The SARS-CoV-2 virus has caused long-term health problems in those who recover from COVID-19, including pulmonary embolism, myocarditis, acute coronary events, and lung scarring.1 While successive SARS-COV-2 variants have demonstrated increased transmissibility, there is no evidence to date that the variants have become more virulent. The severity of the latest COVID-19 infections has been attenuated by widespread prior infection and vaccination.2
For athletes who have contracted COVID-19, there is a need for more research on the appropriate timing of resumption of physical activity. Two clinical vignettes are presented to explore this issue.
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Case 1
A 27-year-old college basketball player was diagnosed with mild symptoms of COVID-19 in June of 2022, including fever and cough, and recovered after resting and isolating for 7 days. The patient is healthy, with no previous medical history or surgeries, and does not take medications other than over-the-counter multivitamins. The patient confirmed receiving the COVID-19 vaccine along with one booster shot. The patient stated this was his first time testing positive for COVID-19. After testing negative for COVID-19, the patient was medically assessed to evaluate if he is able to return to physical activity. A scan of the patient’s lungs showed mild lung damage and the patient is being monitored. The patient is advised to start with light activity and slowly progress, increasing the intensity and duration of his workouts.
Case 2
A 32-year-old professional runner tested positive for COVID-19 in March of 2021 and experienced severe symptoms, including shortness of breath, chest pain, and fever. She was hospitalized for 7 days. The patient has no previous medical history or history of surgeries, and takes multivitamins, vitamin B12, and loratadine, as needed, for allergies. The patient denied receiving the COVID-19 vaccine. The patient stated this was her first time testing positive for COVID-19. After testing negative for COVID-19, she was re-evaluated and additional scans were obtained. The scans show myocarditis and the patient is advised to rest for 3 months. After resting, the patient is reassessed for myocarditis before returning to physical activity. The patient is able to go back to training but her progress is slow; the patient requires rehabilitation and additional monitoring.
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Athletes who partake in exercise during the acute phase of viral myocarditis have increased risk of developing myocardial injury and triggering fatal ventricular arrhythmias.
Return to Physical Activity After COVID-19
When to return to competitive physical activity after COVID-19 is a difficult question to answer as each case is unique. The medical literature has published a number of case reports early in the pandemic that try to address this question. Santos-Silva et al considered the case of a soccer player who developed a pulmonary embolism after being infected with COVID-19.3 The soccer player had a computed tomography (CT) of the chest while he was ill, which did not show a pulmonary embolism. After quarantining for 14 days, the player resumed physical activity. On day 10 of training, he started complaining of shortness of breath and weakness. A computed tomography angiogram (CTA) showed the athlete had a pulmonary embolism. This study showed that although the player did not have any history of medical problems when he was ill with COVID-19, the virus can have residual effects. Caution and reassessment are advised before releasing athletes back to training.3
Metzl et al discussed considerations regarding the length of time athletes should be monitored prior to resuming training. Every COVID-19 case is unique and should be treated individually, based on the athlete’s symptoms and the time it takes them to recover. The authors recommended that the athlete’s activity should progress slowly and that exercise should be withheld if the athlete is still experiencing cough, chest pain, palpitations, fever, or shortness of breath at rest.4
All athletes should be monitored closely during the first 3 to 6 months of activity post COVID-19 infection, and athletes should be educated on notifying physicians of any new symptoms such as chest pain, shortness of breath, or palpitations. Athletes with prior cardiovascular or pulmonary disease should follow up with a physician prior to resuming physical activity. Assessments should include physical examination, testing of lung and cardiac function, and blood work such as cardiac enzymes, blood gases, clotting factors, and complete blood count. These tests are important in monitoring the athletes to ensure that they can safely return to physical activity.
Slowly Initiate Physical Activity
Athletes who were diagnosed with COVID-19 should not initiate physical activity until they no longer experience viral symptoms and should slowly ease back into physical activity. This means that they should not resume their pre-COVID-19 training regimen immediately. Metzl et al4 recommend educating patients on slowly initiating activity by using the 50/30/20/10 rule created by the National Strength and Conditioning Association (NSCA) and Collegiate Strength and Condition Coaches Association (CSCCA) Joint Committee (Table).5 This rule advises that volume of conditioning for the first week should be reduced by at least 50% of the normal exercise load, followed by 30%, 20%, and 10% in the subsequent 3 weeks, if the athlete is comfortable at the end of each week.
The application of this guideline is dependent on the severity of symptoms. Athletes who experienced mild COVID-19 symptoms can use this rule over a 4-week period. Those who experienced more severe symptoms should use this rule over 3 to 6 months, depending on the rehabilitation improvement of the patient. As always, athletes should be educated to monitor themselves for any signs of shortness of breath, chest pain, or fatigue. Patients who are diagnosed with myocarditis should return to exercise with caution, as myocarditis accounts for 7% to 20% of sudden cardiac deaths in young athletes.6
Persistent Symptoms
A study by Petek et al assessed the prevalence of persistent or exertional cardiopulmonary symptoms in competitive athletes following COVID-19 infection.7 The study included 3598 athletes, of whom 1.2% reported persistent symptoms after 3 weeks of infection, and 0.06% reported symptoms lasting longer than 12 weeks. Exertional cardiopulmonary symptoms were present in 4.0% of athletes. Athletes who had chest pain when returning to physical activity underwent a cardiac magnetic resonance imaging (cMRI), where 5 out of 24 athletes (20.8%) had cardiac involvement.7 Athletes who partook in exercise during the acute phase of viral myocarditis had increased risk of developing myocardial injury and triggering fatal ventricular arrhythmias.8
A screening protocol for potential cardiac involvement in competitive athletes recovering from COVID-19 was outlined by Phelan et al in October 2020, during the height of the pandemic and before vaccines were made available.9 In their paper they acknowledge that screening recommendations will continue to evolve. “The evaluation of athletes with persistent symptoms after recovery from acute COVID-19 will be guided by the nature of the symptoms, whereas the evaluation of the asymptomatic athlete will be oriented around screening for subclinical pathology,” they wrote.
Phelan et al recommend a 12-lead electrocardiogram (ECG) for all athletes prior to initiating a training routine. This test will pick up abnormal ventricular beats and arrhythmias. After COVID-19, the authors recommend a high-sensitivity troponin (hs-cTn) test to detect subclinical myocardial injury in athletes.9 If an athlete has a normal ECG and hs-cTn they can be allowed a graded return to play. For patients with positive tests or ongoing clinical concerns, a cMRI is recommended. As noted, cMRI will pick up myocarditis and pericarditis, including pericardial effusion. After cMRI, secondary imaging is directed by clinical suspicion and includes computed tomography (CT) angiography, stress ECG/cardiopulmonary exercise testing (PET), and nuclear PET.9
Conclusion
The prevalence of cardiac problems in athletes related to COVID-19 is difficult to establish due to very limited data. Athletes preparing to return to strenuous exercise after a diagnosis of COVID-19 present a challenge for clinicians caring for these patients. Athletes who contract COVID-19 should not return to physical activity until they have fully recovered from the virus and have undergone a medical evaluation and are approved to return to physical exercise.
There have been reports of pulmonary embolism and myocarditis among athletes recovering from COVID-19 diagnosed via cMRI.2,7-9 Clinicians should treat these athletes individually and screen them based on their symptoms. With proper care and attention, athletes can safely return to physical activity after recovering from COVID-19 and continue to pursue their athletic goals.
