Distinguishing the start of weeks of underperformance and fatigue from normal fatigue in athletes training hard is difficult. It is common for athletes to suffer from a week or two of relative underperformance at times of hard training. Sometimes this underperformance persists for more than two weeks despite adequate rest. Up to 10% of elite endurance athletes per year may suffer from unexplained underperformance syndrome (UUPS). No specific medical cause is found in the majority of underperforming athletes and they can be diagnosed as suffering from UUPS also known as burnout, staleness, overtraining syndrome, chronic fatigue in athletes, sports fatigue syndrome or under-recovery syndrome. The predominant symptoms in these underperforming athletes are fatigue, heavy muscles and depression. Some athletes suffer from frequent minor infections breaking down with an upper respiratory tract infection (URTI) every three to four weeks. Many athletes describe increased lightheadiness (postural hypotension) and a raised resting pulse rate. There is often loss of motivation, energy, competitive drive and libido and loss of appetite with weight loss. Direct questioning reveals sleep disturbance with difficulty getting to sleep, nightmares, waking in the night or prolonged sleep but waking unrefreshed. Athletes often describe keeping up at the beginning of a race but being unable to lift the pace or sprint for the line. Distinguishing UUPS from normal training fatigue (over reaching) is difficult and can only be done once an athlete has failed to recover. Many athletes will be fatigued, irritable, anxious and depressed with increased resting pulse rate and minor infections, but nevertheless recover quickly once the training has been reduced. The challenge for doctors, sports scientists and coaches is to develop reliable measures of recovery so athletes can train as hard as possible but not so hard that they break down for many weeks with UUPS. There are no diagnostic tests for UUPS and the diagnosis is made on the history and objective underperformance. Investigators have tried to identify strategies for early detection, and these will be discussed. Prevention requires good diet, full hydration and rest between training sessions. Coaches and athletes must realise that sports people with full time jobs and other commitments will not recover as quickly as those who can relax after training. Athletes will benefit from a multi disciplinary approach and should see a Sports Dietician and Sports Psychologist if available. Physiologists can also help by confirming underperformance, monitoring recovery and helping to set training levels. During this time rest and regeneration strategies are essential to recovery. Athletes with UUPS show improvement in both performance and mood state with five weeks of relative rest. Athletes are advised to exercise aerobically at a level well below training for a few minutes each day and slowly build this up over many weeks. The starting level and speed of increase in training volume will depend on the clinical picture and rate of improvement. Recovery generally takes 6 to 12 weeks. Once athletes can tolerate 20 minutes of light exercise each day then it is useful to introduce short sprints of less than 10 seconds with at least 3 minutes recovery between each sprint. Conclusion Unexplained Underperformance Syndrome is common in elite endurance athletes and is difficult to prevent and reliably identify. Once a definite diagnosis is made and other medical causes have been excluded then a graded exercise programme over many weeks normally leads to full recovery. This will be most effective with the support of a multidisciplinary team and if there is full co-operation of the coach and athlete with the programme and regeneration strategies.
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