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It all started to go wrong in 2003. From the start of the year I began to feel suddenly very tired during training and would not be able to recover. [A doctor at the British Olympic Association] said that I had unexplained underperformance syndrome, a polite way of saying I’d overtrained.

 Anna Hemmings, world champion canoeist, from The Observer, 2 April 2006

Persistent tiredness, often accompanied by a feeling of lethargy and impaired sporting performance, is a frequent presenting symptom to a sports and exercise medicine practitioner. These symptoms may be the primary reason for a visit to the practitioner, or they may be an additional complaint of a sportsperson presenting with an injury, commonly an overuse injury.

There are many possible causes of persistent tiredness and/or impaired performance in sportspeople. A list of possible causes is shown in Table 57.1. Sportspeople in heavy training are constantly tired but can usually differentiate between normal, “healthy,” tiredness and abnormal tiredness, particularly when this is accompanied by a deterioration in training and competition performance. “Healthy” tiredness is usually easily reversed with a day or two of reduced training or rest. This chapter addresses the problem of the sportsperson with persistent tiredness whose symptoms do not disappear after a brief period of rest.

Table 57.1

Causes of persistent tiredness in sportspeople

Clinical perspective

A summary of the history, examination, and investigations used in the diagnosis of the tired athlete is shown in the box Summary of history, examination, and investigations of the tired sportsperson.




Full medical history including:

  • duration of tiredness

  • degree of tiredness

  • timing of symptoms

  • association with viral illness

  • associated symptoms

  • training diary

  • amount of sleep and rest

  • time commitments

  • psychological problems

  • fluid intake

  • dietary history

  • menstrual history

  • work/personal stress

  • associated medical problems

  • medications

  • allergies


Full medical examination including:

  • pallor

  • resting pulse

  • blood pressure

  • upper respiratory tract including sinuses

  • heart

  • lungs

  • liver/spleen/lymph nodes

  • thyroid

  • others as indicated


Urine testing:

  • blood

  • glucose

  • protein

Routine blood tests:

  • hemoglobin

  • white cell count

  • blood film

  • erythrocyte sedimentation rate (ESR)

  • C-reactive protein (CRP)

  • urea, electrolytes

  • serum ferritin/transferrin receptor saturation level

  • vitamin B12 and folate

  • vitamin ...

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