We’ve come a long way since the start of the COVID-19 pandemic, and for that, we all deserve to celebrate. While experts believe that the coronavirus is here to stay, we now have a much better understanding of the virus, how to reduce its transmission, and how to best treat infected individuals. Vaccines are rolling out, cases are dropping, and restrictions are being eased in many parts of the country.
“For the first time since the pandemic began, I can sense that optimism is spreading faster than the virus.”
High school and college fall sports are one of the many things that were sacrificed last year, but it is now time to look forward to the return of spring sports. So, how do we do this safely for our athletes, coaches, and our communities?
COVID-19 implications for athletes
It is now well known that the risk of severe COVID-19 complications is higher in older individuals and those with underlying conditions, such as hypertension, diabetes or obesity. In general, athletes are young and in good physical health, making them less likely to belong to these high-risk groups. Unfortunately, many athletes have tested positive for COVID-19 after returning to sport (for example, MLB and NFL). And while they may be less likely to develop severe COVID-19 symptoms, the lack of understanding about the long-term impacts of even mild to moderate COVID-19 cases are a concern for athletes and the general population alike.
COVID-19 is not just a respiratory illness – it is a systemic disease that affects all organs. In athletes, the effect of COVID-19 on the heart is of particular concern. The virus can cause injury to the heart, either through direct infection or through the ‘cytokine storm’ that induces inflammation and damage to the muscle cells of the heart. This inflammation of the heart is known as myocarditis. In athletes infected with COVID-19, electrocardiograms (ECG) or cardiac magnetic resonance imaging (MRI) can be used by doctors to help identify cardiac injury.
Last year, one study found ongoing inflammation of the heart in 60% of recovered patients, regardless of preexisting conditions or severity of illness. This was alarming to sports medicine doctors, exercise cardiologists and coaches because myocarditis is one of the most common causes of sport-associated cardiac mortality in young athletes, providing further rationale for cancelling fall sports last year. However, more recent studies in college or elite players suggest it might not be as common in athletes as previously suggested, finding myocarditis in only 1.4% - 15% of the athletes studied.
Researchers are still working to understand the relationship between COVID-19 and myocarditis and to determine the most effective tools for monitoring and diagnosis. This is complicated because athletes can present with a range of non-specific symptoms such as fatigue, reduced performance, muscle soreness or increased resting heart rate. These symptoms can easily be attributed to training-related activities, presenting a major challenge in the testing and diagnosis of COVID-19 associated myocarditis.
As we transition back to pre-COVID sports seasons, a primary goal is to keep athletes safe while avoiding unnecessary restrictions from competition. The return to sport should therefore be discussed with a sports medicine doctor and relevant specialists (for example, a sports cardiologist or respiratory physician, if needed) on a case-by-case basis and should take into account factors such as pre-existing conditions, type of sport, and risk of infection from other athletes.
Current guidelines for return to play
Return to play guidelines have been provided based on recommendations by the American College of Cardiology, the American Medical Society for Sports Medicine, and the National Federation of High School Sports (NFHS). These guidelines seek to provide answers for sports medicine doctors, young athletes, parents and coaches to reduce the risk of COVID-19 associated myocarditis in athletes. Specifically, they recommend:
Return to play no sooner than 14 days after asymptomatic or mild COVID-19 infection.
Get an ECG in cases of moderate COVID-19. If the ECG is abnormal, the athlete should work with their sports medicine doctors, who may consult a specialized cardiologist to determine a safe return to sport plan.
For cases of severe COVID-19 with evidence of myocarditis, the athlete should not participate in any exercise for three to six months, and should consult with a specialized cardiologist to ensure safe return to play.
Luckily, the majority of athletes who experience mild COVID-19 infection do not develop significant cardiovascular symptoms following recovery. Given the lack of long-term data, ongoing monitoring and data collection will be critical for informing the decisions of sports medicine doctors and coaches and for keeping the recommendations up to date for athletes who have recovered from COVID-19.
Important considerations for return to sport
In addition to clinical recommendations for return to play, the NFHS provides guidelines for minimizing the risk of infection for athletes while resuming high school sports. First, community levels of COVID-19 should be considered before scheduling an event, as higher community levels would increase the risk for athletes, coaches and spectators. Other factors that should be considered before resuming spring sports include:
Physical contact of players - Close-contact sports such as wrestling and basketball increase the risk of transmission. Training could focus on improving individual skills rather than competition, or the number of other athletes an individual is exposed to could be limited by training in small groups. Physical distancing should be maintained whenever possible, including on the sidelines or in the dugout.
Environment – Outdoor sports are preferred. If training or competition must be indoors, ensure proper ventilation and air filtration systems and open windows to increase airflow.
Higher risk individuals – Athletes with underlying conditions such as asthma or diabetes should consult with their sports medicine doctor before resuming sport.
Local Pennsylvania guidelines:
Local guidelines have also been released for all sports resuming in Pennsylvania. These guidelines will be updated as more public health data becomes available.
Face masks are required for everyone involved in sports activities (unless eligible for an exemption). Coaches, athletes and spectators must wear face coverings indoors and when they are unable to maintain social distancing of at least 6 feet.
Pre-K to 12 School Sports: After a suspension of sports through January 2021, the Pennsylvania Interscholastic Athletic Association (PIAA) and Pennsylvania Independent Schools Athletic Association (PISAA) advise that sports may be resumed under the guidance of PED Preliminary Guidance for Phased Reopening of Pre-K to 12 Schools and the CDC Considerations for Youth Sports. These guidelines encourage a detailed risk assessment before scheduling events and promote behaviors to reduce the spread of the virus.
Collegiate sports: In-person sporting activities are allowed to resume in alignment with PA Department of Education guidance for resuming in-person activities. Use of the maximum occupancy calculator is required to guide occupancy limits (including athletes, coaches, media, cheerleaders, musicians, etc.), and everyone attending the event must wear face coverings.
Professional sports: Similar to collegiate sports, professional sporting leagues should use an occupancy calculator to guide indoor and outdoor occupancy limits. They must also comply with league or local health department guidelines.
The majority of sports-related COVID-19 infections do not occur during athletic practice, but from social contact off the field such as in the locker rooms, on the sidelines or while traveling.
As always, individuals should practice behaviors that reduce transmission, such as maintaining social distancing, washing your hands frequently, staying home if you have any symptoms, and remaining flexible with changing guidelines. With the help of athletes, coaches, spectators and the wider community, we can move towards a successful spring sports season this year.