{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,26]],"date-time":"2026-10-26T06:33:34Z","timestamp":1792996414311,"version":"4.5.0"},"reference-count":10,"publisher":"BMJ","issue":"7","license":[{"start":{"date-parts":[[2025,7,7]],"date-time":"2025-07-07T00:00:00Z","timestamp":1751846400000},"content-version":"unspecified","delay-in-days":6,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Case Rep"],"accepted":{"date-parts":[[2025,6,27]]},"published-print":{"date-parts":[[2025,7]]},"abstract":"<jats:p>Overtraining syndrome (OTS) is a significant medical condition observed predominantly in endurance athletes and characterised by a decline in performance and disruptions in multiple physiological functions. Given the increasing popularity of endurance training and the complex nature of OTS diagnosis, there is a compelling need for comprehensive case studies. The case series summarises one professional runner, one competitive runner and one recreational runner who were diagnosed with OTS. Key parameters observed include symptoms, diagnostic journey, recovery initiatives and return-to-sport outcomes. All three athletes showed typical OTS manifestations, including impaired performance and multisystem dysfunction (ie, endocrine, nervous, immune and gastrointestinal systems). Following a mandated cessation from training, active recovery strategies were instituted. Two of the three athletes successfully returned to competition. Specific recovery patterns and potential relapse indicators were also identified. The comprehensive examination of the cases underscores the complex nature of OTS diagnosis, its multifaceted symptoms and the critical importance of structured recovery. The case series elucidates the importance of heightened awareness and early intervention to diagnose and manage OTS. In addition, we propose an anecdotal Return to Running Protocol individualised to the athlete\u2019s response.<\/jats:p>","DOI":"10.1136\/bcr-2025-265066","type":"journal-article","created":{"date-parts":[[2025,7,8]],"date-time":"2025-07-08T10:20:47Z","timestamp":1751970047000},"page":"e265066","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":4,"title":["Overtraining Syndrome (OTS) in Three Endurance Athletes and Roads to Recovery"],"prefix":"10.1136","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3912-6992","authenticated-orcid":false,"given":"Jeffrey B","family":"Kreher","sequence":"first","affiliation":[{"name":"Orthopaedics, Mass General Brigham, Boston, Massachusetts, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jan","family":"Stepanek","sequence":"additional","affiliation":[{"name":"General Internal Medicine & Mayo Clinic Aerospace Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robert","family":"Amrine","sequence":"additional","affiliation":[{"name":"Family Medicine Residency of Idaho, Boise, Idaho, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2626-4165","authenticated-orcid":false,"given":"Satyajit","family":"Reddy","sequence":"additional","affiliation":[{"name":"Department of Cardiovascular Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2025,7,7]]},"reference":[{"key":"2025070714421790000_18.7.e265066.1","doi-asserted-by":"publisher","DOI":"10.1177\/1941738111434406"},{"key":"2025070714421790000_18.7.e265066.2","doi-asserted-by":"publisher","DOI":"10.1249\/MSS.0b013e318279a10a"},{"key":"2025070714421790000_18.7.e265066.3","doi-asserted-by":"crossref","DOI":"10.3389\/fnetp.2021.794392","article-title":"Overtraining Syndrome as a Complex Systems Phenomenon","volume":"1","author":"Armstrong","year":"2021","journal-title":"Front Netw Physiol"},{"key":"2025070714421790000_18.7.e265066.4","doi-asserted-by":"publisher","DOI":"10.2147\/OAJSM.S91657"},{"key":"2025070714421790000_18.7.e265066.5","doi-asserted-by":"publisher","DOI":"10.1249\/MSS.0b013e318207f87b"},{"key":"2025070714421790000_18.7.e265066.6","doi-asserted-by":"publisher","DOI":"10.1007\/s40279-021-01491-0"},{"key":"2025070714421790000_18.7.e265066.7","doi-asserted-by":"crossref","DOI":"10.1186\/s13102-019-0132-x","article-title":"Novel causes and consequences of overtraining syndrome: the EROS-DISRUPTORS study","volume":"11","author":"Cadegiani","year":"2019","journal-title":"BMC Sports Sci Med Rehabil"},{"key":"2025070714421790000_18.7.e265066.8","doi-asserted-by":"crossref","first-page":"544","DOI":"10.1016\/j.jsams.2022.06.001","article-title":"Return to exercise post-COVID-19 infection: A pragmatic approach in mid-2022","volume":"25","author":"Hughes","year":"2022","journal-title":"J Sci Med Sport"},{"key":"2025070714421790000_18.7.e265066.9","doi-asserted-by":"crossref","first-page":"564","DOI":"10.2519\/jospt.2020.9533","article-title":"Moving Beyond Weekly \u201cDistance\u201d: Optimizing Quantification of Training Load in Runners","volume":"50","author":"Paquette","year":"2020","journal-title":"J Orthop Sports Phys Ther"},{"key":"2025070714421790000_18.7.e265066.10","doi-asserted-by":"crossref","first-page":"18","DOI":"10.3390\/ijerph181910299","article-title":"Heart Rate Variability-Guided Training for Enhancing Cardiac-Vagal Modulation, Aerobic Fitness, and Endurance Performance: A Methodological Systematic Review with Meta-Analysis","volume":"18","author":"Manresa-Rocamora","year":"2021","journal-title":"Int J Environ Res Public Health"}],"container-title":["BMJ Case Reports"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bcr-2025-265066","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,7,8]],"date-time":"2025-07-08T10:20:50Z","timestamp":1751970050000},"score":1,"resource":{"primary":{"URL":"https:\/\/casereports.bmj.com\/lookup\/doi\/10.1136\/bcr-2025-265066"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,7]]},"references-count":10,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2025,7,7]]},"published-print":{"date-parts":[[2025,7]]}},"alternative-id":["10.1136\/bcr-2025-265066"],"URL":"https:\/\/doi.org\/10.1136\/bcr-2025-265066","relation":{},"ISSN":["1757-790X"],"issn-type":[{"value":"1757-790X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,7]]}}}