Chris G. Koutures, MD, FAAP Pediatric and sports medicine specialist

Please Check Our New Brand and Website:

Comprehensive blend of general pediatric and sport medicine care with an individualized approach that enhances the health and knowledge of patients and their families



Proud physician:
USA Volleyball Mens/Womens National Teams
CS Fullerton Intercollegiate Athletics
Chapman University Dance Department
Orange Lutheran High School

Co-Author of Acclaimed Textbook

Pediatric Sports Medicine: Essentials for Office Evaluation

Orange County Physician Of Excellence, 2015 and 2016


Filtering by Tag: ferritin in athletes

Seven Practical Observations on Dealing with Shin Pain in Athletes

After seeing plenty of shin pain in ballet Nutcracker performers , Olympic Volleyball players and various other athletic activities , here are 7 practical clinical observations to help assess and treat this common problem.

1)      Look above the shin

Landing  from a jump with inadequate hip or buttock strength can lead to an inward collapse of the knee, placing abnormal rotational forces on the shin.  Similar lack of upper leg control can lead to collapse of the foot arch in running, again causing increased stress on the shin. Any complete evaluation of shin pain should include some form of hip/buttock strength- my favorites include the single-leg squat, step-ups,or plie in 2nd position for dancers. Ideal alignment has kneecap directly under the hip and over the 2nd toe.

Plie in second position: note kneecap directly under hip and over 2nd toe

Plie in second position: note kneecap directly under hip and over 2nd toe

2)      Look immediately below the shin

Decreased ankle dorsiflexion (ability to move shin towards the foot or foot toward the shin)is yet another contributor to increased stress of the shin bones. Common causes include tight calf muscles or restricted movements between the tibia (shin bone) and the talus (first bone of the foot).  Side-to-side dorsiflexion motion comparisons can help identify abnormalities.

3)      Try to stand on toes or walk on the outside of the foot

If the calcaenous (heel bone) doesn’t move inward when standing on the toes, or if there is an inability to walk comfortably on the outside border of the foot, start thinking about restricted midfoot subtalar joint motion. Much like limited dorsiflexion, subtalar dysfunction transmits excessive forces to the shin region.  Tarsal coalition is a fairly common and under-recognized form of subtalar restriction.

4)      Never under appreciate the importance of the big toe

Amazing how restrictions within the small 1st metatarsophalangeal joint (aka big toe joint) can lead to big problems in the shin. Limited ability to raise the big toe off the ground toward the shin leads to either increased pressure on the outside of the foot or higher forces on the front of the shin during foot impact with the ground.  Stretching of the flexor hallicus longus muscle that controls big toe motion can be life and career-saving.

5)      Stressful causes of cramping calves

While most forms of generalized tightness or cramping in the calves are usually due to muscle fatigue and relative overuse, be more suspicious of cramps that can be pointed out by a finger tip and are located right next to the upper part of the tibia bone. Have found 2 recent cases of tibial stress reactions that presented with the primary concern of localized calf cramps.

6)      How are the iron stores?

Some cases of long-standing or difficult to treat shin pain may be complicated by low ferritin (measure of iron stores in the body).  More likely in females with heavier menstrual losses or those athletes and performers with restricted dietary iron intake.  I will routinely order laboratory testing in my evaluation of challenging shin pain.

7)      What are you wearing on your feet?



Practicing in Southern California, I often see patients who will select the best in athletic footwear, but then come into my office and routinely report wearing ill-fitting or poorly supportive shoes or sandals for non-athletic activities.  I’ve learned that if you can twist a shoe or sandal like a rolled newspaper, then there isn’t much mid-foot support. Use of relatively inexpensive over-the-counter arch supports in daily use shoes can allow one to be both fashionable and functional, while leaving sandals for the pool or beach.



Should I Take Extra Iron to Increase My Athletic Performance?

Given an  important  role in hemoglobin, which is the part of the red cell that optimizes oxygen delivery to exercising muscles,  sufficient iron stores (best known as ferritin) are definitely essential to providing peak athletic environments.  There is little doubt that low red cell counts, also known as anemia, can torpedo both endurance and strength performance for many athletes.

Thus, should you seek out increased food and even supplement based sources of iron?

Well, the answer isn't so straight forward and depends on your current "group" of red cell counts and iron stores:

  • Group 1: If you have low red cell counts with smaller red cell sizes and low iron stores, experience and science strongly suggest a need and benefit for supplemental iron intake
  • Group 2: If you have normal red cell counts and normal iron stores, the prevailing thought is that supplemental iron intake is not needed and may actually have risks (organ damage, higher risk of liver cancer) that outweigh any benefits to your performance.
  • Group 3: If you have normal or low normal red cell counts and low iron stores,  this is where things get real interesting as scientific studies and the sports medicine and performance communities do not have clear agreement.

If that third category sounds a bit confusing, then let me add a bit more uncertainty to the picture.

  • Athletic individuals have different oxygen transport and muscle function demands. Thus, what many of us consider as "normal" hemoglobin values for less active individuals may not be so acceptable for intense endurance or team sports athletes. Many athletes may strive for hemoglobin levels at least 2-3 points above the lowest range of normal.
  • Hemoglobin or red cell counts can be lower in athletes due to increases in blood volume that allow for more efficient delivery of oxygen to working muscles. This is called pseudo-anemia where the red cell sizes and iron stores are both normal.
  • Using ferritin to measure iron stores can be perplexing. Ferritin levels can be influenced by things like illness or even total body inflammation, so there are often cases where sick or over-trained and under-performing athletes mistakenly appear to be "doing better" with iron intake based solely on higher ferritin levels.
  • If you "trust" ferritin, then deciding on acceptable levels is yet another concern. In many athletes, keeping levels in the 20-30 range is a challenge during period of heavier training or competition, with levels higher than that a true accomplishment.

So, how should you use this information to make sensible decisions for your health and athletic performance?

  • Do not use any supplemental iron products (liquid iron, iron pills, ect) without appropriate medical evaluation and testing.
    • Those tests can include measurements of red cell counts (hemoglobin), total body iron, red cell iron saturation, ferritin, and possibly a test called soluble transferrin receptor which might be more accurate than ferritin in measure iron stores.
  • If you are clearly in Group 1 or Group 2 from above, then your decision is probably more clearly defined.
  • If like many people you are in Group 3, or even if you are in Group 1 or 2 and have questions, strong recommend scheduling a meeting with a sports medicine specialist who has additional experience, training and appreciation for the stresses and demands of higher level athletes to review your diet, training program and lab tests.  

What is Role of Iron Supplementation in Non-Anemic Endurance Athletes?

It is relatively common to have young endurance athletes come into my office requesting lab work to check for anemia (low red cell counts) and iron stores in hopes of finding a relatively straight-forward treatment for fatigue or low performance. While the prevailing trends in the sports medicine literature are more in favor of iron supplementation,  I must also bear caution that iron treatments alone are not a "magic bullet" and that more specific review of training regime, diet, and sleep patterns is absolutely essential.

There is no doubt that endurance athletes are at particular risk for anemia, Potential exercise-related causes include iron losses through sweat, stool and urine along with breakdown of red cells with foot impact against the ground in running. Concerns about the role of chronic training-related inflammation reducing general body iron absorption and recycling and a diet deficient in adequate iron intake may also compound the issue.

We may also hold a higher expectation for red cell count numbers in endurance athletes, and this bias creates more findings of relative anemia. Red cell levels that are in the low normal range may be fine for the less active or couch potatoes of the world, but may not be as acceptable for a higher level runner, swimmer or cyclist.

Over the past 5-10 years, I have definitely seen a movement among athletes, coaches and sports medicine experts to be more apt to recommend iron supplementation for endurance athletes who have low iron stores but who are not be anemic (have low red cell counts). Prior to that time, the prevailing thought was to favor iron treatments only for those athletes who were both anemic and having lower iron stores.  The results of a recent meta-analysis in the British Journal of Sports Medicine lend additional support that iron supplementation for low iron stores without frank anemia can improve iron status and aerobic capacity.

Interesting points discussed in the article that may further influence treatment recommendations include:

  • Selecting appropriate markers to measure iron status-  serum ferritin (measure of body iron stores) can vary from day-to-day and in combination with iron saturation studies, both tests may not be adequate to reflect whole body iron status. Use of soluble transferrin receptor studies may be more accurate, though variations in lab techniques may limit comparisons of findings over time.
  • Higher doses of iron supplementation over a shorter period of time were suggested to be more effective than smaller doses over longer periods with effect on iron stores to be diminished with a treatment period over 80 days. 
  • Optimal dosing amounts, protocols, and routes (oral versus injected) require more study.
  • Female endurance athletes may respond differently to treatment, most likely due to menstrual cycle variations on hormonal levels that may influence iron absorption.

While this information adds significant value to the measurement and treatment of iron issues in endurance athletes, it is crucial to recognize that focusing on iron alone is grossly simplistic and insufficient when evaluating performance issues in endurance athletes.

A comprehensive review of diet may reveal insufficient overall caloric intake as high level athletes often suffer from relative energy availability issues where training related caloric demands may not be met by food intake. I have often found that lower calorie diets often have low intake high protein foods such as meat. poultry, fish, and dairy sources that not only reduce intake of high level, easily absorbed iron sources (red meat, red fish, dark poultry, veal) but also essential calcium (dairy) and the protein stores needed for muscle growth and recovery (especially if ingested within 30 minutes after exercise).

Diet choices that help reduce inflammation can not only aid in absorption of essential nutritional elements, but also minimize joint stiffness, muscle soreness, and reduction in mental sharpness, Less processed foods, lower carbohydrate diets, and diets rich in items such as berries and cherries, fish and fish oils, and spices such as tumeric and ginger are recommended as part of an anti-inflammatory diet.

Inadequate sleep can also lead to inadequate performance. Emerging evidence suggests that a minimum of 8.5 hours a day (can include a short nap of no more than an hour) can reduce risk of injury, illness, and may also contribute to enhanced academic and athletic performance. Sleep is part of the overall recovery process that must be integrated into a thoughtful training program that feature adequate rest days and alternating periods of heavier and easier training that may have to be individualized for each athlete.

Fatigue and under-performance are common concerns in the endurance athletes and human nature often leads us to find convenient remedies. Findings that support iron supplementation in non-anemic athletes give some evidence-based measures of optimism, but must be tempered with the reality that more comprehensive evaluation is necessary to provide optimal outcomes. Seeking counsel from a sports medicine expert versed in training and performance concerns of endurance athletes is a sensible and often very productive step in enhancing overall health.