Return to Sports after a COVID-19 Diagnosis

New COVID-19 diagnoses continue to rise at an alarming rate. As more and more athletes are resuming competitive sports, there will be a proportional increase in those sidelined due to a COVID-19 diagnosis. Additionally, athletes may miss time because their team/sport is shut down for an extended period due to contact tracing or other COVID-related protocols. A period of inactivity of at least 10 days in a competitive athlete can have a big impact. The physical and mental/emotional effects should not be overlooked. Possible direct health impacts of COVID-19 on the athlete include:

  • Myocarditis (i.e., inflammation of the heart muscles) is the most severe, but fortunately the least common of the effects. It can occur in athletes and non-athletes during or after COVID-19 and other viral illnesses. Because exercise puts a lot of strain on the heart, those who are exercising with myocarditis can suffer from life threatening arrhythmias (i.e., abnormal heart rhythms), shock (i.e., sudden drop in blood pressure), or sudden death.
  • Deconditioning due to a prolonged absence can result in feelings of fatigue, decreased endurance, decreased strength, and decreased flexibility. With deconditioned the body is more susceptible to soft tissue injuries if return to play happens too quickly.
  • Soft tissue injuries include:
    • Muscle strains: most commonly hamstring, groin and quads.
    • Ligament injuries (strains or tears):  most commonly knee (ACL) in those who are changing directions, jumping/landing, or playing contact sports; and elbow (Ulnar Collateral Ligament) in throwing sports.
  • Mental health and mood can be affected if playing time or performance is decreased due to time missed and/or deconditioning. Sedentary athletes also do not get the mood-boosting benefit of endorphins that are released when they exercise.

With these considerations in mind experts in the fields of pediatrics, orthopedics and sports medicine have weighed in on appropriate return to play following a hiatus due to COVID-19 diagnosis or team/league shut-down. We address these in the following FAQs.

Does my adolescent need to be medically cleared to return to competitive sports following a COVID-19 diagnosis?

Yes, it is important for your adolescent’s health care provider to review the entire course of illness, assess severity (which sometimes worsens after they are seen at the office and tested), and perform a physical examination to screen for evidence of myocarditis or other complications.

What about pre-pubertal children?

For younger children with either no symptoms or mild symptoms (< 4 days of fever >100.4°F, muscle aches, chills, and/or lethargy), medical clearance is not necessary for leisure and recreational activities. However, the child should be symptom-free for 14 days prior to return to recreational sports. If moderate symptoms (4 or more days of the aforementioned) or hospitalization occur due to COVID-19, please call our office for further guidance.

When should I schedule the medical clearance visit?

Athletes should be symptom-free for 14 days prior to their scheduled medical clearance visit.

Is any testing required for return to play following COVID-19?

If the athlete had no or mild symptoms and has a non-concerning history and physical exam by a physician, further testing is not required.  If an athlete had moderate symptoms (e.g. more than 4 days of fever, muscle aches, chills or lethargy), or was hospitalized due to COVID-19, (s)he should be referred to cardiology for an EKG. Heart ultrasound (i.e. echocardiogram) and blood troponin level may be ordered at the cardiologist’s discretion.

Once my child is cleared, what are the return-to-play recommendations?

Stage 1: 15 min or less of light activity such as stationary bike, light jog or walking. < 70% max heart rate. NO resistance training (i.e., no weightlifting). Duration of at least 2 days.

Stage 2:  30 min or less of light activity + simple movement activities. < 80% of max heart rate. Duration of at least 1 day.

Stage 3:  45 min or less of stage 1 and 2 exercises with light resistance training. < 80% of max heart rate. Duration of at least 1 day.

Stage 4:  60 minutes. Normal training activities but still < 80% of max heart rate. Duration of at least 2 days.

Stage 5:  Full activity/participation

Progression through the 5 stages typically takes about a week and is best conducted under the direct supervision of a team doctor or athletic trainer. This process is similar to gaining clearance following a concussion.

If you have any further questions regarding your athlete and their return to play, please do not hesitate to contact us at (804) 282-4205, and follow the prompts to speak with a member of the clinical team.