Overtraining Syndrome: Causes, Diagnosis, and What's Actually Going On

29:20That 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. 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.

29:58And 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. Yeah, most often under training, like not doing enough training, but simultaneously making the training too hard because they think that's the primary signal. Yeah. John Kiley, a friend of the show, he's given us some good feedback on our silver episodes, which I greatly appreciate because we respect him, published a paper in sports medicine in 2018 called Periodization Theory, confronting an inconvenient truth that makes this argument directly, that the supercompensation model was imported into exercise training without the scientific foundation to support it.

30:36It's in the show notes if you want to take a read. Also, great name, Inconvenient Truth. Who knew? That was interesting. With that in mind, this functional overreaching, non-functional overreaching, overtraining syndrome taxonomy was built on top of this model. 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.

31:13In 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, if available. There's no discrete cycle that resets after each session. The timescale is continuous and cumulative, and it varies based on the athlete's history, not a category label. The clinical taxonomy, you know, descriptors are real in that people experience them, but functional overreaching, non-functional overreaching, and overtraining syndrome are points on a continuum that can only be identified after the fact, not distinct categories 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 non-functional 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 um 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 um 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 this is one of the reasons why injury tends to intervene an overuse injury for example tends to pop up before over training syndrome does in resistance training populations this sort of maybe structural limit hits before any other limiter does and it's 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 but before we get there Austin walk me through uh like a clinical differential for an athlete presenting with fatigue and declining performance in the gym.

33:12Show us where overtraining syndrome actually sits on that list 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 a while. No, 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. 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.

33:56So somebody with like fatigue and any sort of thoracic symptom, for example, like chest discomfort or breathing difficulty or something like that might pull me towards a cardiovascular cause or a pulmonary issue or something like that. 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 endocrinopathies, hormone disorders, because again, blood and hormones go everywhere in the body. And so it's much harder to localize those types of things.

34:29Other metabolic issues, like what if the person has new onset type 2 diabetes or type 1 diabetes 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 probably one of the most common things. But I started out with the quote-unquote no-miss types of issues. Again, there's more dangerous cardiopulmonary causes that can lead an athlete to 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, for example, sometimes I'll see folks who tell me that they've been struggling with fatigue.

35:08Tell me, what did you observe when this first started? Oh, it onset right after I had this horrible illness. Like post-viral fatigue syndromes, super common, can be persistently debilitating for long periods of time, as well as autoimmune and inflammatory issues and things like that. 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 panels, certain hormones, not all hormones necessarily.

35:44It's easy to go way too far down the hormone testing rabbit hole in a very unhelpful way. And it can also be a problem because sometimes the same sorts of hormone things that you might 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 soapbox earlier, and things like that. 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.

36:22Yeah, no, that's well stated. So with that hierarchy in mind, most of this audience is primarily training with weights and the differential for a strength athlete looks different from what this might imply 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 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 people haven't tried to do it. 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.

37:02First, the background. In 2020, there was a systematic review that pulled together every study that could be found on overtraining syndrome in resistance exercise. 22 studies total, 10 of them, nearly half, reported zero performance decline under the overload conditions that the researchers deliberately imposed. Of the 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 in resistance exercise. Not cortisol, not testosterone, not HRV. The one thing that consistently tracked the condition was a sustained drop in performance, which you would have caught without testing anything at all.

37:40So 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 to failure. For the upper body, they did shoulder press, lat pulldowns, chest press, biceps curl, and triceps press downs. Again, five sets of 8 to 12 reps, taken to 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.

38:14Yeah, 90 working sets per week. Nobody met overtraining syndrome criteria. In fact, they got fitter. Before that, Dr. Mike Zordos, 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 submaximal loads. Again, not every few days, but every day for a month. And all three improved. 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.

38:51Three 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 maxed out their bench press every single day for 34 days. Not 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 their one rep max, or five sets of two at 90 % of the one rep max. 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.

39:20Daily one rep maxes fluctuated throughout. Some days were 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 compared that to day seven, they would have called it a regression, 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.

39:53A 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 volume submaximal work. Both arms got stronger by about two kilograms above baseline after the 21 days, but there was no overtraining. The volume arm also hypertrophied. 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?

40:28And the answer is maybe. Fry and colleagues tried to do it in 1994 where they took 11 trained males and had them perform 10 sets of one at their one rep max on a Smith machine. every single day for 14 consecutive days. That's 140 maximal singles total. The overtraining groups one rep max dropped by about 12 kilos. And when they tried to stimulate the legs using electrically stimulated force production, well, that declined too. Recovery took two to eight weeks. Then the hormonal data came back and it didn't look like what the endurance overtraining literature had primed everyone to expect. Typically, they're looking at a decline in testosterone to cortisol ratio.

41:04But 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. 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.

41:39Maximal lows produced a transient decrease in one rep max, whereas submaximal daily training produced an improvement. In resistance training, 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. 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.

42:08The Margonis 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, hang 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 100 % of their one rep max. 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.

42:42It'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. 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 was the wrong one for the population.

43:16Performance on it never even collapsed below baseline. 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.

43:48and like the more, 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. Uh, you know, as if you give them a long enough window to adapt. So Austin, if a strength athlete came to you saying they felt over-trained and that they're training four days a week, what is the actual probability in your, uh, in your clinical experience that training volume is the primary driver here? Typically low. Uh, 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 over-trained, question one, and then question two, tell me about your training.

44:25And it might be a moderate to even a high-volume training program, but much more often, you know, the question in my mind is, 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. 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 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.

44:59They may also have some iron deficiency that's been undiagnosed or their nutrition might not be where it needs to be. Their sleep is often not in a great situation. So 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 setup 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 they're able to tolerate it?

45:31That 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. Yeah. Yeah. What I typically see in this type of scenario, it's 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, if training load is not only how much training you're doing, but the nature of the training life load is everything else that's going on outside of the gym um so what's your nutrition look like what's your sleep look like what's your life stress you know occupational relationship stress etc psychological state uh medical uh you know health um sort of stuff how does that you know effectively that's that is your uh your life load and if that starts to creep up you have less sort of resources to deal with training load so that can sort of lead to this sort of transient shift towards well no longer can i tolerate my previous training not over training syndrome though not overtraining syndrome because overtraining syndrome 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 uh the exercise that they were doing the other thing that i see is that volume actually stays the same sets reps etc but the intensity goes up um to to a level that they can no longer tolerate generally this would be an rpe you know rate of perceived exertion they 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.

47:12And we come back to this all the time. Your 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 gonna feel the same level of hardness later on but it's gonna be heavier weight right um so what people will do is i gotta add weight i gotta i gotta or i gotta add uh you could theoretically add add volume before again 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 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.

47:55Now, with all that in mind, what actually causes overtraining syndrome? When we come back from the break, we'll cover the leading theories. If you've seen my Instagram lately, you know that my new house is currently a construction zone and my schedule is a bit crazy. Between everything that's going on, the last thing I want to do at 8 p.m. is chop vegetables and then deal with a cast iron skillet for 20 minutes. Factor has been my lifeline here. They are fully prepped meals designed by dietitians and chefs that actually taste like real food. I've been leaning hard into the Muscle Pro collection because the macros are pretty spot on for my training, but they also have over 100 rotating options including the Mediterranean diet, a higher protein option, even something for those that are on GLP-1s.

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49:06That's factormeals.com slash BBM50off. turn your tax refund into a new bathroom at menards make this the year you check that project off the list upgrade your bathroom with max with more than 1 000 showers bathtubs and surrounds you're sure to find exactly what you need to add luxury and style to your bathroom save big on our entire selection of max bathroom products plus check out our weekly flyer on menards.com for all the great deals happening now. Save big money at the Nards. Hey, I'm Josh Spiegel, host of the podcast Lunatic in the Newsroom. If you enjoy journalism that drifts into mild panic, wild overthinking, and a guaranteed nervous breakdown, Lunatic in the Newsroom is for you.

49:54It's news like you've never heard before. The only newsroom with a panic button. You'll laugh, you'll cry, and gasp in horror as the show spirals completely out of control. It's not just news. It's emotionally unstable. Lunatic in the newsroom. Listen today. 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.

50:33let's go through them first is the uh the sort of anchor here that we have one hpa response hypothalamic pituitary adrenal response this is basically how you respond to stress okay so it's uh 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 hard training week bad sleep work crisis family situation it's just how your body responds to stress 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.

51:10And 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. 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.

51:44Glycogen depletion specifically. 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. 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.

52:22The 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 branch chain amino acids, which competes with tryptophan for transport across the blood brain barrier. 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 fatigue sleepy amino acid it's elegant it sounds truthy if you will uh the problem is that branched chain amino acid supplementation doesn't prevent overtraining uh syndrome uh also um the serotonin levels vary wildly uh in in athletes 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 So a third hypothesis is the autonomic bias.

53:20This is one of the oldest frameworks in literature. It's actually a two-type model that there's sympathetic overtraining and parasympathetic overtraining. 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.

53:51The two type models still get cited to date. 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. Muscle damage triggers an inflammatory cascade of interleukin-6, interleukin-1-beta, TNF-alpha. And sustained cytokine elevation produces what immunologists can call sickness behavior.

54:27So fatigue, mood disruption, anhedonia. People don't take any pleasure in activities, reduce 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 to days 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.

55:05Which 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. Again, this is the central coordinator of your stress response. But under conditions of chronic unrelenting training load, the system shows a 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.

55:41Now, 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. 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.

56:15There's this really famous study gets 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 they use what's called an insulin tolerance test you familiar with this test baracki i've never done an insulin tolerance test for a cth axis testing yeah right very specialized endocrinologist uh level 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 hypothalamus the pituitary gland and the adrenal gland the hypothalamus releases uh uh this hormone crh uh that goes to the pituitary gland which 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.

57:22So 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 to, hey, you should go get an insulin tolerance test and to see if you're overtrained. So the main takeaway from this is that maybe there's something going on at the level of the hypothalamus pituitary gland.

58:02It'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, this study's findings in your exercise prescription, 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, OK, but how do you feel? yeah and the other aspect is i still am unconvinced in terms of uh how much of this is an effect of the syndrome rather than a cause of it 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 um 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 thyroid hormone, their thyroid function might decline as an adaptive mechanism.

59:04Their gonadotropins and their testosterone and things like that might also go down as an adaptive mechanism. And so the idea that in this state, you know, 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. This is, you know, they might not be able to tolerate this and so things get turned down on the back end because an implication or another way to test this would be, oh, if I were able to stimulate that axis, would it resolve your syndrome?

59:49Because there are ways to do that. I have ways to stimulate your HPA axis. I actually do that test in the hospital all the time. We call it a cosentropin stem test to see what happens. 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 illustrate that. But would that resolve somebody's overtraining syndrome if they met the clinical criteria for it? 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 to recruit people into this study they used symptoms that overlap with hpa access dysregulation anyway 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 been nice if you did it early before they were quote over trained to see like oh and then it subsequently changed 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 and again you can't do this test so like yeah yeah unclear 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 um this is from a 2022 paper from armstrong that proposes that treating overtraining syndrome as an emergent complex systems phenomenon there's no single pathway that produces overtraining syndrome.

1:01:13No 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 and overtraining syndrome is just the label we applied to it.

1:01:49The residual case that true load-induced overtraining syndrome is in an adequately nourished, well-rested, psychiatrically healthy athlete without PED exposure has 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 say with confidence, you can't confirm overtraining syndrome with a single biomarker because there is no confirmed mechanism. 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.

1:02:24Is that 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. In other words, injury, like when we think about like, yeah, Olympic level athletes, they're able to tolerate and do a massive amounts of training on the quadrennial cycle to prep for the Olympic games.

1:02:59And 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. And then they have all the resources and depending on the sport, of course, 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 get to that level, but also get selected out earlier in life through injury, through setbacks, through other things like that. And so you're right that this is a complex multivariable thing rather than just too much training in the vast majority of cases.

1:03:33Yeah. Yeah. So let's let's move on. There's a couple of 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. 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.

1:04:10So 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. Let's address both. First, it has to do with cortisol and testosterone to 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 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.

1:04:49Here's what the evidence shows about that. First off, cortisol. Resting cortisol is normal in at least 75 % of individuals who've been diagnosed with overtraining syndrome. Again, it's like, how did they get diagnosed with overtraining syndrome? If you know not, you've seen the cortisol level, but it's normal in at least three quarters of them. The testosterone to cortisol ratio is very influenceable by the time of day 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.

1:05:27It'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 and the way i think about this is that your performance potential on a given day 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-diagnosed overtraining is an athlete testing performance during intentional load accumulation intentionally fatiguing sort of protocols and interpreting as a pathology much of the 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 that tracked training load changes with greater sensitivity greater consistency than objective measures, which include various hormones, resting heart rate, and heart rate variability.

1:06:37When the two diverge in practice, we should probably weight the subjective. 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 creatine kinase? It feels like the biomarker has to be better, but it really just isn't just asking people talking to them how do you feel uh is is way more useful to me than biomarkers in these types of situations yeah there's one interesting study i think it's worth mentioning they uh 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 tests basically within four hours and they did serial blood draws after both those that had overtraining syndrome showed a blunted ACTH response, um, on the second bout, whereas those who didn't, um, showed an exaggerated response effectively, like they were more primed for the second maximal exercise test.

1:07:40The problem is it's only 10 athletes. Yeah. And like, what does that mean? And so again, if you're trying to identify, uh, overtraining, do you have like a, you got a wind gate or a treadmill in your, in your office and you, and then you're going to do some blood sampling afterwards. Yeah. Insane. Uh, Austin, if you ever had a patient come in on 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 weighting the clinical value of that data?

1:08:14Yeah, 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-1 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-1 receptor agonists that is thought to be due to multiple different factors. Some people have a little bit of a disproportional increase, a bit more than average. And then HRV tends to actually go down, which is like the not desirable direction for hrv 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 there are other biomarkers their 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 Maybe they have a disproportionate increase in their resting heart rate and a disproportionate decrease in their HRV, meaning it goes in the undesirable direction more than I would expect, and they're telling me that they feel really terrible.

1:09:30That's a little bit harder to tease apart how much of it is all 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 watch versus a nocebo-type component. 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.

1:10:01I 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 HRV, heart rate variability there is a specific pattern that gets misread as overtraining in um quite often in the exercise science and sports medicine world um it probably needs its own framing this is called the exercise hypogonadal male condition ehmc this was first observed in the 80s in marathon runners now has been recognized in some high volume strength power athletes as well affects anywhere from 15 over 50 percent of elite male endurance competitors um and ultimately what you see is some of the fittest athletes alive present with testosterone levels that are comparable to sedentary 80 year olds but this is not overtraining syndrome ehmc involves simultaneous dysfunction at two levels of the hypothalamic pituitary gonadal axis effectively your brain to balls pathway for producing testosterone centrally at the level of the brain the hypothalamus reduces gnrh 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.

1:11:22EHMC athletes produce 15 to 40 percent less testosterone than healthy controls. Effectively, the chronically high training load has reduced the functional capacity of the Leydig cells in the testes themselves, not just a regulatory signal coming in. the timeline to these testosterone levels is also faster than some people might assume one military study involving high energy expenditures they were using a lot of calories with low energy intake so they didn't have enough coming in 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 ehmc athletes continue to perform at a high level despite profoundly suppressed testosterone levels.

1:12:03The body has seemingly adapted and reallocated resources, or perhaps it's just something that happens that has no real effect on their performance level at all. In overtraining syndrome, there is a precipitous drop in strength, speed, recovery capacity, ultimately performance. The practical implication of 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 hormones might be. Performance is the major distinction here. And hormone levels in trained athletes are noisy, context-dependent, that require its own sort of interpretation that's very, very carefully done.

1:12:43Austin, this EHMC 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. 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.

1:13:13And if I'm going to fish in my history for specific signs or symptoms that would be suggestive of a clinical endocrinopathy of clinically significant testosterone deficiency or something like that before entertaining a potential recommendation for therapy. 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 looked way better? Maybe you live at this and this is your normal in general. Maybe it's adaptive to your training for all the reasons that you just laid out.

1:13:49Or 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. 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, oh, it's just curious, then it's often a lot easier to say, okay, well, nothing to worry about, carry on. If they're like very hypervigilant focused, then we need to dig in a little bit more.

1:14:19Yeah, yeah. It's like, why was it tested? Like, are you feeling okay? like yeah yeah like almost talking somebody off uh talking about 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 and 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 you're you know you're just lying about the test or something else is going on it's like a trt level uh testosterone level and 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 be 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 a workout sure but like over time if you're doing a lot of training load it's more likely that 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.

1:15:22So anyway, there's a lot of caveats there, but does that ring true to you? Like when you see somebody brag about a, you know, spuriously high testosterone level and someone you would expect to be doing a ton of training, you're like, I don't know. It kind of depends on how high 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. Um, I mean, I trained a fair amount. It's not like an ultra endurance level training, but a fair amount across multiple different modalities.

1:15:51And I think the level that came back was around 700-ish or something like that, which is a solidly normal range level. If it was much higher than that, 900, 1 ,000, 1 ,200, I'm starting to have some other questions starting to creep up a little bit. And then if it's like in the 300 to 400 range, again, 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 the levels to be like mid-range to lower uh and not not very high yeah when somebody's like it's 1200 i'm like yeah yeah that's probably something else going on um usually involving a needle all right we're back to back to this this other marker heart rate variability it has been put forth similarly to testosterone 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.

1:16:49You know, heart rate variability measures the variation in time between heartbeats. It's the sort of indirect window into the autonomic nervous system's state. It's suggested to use a sort of seven-day average of heart rate variability compared to the previous like four to six weeks just to see like, hey, did heart rate variability go down, which would be, you know, interpreted as training load too high compared to resources available to tolerate it. 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.

1:17:26And even resistance training is much worse. So like strength recovery, in Olympic weightlifters, and this particular study occurred approximately 30 hours after the workout, meaning they were back to baseline, but heart rate variability doesn't normalize till 60 hours. And you're like, if you were 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 going to 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 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 um 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.

1:18:14But you might want to investigate like, Hey, how, how are my training resources or my available resources? Um, I'm going, how much time, um, and opportunity do I have to sleep? What's my nutrition look like? Those would be the two biggest ones. Um, instead of using heart rate variability, testosterone to cortisol ratio, freaking, you know, insulin tolerance testing, I would look for RPE creep in particular session RPE. So you think about the end of a session, you can rate it one through 10, 10 being this is the hardest thing I've ever done. I feel terrible. I got wrecked, hit by a bus, whatever dramatic language you want to use.

1:18:47We 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. No big deal. So you rate it one 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, but your session RPE is going up.

1:19:18To 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 it. 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? Or in fact, am I underloading? 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 training program to person match or mismatch.

1:19:53And then once you start seeing signs of that mismatch, you know, starting to develop, and certainly if that mismatch is widening, then yeah, something's gotta 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 to cortisol ratio. 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?

1:20:24The prevalence data changes how you think about the differential in the first place. Now, we said there was this vacuum in the evidence that's led to some kind of interesting theories. We talked about the first one, the people trying to fit in or shove in testosterone to cortisol ratio, heart rate variability, this, that, and the other. Well, the prevalence data on overtraining syndrome is not very good. The 60 % figure is the 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.

1:20:57The term used in this particular study was staleness. And that figure almost certainly captures all three categories of the continuum. So functional overreaching, non-functional overreaching, and overtraining syndrome. And it may include presentations that would now be classified as REDS or relative energy deficiency in sport. Also could include clinical depression or even illness. Because again, all they were asking for was staleness. With that in mind, how prevalent is overtraining syndrome? In resistance training populations, attempts to produce overtraining syndrome through resistance exercise have largely failed.

1:21:29I've said that 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. 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 symptoms. syndrome diagnostic criteria. It's never cleanly separated in the prevalence literature. PED use and cessation. So think about an athlete coming off the use of exogenous testosterone or erythropoietin, EPO, would show the exact same hormonal profile attributed to overtraining syndrome, a blunted HPA axis, mood disturbance, performance collapse, prolonged recovery.

1:22:13The overtraining syndrome largely ignores this variable, which is remarkable given how often that elite athletes actually use performance enhancing drugs psychiatric conditions or is another potential confounder the overlap between overtraining syndrome and like major depressive disorder is remarkable um 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 one of the most well-known confounders however is low energy availability in a recent study 86 percent of overtraining syndrome studies showed a co-occurrence with reduced energy availability with overtraining syndrome-like presentations.

1:22:55Now, causally, this is a leap that I'm taking here, but the implication is clear. You got to assess energy availability. A person who's like, I'm overtrained. It's like, how's your weight been recently? Has there been any, you know, direct or maybe indirect change in your energy intake? So either on purpose or kind of something else going on, got to 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 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 that's never been characterized and I suspect would be a small sliver of any of the remaining cases.

1:23:55My thought is that overtraining syndrome is almost always an unaddressed life variable that the athlete is either not disclosing or the researcher is not measuring. Austin, how does that square with what you've heard so far? It is provocative and I think it's likely to get the people going, as they say, 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. 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 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 and then also the idea that if you do have this, uh, this unicorn person that you were describing who is, uh, well-nourished, psychiatrically healthy, sleeping well, not using PEDs, things like that, that if they are trying to train enough to plausibly lead to the syndrome, I feel like more often there's going to be some survivorship bias of like, uh, injury structural issues are going to take them out before they get to that point in the, in the majority of cases.

1:25:30Um, but yeah, what you, your, 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 will have some likely interesting responses in the comments. So looking forward to that. So the epidemiology is uncertain. The well-documented confounders probably explain most persistent 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.

1:26:06In my experience, it's almost always one of three specific and correctable problems, none of which require the overtraining syndrome label to address. The first tier is this programming test mismatch. So effectively, the person's programming does not reflect how they're assessing their progress correctly. The body's adapting, but the program isn't just designed for how progress is being tested. So imagine somebody's running like a full-on bodybuilding program, right? But the outcome that they're testing is one rep max strength. It's like, okay, well, you would expect some strength gains to happen in the lifts that are being trained.

1:26:39That'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 their one rep max squat, bench press or deadlift, but they're not seeing any of those exercises in the program. It's like, this isn't really indicative of like, you're doing, 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 your sleep and nutrition are normal there's probably a programming 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 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.

1:27:30So it can be hard not to anchor to historical performances. So if you're a little weaker, you're like, performance is down. Or if it's a little better, you're like, Oh, actually got stronger. 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 didn't get stronger compared to the last time i trained and you're like well when's the last time you trained you're like they said yesterday you're like i wouldn't expect progress to happen they're like last week you're like well it's only one week now if someone says like for months on end that seems like a more reliable signal now whether you're over trained or under trained 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 rep max should go up somewhere uh in about four weeks uh over four weeks and that's relative to your most recent um estimated one rep max so not like historical for example same thing for conditioning to the extent that your cardiorespiratory fitness is going to go up we would expect an improvement in that within about four weeks compared to again the start and then for hypertrophy six to eight 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.

1:28:51Again, 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. And this can happen in both directions. A person who's not progressing because they're 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 underloading and interpreting normal fatigue as a warning signal probably needs to increase their training load.

1:29:26Similar presentations, not progressing, but opposite interventions. So it's the interpretation that matters here. Getting this wrong towards underloading is just as costly as getting it wrong towards overloading. It's 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 assessment? You've been in this space for a while. Yeah, I really have little to add, I think, to the way that you've fleshed this out and the way that we think about it.

1:29:56A lot of this involves conversations with people to try to get a feel with how they've been approaching not just their training program broadly, but what it's like for them to approach each individual training session, what it feels like 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 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 so there's some interesting similarities there when we look at it as a mismatch between their tolerance um and the and what's being asked of them yeah yep and so as we discussed in the training plateau action plan uh if somebody presents with performance going down um and they're sore all the time they're tire, their motivation is decreased and their session RP has gone up and is climbing, probably a good idea to reduce training looks is too high for the current resources.

1:31:13If they're relatively fresh, they're not sore, motivation is high, their session RP has been going down or it's 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 wanted to do. 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 we got the vocabulary with the caveat that it imposes this sort of false precision on a continuous variable that's noisy we have some of the biological background with the acknowledgement that the subjective report of the individual outperforms laboratory testing most of the time 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?

1:31:59We keep going back to assessing trends, right? So with performance, what's happening over weeks and months versus day to day. Day to day is almost irrelevant to me outside of like an acute injury, right? Even if someone's strength was down, for example, it's down 30%. 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 RPE, is it creeping up? How's your session RPE look over the last week, two weeks compared to the three to four weeks before that? Again, trends, not what's happening on a single day.

1:32:32Same thing with environment. What's your dietary pattern been looking like over the past few weeks? How has your weight changed? How has your sleep looked over the last few weeks? For example, what's your life stress look like? Again, short term, I missed a meal. I slept 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 life stress has been high training performance is just too noisy to sort of map to a single short-term single day type issue so again look at trends in those things finally look at soreness mood and motivation relative to training load.

1:33:20If you're becoming gradually more sore, your, uh, uh, your mood is, 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? Um, if performance is going down and these things are going up, session RP is going up, soreness is going up, uh, motivation is going down. Consider, uh, 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, session RPE is not going up.

1:33:55It's 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. 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 in volume up a little bit, and maybe average intensity, and then circling back around and saying, hey, look, was this actually a good formulation of training for you with respect to exercise selection, for example, so still, you're addressing these both through programming.

1:34:42If changing the programming, and addressing lifestyle factors does not resolve this sort of performance decline. Consider a medical workup. Austin, what would that look like for you? If you had a person who's, look, I've got the Barbo Medicine Training Plateau Action Plan. I went through all the steps. Use your guys' programs. Nothing doing. How do you start that workup? And, you know, obviously you're an internist, so this could go in legitimately thousands of different directions, but how would you do that? Yeah. I mean, the easiest answer here is to set up a consultation with a trusted healthcare professional that could be one of us we and i i do these kind of consults with people semi regularly we offer them through through barbell medicine to to be a bit uh 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 or resource that they um they can work through this with 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 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 trigger this kind of thing, endocrinopathies, whether thyroid or testosterone, things like that.

1:36:20If the person's on other medications and supplements, how could those be impacting things? So it's gonna 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, or I would say not signal, a lot of the results that we end up getting turn out to not be signal and end up being noise that is unhelpful.

1:36:53And 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. We've divided into three categories that look identical at the time of presentation. Zero-controlled studies have taken a person from healthy to over-trained 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.

1:37:26What 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. 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, you 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 bed session is probably fine to ignore. Now, if programming 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.

1:38:03The 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 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 medicine podcast i'm dr jordan feigenbaum we'll catch you next week

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