quickly and how much, and how robust the electric signal is to the muscles. Those adaptations take, you know, days to weeks hypertrophy, you know, takes weeks to months.

00:23:29:11 – 00:23:52:03

Unknown

Connective tissue remodeling and adaptations. It takes months to even longer than that. And they don’t synchronize into a single wave that crests at a predictable moment after each session. The model describes a sort of idealized single system response that gets applied to, you know, multi-system, multiple things going on at one time in the human body. The second problem here is this window of opportunity at the peak of the way.

00:23:52:03 – 00:24:11:05

Unknown

That’s when you want to go back to the gym again and add weight. So if there was an optimal moment to apply the next training stimulus, the next stressor, the window after recovery, where the system is briefly above baseline, then missing that window means missing the adaptation, which produces weird programing decisions like am I recovered enough? Did I time this right?

00:24:11:05 – 00:24:37:08

Unknown

Am I overtraining or undertrained? But none of this has evidentiary support. The window doesn’t work the way the model implies for most real training scenarios, and I think this all breaks down to this recovery versus adaptation. Sort of issue. The model obscures, you know, why functional overreaching and nonfunctional overreaching look identical at presentation. Recovery from a session means return to baseline performance.

00:24:37:08 – 00:25:07:21

Unknown

Capacity adaptation means improvement above it. These are different things on different timescales, driven by different processes, not completely different. There’s some overlap. The Venn diagram does overlap in the middle, but they’re not identical. And conflating them is what makes this taxonomy, you know, feel meaningful. And when it’s not in reality at the moment, an athlete or lifter present with fatigue and declining performance, you can’t distinguish between someone who’s in the trough, you know, of their recovery, right?

00:25:08:00 – 00:25:32:04

Unknown

And an athlete who’s lost the ability to respond to exercise entirely. It’d be the same point, but different trajectories, same presentation. The taxonomy only resolves post hoc. I you know, in retrospect, now after the outcome is known, we think that, you know, you instead of trying to time this peak, you instead would add load once that peak has already occurred.

00:25:32:10 – 00:25:56:00

Unknown

Right? You add weight because you got stronger not to get stronger. Fitness accrues continuously when the inputs are adequate. Things like sleep, nutrition, training load, life, stress recovery capacity. The question is never whether you timed the next session to hit the super compensatory peak. The question is whether the inputs were adequate over time. When they are adaptation happens and whether or not it doesn’t.

00:25:56:02 – 00:26:24:14

Unknown

The consequence of the model being too literally applied, in my opinion, is that coaches and athletes again make weird decisions based on a mental model of fitness that does not reflect how adaptation actually works in response to exercise. And it’s weird to me that it kind of fails in two different directions at the same time. On the one end, trying to add weight to the bar every single time you go in the gym, whether the adaptation is actually occurred, you’re trying to hit this imaginary super compensatory window before it closes.

00:26:24:16 – 00:26:52:22

Unknown

On the other hand, you reduce volume when progress stalls, on the assumption that a failure to improve means that you’re overtraining, you’re doing too much, and you need more recovery time. So you train less. The irony is that both errors can coexist in the same program. Intensity stays high because the model implies that this adaptation or super compensatory signal requires a maximal stimulus while volume gets cut in the name of recovery, so the athlete ends up simultaneously being overloaded by intensity demands and under loaded by the reduction in total training load.

00:26:52:22 – 00:27:11:19

Unknown

Because volume is cut, we can think of it this way fitness is less like a wave that you need to catch at just the right time. It’s more like a bank account. Deposits accumulate over time, and what matters is whether the balance of inputs and recovery is positive over weeks and months, not whether you timed a single transaction perfectly.

00:27:11:21 – 00:27:41:00

Unknown

That that makes sense to you. I think so, and I think that the longer you train, the more, as I said, mental gymnastics you have to do to keep the original paradigm in mind and, the more apparent it becomes that things are a lot more complex and, a lot more variables are dynamic and interacting all the time, especially at the much later stages of, of our training career where we recognize that, like, yeah, it takes a lot of consistent training, a lot of training itself.

00:27:41:00 – 00:28:00:13

Unknown

And we need, like a lot of other stars to align for us to be able to put up a PR maybe a couple times a year, like if we’re lucky. And yet it is still possible for us to make progress. But there is like no possible way that we could draw out some sort of like, you know, predictable, you know, stress rate out, recovery, adaptive cycle.

00:28:00:15 – 00:28:15:17

Unknown

At this stage in our career, there’s just too much mess, going on. And if you think about it, even at the beginning of someone’s training career, even though it might appear to be simpler that somebody is able to progress a little bit more quickly, there are still tons of variables that are going into that process. Right?

00:28:15:19 – 00:28:43:14

Unknown

And as you said, there are a lot of, you know, collapsing it all down into adaptation itself as an oversimplification because of the all the different adaptations that are happening, you will have neurological adaptations within during the training session. Right? As you develop the skill. And maybe you if you have a coach or you’re like refining your technique or something is like self-organizing, you’re like literally having neurological skill adaptations while you’re doing the lifts.

00:28:43:18 – 00:29:05:18

Unknown

That is like the fastest, shortest term, you know, adaptation that might lead to an improvement in performance. Whereas the process to like, lay down additional, you know, muscle cross-sectional area is going to take a substantially longer period of time, during that phase. But all of these things ultimately are what are contributing to, the performance improvements, that we observe over whatever timescale we’re looking at.

00:29:05:18 – 00:29:30:03

Unknown

So it’s just way more complicated. And the simplistic elements, while appealing for explanatory purposes, because humans, we like breaking things down into parts and generating simple explanations for them. That’s only useful if it leads to, you know, the correct management. As a result. And the problem here is this simplistic paradigm leads to people making the wrong decisions, in their training more often than it leads them to make the right ones.

00:29:30:05 – 00:29:52:03

Unknown

Yeah, most often under training, like not doing enough training, but simultaneously making the training too hard because I think that’s the primary signal. Yeah. John Kiely, a friend of the show, he’s given us some good feedback on, on some episodes, which I greatly appreciate because we respect him. Published a paper in sports medicine in 2018 called Periodization Theory Confronting an Inconvenient Truth.

00:29:52:05 – 00:30:16:09

Unknown

That makes this argument directly that the super compensation model is imported into exercise training without the scientific foundation to support it. Then the show notes you want to take a read. Also great name, Inconvenient Truth. Who knew those? Interesting. With that in mind. Dysfunctional. Overreaching. Nonfunctional. Overreaching. Overtraining. Overtraining syndrome taxonomy was built on top of this model.

00:30:16:11 – 00:30:48:00

Unknown

Functional overreaching is defined specifically as the overload that triggers adaptation. But if the stress recovery adaptation cycle doesn’t work the way the model assumes where each workout is, the stress recovery happens between sessions, and adaptation is the result of that specific stimulus. Then the categories built around it are shakier than they appear. In my opinion, a more accurate description would be that every fitness adaptation is the result of the training load that has accrued over weeks and months, which is built on top of years of prior history.

00:30:48:00 – 00:31:13:14

Unknown

If available, there’s no discrete cycle that resets after each session. The timescale is continuous and cumulative, and it varies based on the athletes history, not a category label. The clinical, taxonomy, you know, descriptors are real in that people experience them, but functional, overreaching, nonfunctional, overreaching, and overtraining syndrome are points on a continuum that can only be identified after the fact, not distinct categories.

00:31:13:14 – 00:31:41:23

Unknown

With clear boundaries, you can locate at the time of the presentation. So again, to your point, does classifying somebody is I think it’s functional overreaching versus nonfunctional overreaching versus overtraining syndrome that change your management. If you haven’t observed what’s happened to them after you’ve done something, after you’ve intervened? Yeah. To me it doesn’t. And and I think here’s an interesting thing that actually takes us into the next section on resistance training and its prevalence in overtraining syndrome.

00:31:42:01 – 00:32:05:02

Unknown

It’s connective tissue. We kind of miss this. You know, you said neural adaptations happen, you know, while you’re doing the workout, that can happen also, you know, days, hours after, after a session. But connective tissue, tendons, ligaments, joint structures, bones, one of the more slowly adapting systems. It’s also the tissue that’s most likely to fail under accumulated load.

00:32:05:02 – 00:32:28:09

Unknown

This is one of the reasons why injury tends to intervene. An overuse injury, for example, tends to, pop up before overtraining syndrome does. In resistance training populations, this sort of maybe structural limit hits before any other limiter does. And so one of the reasons why the resistance training picture looks a whole lot different from what the endurance literature would predict, which is exactly where we’re going before we get there.

00:32:28:09 – 00:32:49:04

Unknown

Austin, walk me through, like a clinical differential for an athlete presenting with fatigue and declining performance in the gym, show us where overtraining syndrome actually sits on that list in your in your brain, man. You’re asking an internist to elaborate a differential diagnosis for you, which means, you got to buckle up. This could go on. This could go a while.

00:32:49:06 – 00:33:07:18

Unknown

Now, I’ll try to keep it brief, but the differential truly is very, very large for fatigue in general. And so obviously, the way that I would start to approach the problem is with a much more detailed history, specifically focusing on the nature of any more specific symptoms that I can gather and the timeline that the person has been experiencing this on.

00:33:07:18 – 00:33:31:19

Unknown

So if it’s been like much more abrupt onset fatigue over the past few hours, days, weeks versus it’s been going on for months, if not years, and then whether there’s any other associated symptoms, mainly to help me try to localize a potential problem. So somebody with like fatigue and any sort of thoracic symptom, for example, like chest discomfort or breathing difficulty or something like that, might pulmonary towards a cardiovascular cause or a pulmonary issue or something like that.

00:33:31:19 – 00:33:49:12

Unknown

If it’s much more generalized, then that makes it again a harder part of my job. And I might look for more systemic things, than something that’s very localized to a particular organ that might be going wrong, but looking for anemia and iron deficiency and endocrine ofthese hormone disorders, because, again, blood and hormones go everywhere in the body.

00:33:49:12 – 00:34:10:13

Unknown

And so it’s much harder to localize those types of things. Other metabolic issues, like what if the person has nuance that type two diabetes or type one diabetes that hasn’t been, that hasn’t manifested in more obvious ways, things like fatigue up front. I’m also looking for evidence of sleep apnea or just poor sleep hygiene habits, things like that in general, as like probably one of the most common things.

00:34:10:18 – 00:34:28:11

Unknown

But I started out with like the quote unquote no miss types of issues. Again, this like more dangerous cardiopulmonary causes that can lead an athlete to, like, die. But that’s much less common, in this, situation, it’s just the way that our brains are trained to think. And then I’d be curious based on the timing of onset.

00:34:28:11 – 00:34:46:15

Unknown

For example, sometimes I’ll see folks who tell me that they’re just been struggling with fatigue. Tell me, what did you observe when this first started it? Oh, it it onset right after I had this, like horrible illness like post-viral fatigue syndromes super common, can be persistently debilitating for long periods of time as well as like autoimmune and inflammatory issues and things like that.

00:34:46:15 – 00:35:12:20

Unknown

So there’s a pretty broad list of I’d say cardiovascular, pulmonary, endocrine, metabolic, autoimmune, inflammatory. And then kind of more nebulous, types of things from there that I would be thinking through. There would be probably some basic lab evaluation that would happen looking at blood counts, metabolic panel, certain hormones, not all hormones necessarily. It’s easy to go way too far down the hormone testing rabbit hole in a very unhelpful way.

00:35:12:22 – 00:35:30:19

Unknown

And it can also be a problem because sometimes the same sorts of hormone, things that you might think are causing the syndrome can also be, the result of it as well. So determining that causality can be challenging. Checking iron panels is something that I do very aggressively. If you couldn’t tell based on my, my soapbox earlier, and things like that.

00:35:30:19 – 00:35:54:21

Unknown

So the differential obviously is massive. And I think that most people, especially coaches, who casually throw around the term overtraining are insufficiently qualified, to really try to tease apart and differentiate some of these things and certainly to evaluate for them directly. Yeah, no, that’s that’s, that’s well stated. So with that hierarchy in mind, most of this audience is primarily trained with weights.

00:35:54:23 – 00:36:16:21

Unknown

And the differential for a strength athlete looks different from what this list might apply for an endurance athlete. The evidence on resistance training and overtraining syndrome specifically is worth going through directly because it changes the picture, at least, at least in my mind. And I’ll be the first to say this. I don’t think that overtraining syndrome in resistance training has ever been adequately characterized, and not that it hasn’t, that people haven’t tried to do it.

00:36:16:23 – 00:36:37:23

Unknown

Let me go through what the resistance training evidence based on overtraining actually looks like, because it changes the picture significantly compared to what the endurance literature would otherwise imply. First, the background. In 2020, there was a systematic review that pulled together every study that could be found on overtraining syndrome and resistance exercise. 22 studies total ten of them, nearly half reported zero.

00:36:37:23 – 00:37:03:22

Unknown

Performance decline under the overload conditions that the researchers deliberately imposed, other studies that did show a decrement only eight had follow up data long enough to say anything meaningful about recovery. The conclusion no marker has been reliably established as an indicator of overtraining and resistance. Exercise not cortisol, not testosterone, not heavy. The one thing that consistently tracked the condition was a sustained drop in performance, which you would have caught without testing anything at all.

00:37:04:00 – 00:37:24:02

Unknown

So with that background, here’s what people have actually tried in order to induce overtraining syndrome. In 2024, Coleman did a supervised nine week study with extremely high training volumes. The program included Smith machine squats, leg extensions, calf raises all for five sets of 8 to 12, two minutes rest, and each of these sets was taken a failure for the upper body.

00:37:24:02 – 00:37:41:19

Unknown

They did shoulder press, lat pull downs, chest press, biceps curl and triceps press downs. Again, five sets of 8 to 12 reps. Again a failure with two minutes of rest. They did each of these sessions twice per week for a total of roughly 90 working sets per week. Yeah, 90 working sets per week. Nobody met overtraining syndrome criteria.

00:37:41:19 – 00:38:02:12

Unknown

In fact, they got fitter before that. Doctor Mike Zourdos, friend of the show, took three competitive strength athletes, two powerlifters and one weightlifter who agreed to attempt a one rep max squat every single day for 30 consecutive days. Plus, they did additional volume work at sub maximal loads again, not every few days, but every day for a month, and all three improved.

00:38:02:14 – 00:38:37:02

Unknown

One of the powerlifters took their squat from 473 pounds to 500 pounds. Another took their squat from 275 pounds to 303 pounds. The weightlifter went from 484 to 530 pounds three subjects. It is a case series so you can’t generalize this widely, but the directional signal is hard to reconcile with the overtraining narrative. And there’s a similar study where seven people max out their bench press every single day for 34 days now worked up to a heavy single, but they actually attempted a one rep maximum every day, followed by either five sets of three at 85% of the one rep max, or five sets of two at 90% of the one rep max.

00:38:37:04 – 00:38:56:17

Unknown

All seven improved. The study is small, and we’re not recommending daily maxing, although we have tried it before. But here’s what’s relevant daily one rep max has fluctuated throughout some days. Worse, some days were better. One participant was weaker on average her second week than her first. If a coach had checked in at day 14 and compare that to day seven, they would have called it a regression.

00:38:56:19 – 00:39:16:19

Unknown

But she went on to improve 23% anyway. The person who made the biggest gains, 50 pounds on their bench press, tested 20 pounds below their peak on the final day. That’s performance variability on top of a strongly upward trend, and the most experienced lifter in the group had the noisiest day to day numbers. More training history means more short term variability, not less.

00:39:16:21 – 00:39:37:17

Unknown

A study in 2017 took five trained men, and they did daily arm training for 21 consecutive days, but they alternated what type of training was done on each arm. One arm did a one rep max each session and that was it. The other arm did higher volumes of maximal work. Both arms got stronger by about two kilograms above baseline after the 21 days, but there was no overtraining.

00:39:37:19 – 00:40:04:06

Unknown

The volume arm also hypertrophy. It got bigger, whereas the one rep max only arm didn’t, which is its own finding about what actually drives muscle growth. But that’s a separate conversation. Now the question is can you actually produce overtraining through resistance training? And the answer is maybe. Fry and colleagues tried to do it in 1994, where they took 11 trained males and had them perform ten sets of one at their one rep max on a Smith machine every single day for 14 consecutive days.

00:40:04:08 – 00:40:23:18

Unknown

That’s 140 maximal singles total. The overtraining group’s one rep max dropped by about 12 kilos, and when they tried to stimulate the legs using electrically stimulated force production, well, that decline to recovery took 2 to 8 weeks. Then the hormonal data came back and it didn’t look like what the endurance over training literature had primed everyone to expect.

00:40:23:20 – 00:40:46:19

Unknown

Typically, they’re looking at a decline and testosterone to cortisol ratio, but in this case, exercise induced cortisol went down and testosterone slightly increased the testosterone to cortisol ratio. Again, this marker that’s most commonly cited in coaching context as the overtraining signal moved in the wrong direction. The classical endurance overtraining syndrome biomarkers don’t seem to apply to high intensity resistance training.

00:40:46:20 – 00:41:09:14

Unknown

Now, in contrast to the Fry data, a similar study also did daily leg training for two weeks, but this time at sub maximal loads. One rep max increased 6%. Yeah, increased 6%. Fatigue resistance improved. Compare this directly to the Fry data. Maximal loads produced a transient decrease in one rep max, whereas sub maximal daily training produced an improvement in resistance training.

00:41:09:14 – 00:41:31:05

Unknown

Intensity, not necessarily frequency, appears to be the necessary ingredient for overreaching or in this case, overtraining. You can train every day and get stronger if the training is dosed correctly. And in fact, we think that training frequency is just an instrument or a tool to distribute the training load. More frequency doesn’t necessarily mean more training load unless volume increases, but in this case, it’s training intensity that seemed to be the linchpin.

00:41:31:06 – 00:41:58:22

Unknown

The Margonis, in a study from 2007, is the one resistance training study that potentially crossed into overtraining syndrome territory. 12 males went through 12 weeks of progressive loading on seven exercises. They did the bench press, squat, snatch and clean deadlift. They did some biceps curls, they did some rowing, and they started originally at two days per week, built to six days per week by the third phase, with intensity climbing from 70% to 85 to a 100% of their one rep max.

00:41:59:03 – 00:42:17:07

Unknown

Then they did a taper, then they did three weeks of complete rest. The primary strength marker was the hang clean, which is a problem. It’s a highly technical lift, and performance on it reflects skill as much as it does strength. When you look at the numbers though, the hang clean one rep max actually peaked during the high volume phase and it never dropped below baseline after that.

00:42:17:09 – 00:42:41:16

Unknown

By the time the rest period rolled around, it was still above where it started, but down from the peak during the high volume phase. Given that it was after weeks of rest that looks more like a skill decay thing rather than overtraining. So the claim that this study produced genuine overtraining syndrome is shakier than it’s usually presented. The one performance biomarker that they tracked it was the wrong one for the population performance on it never even collapsed below baseline.

00:42:41:16 – 00:43:18:14

Unknown

Calling it confirmed overtraining syndrome overstates what the actual data shows. So to summarize, no study has cleanly induced overtraining syndrome through lifting weights, at least not by the current definitions. The most likely explanation is that there’s something else that tends to intervene first, we think that’s probably overuse injury. When training load is too much for somebody to currently tolerate, they’re more likely to suffer an overuse injury before they ever get anywhere close to overtraining syndrome, or because we’re just really, really adaptable and like them, you know, provided you don’t get injured ratcheting up your training load over time, it seems like people are just going to get better.

00:43:18:16 – 00:43:45:01

Unknown

You know, if you give them a long enough window to adapt. So often, if a strength athlete came to you saying they felt overtrained and that their training for four days a week, what is the actual probability in your, in your clinical experience, that training volume is the primary driver here, typically low? I think in my experience and I suspect in yours as well, I’m going to similarly take a detailed history about what do they mean when they say they feel overtrained.

00:43:45:03 – 00:44:04:20

Unknown

Question one. And then question to tell me about your training. And it might be a moderate to even a high volume training program. But much more often, you know, the question in my mind is if the idea here is if training volume is the primary driver, then it means that this person is like essentially incapable of tolerating that level of training volume.

00:44:04:20 – 00:44:22:03

Unknown

And most often we find that that is not the case. They may or may not truly need that level of training volume to make the kind of progress they’re, they’re looking for. But much more often it’s a more complex byproduct of multiple variables coming together. The intensity might be too high for the amount of training volume that they’re doing.

00:44:22:03 – 00:44:52:07

Unknown

They may also have some iron deficiency that’s been undiagnosed or their nutrition might not be, you know, where it needs to be. Their sleep is often not, in a, in a great situation. So there might be there are very often numerous variables at play that need to be modified. And so, you know, if on the back end, because this is again something that you can only determine kind of more retrospectively, but let’s say is there a scenario on the back end where the person we have a training set up for them, where they’re actually doing at least as much training volume, if not more, but the other variables have been modified such that

00:44:52:07 – 00:45:11:03

Unknown

they’re able to tolerate it. That very often is the case. And then by definition, the training volume was not the primary driver up front. It was the collection of all of these variables that ultimately a mismatch between the training and the person, much more so than they were just like, oh, you’re just doing too much. And this is like a hard limit that you’re not going to be capable of ever tolerating.

00:45:11:05 – 00:45:29:21

Unknown

Yeah, yeah. What I typically see in this type of scenario is not the volume per se, literally just the number of sets and reps. It’s either, as you alluded to, a sort of life load, right? If training load is not only how much training you’re doing, but the nature of the training life load as everything else that’s going on outside the gym.

00:45:29:23 – 00:45:48:13

Unknown

So what’s your nutrition look like? What’s your sleep look like? What’s your life stress, occupational relationship stress, etc.. Psychological state. Medical, you know, health, sort of stuff. How does that, you know, effectively that’s, that is your, your life load. And if that starts to creep up, you have less sort of resources to deal with training load.

00:45:48:13 – 00:46:09:23

Unknown

So that can sort of lead to this sort of transient shift towards, well, no longer can I tolerate my previous training. Not overtraining syndrome, though. Not overtraining syndrome because overtraining is in there requires people to stop training to rest, and there’s no resolution of their symptoms. Right. And also, oh by the way, they can’t get fitter from their from the the exercise that they were doing.

00:46:10:01 – 00:46:34:22

Unknown

The other thing that I see is that volume actually stays the same sets reps, etc., but the intensity goes up, to to a level that they can no longer tolerate. Generally this would be an RPE, you know, rate of perceived exertion. They get closer to failure, for example, which basically indicates they are trying to add training load via intensity before the adaptation has actually occurred, making them stronger.

00:46:35:00 – 00:46:54:15

Unknown

And we come back to this all the time. You’re training shouldn’t get harder over time. It should stay the same relative level of hardness, but you get fitter, so you’re doing more, right? You know, your very first day in the gym, if we had you max out, that’s going to feel a certain level of hardness. It’s going to feel the same level of hardness later on, but it’s going to be heavier weight.

00:46:54:17 – 00:47:10:08

Unknown

Right. So what people will do is I got to add weight, I got it, I got or I got to add, you could theoretically add, add volume before again your, you’re, you’ve actually gotten fitter. And so now at this point the training load has actually been ratcheted up to a point where no no longer can they can they tolerate.

00:47:10:08 – 00:47:29:21

Unknown

So again it’s all a mismatch. But as far as like what side of the equation the mismatch is coming from can vary. But that’s typically what I see. Now with all that in mind, what actually causes overtraining syndrome? We come back from the break. We’ll cover the leading theories.

00:47:29:23 – 00:48:02:00

Unknown

All right. We’re back here on the Barbell Medicine podcast. We’re talking about overtraining syndrome specifically. Now what causes overtraining syndrome. So there are six primary hypotheses in the literature. Understanding where each one comes from, what it explains and where it falls short tells you something important about how genuinely unresolved this condition still is. Let’s go through, first is the, the sort of anchor here that we have one HPA response hypothalamic pituitary adrenal response.

00:48:02:00 – 00:48:18:16

Unknown

This is basically how you respond to stress. Okay. So it’s, you can think of this as a central command that decides how your body responds to any stressor coming in. It doesn’t label the stressors coming in, doesn’t know if it’s from a heart training week, bad sleep, work crisis, family situation. It’s just how your body responds to stress.

00:48:18:16 – 00:48:40:04

Unknown

It only knows the total. So what we’re really talking about when we’re talking about overtraining syndrome is a ratio total life load relative to recovery capacity. And when that ratio stays unfavorable for long enough, something can break down. Now, training is not inherently pathological. You can take the same athlete, the same program and produce overreaching in one context and normal adaptation in another.

00:48:40:05 – 00:49:02:18

Unknown

Be like, college athletes during finals week, for example. But these six hypotheses are all trying to answer the same downstream question. Once that threshold is crossed, what is the biological chain of events that produces the performance decline and the symptom constellation that we call overtraining syndrome? So the first up is very simple. It’s the glycogen theory glycogen depletion specifically.

00:49:02:23 – 00:49:29:20

Unknown

This is from the late 90s. This was proposed that insufficient carbohydrate availability depletes the muscle and liver glycogen stores. And the resulting substrate deficit explains the fatigue and the performance decrement. I guess it made sense when it was proposed. If you can’t fuel the engine, the engine fails. The problem is that overtraining syndrome, symptoms persist even with adequate carbohydrate intake, by definition, and athletes meeting the overtraining syndrome criteria can’t refuel their way out of it.

00:49:29:20 – 00:49:57:01

Unknown

You can’t overeat and just get back into the game. So this model explains bonking, maybe during endurance events, but it doesn’t, explain the syndrome. The next up is this serotonin branch chain amino acid theory. It’s a little more sophisticated. Central fatigue via serotonin. The logic goes like this. Intense exercise oxidizes branched chain amino acids, which competes with tryptophan for transport across the blood brain barrier.

00:49:57:05 – 00:50:21:23

Unknown

So you’ve depleted, some of the branch chain amino acids and more. Tryptophan gets through. More tryptophan means more brain serotonin and more brain serotonin means central fatty, sleepy amino acid. It’s elegant. It sounds truthy, if you will. The problem is that, branched chain amino acid supplementation doesn’t prevent overtraining. Syndrome. Also, the serotonin levels vary wildly, in athletes.

00:50:21:23 – 00:50:43:03

Unknown

So if the mechanism were correct, you would see sort of reliable changes with not only branched chain amino acid supplementation, but also like tryptophan levels, serotonin levels, etc.. And we just don’t. Third hypothesis, is the autonomic bias. This is one of the oldest frameworks in literature. It’s actually a two type model that there’s sympathetic overtraining and parasympathetic overtraining.

00:50:43:03 – 00:51:07:13

Unknown

Now your autonomic nervous system again is comprised of two major arms parasympathetic and sympathetic sympathetic being fight or flight parasympathetic being rest and digest. So with the sympathetic type overtraining you’d see an elevated resting heart rate, irritability, sleep, disruption, reduced appetite. And if it’s parasympathetic, overtraining. You see a low resting heart rate, deep fatigue, mood, depression, motivational, decreases.

00:51:07:15 – 00:51:31:16

Unknown

The two time models still get cited to date. And but the limitation here is that autonomic changes appear to be downstream effects. Basically whatever the primary disruptor is, not necessarily the cause of it. And also, again, people are varying wildly when it comes to overtraining syndrome and those who have been diagnosed with it. The next theory has to do with cytokines, heavy training produces muscular damage.

00:51:31:16 – 00:52:08:14

Unknown

Muscle damage triggers an inflammatory cascade of interleukin six, interleukin one beta, TNF alpha, and sustained cytokine elevation produces what immunologists can call sickness behavior the fatigue, mood disruption, anhedonia. People don’t take any pleasure in activities. Reduced motivation to train this, again, is intuitively appealing for athletes who look quote unquote depleted and feel sick. The problem, with this chronic cytokine picture and overtraining syndrome is that it doesn’t replicate cleanly across studies, and acute exercise induced cytokine elevation resolves normally with adequate recovery, usually in like hours.

00:52:08:14 – 00:52:32:14

Unknown

Today’s, So you’d expect a distinct signature that persists in true overtraining syndrome. Again, if things don’t resolve in, you know, with with a complete rest in weeks to months, which you don’t really see that here. Which brings us to the hypothesis with the strongest current evidence, HPA axis dysregulation. So the hypothalamic pituitary adrenal axis dysregulation, your stress response is pickled.

00:52:32:16 – 00:52:58:08

Unknown

Again, this is the central core coordinator of your stress response. But under conditions of chronic, unrelenting training load, the system shows, pattern of dysregulation, not at the level of the adrenal glands, which sit on top of your kidneys, but upstream. The pituitary gland specifically has reduced ACTH output. That’s a specific hormone that basically, causes the adrenal glands to, spit out some cortisol, down the road.

00:52:58:10 – 00:53:21:06

Unknown

Now, this is an important distinction because people talk about adrenal fatigue, which implies adrenal insufficiency where the glands themselves are failing to produce cortisol. But that is not what is happening here. The adrenals are intact. They, appear to respond normally. The problem, would be in the brain. The regulatory signal from the pituitary gland is decreased, which means the adrenals really receive less instruction to respond.

00:53:21:11 – 00:53:44:18

Unknown

And so you can have a normal resting cortisol and still have significant HPA dysregulation because the problem is in the responsiveness of the axis, not the baseline output. This is really famous study. You get cited all the time in the overtraining syndrome literature called the Eros study. They found ACTH blunting in 78.6% of the athletes meeting overtraining syndrome criteria.

00:53:44:18 – 00:54:09:08

Unknown

They use what’s called an insulin tolerance test. You’re familiar with this test, but I have never done an insulin tolerance test for, ACTH. Yeah. Testing. Yeah, right. Very specialized endocrinologist, level of testing. So basically it takes some insulin and it induces hypoglycemia. So low blood sugar, which is a physiological stressor that should drive the full cascade of the hyper, hypothalamus, the pituitary gland and the adrenal gland.

00:54:09:12 – 00:54:38:09

Unknown

The hypothalamus releases, this hormone CRH, that goes to the pituitary gland, causes it to release ACTH. And then that travels to the adrenal glands to make it release cortisol. So basically you can see is the system intact or not? In 11 out of 14 athletes, this test produced a level of cortisol. 17.9 which compared to adrenal insufficiency, is 18.

00:54:38:09 – 00:55:10:06

Unknown

So pretty close there. I think the methodology here is actually pretty rigorous, more than critics usually give it, credit for. But we’re only talking about 14 athletes, and they were all classified with overtraining syndrome, sort of, by subjective symptoms anyway. And oh, by the way, the test here, how are you going to access it? Like if, if you’ve never done one of these tests in the hospital and you have access to it, you’re telling athletes, Tim age, you should go get an insulin tolerance test and to see if you’re overtrained.

00:55:10:08 – 00:55:31:10

Unknown

So the main takeaway from this is that maybe there’s something going on at the level of the hypothalamus, pituitary gland. It’s not really happening at the adrenal gland. So when people say adrenal fatigue, we can kind of write that off. That’s not really what’s happening as far as how to, you know, implement this, these studies findings in your exercise prescription.

00:55:31:11 – 00:55:56:15

Unknown

Big shoulder shrug because no one’s doing this test right. And further, even if you had results from this test, how does it, you know, affect your management? If somebody did this test and like, look, my levels, you know, 17.7 and you’re like, okay, but how do you feel. Yeah. And the other aspect is I still am unconvinced in terms of, how much of this is an effect of the syndrome rather than a cause of it.

00:55:56:15 – 00:56:26:09

Unknown

Right. Because we know that there are endocrine disruptions from all sorts of things. Our endocrine system is not static. It is dynamic and responds to our environment. And we’ve talked about, for example, how, in the context of obesity, for example, you know, testosterone levels tend to go down when somebody has that state of low energy availability. A lot of their their thyroid hormone, your thyroid function might decline as an adaptive mechanism there and there, you know, gonadal gonadotropin and their testosterone and things like that might also go down as an adaptive mechanism.

00:56:26:11 – 00:56:52:12

Unknown

And so the idea that in this state, you know, the the HPA axis might also turn down a little bit, I find to be a plausible result of the syndrome at least as much as something if we’re trying to dig into, like the cause, it might be that it wasn’t able to, you know, I guess the proponents of it as a causal theory are that the system broke down because it wasn’t able to tolerate the stressor, but at the same time, it might be an adaptive mechanism to like, hey, rein the person in.

00:56:52:12 – 00:57:08:20

Unknown

This is, you know, they might not be able to tolerate this. And so things get turned down on the on the back end because the an implication or another way to test this would be, oh, if I were able to stimulate that access, would it resolve your syndrome. Because there are ways to do that. I have ways to stimulate your HPA axis.

00:57:08:20 – 00:57:23:13

Unknown

I actually do that test in the hospital all the time. We call it a cousin trope and stim test to see what happens to can I yell at your adrenals enough to spit out enough cortisol to handle whatever physiologic stressor you need to be able to handle. And so doing that type of testing can can illustrate that.

00:57:23:13 – 00:57:43:22

Unknown

But would that resolve somebody’s overtraining syndrome if they were, you know, at the clinical criteria for it? I, I doubt it. So this whole world is pretty messy. And the direction of causality is not clear to me. Yeah, yeah. The other thing is like they recruit people into this study. They used symptoms that overlap with HPA axis dysregulation anyway.

00:57:44:01 – 00:58:03:20

Unknown

So it’s like, okay, you recruited people in here that are experiencing symptoms that are that, you know, mapped to this condition. And then you found this condition and it’s like, it’d be nice if you did it early before they were overtrained to see, like, oh, and then subsequently change that would make you feel better about this maybe being causal, but it could also just be like, yeah, this happened at the same time.

00:58:03:20 – 00:58:29:08

Unknown

And again, you can’t do this test. So like yeah, yeah. Unclear of of of how useful it is. So the sixth and final framework isn’t actually a mechanism. It’s sort of like a meta level observation about why we don’t have a single mechanism. This is from a 2022 paper from Armstrong that proposes that treating overtraining syndrome as an emergent complex systems phenomena, there’s no single pathway that produces overtraining syndrome.

00:58:29:08 – 00:59:02:16

Unknown

No single biomarker reflects it. It arises when multiple systems are simultaneously affected from chronic training load. This may point at a deeper problem as well. If overtraining syndrome is what happens when multiple systems are simultaneously pushed past their adaptive ceiling, and experimental data keeps failing to produce it through resistance training alone. The question worth sitting with is whether overtraining syndrome is a distinct pathological entity, or whether it’s simply what severe, prolonged training load recovery mismatch always looks like.

00:59:02:16 – 00:59:33:14

Unknown

And overtraining syndrome is just a label we apply to it. The residual case that true load induced overtraining syndrome isn’t adequately nourished in an adequately nourished, well-rested, psychiatrically healthy athlete without PED exposure was never been cleanly characterized. The defining features of overtraining syndrome versus overreaching prolonged performance decrement almost always has an unaddressed or hidden variable underneath it. But we can’t say with confidence you can’t confirm overtraining syndrome with a single biomarker because there is no confirmed mechanism.

00:59:33:17 – 01:00:05:00

Unknown

You’re looking for a pattern, and the pattern can only be assembled after the fact, which is why this remains a diagnosis of exclusion that’s satisfactory to you. Yeah, I keep coming back to this mismatch type of a paradigm instead of just the training load itself. I suspect that when most of those other variables are in line, what you mentioned adequately nourished, and they’re getting enough rest and things like that, I suspect that structural issues are likely to emerge before you end up in this like, quote unquote, overtraining syndrome type state.

01:00:05:00 – 01:00:23:22

Unknown

In other words, injury, like when we think about like, yeah, Olympic level athletes, they are able to tolerate and do massive amounts of training on their quadrennial cycle to prep for the Olympic Games. And there is certainly a high degree of selection bias and survivorship bias, in that population. Right. They’re already elite genetic freaks who are able to do that.

01:00:24:00 – 01:00:43:09

Unknown

And then they have all the resources and, depending on the sport, of course, of the time and the nutrition and the recovery to be able to get there. And those who are not able to survive that, I suspect, are either not of the genetic stock to to get to that level, but also get selected out earlier in life through injury, through setbacks, through other things like that.

01:00:43:11 – 01:01:09:20

Unknown

And so you’re right that this is a complex, multivariable thing rather than just too much training in the vast majority of cases. Yeah, yeah. So let’s, let’s move on. There’s a couple gaps here that have been established, because of this taxonomy, it’s fundamentally retrospective. It’s built on continuous variables that are treated as discrete categories. And the model of adaptation was imported from the general stress physiology without validation in sport.

01:01:09:22 – 01:01:34:06

Unknown

A resistance training, evidence base that has largely failed to produce overtraining syndrome despite deliberate attempts at doing so, and six mechanistic hypotheses with partial inconsistent support, the best supported of which requires a test that most clinicians have never run and athletes don’t have access to. So there’s this vacuum, in this evidence base. And that vacuum has been filled by two specific narratives and coaching practices that the data doesn’t support.

01:01:34:06 – 01:02:05:10

Unknown

Let’s address both. First, it has to do with cortisol and testosterone, a cortisol ratio, and also heart rate variability. It’s like, well, look, if it’s not any of these other things, it’s got to be, maybe some sort of, test we can monitor. These two tools have been put forth as, instruments for diagnosis, diagnosing and monitoring, overtraining syndrome, which shapes how sports medicine workups have been structured and what coaching certifications teach and what commercial wearable companies market.

01:02:05:12 – 01:02:31:16

Unknown

Here’s what the evidence shows about that. First off cortisol resting cortisol is normal in at least 75% of individuals who have been diagnosed with overtraining syndrome. Again, it’s like, how did they get diagnosed with overtraining syndrome? If you know not you’ve seen a cortisol level, but it’s normal in at least three quarters of them. The testosterone to cortisol ratio, is very, influential by the time of day.

01:02:31:16 – 01:02:57:04

Unknown

It’s it’s taken the training type, the fitness level of the individual. And whether total or free testosterone is measured. Acute drops happen routinely after intense exercise like a marathon normalizes within days. It’s never been validated against clinical outcomes. As an individual. Diagnostic for overtraining syndrome. Performance, on the other hand, can be useful. Performance potential, however, is driven by many factors.

01:02:57:06 – 01:03:22:04

Unknown

And the way I think about this is that your performance potential on a given day is, equals your fitness adaptations minus the current fatigue that you’re carrying on board in a specific environment. Fatigue is transient and expected from exercise, but most self-diagnose overtraining is an athlete testing performance during intentional load accumulation intentionally fatiguing, sort of protocols, and interpreting as a pathology.

01:03:22:06 – 01:03:52:16

Unknown

Much of this biomarker literature has the same problem. Hormones are sampled when fatigue is deliberately elevated from exercise. A recent study compared subjective versus objective monitoring tools. So subjective measures like mood, perceived fatigue, sleep quality, well-being, ratings, etc. they’re tracked. Training load changes with greater sensitivity, greater consistency than objective measures, which include various hormones, resting heart rate, and heart rate variability.

01:03:52:18 – 01:04:14:19

Unknown

When the two diverge in practice, we should probably weight this objective. It just correlates better. We’ve been saying this for years. We prefer RPE on a given set session, RPE for training session monitoring that over time versus like what was your testosterone to cortisol ratio? What was your creating kinase. It feels like the biomarker has to be better.

01:04:14:19 – 01:04:39:14

Unknown

But it you know, really just isn’t just asking people, talking to them. How do you feel? It’s way more useful to me than biomarkers in these types of situations. Yeah. There’s one interesting study that I think it’s worth mentioning. They, they took people who had been kind of not self-diagnosed, but they’ve been classified as having overtraining syndrome, and they had them do two max exercise, stress test basically within four hours.

01:04:39:14 – 01:05:09:01

Unknown

And they did serial blood draws after both those that had, overtraining syndrome showed a blunted ACTH response. On the second bout, whereas those who didn’t showed an exaggerated response effectively, like they were more primed for the second maximal exercise test. The problem is it’s only ten athletes. Yeah. And like what does that mean? And so again, if you’re trying to identify, overtraining, do you have like a you had a Wingate or a treadmill in your, in your office and, and then you’re going to do some blood sampling afterwards.

01:05:09:04 – 01:05:29:18

Unknown

Yeah. Insane. Austin, if you ever had a patient come in your telemedicine services, with a concern about something that their wearable device told them, like, something with a heart rate variability or like their whoop recovery scores or strain or something like that. How does that conversation go? And, like, how are you waiting? The clinical value of that data.

01:05:29:20 – 01:05:57:06

Unknown

Yeah, I actually have, more so relating to either resting heart rate or heart rate variability is something that I’ve seen come up a handful of times. And this is something we’re seeing a bit more when people are, being alerted to these things, especially in the era of GLP one receptor agonists, because we know that in some, you know, on average, there’s a modest increase in resting heart rate, a few beats per minute on average on GLP one receptor agonist that is thought to be due to multiple different factors.

01:05:57:11 – 01:06:15:14

Unknown

Some people have a little bit of a disproportional increase, a bit more than than average. And then RV tends to actually go down, which is like the not desirable, direction for RV to go. For most people, this is of no meaningful consequence to them. They generally are in a better spot being on the medicine than off in terms of their general health.

01:06:15:14 – 01:06:43:05

Unknown

There are other biomarkers there. How they feel their performance. And so in those situations, it’s more straightforward to, kind of dismiss that data or to like, not keep track and not monitor it. There are other people who I’ve had who also in, you know, simultaneously to reporting those types of things, maybe they have a disproportionate increase in their resting heart rate and a disproportionate decrease in their, I mean, it goes in that in the undesirable direction, more than I would expect.

01:06:43:05 – 01:07:00:09

Unknown

And they’re telling me that they feel really terrible. That’s a little bit harder to tease apart. How much of it is, all, you know, legitimately under the hood, things are not going the direction I want versus this person puts a ton of stock into the data that they’re getting from their watching that, you know, versus like a nocebo type component.

01:07:00:11 – 01:07:16:13

Unknown

But I’m not going to tell them that what they’re feeling is not real. And so then I might do some medical tinkering with their with their therapy to see if we can get things going in the right direction. Either because the biomarkers, they prefer to see them go in that direction or legitimately they’re having a negative, consequence, from the medicine that’s being reflected that way.

01:07:16:13 – 01:07:36:21

Unknown

I would say that’s the most common, area where I’m seeing it. These days. And it’s just a case by case basis. Yeah, yeah, as well said. Before we go further on the biomarkers, specifically heart rate variability, there is a specific pattern. It gets misread as overtraining in, quite often in the science and sports medicine world, it probably needs its own framing.

01:07:36:21 – 01:08:02:16

Unknown

And this is called the exercise hypo gonadal male condition MC. This is first observed in the 80s in marathon runners. Now has been recognized in some high volume strength power athletes as well effects anywhere from 15 over 50% of elite male endurance competitors. And ultimately what you see is some of the fittest athletes alive present with testosterone levels that are comparable to sedentary 80 year olds.

01:08:02:16 – 01:08:37:11

Unknown

But this is not overtraining syndrome. EMC involves simultaneous dysfunction at two levels of the hypothalamic pituitary gonadal axis. Effectively, your brain. The ball’s pathway for producing testosterone centrally at the level of the brain, the hypothalamus reduces H pulse frequency, which suppresses luteinizing hormone, LH and testosterone production peripherally, even when the testes in these individuals are stimulated experimentally with exogenous hCG, which would normally bump testosterone production, bypassing the need for the brain’s signal entirely.

01:08:37:14 – 01:09:03:22

Unknown

EMC athletes produce 15 to 40% less testosterone than healthy controls. Effectively, the chronically high training load has reduced the functional capacity of the leading cells in the testes. Themselves, not just, regulatory signal coming in the timeline to these testosterone levels is also faster than, some people might assume one military study involving high energy expenditure. So they were using a lot of calories with low energy intake, so they didn’t have enough coming in.

01:09:04:00 – 01:09:28:03

Unknown

And sleep deprivation on top of that showed a 50% drop in testosterone in just eight days. But the clinical distinction here from overtraining syndrome is performance. EMC athletes continue to perform at a high level despite profoundly suppressed testosterone levels. The body has seemingly adapted and reallocated resources. Or perhaps it’s just something that happens. It has no real effect on their performance level at all.

01:09:28:05 – 01:09:53:11

Unknown

In overtraining syndrome, there is a precipitous drop in strength, speed, recovery capacity, ultimately performance. The practical implication of this, these differences are straightforward. If someone is performing well with what looks like a broken hormone panel, they’re not overtrained. But a poorly performing athlete with normal hormone might be. Performance is a major distinction here, and hormone levels in trained athletes are noisy, context dependent.

01:09:53:14 – 01:10:16:20

Unknown

That requires its own sort of interpretation. That’s very, very carefully done. Austin, this HMC presentation, high performing athlete testosterone levels that look like a sedentary 70 year old. How do you approach that clinically? Like have you ever seen a patient with that personally? And then, what does that conversation go like? Yeah, not terribly often. Certainly people have approached with these kind of concerns.

01:10:16:20 – 01:10:45:03

Unknown

And it similarly is just a very individualized conversation, starting with like, why was this checked in the first place? Of course, most of the time it’s just like because of curiosity or somebody told me that I should because of optimization or something like that, and, you know, if I’m, I’m going to fish in my history for, you know, specific signs or symptoms that would be suggestive of, you know, a clinical endocrinologist of, of, you know, clinically significant testosterone deficiency or something like that before entertaining, a potential recommendation for, for therapy.

01:10:45:03 – 01:10:59:21

Unknown

But if we’re coming up empty handed, then, yeah, this ultimately ends up coming back to a couple different, questions. And one of them might also be like, if you’re checking this over time, did you have a prior baseline, maybe prior to this training that like looked way better? Maybe you like live at this and this is your normal in general.

01:11:00:02 – 01:11:19:23

Unknown

Maybe it’s adaptive to your training for all the reasons that you’ve just laid out. Or maybe it is pathological, in which case I would be looking for some signs or symptoms and then kind of going from there because each person, is going to kind of equilibrate at a given level over time, based on their receptor sensitivity and all sorts of other things that are beyond our scope here today.

01:11:19:23 – 01:11:34:13

Unknown

So super individualized, getting a sense of why it was tested, what their expectations are, what they’re worried about, if anything, and then if they’re like, I was just curious, then it’s often a lot easier to say, okay, well, nothing to worry about. Carry on. If they’re like, very hyper vigilant, focused, then we need to dig in a little bit more.

01:11:34:15 – 01:12:00:19

Unknown

Yeah, yeah. It’s like, why was it tested? Like, are you feeling okay? Like, yeah. Yeah, I can almost talking somebody off. Talk talk him off the ledge. You know, it’s interesting. You see, people brag about their testosterone levels all the time. My testosterone levels, 900 nanograms per deciliter. It’s like, are you training a lot? Yeah, because when I see that in somebody who I would assume who’s doing a lot of training, I’m like, either this test, your, you know, your line about the test or something else is going on.

01:12:00:20 – 01:12:26:17

Unknown

It’s like a TRT level, testosterone level in somebody with a high volume of training. Not that I expect universally across the board. Anyone who’s training it with a high training load to have a, you know, low, normal testosterone level or even B below, but I don’t expect it to be maxed. Just just generally speaking, from what we know about how testosterone responds to exercise, generally speaking, exercise doesn’t increase testosterone levels chronically in the short term, like 30 minutes after workout.

01:12:26:17 – 01:12:50:17

Unknown

Sure. But like over time, if you’re doing a lot of training load, it’s more likely it’s going to go down slightly than increase, unless you’ve also simultaneously lost body fat and it was previously too high to begin with. So anyway, there’s a lot of caveats there. But does that ring true to you? Like when you see somebody brag about, you know, spuriously high testosterone level in someone you would expect to be doing a ton of training or like, I don’t know, it kind of depends on how high.

01:12:50:17 – 01:13:13:20

Unknown

There’s just so much variation here. Like, you remember that I although it was, you know, because I was invited and gifted a free test that I was doing for investigative purposes. I mean, I trained a fair amount. It’s not like in ultra endurance level, training, but a fair amount across multiple different modalities. And I think the level that came back was around 700 ish or something like that, which is a solidly normal range level.

01:13:13:22 – 01:13:39:21

Unknown

If it was much higher than that, 900,000 1200 I got, I’m starting to have some other questions starting to creep up a little bit. And then if it’s like in the 3 to 400 range, again, there’s some, that kind of takes me in a different direction in terms of my line of questioning. But if somebody is like a very high performing elite level athlete, definitely in like an endurance or ultra endurance realm, I would generally expect their levels to be US like mid-range to lower, and not, not very high.

01:13:39:23 – 01:14:04:12

Unknown

Yeah. When somebody like gets 1200, I’m like, yeah, yeah, that’s probably something else going on. Usually involving a needle. All right. So we’re back to back to this, this other marker, heart rate variability. It has been put forth similarly to testosterone to cortisol ratio. Like hey look we should use this to maybe monitor for overtraining syndrome. But it has the same interpretive problem that these other markers have.

01:14:04:14 – 01:14:31:18

Unknown

You know how heart rate variability measures the variation in time between heartbeats. It’s sort of indirect window into the autonomic nervous systems state. It’s suggested to use a sort of seven day average of heart rate variability compared to the previous, like 4 to 6 weeks, just to see like, hey, did heart rate variability go down, which would be, you know, interpreted as training low to high compared to, resources available to, to tolerate it.

01:14:31:18 – 01:14:52:16

Unknown

And if heart rate variability went up, that would be, observed, say, oh, you could potentially do some more training. Unfortunately it doesn’t actually map to overtraining syndrome, nearly at all. And even resistive training is much worse. So like strength recovery, in Olympic weightlifters in this particular study occurred approximately 30 hours after, the workout, meaning they were back to baseline.

01:14:52:17 – 01:15:13:14

Unknown

But heart rate variability didn’t normalize till 60 hours. And you’re like, if you’re using that to make training decisions you’d miss, you’d miss an opportunity to train, right? Right. Yeah. So I think if you’re gonna use heart rate variability, you could certainly analyze the trend over weeks. And the best use case of, in my estimation, is adding an additional session.

01:15:13:14 – 01:15:36:05

Unknown

If your heart rate variability is going up and up and up and you’re like, oh my gosh, I’m just like, I guess things are going well, you could add more training. I don’t necessarily think that if heart rate variability is going down that you should, you know, diagnose yourself with overtraining syndrome and stop training, but you might want to investigate like, hey, how how are my training resources, or my available resources?

01:15:36:07 – 01:15:58:17

Unknown

I’m going how much time? An opportunity to have to sleep. What’s my nutrition look like? Those would be the two biggest ones. Instead of using heart rate variability, testosterone to cortisol ratio for, you know, insulin tolerance testing, I would look for RPE creep in particular session RPE. So if you think about the end of a session you can rate it one through 1010 being this is the hardest thing I’ve ever done.

01:15:58:17 – 01:16:12:01

Unknown

I feel terrible, I got wrecked, hit by a bus, whatever. Dramatic. Like what you want to use. We don’t really love dramatic language here, but for the purposes of entertainment, you guys get it. Or you can rate it a one barely more than than resting. You know, effectively, I feel fine. I could do the exact same training session again.

01:16:12:06 – 01:16:30:01

Unknown

No big deal. So you rate 1 to 10 if the training load is staying roughly the same, meaning you’re hitting similar weights and or similar, proximity to failure. So even if you’ve added weight but like it’s not, you’re still keep two reps left in the tank, for example, and you’re doing about the same volume, the amount of training.

01:16:30:05 – 01:16:54:23

Unknown

But your session RPE is going up. To me, that is a signal that the ratio of your total life load. So everything that’s happening not only in the gym but outside the gym has gone up relative to your resources available to tolerate. If there’s a mismatch that you’re sort of uncovering, that, to me would be the best sort of test of like, am I on the road to quote unquote, overtraining syndrome to the extent that it actually exists?

01:16:55:01 – 01:17:11:20

Unknown

Or, in fact, am I under loading if it’s going down, for example, your session RPE trend is going down. You’re like, I can probably train a little bit more. How does that strike you? Yeah, I really continue to like the framing of the, you know, training program to person match or mismatch. And then once you start seeing signs of that mismatch, you know, starting to develop.

01:17:11:20 – 01:17:31:08

Unknown

And certainly if that mismatches widening then yeah something’s got to change for sure. The session RPE trend over weeks is the monitoring tool that maps most directly to what overtraining syndrome represents. A ratio of training load to recovery capacity that has been unfavorable long enough to produce a clinical picture. Not your wearable score, not your testosterone, a cortisol ratio.

01:17:31:10 – 01:17:47:07

Unknown

Before we get into the practical decision framework, there’s one more question worth addressing directly how common is overtraining syndrome and why does it persist when it does occur? The prevalence data changes how you think about the differential in the first place. Now, we said that there was this vacuum in the evidence that’s led to some kind of interesting theories.

01:17:47:07 – 01:18:11:17

Unknown

We talked about the first one that people try to fit in or shove in testosterone, the cortisol ratio, heart rate variability. This and the other. Well, the prevalence data on overtraining syndrome is not very good. The 60% figure is most commonly cited. Overtraining syndrome prevalence estimate. But it should be noted that this is a retrospective study, self-reported without any standardized definition, and it was conducted before the current taxonomy existed.

01:18:11:19 – 01:18:35:04

Unknown

The term used in this particular study was staleness. And that figure almost certainly captures all three, categories of the continuum. So functional, overreaching, nonfunctional, overreaching and overtraining syndrome. And it may include presentations that would now be classified as reds or relative energy deficiency. And sport also could include clinical depression or even illness because again, all they’re asking for was staleness.

01:18:35:06 – 01:18:56:21

Unknown

With that in mind, how prevalent is overtraining syndrome in resistance training populations? Attempts to produce overtraining syndrome through resistance exercise have largely failed, I’ve said that said, at the outset I did not see a good study showing like, yep, definitively this is overtraining syndrome. People don’t get stronger on average. And in fact, what I would predict is that an overuse injury would happen before overtraining syndrome actually occurred.

01:18:56:23 – 01:19:28:10

Unknown

There are additional confounders that nobody names directly. For example, aging out of sport, natural performance decline plus motivational drift can meet several of these overtraining syndrome, diagnostic criteria. It’s never cleanly separated in the prevalence literature. PEDs and cessation. So think about an athlete coming off the use of exhaustion as testosterone or erythropoietin. EPO would show the exact same, you know, hormonal profile attributed to overtraining syndrome, a blunted, HPA axis, mood disturbance, performance collapse for a long recovery.

01:19:28:12 – 01:19:54:16

Unknown

The overtraining syndrome largely ignores this variable, which is remarkable given how often that elite athletes actually use performance enhancing drugs psychiatric conditions are on is another, potential confounder. The overlap between overtraining syndrome and, like major depressive disorder is remarkable. So any overtraining syndrome workup without a formal depression screen, is incomplete. Although I know you hate the depression screen, but it is a possible confounder.

01:19:54:18 – 01:20:20:07

Unknown

One of the most well known confounders, however, is low energy availability. In a recent study, 86% of overtraining syndrome studies showed a co-occurrence with reduced energy availability with overtraining syndrome like presentations. Now causally, this is a leap that I’m taking here, but the implication is clear you got to assess energy availability. A person is like, I’m overtrained. It’s like, how’s your weight been recently?

01:20:20:11 – 01:20:48:10

Unknown

Has there been any, you know, direct or maybe indirect, change in your energy intake? Yeah. So either on purpose or kind of, something else going on. Gotta assess for that. Which brings me to to a thought I’ve been kind of beating around this entire time. Is overtraining syndrome real? So if persistent low energy availability explains many cases, then overtraining syndrome is not a separate entity from relative energy deficiency in sport or low energy availability.

01:20:48:12 – 01:21:18:17

Unknown

If aging, PED cessation, or psychiatric conditions explain most of the remainder, then overtraining syndrome is a symptom of those things. The residual true training load induced overtraining syndrome in an adequately nourished, psychiatrically healthy non PED using athlete. But it’s never been characterized and I suspect would be a small sliver of any of the remaining cases. My thought is that overtraining syndrome is almost always an unaddressed life variable that the athlete is either not disclosing or the researchers not measuring often.

01:21:18:17 – 01:21:40:16

Unknown

How does that, square with the what you’ve heard so far? It is, you know, provocative and I think it’s likely to get the people going, as they say, if you if you make that claim. I mean, some of this is interesting to think about in terms of the direction of causality, right? So there are certainly some people for whom they have low energy intake, at the outset, that limits their ability to tolerate a given training load.

01:21:40:16 – 01:21:58:04

Unknown

I also wonder how many people more so in that like ultra endurance realm, as a result of their training load, maybe if there’s some, you know, degree of appetite suppression from it that leads to inadequate intake and then it kind of perpetuates a negative sort of a vicious cycle from there. Or like the syndrome itself leads to loss of appetite, and then they end up under eating.

01:21:58:04 – 01:22:19:14

Unknown

And then they manifest in these data sets as part of that high proportion of people with some low energy availability. So I could see both cohorts of people, plausibly getting lumped into the same. And so again, I think there’s so many different ways or pathways that are, that are involved here and relevant. But I keep coming back to this idea of a, there’s probably a degree of training to trainee mismatch.

01:22:19:16 – 01:22:45:15

Unknown

And then also the idea that if you do have this, this unicorn person that you were describing who is, well nourished, psychiatrically healthy, sleeping well, not using PEDs, things like that, that if they are trying to train enough to to plausibly lead to the syndrome, I feel like more often there’s going to be some survivorship bias of like, injury structural issues are going to take them out before they get to that point in the in the majority of cases.

01:22:45:17 – 01:23:04:11

Unknown

But yeah, what you your thoughts? I think you have a plausible and interesting argument and, I suspect that there are people out there who have, both stronger and more weakly held opinions on this topic who would be, who who will have some likely interesting responses in the comments. So looking forward to that. So the epidemiology is uncertain.

01:23:04:14 – 01:23:27:16

Unknown

The well-documented confounders probably explain most persisting cases and the residual case of true load induced overtraining syndrome in an otherwise healthy athlete may be vanishingly rare. Which brings us to what’s actually happening when a lifter presents saying that they feel overtrained. In my experience, it’s almost always one of three specific and correctable problems, none of which require the overtraining syndrome label to address.

01:23:27:18 – 01:23:48:16

Unknown

The first here is this programing test mismatch. So effectively the person’s programing does not reflect how they’re assessing their progress correctly. The body’s adapting, but the program isn’t just designed for how progress has been. Tested. So imagine someone is running like a full on bodybuilding program. Right. But the outcome that they’re testing is one rep max strength.

01:23:48:18 – 01:24:04:11

Unknown

It’s like, okay, well, you would expect some strength gains to happen in the lifts that are being trained. That’s just how we respond to exercise. It’s not really specific for the test that you care about the most. Right. Or if somebody is testing a one rep max squat bench press or deadlift, but they’re not seeing any of those exercises in the program.

01:24:04:11 – 01:24:29:20

Unknown

It’s like this isn’t really indicative of like you’re doing, oh, you’re overtrained, you’re undertrained or whatever. It’s just that the training is not matched to how you’re assessing it. The key here again is to monitor the session RPE and, you know, if you’re sleeping nutrition or normal, there’s probably a programing, formulation issue in this case, meaning that how your training does not accurately reflect the variables that you’re testing, the metrics that you’re testing.

01:24:29:22 – 01:24:53:07

Unknown

The second problem here is monitoring. Too often we know that performance varies day to day. Again, it’s like your fitness adaptations on board relative to the fatigue you have on board in a particular environment. And all workouts simultaneously develop and also test performance. So it can be hard not to anchor, to historical performances. So if you’re a little weak or you’re like, performance is down, or if it’s a little better, you’re like, oh, I actually got stronger.

01:24:53:09 – 01:25:09:23

Unknown

But day to day and even week to week variability can be high. We talked about that in our daily max studies that we cited earlier. And fitness adaptations occur over time. Again, like building a savings account requires deposits to accumulate over time. So when people are saying, look, I think it’s stronger compared to the last time I trained.

01:25:09:23 – 01:25:34:10

Unknown

And you’re like, well, when’s the last time you train? You’re like, they said yesterday. You’re like, I wouldn’t expect progress happened like last week. Like, well, it’s only one week now. Someone says like for months on end. That seems like a more reliable signal. Now, whether you’re overtrained or undertrained, that can be hard to tease out. Fortunately, we developed this training plateau action plan that we released a few months ago, and we think about for strength that your estimated one rep max or tested one.

01:25:34:11 – 01:25:53:13

Unknown

I’m actually go up somewhere in about four weeks, over four weeks. And that’s relative to your most recent, estimated one rep. Max. So not like historical, for example, same thing for conditioning to the extent that you were your mastery fitness is going to go up. We would expect an improvement in that within about four weeks compared to, again, the start.

01:25:53:15 – 01:26:18:13

Unknown

And then for hypertrophy, 6 to 8 weeks is a reasonable time frame to see seemingly observe. An increase in muscle cross-sectional area, assuming that the environment is supportive of these things. Again, adequate amount of sleep, adequate nutrition, and that you’re actually doing the training. The third way that people get this wrong is the same thing we’ve been talking about the entire podcast, a mismatch between your training load and the resources that you have to deal with it.

01:26:18:13 – 01:26:40:00

Unknown

And this can happen in both directions. A person who’s not progressing because they are genuinely overreached would probably warrant a load reduction, meaning like their life total life load has gone up. They probably need to reduce their training load. An athlete who is not progressing because they’ve been systematically under loading and interpreting normal fatigue is a warning signal, probably needs to increase their training load.

01:26:40:02 – 01:27:03:23

Unknown

Similar presentations not progressing, but opposite interventions. So it’s the interpretation that matters here. Getting this wrong towards under loading is just as costly as getting it wrong towards overloading is probably more common, I think in the population that reads and listens to overtraining content, I just don’t see people kind of getting to a truly overtrained state that often does that kind of, square with your your assessment.

01:27:04:00 – 01:27:23:16

Unknown

You’ve been in this space for a while. Yeah. I really have little to, to add, I think, to the way that you’ve fleshed this out in the way that we think about it. A lot of this involves conversations with people to try to get a get a feel with how they’ve been approaching, not just their, you know, their training program broadly, but what it’s like for them to approach each individual training session, what it feels like.

01:27:23:16 – 01:27:42:06

Unknown

And, we can often draw some conclusions and nudge them in a more favorable direction kind of over time. But yeah, I think I keep coming back to mismatch, which really, you know, there’s even some utility in looking at this similar to how we talk to people about injury. If you think about this type of a syndrome as a quote unquote injury, we would approach it similarly.

01:27:42:06 – 01:27:58:05

Unknown

We often will broaden the variation that they’re exposed to pull back, you know, their their RPE is how close to failure they’re getting. And then tinker with other variables like volume and frequency, really based on their like preferences and their current tolerance. But those aren’t like the primary levers that we’re often messing with, even in like a rehab context.

01:27:58:05 – 01:28:22:13

Unknown

So there’s some interesting similarities there when we look at it as a mismatch between their tolerance, and the and what’s being asked of them. Yeah. Yep. And so as we discussed in the training Plateau Action Plan, if somebody presents with performance going down, and they’re sore all the time, they’re tired, their motivation is decreased and their session RRP has gone up and is climbing.

01:28:22:15 – 01:28:42:02

Unknown

Probably a good idea to reduce training looks is too high for their current resources. If they’re relatively fresh, they’re not sore. Motivation is high. Their session RPE is going to be going down or steady. Their training load is likely too low for the resources that they have on board, and so they would likely increase that to, get performance to do the thing that they want it to do.

01:28:42:06 – 01:29:04:19

Unknown

This is all covered in our free, training Plateau action plan. You can check that out. It’s linked in the description. So what do we do with all this? Got the vocabulary with the caveat that it imposes the sort of false precision on a continuous variable that is noisy. We have some of the biological background with the acknowledgment that the subjective report of the individual outperforms laboratory testing most of the time.

01:29:04:21 – 01:29:24:04

Unknown

And we have a very clear picture now of how challenging interpreting training results can be. So what remains is like, well, what do you what do you do about all this? We keep going back to assessing trends, right. So with performance, what’s happening over weeks and months, first day to day, day to day is almost irrelevant to me outside of like an acute injury, right?

01:29:24:10 – 01:29:43:07

Unknown

Even if someone’s strength was down, for example, it’s down 30%. And I’m like, sounds like you’ve had a bad run of it, you know, in the last few days. Let’s see what happens over the next week. For example. Sure. Session RRP is it creeping up? How is your session RRP look over the last week two weeks compared to the 3 to 4 weeks before that?

01:29:43:09 – 01:30:01:10

Unknown

Again, trends not what’s happening on a single day. Same thing with environment. What’s your dietary pattern been looking like over the past few weeks? How is your weight changed? How is your sleep looked over the last, you know, few weeks? For example, what’s your life stress look like again? Short term. And I missed a meal.

01:30:01:11 – 01:30:26:13

Unknown

I slept, you know, poorly last night. I had a pretty stressful day. Yes. Can there be some acute effect? Especially severe. Sure. But like everyone who’s listening this podcast has had an out-of-body experience at least one time in the gym when they felt hung over, when they felt tired, when they missed a meal. When live stress has been high, training performance is just too noisy to sort of mapped to a single short term, single day, type issue.

01:30:26:13 – 01:30:45:23

Unknown

So again, look at trends in those things. Finally look at soreness, mood and motivation relative to training load. If you’re becoming gradually more sore, your your mood is tend to suffer. Your motivation is going down. To me. Those are the variables I’m using to tease apart. Is this too much training load for the person right now versus too little?

01:30:46:01 – 01:31:07:05

Unknown

If performance is going down and these things are going up, session rp’s going up, soreness is going up. Motivation is going down. Consider the training load is probably too much. Reduce the intensity of the volume. 20% reduction in both of those is a reasonable target. Admittedly, I just made that up. It’s speculative. If performance is going down, but these things are steady or improving.

01:31:07:05 – 01:31:25:02

Unknown

Session RPE is not going up. It’s it maybe going down. Your motivation to train is still there. You’re not feeling too sore. It’s probably too little training stress, too little training load. So you can increase training load usually volume if previously responsive to that same program about a 10% increase. So another set or two is a reasonable modification.

01:31:25:02 – 01:31:52:12

Unknown

Again, admittedly speculative, but that’s what I do in practice. If you weren’t previously responding well to a program, you’re five weeks into it, haven’t gotten any fitness adaptations. There’s something deeper going on there, potentially with the program, whether it’s exercise selection, whether it’s your average intensity, there’s a lot of different changes you can make. I would start with increasing volume up a little bit and maybe average intensity, and then circling back around and saying that they look, was this actually a good, formulation of training for you with respect to exercise selection, for example?

01:31:52:12 – 01:32:13:18

Unknown

So still, you’re addressing these both through programing. If changing the programing, and addressing lifestyle factors does not resolve this sort of performance decline, consider a medical workout. Austin. What would that look like for you? If you had a person who’s look, I got the barbell medicine training action, train plateau action plan. I went through all the steps, use your guys programs.

01:32:13:20 – 01:32:30:00

Unknown

No, nothing doing. How do you start that work up? And, you know, obviously you’re an internist, so this could go in legitimately thousands of different directions, but how would you how would you do that? Yeah, I mean, the easiest answer here is to set up a consultation with a trusted health care professional. That could be one of us.

01:32:30:00 – 01:32:49:06

Unknown

We and I do these kind of consults with people semi-regularly. We offer them through through barbell medicine to to be a bit, self-serving there, I suppose, in the sense that. Hey, I recommend such a service if somebody is having trouble navigating the space. And maybe if they don’t have another trusted clinician, a resource that they, they can work through this with.

01:32:49:07 – 01:33:12:05

Unknown

But, you know, I’m looking at, based on the history that they’re describing, again, are there localizing symptoms that make me more concerned about a particular area or organ system, or is it a more generalized process, in which case I’m looking at more of these generalized things. In many patients, especially women, younger women, reproductive age women, iron deficiency. Again, that prevalence is just so high and so many people don’t test for it or they test for it improperly.

01:33:12:10 – 01:33:30:11

Unknown

A blood iron level is not the right test. A blood ferritin level is the right test. But there are caveats to interpretation. You cannot trust lab reference ranges. So I’m going to, you know, rant about that again. Sleep sleep apnea testing working with a sleep medicine physician. If you need to. Looking for a prior history of post-viral syndromes infections that triggered this kind of thing.

01:33:30:11 – 01:34:02:08

Unknown

Endocrine apathy is with whether thyroid or testosterone, things like that. If the person’s on other medications and supplements, the how could those be impacting things? So it’s going to really involve a detailed history and then an individualized, evaluation and assessment plan. It’s not necessarily just like getting a massive panel of like every lab under the sun. I do have people who come in with those sorts of, like, massive lab test panels that they’ve had done, whether they’ve self sought those things out, whether somebody else has checked them, and honestly going through them, especially when it comes to hormone testing, a lot of the signal that we end up getting will not signal a

01:34:02:08 – 01:34:21:16

Unknown

lot of the results that we end up getting turn out to not be signal and end up being noise. That is unhelpful. And in many cases shouldn’t have been tested at all. So it can be messy and you need to work with someone you trust for this. All right. Here’s the short version of everything. Overtraining syndrome is a retrospective diagnosis applied to a continuous variable.

01:34:21:19 – 01:34:48:21

Unknown

We’ve divided into three categories that look identical at the time of presentation. Zero control studies have taken a person from healthy to overtrained under experimental conditions. The biomarkers most commonly used to monitor it don’t reliably detect it. The six mechanistic hypotheses are each partially supported and each fall short. What does that mean practically, when performance goes down, we should probably start with sleep and dietary intake, calories and carbohydrates specifically before you touch training load.

01:34:48:23 – 01:35:10:03

Unknown

If these can’t be modified for some reason, reduce your training load by about 20% to match your current training resources. Better to avoid getting there in the first place. Should track your session RPE trend over weeks, not days three consecutive weeks of rising session RPE at the same relative training load is a real signal worth looking at. One bad session is probably fine to ignore.

01:35:10:05 – 01:35:29:04

Unknown

Now if programing adjustments and lifestyle factors don’t move, the needle, consider a chat with a trained medical professional to see if you would benefit from a medical workup. The people who get hurt by the overtraining narrative are usually not the ones doing too much. They’re the ones who reduced training they didn’t need to reduce based on framing of normal fatigue as a system failure.

01:35:29:06 – 01:35:44:04

Unknown

All of the studies are in the show notes. Our Training Plateau Action plan is free on the website. It’s a good, practical tool for figuring out whether you’re doing too much, too little, or testing the wrong thing. Link is in the show notes below. Thanks for listening to the Barbell Medicine Podcast. I’m Doctor Jordan Feigenbaum. We’ll catch you next week.