This sports season, of course, will be like no other. Athletes have had workouts and practices disrupted for months, and now they return to new rules for social distancing, sanitization and medical testing. Some athletes who’ve had COVID-19 have understandable concerns about its lasting effects on their health and performance.
We talked with three specialists – a sports cardiologist, a neurologist and a sports medicine doctor – to get advice for athletes of all levels as they return to play. We also ask about lasting effects of COVID-19, and how those may affect athletes who have had the virus. (Related story: New Guidelines Issued for Athletes Who Had Coronavirus)
Dermot Phelan, MD, PhD, FASE, FACC
Director of Sports Cardiology at Atrium Health Sanger Heart & Vascular Institute
As athletes return to play during a pandemic, what are your recommendations?
Athletes who’ve had COVID-19 and have been symptomatic may be at risk of developing a complication of the heart muscle called myocarditis, so they need to be evaluated from a cardiology perspective. Myocarditis is a condition where the virus infiltrates the heart muscle causing inflammation and potentially scarring of the muscle. If you exercise with myocarditis, it makes the disease worse and increases your risk of sudden death, so it’s important to define whether the athlete has that.
For those athletes who have not had COVID-19, the concern is figuring out how we can limit their risk of infection. It comes down to optimizing testing and making sure that athletes are kept in “bubbles” where they're not exposed to those with the infection.
What advice do you give athletes about protecting themselves from COVID-19 exposure?
For some sports, like golf or tennis, where there's no bodily collision, safeguards may be pretty easy to institute like physical distancing, hand sanitization and mask wearing. They should also perform daily self-health checks. Tennis and other sports should be played outdoors where possible.
For sports where there is bodily collision – football and basketball, for example – that becomes a much more difficult puzzle to solve. There is really no way two linemen can go up against each other and ensure that they're not going to infect each other, unless they're actually tested. I think they only way to be safe is frequent and repeated testing to ensure that people do not have the disease and controlling their social bubble when they are not playing. This involves commitment from the athletes themselves and campus policies that recognize the risk.
For athletes who have had COVID-19 with symptoms, what do you want them to know before they return to sports?
Many physicians feel that if people have not had severe COVID requiring hospitalization, the likelihood of a severe long-term effect is low. But we are still learning about this disease, and we don't know that for sure. What we do know is that we have never dealt with a virus this dangerous before. To be cautious, we recommend that athletes who have had COVID-19 and experienced symptoms should be evaluated by their local doctor, team doctor and potentially a cardiologist to get testing to evaluate the heart. Those tests would include a blood test, electrocardiogram and echocardiogram.
After an athlete with COVID-19 becomes asymptomatic and they've been cleared from a cardiac perspective, then athletes should return to play with a graded increase in exercise intensity over a couple of days.
Sudden cardiac arrest is among the leading causes of death in young athletes. What should athletes and coaches and families do to decrease that risk?
Before COVID-19, sudden cardiac death was the leading cause of death in young athletes. This is usually caused by underlying cardiac conditions that the athlete was born with. It’s important that they speak with their team doctor or trainer about any family history of cardiac disease or any symptoms that they're concerned about. However, even before COVID-19, myocarditis was a leading cause of death in young athletes. In the year of COVID, it’s become a major concern. COVID seems to cause more heart damage than any virus we've had experience with.
You co-authored guidance in JAMA Cardiology for athletes returning to sport and exercise after having COVID-19. What was the importance of that publication?
There was no standard of care for athletes who have been infected with COVID-19, and athletes, coaches and sporting bodies were seeking guidance from sports cardiologists like myself and the American College of Cardiology (ACC) Sports and Exercise Council. Recognizing the lack of data we had – and still have – but taking from our experience and extrapolating what we know about other viral infections and the heart, we established these recommendations for how to address the question of return to play in athletes who have experienced COVID-19. These guidelines are primarily directed towards competitive athletes and really are a conservative guideline as we continue to gather data.
Jeffrey Bodle, MD
Atrium Health Neurosciences Institute - Neurology, Cabarrus
As athletes return to play, what should they keep in mind about concussions? What are some of the most serious lasting effects of concussions?
The most serious lasting effects are headaches, cognitive issues, memory problems, mood instability, insomnia and poor energy.
How do you encourage athletes to prevent concussions?
By avoiding head injuries, which is challenging in sports like football. In football, there's been a lot of education about proper ways to tackle, and there have been a lot of rule changes to avoid leading with the head to minimize head injuries.
It’s also important to remember that it only takes a hard hit to the body to shake the head. The mechanism of a concussion is the brain moving around inside the skull, and we see people develop post-concussive syndrome and symptoms after just having a hard blow to the body without even striking their head. Along those same lines, females develop differently and there's not quite the same level of musculature in females as there is in most males. For that reason, we see more concussions in sports like women’s soccer that have lots of body blows.
What other types of brain injuries should athletes be aware of as they return to playing sports?
They should be aware of mild traumatic brain injuries or even sub-concussive impacts. Even when the head is hit lightly, the brain still shakes inside the skull and you can see post-concussive symptoms. We see that a lot in football linemen who are running into somebody for each play, and they’re not necessarily dramatic brain injuries. But those sub-concussive impacts can really add up and make the brain more vulnerable to experiencing worse effects with future concussions.
Also, people who've already had a head injury or concussion can have a lower threshold and experience more significant symptoms with another head impact.
Are athletes who have tested positive for COVID-19 at an increased risk of brain injury?
They may be. I've seen some patients who've had COVID-19, and they have had the same symptoms that people get after a head injury or concussion. It seems like the inflammatory response in COVID-19 and the effects it has on the brain can actually mimic a concussion.
People in that situation should be as safe as possible. Those who have had head injuries or have had post-concussive symptoms after COVID-19 should really, really consider whether they want to put themselves in a situation where they can have another head injury. Maybe they consider more non-contact sports. They should definitely meet with a doctor before they decide to play.
Co-Chief, Primary Care Sports Medicine at Atrium Health Musculoskeletal Institute
What type of evaluations do you recommended before allowing athletes to return to play?
For athletes at the high school and middle school level who had a valid physical during the last academic year, they’ve been given a one-year extension by the High School Athletic Association due to difficulties of COVID-19. However, an annual check-in with their health care provider is still recommended. If the athlete has tested positive for COVID-19 at any time, they absolutely have to be cleared by their physician before returning to sport. Evidence shows that there are issues, both cardiac and pulmonary, that can occur in individuals who were positive for COVID-19.
For younger kids playing recreational sports, they just need their normal annual evaluation with their health care provider. For adults returning to recreational sports, they should be able to proceed, unless they’ve tested positive for COVID-19 – then they really need to be seen by a physician before going back to strenuous exercise.
What changes do you foresee to enforce social distancing among athletes?
The challenge is how to minimize the exposure of risk for athletes, given the demands of the sport. Organizations are trying to create the appropriate rules to allow athletes to return to activity in a safe fashion. You'll see that professional sports have created bubbles that allow them to restrict outside exposures. We need to apply the same mentality to high school sports, so once the team is together, then they should try to minimize experiences outside of that bubble.
Our challenge will be when individuals are exposed to COVID and bring the virus into that bubble. That’s when we'll see restrictions on sports, or even the shutting down of certain teams or potentially schools.
Given the prolonged training restrictions due to COVID-19, do you predict an uptick in sports-related injuries? And if so, which injuries do you anticipate being the most common?
As is true with the beginning of any season, those athletes who have not continued with training are more susceptible to overuse injuries. Those would create injuries such as tendonitis, particularly around the knees, or – for the overhead athlete – more shoulder-related problems. This year, we might see more of these because of the extended period of inactivity that occurred due to the shutdown of the schools and sports programs through the spring.
What are some sideline recommendations for coaches and athletes to maintain the health of teammates, during and after practice?
When possible, wear a mask. For sports personnel – coaches, athletic trainers, team physicians and so on – masks are recommended in most situations. Most people say that athletes don’t need a mask during exertional activities, but If they choose to do so, they should be allowed to do so. But If athletes are gathered in a team meeting or if they’re sitting in the dugout, wearing a mask could potentially decrease the spread.
If you're using training equipment, sanitize those surfaces between uses. Don’t share water bottles. If there’s a need for refilling water, then have one designated person in charge of filling those containers for all the athletes to minimize the contact between multiple athletes on those surfaces.
What should athletes keep in mind as they return to a “new normal” of sports this fall?
It’s never been more important to be a team player. If you feel ill, you need to stay away from practice. The potential of bringing COVID-19 to your team could mean that your entire team gets shut down. Remembering the bigger picture is going to be very important as we return to sports.
See the latest COVID-19 information and learn where to find care.
Learn more about heart care at Sanger Heart & Vascular Institute or call 704-512-2785 to schedule an appointment. For sports medicine information, please visit Sports Medicine & Injury Care. For information on neurology care, please visit Atrium Health’s Neurosciences Institute.
