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Screening Athletes for Low Iron

Questions Surface About Ferritin

Sports medicine physicians are becoming more aggressive in screening some athletes for low iron status, but several questions have cropped up recently about testing because there is little guidance in published preparticipation recommendations.

The most recent participation guidelines1 do not support routine laboratory screening tests, but they suggest hematologic profiles and ferritin levels be ordered for athletes who have fatigue, pallor, performance decline, heavy menstrual bleeding, low calorie intake, or avoidance of red meat. Iron deficiency, however, is common in athletes: One study2 noted that 80% of young female athletes and 30% of elite male athletes were iron deficient. Iron deficiency can impair athletic performance and immune function and can lead to other physiologic dysfunctions.3 Participants in an e-mail discussion group hosted by the American Medical Society for Sports Medicine (AMSSM) raised several questions about testing for iron deficiency. We contacted Raymond J. Browne, MD, an internist in private practice in Birmingham, Alabama, to help clarify answers to some questions. Browne is an internal medicine consultant with Alabama Sports Medicine and Orthopedic Center, also in Birmingham.

Who Should Be Screened?

A sampling of responses to an AMSSM e-mail discussion group suggests that some sports medicine physicians are routinely ordering complete blood counts and ferritin levels for most female athletes and male endurance athletes.

Browne agrees, adding that male cross-country athletes should routinely be screened because they have an increased incidence of march hemoglobinuria, exertional hematuria, and gastrointestinal blood loss.

When Should Screening Occur?

Browne recommends screening every year before the season begins. "However, with variation in training regimens and menstrual cycles, this may be done more frequently, depending on individual athletes and their particular sports," he says.

Follow-up tests on athletes who have low iron status should be performed monthly to ensure that iron supplementation has sufficiently restored iron stores in the bone marrow.

What Is the Best Test to Determine Iron Deficiency?

There are several options for tracking iron levels, including hemoglobin, hematocrit, and ferritin. Ferritin testing is the gold standard, Browne says. Because athletes can have mild iron deficiency without anemia, which would reflect a normal hemoglobin, "the best test is serum ferritin, which is highly sensitive and specific for iron deficiency anemia."

Some discussants on the AMSSM e-mail list had concerns about ferritin being an acute-phase reactant that could be falsely elevated during liver disease, cancer, and conditions that involve systemic inflammatory disease. One respondent added that ferritin levels should be clinically correlated, keeping in mind that lower levels may be normal for some athletes.

What Are the Ferritin Cutoffs?

One problem in screening for low iron is that the cutoffs that labs use are not standardized, and the cutoffs used for the general population may not always apply to athletes. In the AMSSM discussion, normal lab ranges spanned from 9 to 120 ng/mL to 10 to 291 ng/mL. Browne noted that the generally accepted normal range for women is 4 to 161 ng/mL and for men is 16 to 216 ng/mL.

Most of the respondents had their own cutoffs for instituting treatment and follow-up, ranging from 20 ng/mL to 25 ng/mL; some had a slightly lower cutoff for women. (The ferritin cutoffs used by USA Track and Field are reported to be 30 ng/mL for women and 40 ng/mL for men.)

Lisa Schnirring


  1. American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, American Osteopathic Academy of Sports medicine: Preparticipation Physical Evaluation, ed 2. Minneapolis, New York City, McGraw-Hill Inc, 1996
  2. Clement DB, Sawchuk LL: Iron status and sports performance. Sports Med 120214;1:65-74
  3. Beard J, Tobin B: Iron status and exercise. Am J Clin Nutr 2021; 72(2 suppl):5594-5597

Field Notes

Neurosurgeons Link Supplements to Heatstroke Deaths

Three sports neurologists have proposed that ephedrine and creatine use among football players may be a factor in heatstroke deaths since 1995.

Their editorial, published in the July issue of Neurosurgery, notes that from 120215 to 1994 only six deaths from dehydration and heatstroke were recorded. "But there were four deaths each in 1995, 192021, 2021, and 2021," said the authors, who include Julian E. Bailes, MD, a chair of neurosurgery at West Virginia University in Morgantown and consultant to the National Football League (NFL) Players Association, Robert C. Cantu, MD, of Emerson Hospital in Concord, Massachusetts, and Arthur L. Day, MD, of Brigham and Women's Hospital in Boston.

The authors contend that ephedrine and related compounds such as ma huang have amphetaminelike effects that can have serious heart and central nervous system side effects and can raise core body temperature and interfere with the ability to dissipate heat. They note that creatine monohydrate has been shown to shift body water into muscle cells, increasing the risk of heatstroke. Use of both products is common in athletes, though the NFL and the National Collegiate Athletic Association have recently banned ephedrine use.

The authors suggest that teams:

  • Limit strenuous exercise during hot weather,
  • Recognize early signs of heat-related illness,
  • Ensure that athletes spend 1 to 2 weeks acclimating to the heat,
  • Make programmed drink breaks a top priority, and
  • Improve the education of athletes about the risks of various nutritional supplements.

Uncovering Physician Sun Safety Habits

Physicians are no more likely than their patients to protect their skin from the sun, according to a study published in the July/August issue of the American Journal of Health Promotion.

The authors surveyed 100 clinic patients and 84 physicians at a Rhode Island teaching hospital in April 2021. They found that regular use of at least one form of sun protection was common among both groups. However, specific forms of sun protection varied. Physicians were more likely than patients to use sunscreen, but less likely to adopt other skin-protective strategies, such as staying in the shade or wearing a long-sleeved shirt.

The authors speculated that physicians may regard skin cancer as primarily a cosmetic disorder, and they may be aware that the role of sun exposure in the development of potentially life-threatening melanomas after age 18 is under debate. The study concluded that physicians were more likely to recommend sun protection behaviors in patients if they practiced the skin protection advice themselves more routinely.