Emily Kraus, Sports Med Physician on Running Medicine, Injury Prevention and the Female Athlete

Dr. Emily Kraus (@ekraus) is one of those rare individuals who incorporates her passion into her work. As an Assistant Clinical Professor at Stanford Children’s Orthopedics and Sports Medicine, Dr. Kraus focuses on bone health, running medicine and the female athlete. She is at the forefront of two issues gaining traction, the female athlete triad and RED-S. An experienced marathon runner with a PR of 2:50, she is active in the Bay Area running and cycling communities and trains with coach Mario Fraioli (@mariofraioli). 

Her work doesn’t stop in the clinic. For the ultrarunners, you’ve likely seen Dr. Kraus the last two years at Western States doing research exploring genetic and serologic determinants of bone health in ultramarathoners. 

We asked Dr. Kraus to share her journey to running and medicine, and provide a foundation for how she thinks about some of the most common themes for athletes on Prokit: Training, injury prevention, sports specialization, and the female athlete. We hope this is just the start; let us know in the comments or in this brief survey where you’d like to see us expand with Dr. Kraus.  

Emily Kraus’ Journey 

A Runner is Born

I proudly grew up in a small rural town in Nebraska (Go Big Red). When I was in middle school, the cross country coach invited me to a summer morning training run on the local public golf course. I grew up playing golf with my family on that course and I was thrilled by the idea of running on it. Running was a natural fit for the hyper, endless-energy kid in me. I ran XC all through high school while also playing basketball, tennis, and a little golf with my family. I’m proud to say I “lettered” in three separate sports in high school. 

In high school, I already knew my “dream job” was working in sports medicine and this interest only increased while in college. I chose to keep running as a therapeutic release from the high academic and extracurricular expectations I too often placed on myself. These runs allowed me to develop a love and appreciation of the sport that I hadn’t fully experienced in high school. I ran my first marathon my last year in college (San Diego Rock’n’Roll, 3:13.07) using what many young marathoners use: an online, very generic coaching program, with most training done alone. I was oblivious to the importance of proper training, fueling, and recovery. I was a college senior who had already gotten accepted into medical school thanks to early decision (i.e., the academic pressure was off my shoulders for a brief period). Somehow, I qualified for Boston while having the most social times (and late nights) of my college career. Looking back, I was also probably the most relaxed of my college career.

In medical school, I joined Team Nebraska Brooks and was finally introduced to the community of runners I didn’t even know I needed in my life. Thanks to this group of runners of all ages, all walks of life, the sport became far more than just an outlet for the stress and pressure of medical school. The sport of running became a network that channeled so many of my passions into one place. I remember cold winters where I would wake up early, run 20 miles on snowy country roads swapping stories or suffering silently with company. We’d enjoy a nice, warm meal and then I’d spend the rest of the day and night studying in the library. I think I survived the dark moments of medical school thanks partly to those types of relationships and experiences.   

I eventually moved to California for residency and found myself back in survival mode. I was running solo and socializing separately during any spare moment away from the emotional, physical, and mental demands of residency training. Although I needed both (the running and the social life), I was constantly burning the candle from both ends, running hard too much, recovering too little, and (surprise, surprise), underperforming. 

At the end of residency, I serendipitously connected with David Roche through his (super)wife Megan, who collaborated with me on a study on collegiate runners. He took one look at my overtraining on Strava and saw potential in me while tactfully highlighting my terrible training habits. A few months later, I ran and won my first 50k, then PR’d at Boston with a 2:57 (my first sub-3). 

Around this same time, I met Laura King (@laura). I was running my first SFRC Saturday morning run in the breathtaking Marin Headlands. After getting lost at least three times, a speedy Laura zoomed past me and I asked her for directions back to the store (which was around the corner). Once back at the store, we laughed, grabbed brunch with a fun crew, and I rediscovered the incredible energy of the running community. 

Fast forward, I’ve now run 9 marathons, with a new PR of 2:50 at California International Marathon under the expertise of good friend, and excellent coach, Mario Fraioli. 

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This is an appropriate time to mention that I eventually caught the cycling bug with my move to the Bay Area. I love many things about the bicycle, but highlights include: the amount of beautiful land you’re able to cover on two wheels, the equally incredible cycling community and the thrill of group rides, and having the bike as a running “back-up” option comes in handy for weekend adventuring when the impact of running isn’t advisable. 

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The Path to Sports Medicine

I fondly remember my 7th grade science teacher. She was one of those exceptional teachers who would challenge you in a way that gave whatever you were doing purpose. I loved studying the human body, and I soon began dreaming up careers that incorporated people, health, and the musculoskeletal system. I particularly enjoyed the challenging, often maze-like journey to reach a diagnosis and treatment plan. I envisioned a career in medicine then quickly fell in love with the field of sports medicine. 

Treating athletes to get them back to the activities they love to do seemed like the most impactful way for me to make a difference in a person’s life. I began on a focused path to become an orthopedic surgeon, but soon realized I didn’t love the operating room nor did I feel it was where I could give my best self to the patient. It was frightening to walk away from a track I thought was the only path to my dream job, but I found myself headed towards a field ripe with potential: physical medicine and rehabilitation (also known as PM&R or physiatry). A physiatrist strives to get patients back to optimal functional status, whether recovering from a spinal cord injury, stroke, amputation, or sports-related injury. A physiatrist takes a multidisciplinary team approach utilizing the expert knowledge of other professionals (physical therapists, dietitians, chiropractors, massage therapists, the list goes on) to provide a comprehensive, holistic treatment plan for the patient. Jackpot! 

After medical school in Nebraska, I matched at Stanford for residency in PM&R. Post-residency, I was accepted for a sports medicine fellowship, also at Stanford. During those five years of training, I dove into research and outside projects I was most passionate about: bone health, the female athlete triad, and running/endurance medicine. I gained the mentorship and direct athlete experience I needed to feel confident to launch my own career. I’m proudly board-certified in sports medicine and PM&R, which allows me to span my practice across many different sports, ages and types of injuries. 

I’m currently an Assistant Clinical Professor at Stanford Children’s Orthopedics and Sports Medicine, where I treat athletes of all ages. My passion is in bone health, running medicine, and the female athlete. My typical week consists of 1) direct clinical care of the athlete  2) research on the above topics to further the science 3) outreach to educate the community. I find all three pieces are incredibly important for me to have a well-rounded practice. 

Training, Injury Prevention and Longevity 

Training and the Body

Our human body is this intricate interplay of physiologic responses occurring simultaneously at a subconscious level. This is how we stay alive each day (not that strong morning coffee). Our conscious acts move the body, often in extraordinary ways. How far our body can be pushed depends on numerous factors, including fitness, baseline physiologic health (i.e., are you sick? injured?), mental/emotional health, sleep, and nutrition. We’re all unique in our response to training and competition. Our bodies weren’t created the same, so why do we try to compare our training or bodies to someone else’s? The broad strokes may be similar, but the finishing touches will need to be tailored to the individual.   

General Guidelines 

Creating general guidelines to help athletes really depends on the sport. An easy example is baseball — a pitcher is demanding a great amount of load from the same limb repetitively over the course of a game or practice. It makes sense to have recommended upper limits on pitch count based on level of training and age. Similar broad guidelines are used in other sports, but the area becomes grey very quickly, especially in endurance sports. I wish our research was more robust to provide set guidelines for mileage, intensity, and duration in the endurance sports world, because I see athletes regularly fly scarily close to the sun in their training. Sometimes it leads to the desired goal/outcome, but more often than not, they lose weeks or even months of training while recovering from an injury or burnout. Some athletes need motivation to do more, while others are plenty motivated and need guidance on when and why it’s important to do less. A good coach can recognize that critical difference, but many recreational athletes don’t have a coach and are trying to figure this out on their own. 

Preventing Injuries – Watch the Signs

Injuries are detrimental to an athlete. Not only can they derail a training cycle for a big competition or event, but they also disrupt an athlete’s routine that may be essential for overall stress relief, socialization, and health. Sometimes, a season-ending or career-ending injury is unavoidable. More often than not, there are “signs” that a coach or sports medicine professional can spot and then tell an athlete to slow down or stop training before an injury forces him or her to stop.

What are these magical “signs”? Without getting too deep into the sports science weeds, I’ll list some more obvious signs that may be indicators that an athlete is flying too close to the sun:

• Skimping on the rest and recovery: I am so happy we have more sophisticated research on how sleep affects performance and recovery. Talking about sleep is essential when addressing factors that can easily improve or impair performance. Identification of a sleep deficit may be the easy part. Correctly identifying the trigger of the deficit and how to fix this trigger is the bigger challenge. For example, work-related stress may be a trigger, but most people aren’t in a situation where they can easily leave their jobs. 
•  Fueling errors: Underfueling, improper fueling (wrong food choices), or improper fuel timing during increased training intensity or volume could lead to unnecessary fatigue (and underperformance) or increased injury risk (think, bone stress injury or stress fracture), especially if done over a prolonged period of time (weeks to months). 
• Missed periods: See below on The Female Athlete. 
• Prolonged decrement in performance: If an athlete is consistently having performance decrements, this may be a sign of overtraining which can presumably place an athlete at overall increased injury risk.  
• Mood changes: Although a change in mood can be due to a number of factors, an overtrained state can be one contributor, especially to increased irritability and sleep disturbances.
• Localized pain: This is a tricky one, especially for athletes who may be new to sport or just returning from time off (maybe even from an injury). Soreness is inevitable and certain aches and pains often feel like an injury. If the pain localizes to the same area on consecutive days and increases with exercise, this is probably a sign that the area (bone, tendon, muscle) is getting overworked. In that case, I usually recommend taking a step back to look at the training, take 1-3 days off to let things cool off, and then ease back into the training for the rest of the week. If the pain intensifies, is leading to functional limitations even outside of training, or doesn’t improve with the “cool off,” follow up with a healthcare professional who works closely with athletes. 

On Specialization and Injury Prevention in Youth Athletes

Youth sports are much different today than they were 30 years ago. There is a greater emphasis on organized sports. Children are encouraged to specialize in one sport as young as 7 years old. Sports specialization is intensive year-round training in a single sport at the exclusion of other sports. 

Many parents think specialization will help children excel at their sport, but studies show that the odds of reaching the elite level in sports are not increased by early sports specialization. Instead, sports specialization leads to a higher rate of injuries and burnout. As many as 70% of kids stop playing organized sports by 13. Current evidence suggests that delaying sport specialization for most sports until kids are around 15 or 16 years old will minimize injuries and lead to a higher likelihood of athletic success. 

The Female Athlete

After Title IX, of the Education Amendments Act of 1972, female sports participation increased dramatically both in high school and collegiate sports. This also increased awareness of important unique differences between female and male physiology and the direct effects these differences can have on performance and injury risk. 

Two important topics that need to be addressed and better understood in the female athlete are the female athlete triad and RED-S. 

Female Athlete Triad: The female athlete triad is comprised of three interrelated components: low energy availability with or without disordered eating, menstrual cycle disturbances, and low bone mineral density (BMD). Research has shown that females who engage in endurance sports and/or in sports which emphasize “leanness” have greater elements of the Triad. Females with more components of the female athlete triad are at greater risk for bone stress injury (BSI) and those who sustain a BSI have delays in return to sport. As our understanding of the Triad has evolved, we’ve found a male equivalent that can also increase risk of BSI in certain populations (endurance runners). 

RED-S: Relative energy deficiency in sport (RED-S) expanded upon the Triad definition. It is a syndrome of health and performance impairments resulting from an energy deficit in both men and women. An energy deficit or low energy availability (LEA) is when a person’s dietary intake is insufficient to cover basic physiological demands (see figure below). The body responds to LEA by downregulating fundamental physiological processes. This ‘energy-saving mode’ can negatively affect endocrine function. For women, LEA can manifest itself as menstrual disruption (loss of or irregular periods); while in men this corresponds to low testosterone and/or other hormonal abnormalities.

Although an athlete may notice initial gains in athletic performance with short-term LEA, long-term LEA will lead to deterioration in health and performance, and increased injury risk, particularly BSI/stress fracture. 

I still see young female athletes in my clinic who think it’s normal to lose their period during heavy bouts of training. Fired up, I made this infographic to educate coaches, parents, and athletes misconceptions on hormonal contraception & bone health.

Emily Kraus’ Recommended Resources

Resistance Training
One thing I’ve learned early on in my professional career: build a network of colleagues you respect, trust, and who are smarter than you! Derek Miles is a physical therapist I’ve been fortunate to work with for the past three years and he has written a great series on resistance training for the endurance athlete. I agree wholeheartedly with this well-written piece.

Sports Specialization
I expand on specialization in this article for Bridge Athlete. Also, Derek Miles summarizes sports specialization wonderfully.  

Triad and Red-S
More information on RED-S and the Triad for athletes and coaches. 

Follow Emily on Prokit, Instagram and Twitter, or check out her Podcast with Tina Muir on the link between nutrition and injury. For Bay Area parents, check out Stanford Children’s, The Young Athletes Academy Running Program.

If you liked this, join the Prokit community and check out Prokit’s interview with Emily’s coach, Mario Fraioli, a look at exercise during pregnancy by her friend Laura King, and our Prokit Women in Sport on goal setting strategies.

What would you like to see us cover next with Dr. Kraus? Let us know in the comments or in this brief survey.