The return of organized sports earlier this year has brought much excitement throughout the community. As schools and sports organization re-establish their seasons, they must also manage the COVID-19 restrictions and guidelines set forth by the Center for Disease Control (CDC) and Illinois Department of Public Health (IDPH). One frequent question being asked is how an athlete can return to sport following a COVID-19 infection.
Athletes, who tend to be younger with no comorbidities, are less likely to develop moderate to severe symptoms from COVID-19 and may instead be asymptomatic or experience a mild illness. However, the long-term effects of this virus are unclear, and it is known this virus can lead to damage of the heart, brain, lungs and kidneys. Some people might experience lingering symptoms, including shortness of breath, muscle aches, loss of stamina and exhaustion, all bad news for athletes. In addition, there is concern for increased risk of complications after return to sports in athletes who have had COVID-19, including the development of inflammation of the heart muscle (myocarditis) or heart (myocardial) damage. Unfortunately, at this point there is no way of identifying which patients will develop these long-term effects and complication.
Therefore, the decision to return to sport in athletes after a COVID-19 infection must follow a logical and careful approach. This method parallels my approach to concussions, which I created about 5-10 years ago when the rate of concussions and time away from sport in high school athletes increased dramatically. By developing a program that focused on consistency in its guidelines and open communication between athletes, parents, athletic trainers and medical personnel, the time away from sport was minimized and the overall program succeeded. I am hopeful for the same results with these COVID-19 Return to Sport guidelines.
COVID-19 Infection
An athlete can be diagnosed with COVID-19 infection with either a positive COVID-19 test or having symptoms consistent with COVID-19. These symptoms include shortness of breath, dry cough, fever, GI symptoms such as diarrhea and nausea, and loss of taste or smell. The CDC has recommended that anyone with these symptoms be tested to determine if these symptoms are the result of a COVID-19 infection or a different viral or bacterial infection. A negative test would prevent these athletes from being quarantined and requiring a longer time out of sport, whereas an individual with symptoms who is not tested is assumed to be positive and would have to follow the normal COVID-19 protocols.
Severity of COVID-19 Infection
Most young athletes that contract COVID-19 are asymptomatic or have very mild symptoms such as fevers > 100.4° F and a short duration of muscle aches, chills and lethargy. More moderate disease display these symptoms for more than four days, and can result in a non-ICU hospital stay. Luckily, only 2.5 per 100,000 patients with COVID-19 aged 18 to 49 years in the United States required hospitalization. However, those with severe disease progressed rapidly, establishing the importance of close monitoring. People with the most severe COVID-19 disease have severe shortness of breath, require oxygen and often times require intubation and an ICU stay.
Evaluation of Post-COVID-19 Athletes
The assessment for return to sport should occur no earlier than 10 days after the initial diagnosis, while also being symptom free for seven days without treatment including fever-reducing medication. For athletes with moderate to severe symptoms, the American Academy of Pediatrics (AAP) and the American College of Cardiology (ACC) have recommended an electrocardiogram (ECG) and evaluation by a cardiologist prior to returning to sports.
Fortunately, most athletes will be either asymptomatic or present with mild symptoms that do not require as rigorous of a medical evaluation. These athletes should be evaluated with a 14-point preparticipation screening emphasizing heart symptoms including chest pain, shortness of breath, lightheadedness and palpitations. Any abnormalities found during this screening procedure should be referred to their primary care provider or a cardiologist for an ECG and cardiac evaluation. Athletes that complete the screening process without any findings can advance to the return to play guidelines after the 10 days have passed since the initial diagnosis, as well as no symptoms for the past 7 days while off all fever-reducing medications.
14-Point American Heart Association (AHA)
Preparticipation Screening
Personal History
- Exertional chest pain/discomfort
- Unexplained syncope or near-syncope
- Excessive exertional and unexplained fatigue/fatigue associated with exercise
- Prior recognition of a heart murmur
- Elevated systemic blood pressure
- Prior restriction from participation in sports
- Prior testing for the heart, ordered by a physician
Family History
- Premature death-sudden and unexpected before age 50 yo. due to heart disease, in one or more relatives
- Disability from heart disease in a close relative < 50 yo.
- Specific knowledge of a certain cardiac condition in family members: hypertrophic or dilated cardiomyopathy, long-QT syndrome or other ion channelopathies, Marfan syndrome, or clinically important arrhythmias
Physical Examination
- Heart Murmur-exam supine and standing or with valsalva, specifically to identify murmurs or dynamic left ventricular outflow tract obstruction
- Femoral pulses to exclude aortic stenosis
- Physical stigmata of Marfan syndrome
- Brachial artery blood pressure (sitting, preferably taken in both arms)
Graduated Return to Play Protocol
Athletes that enter into the return to play protocol after medical clearance will experience a gradual increase in the duration and intensity of exercise. This program should be completed under the supervision of an athletic trainer or other medical personnel. If any symptoms return during this protocol, the athlete should stop activity to be reevaluated by a health professional.
Stage 1: Light Activity
- 2 days minimum
- Walking, light jogging, stationary cycle
- <15 minutes duration at light intensity
- No resistance training
Stage 2: Frequency of Training Increases
- 1 day minimum
- Simple movement activities (running)
- <30 minutes duration at moderate intensity
- No resistance training
Stage 3: Duration of Training Increases
- 1 day minimum
- Progress to more complex training activities
- <45 minutes duration at moderate intensity
- May add light resistance training
Stage 4: Intensity of Training Increases
- 2 days minimum
- Normal training activity
- <60 minutes duration at moderate progressing to high intensity
- <60 minutes duration at moderate progressing to high intensity
Stage 5: Return to full activity
To many athletes, parents and coaches, this program may seem excessive for symptoms commonly seen with the common cold or flu, in which athletes are able to bounce back quickly and return to sport in no time. However, the long-terms effects of a COVID-19 infection are not fully understood yet. Eventually, as we learn more about COVID-19, we will likely be able to ease up on these guidelines. Until that time happens, every precaution should be taken to insure a healthy return to sport in the short and long-term.
References
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Kim JH et al. Coronavirus Disease 2019 and the Athletic Heart. Emerging Perspectives on Pathology, Risks, and Return to Play. JAMA Cardiol 2021; 6(2): 219-227.
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Phelan D e tal. A Game Plan for the Resumption of Sport and Exercise after Coronavirus Disease 2019 (COVID-19) Infection. JAMA Cardiol 2020: 5(10): 1085-1086.
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“Return to Play Procedures after COVID-19 Infection.” Illinois High School Association. Return to Play Procedures After COVID19.pdf (ihsa.org)
