As more programs encourage young athletes to train like professionals, female runners report problems with restrictive eating, irregular menstrual cycles, and long-term bone damage.

By Margie Cullen and Anne Marshall-Chalmers. This story appeared in Runner’s World on November 18, 2022.

Desiree Stinger ran her first race in hot-pink Crocs. She was 10 years old, and when she got dressed that morning, she had forgotten that the fourth-grade fun run that looped around her elementary school was that day. She wanted to win, even in those awkward shoes, and burst ahead, ignoring the pleas of a friend—“Desi, wait for me!” Classmates were left huffing in her wake as she claimed first place.

Stinger’s parents and her P.E. teacher saw the win as a glimmer of big things to come. She continued to run, off and on, with her middle school team. After clocking a 6:32 mile in eighth grade, she caught the eye of Doug Soles, the cross country and track coach who had taken Great Oak High School in her hometown of Temecula, California, from not qualifying for the state championship to winning it. Over the next few months, Soles emailed Stinger and her family repeatedly, and girls from the high school team crashed her middle school graduation party to drop off a T-shirt and a list of 10 reasons she should join the team. Stinger was overwhelmed. She had a vision of herself playing volleyball in high school, or doing theater. But the persistent requests from Soles eventually wore her down, and she plunged into the life of a distance runner on one of the country’s top-performing high school teams.

At the time, Stinger was 14. By the end of her freshman year, her weekly training would begin with a 13-mile run on Monday morning before school. In the afternoons, she and her teammates would usually return for another six miles. Experienced runners on the team averaged 60 to 80 miles a week. Some parents didn’t think twice—to be the best, the thinking went, you need to do more than the others.

But Stinger’s father, Craig, grew nervous. Distance running, he felt, could be “brutal” on the body. While he worried about Desi’s physical and mental health, he also wanted to support her and her Great Oak team. “How I looked at it was, we’re part of their program, so we’re following their program,” he says. “But at the time you don’t know how much of a toll it’s taking.”

Soles often spoke to his runners about “finding their why,” or the inner fire that would motivate them to run at an elite level. He was known for lengthy motivational speeches and would meet with runners individually at lunch so they could set goals and talk about running. He made runners feel important, and when he’d call a group of newbie freshmen “my future state champions,” they believed it. “Our coach had our full and undivided trust,” Stinger says. As her times improved, so did her trust in him. “Whatever he said, we did.”

Stinger’s father became a one-man support squad. To ensure his daughter was fueling well, he would hand her a protein-packed smoothie when she came home from practice. To treat her sore, depleted legs, he kept 10-pound bags of ice in the freezer for nightly ice baths. To prevent fatigue, he instituted an early bedtime of 9 p.m. Stinger embraced these habits; once she joined Great Oak, she never wavered on her commitment.

During her high school years, from 2012 to 2016, Great Oak won four state championships and placed second at Nike Cross Nationals. Stinger graduated with seven varsity letters and a sub-five-minute 1600-meter time, securing her an athletic scholarship at Washington State University. But she arrived in 2016 with a nagging pain in her lower leg. She felt tired, unable to run anywhere near her high school times.

A DEXA bone density scan revealed that her 18-year-old bones were on the borderline of osteopenia, a precursor to osteoporosis that generally occurs in postmenopausal women over age 50, putting her at risk for stress fractures and possibly hampering her ability to run well into adulthood. Many of her high school teammates had it worse: One would learn she had severely low bone density after developing three stress reactions in her hips, while another tore both of her labrums, the thick cartilage that acts as a bumper around the hip socket. Ultimately, both girls were so debilitated they had no choice but to quit their collegiate teams. Stinger’s best friend from Great Oak suffered similar problems, racking up a stress fracture in each of her femurs in high school. Burned out, she left her college team after just one season.

The likely culprit, Stinger’s WSU team doctors told her, was all the heavy training she and her friends did at Great Oak in their early teens.

Competitive runners often struggle to walk the line between training and overtraining, between fueling and the belief that extra pounds doom performance. Stakes are highest for runners in their early teens. At that age, athletes are rapidly building bone density, a process that requires a slew of hormones. Girls who pound out 40- or 60- or 80-mile weeks and don’t eat sufficiently can end up deprived of necessary hormones, sometimes to the point where they stop menstruating. According to one 2011 study, for every year menstruation is delayed, the risk of bone stress injuries increases by 34 percent.

Stinger says that at Great Oak, when some girls missed their periods, “We all thought it was normal.”

Through interviews with researchers, parents of athletes, a dozen running coaches, and nearly two dozen young women who participated in top high school running programs in the United States, we unraveled a youth running culture for girls that pushes the most promising young athletes into intense, year-round training that may batter their bodies with effects that last far beyond high school. Those who emerged from the sport without succumbing to restrictive eating patterns or repeated injuries would often describe themselves as “lucky,” as if mystified at how they threaded the needle just so.

Competitive running boomed in the U.S. in the 1970s and ’80s. As track and cross country grew in popularity, high school track programs became increasingly competitive, pushing high mileage and rigorous training. Coaches occasionally plucked speedy grade schoolers to race at the high school level. (In 1993, a fifth grader in Kentucky won the state’s 3-A Division cross country championship.)

In the early ’90s, researchers followed 60,000 high school athletes in 18 different sports—including football, wrestling, and soccer—and found that athletes in girls’ cross country had the highest injury rate of any sport. More recent research builds on these findings, showing that female cross country runners have the highest rate of bone injury of any U.S. high school athlete. (Male cross country athletes are third.)

Currently, around 1.2 million high school boys and girls compete in track and field and 500,000 in cross country (likely with overlap). The competition has only grown fiercer. Most of the high school girls’ distance records have been set in just the last decade. The number of high school boys who have broken the four-minute mile barrier has more than doubled in the last decade. New powerhouse teams keep popping up: Newbury Park in Thousand Oaks, California, achieved the unheard of when, in 2021, it crossed the boys’ state cross country championship finish line 1, 2, 3, 4. Its top runner in the 2021–22 season set three national high school records.

“It’s hard not to celebrate it,” says Emily Kraus, M.D., a sports medicine physician and researcher at Stanford University, as well as a runner. She’s also witnessing the downsides in her clinic.

Kraus says that over the past few years, she’s seen more and more young runners get injured and struggle under the intense pressure to perform. She’s noticed athletes commit to running year-round at an early age, presumably with the blessing of their parents. (A coach of a postcollegiate elite team in Minnesota says he has had parents of 9-year-olds ask to join.) Kraus is concerned that many of her patients are too restrictive in how much and what they eat. It stems from an old, misguided practice in which distance runners believe lighter is faster, only to put themselves at risk for anemia, relative energy deficiency in sport (RED-S), and a range of musculoskeletal injuries including suboptimal bone health prone to stress fracture. “These habits do have long-term consequences,” Kraus says.

In 2018, some of Kraus’s colleagues began organizing what they hoped might serve as a wake-up call for the sport. Adam Tenforde, M.D., director of running medicine at the Harvard-affiliated Spaulding National Running Center, along with two other doctors who specialize in youth running, believed that not enough was known about safe training levels for preteens and teens, whose bones are lengthening and whose muscles and tendons are conforming to a new body. They felt that youth running culture had become hypercompetitive, stocked with club teams and professional coaches for hire; some middle schoolers were training like high schoolers and many high schoolers were training like collegiate athletes or professionals.

Over several months, the trio recruited nearly 20 other researchers and doctors, including Kraus, to review and distill 1,602 scientific studies and articles into a youth running consensus statement published in the British Journal of Sports Medicine in the fall of 2020. It’s an imperfect document, and some findings seem obvious: The more hours that 9- to 15-year-old girls spend running, the greater their risk of bone injury. There was no clear answer as to exactly when and how much young athletes should train.

But the statement ends with a call for “essential tasks,” including further research on the diets of youth runners and the potential long-term risks of starting competitive running in middle school or younger, as well as better screening for runners who may be prone to injury, whether due to poor mechanics, undereating, or strenuous regimens.

Just as the sports medicine community galvanized attention around concussions in football 20 years ago, the hope was that the published consensus statement might spur similar concerns about the well-being of young runners. “From an education standpoint, you can see the shift on what happened with concussions,” Tenforde says. “There could be a tidal wave of change if enough people get upset and outraged.”

Nearly every region in the U.S. has its legendary coaches with dazzling accomplishments driven by a mysterious alchemy. Doug Soles was one of them. He won. A lot. Over his 17 years at the helm of Great Oak, his teams claimed 14 state cross country titles, six national podium finishes, and one national title. “I love what I learned from running under Soles,” one of his former runners says. “It was intense. It was hard, but it taught me self-discipline. It taught me dedication. It taught me how to work as a team. It taught me a ton of great things that I still use every day.”

“Our coach had our full and undivided trust,” Desiree Stinger, a former Great Oak runner, says. As her times improved, so did her trust in him. “Whatever he said, we did.”

Just west of Chicago, the late Joe Newton of York High School earned icon status—solidified by a 2008 documentary—for his 60 years of consistently producing strong male runners, some of whom logged 80-mile weeks. Outside of Syracuse, New York, there’s Bill Aris, longtime coach of Fayetteville-Manlius, whose “gender-blind” program preached a “Stotan” philosophy—a mix of stoicism and Spartan toughness. “Pain is the purifier,” Aris would repeat to his athletes. His methods have brought the Stotans to the national championship every year since at least 2006.

Aris, the subject of the 2019 book Amazing Racers, created a program that entailed two-hour runs and recovery runs at a pace of, as one runner put it, “if you could talk, you weren’t going fast enough.” Mackenzie Carter, a Fayetteville-Manlius alum, would often get anxious in workouts and fall behind. Now, at 30, she knows she was having panic attacks, but she recalls that her coaches did not take her condition seriously.

At Great Oak, Stinger and several other runners recalled that Soles required his athletes to wear GPS watches during practice; any runner who showed up without a watch wouldn’t be allowed to train with varsity, according to an early season handout. (Coaches could also use GPS data to tell athletes to slow down their runs, Soles said in a message responding to our questions, in which he requested that his answers remain off the record.) “No more my mom doesn’t want me to run for 3 days,” another one of his expectation sheets read. If they felt pains, Soles insisted that they talk to coaches first before a doctor.

Some girls on the Fayetteville-Manlius team would commit to highly regulated meals, like peanut butter and jelly sandwiches or salmon, sweet potatoes, and leafy green vegetables. No desserts. Come Thanksgiving, with the regional meet in two days, many runners heeded Aris’s advice to swap a large turkey dinner for pasta and vegetables. (Aris called this a “total misrepresentation” of his guidance, which “encouraged, not demanded… nutrient-filled eating.”) In Amazing Racers, a runner’s decision to avoid a big holiday meal two days before an important regional meet comes down to tryptophan, the amino acid that causes fatigue. “I use this old analogy: You guys are not Volkswagens. You’re Ferraris or Porsches. You need to put plenty of high-octane fuel in,” he says.

Soles offered similar guidance at Great Oak; many runners recall a seven-week plan leading up to the state meet that encouraged cutting back on bread and sugar. Nothing was enforced, and Soles and Aris say that some runners would devise their own strict diet plans. But as one runner put it, they restricted their eating to signal a commitment to the team’s goals.

Aris is aware that some college coaches won’t recruit his runners because they believe the athletes have already peaked. (It’s not uncommon for college coaches to research training load and injuries in high school to weigh a potential recruit’s future success.) But he also believes that his success unfairly made him a target. “One of the common accusations of our program, in me personally, is that I run kids into the ground to where there’s nothing left for them when they go to college,” he says. He calls that idea “ridiculous.”

“The kids I have coached are not overtrained nor run into the ground as has been insinuated,” he wrote in an email. “Many factors affect kids when they leave home (and our program) to go to college.”

Bill Aris, longtime coach of Fayetteville-Manlius outside Syracuse, New York, preached a “Stotan” philosophy—a mix of stoicism and Spartan toughness. His methods have brought the Stotans to the national championship every year since at least 2006.

Aris also believes that parental pressure, not coaching, is more often the source of unhealthy behaviors. While that may be true in some cases, several runners say that as young athletes, they believed success required complete obedience to their coaches. They also felt uncomfortable rejecting guidelines that they believed would lead to a coveted college scholarship. “I felt so stuck,” Carter says. “The idea hardly crossed my mind that I would be able to go to school for something other than running.”

In high school sports, there’s little outside oversight; it’s wholly unlike the NCAA, which requires compliance officers on campuses to enforce rules such as limited practice hours, or professional sports leagues that engage with player unions to hammer out guidelines that protect athletes. Most schools don’t have the money to hire nutritionists or team doctors. Coaches aren’t required to report injuries to any central governing body, team trainer, or athletic director.

Chris Lundstrom, a volunteer assistant high school coach and the head coach of an elite postcollegiate team, says the gap between science and coaching is troubling. “There’s this whole academic side, and that information is not generally consumed by coaches. It’s just not.”

Coaches learn their trade from many sources, but often from one another. Runners from Great Oak recall Soles scouring the internet for tips, while Aris researched notable coaches from the 1900s such as Arthur Lydiard and Franz Stampfl, as well as Percy Cerutty, an Australian coach from the 1950s and ’60s.

​​Lundstrom is concerned about what he calls “professionalized high school programs,” that produce “short-term results, sometimes at the expense of an athlete’s long-term health.” Tenforde says it’s hard to gauge how “early youth specialization” is impacting runners over the long term. Studies are hard to do; there’s not a lot of funding, and getting buy-in from coaches, parents, and athletes can be challenging. (Tenforde is among a group of researchers with the American Medical Society for Sports Medicine that plans to further study early youth sports specialization.)

As an elite coach, Lundstrom wants runners to peak in their 20s and 30s. High school coaches operate on a much more compact timeline. Athletes come and go in four years’ time, and coaches set the tone for how that time is spent.

Soles had a feverish desire to produce nationally ranked teams. In a 2018 coaching clinic, he framed coaching this way: Either you develop “wonderful human beings, life is great and whatever the results are we’ll live with it,” or you coach to win. “I want to win at the end of the day,” he said. “And we’re going to come up with a process that makes sure we do it whatever the work is.” (Soles, who resigned from Great Oak in 2021, did not agree to an interview for this story but sent a lengthy statement in response to our inquiries. He felt the subject matter would only make parents of runners scared and coaching more difficult, and he suggested that other high school sports are much more rigorous. He is now the head coach of Herriman High School in Utah.)

One parent, who did not want to be named, credits Soles with his daughter’s strong work ethic and confidence—traits she has carried into adulthood. Indeed, Aris said that his goal was to set up his athletes well for life. But there’s no standardized training for high school coaches. Elizabeth Carey, an assistant track and cross country coach in Washington state, believes that so much autonomy can be precarious. “There is such a thin line between disorder and things we praise,” she says. “Do you have a really strong work ethic or are you compulsive?”

When high school girls read online running forums, they see posts like these: “When women go hardcore about diet, they run fast” or “The most successful runners in college will be the girls with the best stride who weigh the least.” Runners also regularly encounter more subtle suggestions about their weight. A few runners recalled Soles repeating that once-speedy high school girls would often go to college and find boys, gain weight, and slow down.

During his 2018 presentation at the Boulder Running Clinic, an annual gathering of top-tier high school running coaches, Soles advised his colleagues to ignore those who frown at high mileage. “At the end of the day, guys, we run. We’re coaching runners. Don’t be afraid to get out there and get some mileage in.” He also praised his “fit” runners, reassuring the crowd that his runners weren’t skinny, but strong. “I’m always talking with the kids about burning calories, making sure that they are using up the extra stuff,” he said. “You get those girls who come in, and maybe they’re five or six pounds heavy. I’m never going to ask them to not eat. We eat a ton. But I’m going to do everything I can to make sure that we get rid of that excess weight through training.”

(“Cherry-picking quotes from videos and trying to apply them to a story like it was something said for the story is wholly incorrect,” Soles told us. “I’ve always said I want to win, but never at the expense of an athlete’s health.” Soles said he always kept protein bars, protein shakes, and Gatorade in his classroom for runners to snack on, and two of his former runners say they remember him as someone who was always trying to be the best coach he could be.)

A couple of years ago, Carey found a newspaper article from her high school running days in which she linked her success with not eating “bad” foods all season. “I probably wasn’t eating enough. That’s why I got stress fractures,” she says. “That language is so ingrained and intertwined with our sport that it’s very difficult for some folks to understand how that can be disordered.”

According to the National Eating Disorders Association, around 42 percent of high school athletes who compete in sports that place value on leanness—such as gymnastics, figure skating, or bodybuilding—reported developing restrictive or compulsive eating habits. Recent research at the collegiate level has shown that female distance runners are also at risk for disordered eating. Studies at the high school level are limited due to the need for parental consent, but a 2013 study of adolescent runners by Tenforde indicates that the risk of developing a stress fracture among female runners with an eating disorder is five times greater than that of runners without one. One coach we interviewed says they avoid talking about eating altogether out of fear that even a well-intentioned suggestion toward healthy meals can tip into restrictive eating.

“When you’re in high school and you’re a high school girl, you’re literally at your most vulnerable,” says Nicole Rice, a former Great Oak runner who’s now 23. “I measured how I felt about myself with how proud [Soles] was of me.”