20yo college swimmer presents to the ED with a constellation of non-specific symptoms such as poor sleep, fatigue, depression/anxiety, weight loss. 

Despite regular 2/day practices, his coach tells him his performance is worse than ever.

Additional Information

Overtraining syndrome

A maladaptive response to excessive exercise without adequate functional rest

-Results in disturbances of multiple body systems (neurologic, endocrinologic, immunologic and psychologic) which causes a broad constellation of symptoms

- May be caused by systemic inflammation and resultant neurohormonal changes (hypothalamic-pituitary-adrenal axis)
            - Multiple hypotheses exist

The ACSM 2025 consensus statement on the adolescent athlete highlights that overtraining risk is particularly elevated in those who specialize in a single sport early, train more hours per week than their age, or maintain a >2:1 ratio of organized sport to free play.

Symptoms

The ACSM/AMSSM consensus statement categorizes these into physical and psychosocial domains: 

Physical symptoms:

• Persistent fatigue and severe exhaustion disproportionate to training
• Unexplained performance decline not improved by usual rest/recovery
• Dizziness and shortness of breath 
• Elevated resting heart rate and blood pressure
• Weight loss and decreased appetite
• Muscle pain, soreness, and stiffness
• Gastrointestinal distress
• Delayed recovery from exertion
• Disturbed sleep (both initiation and maintenance of sleep)
• Increased susceptibility to upper respiratory infections and illness

Psychosocial symptoms:

• Loss of confidence, apathy, and irritability
• Emotional and motivational changes
• Depressed mood 
  • Up to 80% of affected athletes may show signs of clinical depression
• Concentration difficulties 
• Anxiety and excessive worry

Decreased maximal heart rate during exercise testing (-3.6 to -7.5 bpm) is the most consistent cardiovascular finding

ED workup may include: CBC, CMP, iron studies, TSH, CK.

The only treatment is reduction in training combined with optimized nutrition, increased sleep, and stress reduction. Subsequent improvement in symptoms and performance confirms the diagnosis but may take months depending on the severity and duration of maladaptation.