A Summary Of Current Return To Play Guidelines After COVID-19 Infection

Reprinted from the Spring 2021 Issue of The Ohio Family Physician

By: Jessica C. Tomazic, MD, PGY-2, Family Medicine Residency Program, Cleveland Clinic Foundation, and Marie Schaefer, MD, Associate Staff Physician, Department of Orthopaedics, Division of Sports Medicine and Department of Family Medicine

Individuals often turn to family physicians to provide guidance not only on starting an exercise program, but also participation in exercise while managing illness or injury and subsequent recovery. With widespread reports of significant cardiovascular and pulmonary sequelae among COVID-19 positive individuals,¹ asymptomatic and symptomatic COVID-19 positive individuals now rely even more heavily on their family physicians to provide guidance and reassurance regarding their safe return to exercise after infection.

In this article, we aim to inform family physicians of current return to play (RTP) guidelines for both adult and student athletes who have tested positive for COVID-19, with a special focus on RTP criteria by the Ohio High School Athletic Association (OHSAA) for Ohio middle and high school students. For the purposes of this article, we define athletes as “individuals who place a high premium on training, competing, and sports achievement.”¹ We recognize that athletes may range in age from youth and student-athletes, to young and older adults with performance levels ranging from recreational level (i.e., daily joggers) to the weekend warrior to highly competitive, performance-level athletes.

Clearance for Athletic Participation after COVID-19
All athletes with a known diagnosis of COVID-19, even if asymptomatic, should not train during the required 10-day isolation period^Δ which starts the day of a positive test or first day of symptoms. For symptomatic athletes, exercise should not begin until completion of the 10 day period and resolution of all symptoms, except for the return of smell or taste.¹ It often takes longer for smell and taste to return and exercise can be resumed even when still experiencing these symptoms. Table 1 shows detailed information regarding the most updated medical clearance guidance.²

The remainder of this article will focus on RTP progression for asymptomatic and mildly symptomatic COVID-19 positive athletes. All moderate and severely symptomatic athletes, especially those who were hospitalized, should undergo consultation by a cardiologist before considering any form of exercise.

Adult Athletes
Current recommendations define adult athletes’ cardiovascular (CV) risk primarily by conventional risk factors (such as age, sex, and family history¹) even in the case of patients with asymptomatic or mild COVID-19 infections. Of these athletes who are older than 65 years of age, current guidelines advise against additional CV testing¹ (i.e., an electrocardiogram (ECG)). Rather, testing should be individualized based on pre-COVID CV history and complexity and duration of symptoms.¹ In athletes older than 65, especially those with pre-existing CV conditions, and patients who experienced moderate to severe COVID infections, current guidelines recommend evaluation by a cardiologist before starting a RTP progression.¹

Adult athletes who are asymptomatic may return to activity gradually once their isolation period has concluded. Mildly symptomatic athletes may gradually return to play after the 10-day isolation period once symptoms have resolved completely. CV testing may be considered per CV history and COVID-19 symptom duration.¹ Both asymptomatic and symptomatic athletes should follow a RTP progression like that outlined in Table 2. Development of cardiovascular symptoms at any stage should prompt a CV workup that includes an ECG, high-sensitive cardiac troponin (hs-cTN), and echocardiogram, and these athletes should be considered for referral to a cardiologist.¹

In moderately symptomatic athletes who have not been hospitalized and in athletes with either a known cardiovascular history and/or age older than 65 regardless of symptom severity, current guidance recommends evaluation by a medical professional who should consider CV testing based on history and exam.¹ Abnormal test results warrant referral to a cardiologist for further diagnostic intervention.¹

Student-Athletes
According to OHSAA, all student-athletes that test positive for COVID-19, regardless of symptom status, must be evaluated and cleared by a licensed medical professional before resuming any exercise, especially practice and competition. The medical authorization requires a cardiac risk evaluation and examination of the student-athlete. The form for clearing these student-athletes that participate in athletic programs managed by OHSAA can be found online.

Return to Play Progression for COVID-19 Positive Athletes
Adult Athletes
Once adult athletes have met clearance criteria, they should follow a graduated approach in returning to exercise. Family physicians should encourage these athletes to check in regularly as they move through the RTP progression outlined in Table 2. Athletes who have been required to obtain cardiology clearance, as discussed previously, should be closely followed by a physician.

Student-Athletes
Once the student-athlete has met clearance criteria, they should follow a graduated approach in returning to exercise as outlined in Table 2. These athletes should be closely supervised by athletic trainers. In any student-athlete diagnosed with myocarditis, RTP progression must be managed by a physician, preferably a sports cardiologist, using previously defined RTP protocols for myocarditis.⁴

Monitoring
All athletes should be monitored for signs and symptoms listed in Table 3. All student-athletes should be closely monitored by athletic trainers. If any of the listed signs and symptoms are noted, the athlete should rest for 24-hours and then return to the previous stage.² Secondary measures are also listed in Table 3 and may prove useful to athlete monitoring during and after the RTP progression.² It is also recommended to monitor heart rate before and after exercise and during recovery.²

Since it can be difficult to distinguish normal deconditioning from new onset exercise intolerance, all returning athletes should be monitored closely. Family physicians should encourage consistent and regular follow up.

If symptoms persist beyond 24-48 hours, prevent exercise initiation, lead to early exercise termination, or are associated with abnormal objective factors such as heart rate, athletes should refrain from exercise and RTP progression and return to their family physicians for further evaluation and management.

Conclusion
Return to exercise after a COVID-19 infection can occur safely if initiated after recommended clearance, performed according to currently published guidelines, and monitored appropriately.

Footnotes
^ΔIsolation occurs for individuals with a positive test, whereas quarantine occurs for individuals with exposure to COVID who have not yet been tested. Quarantined athletes may continue to exercise if they remain quarantined from others.

References available online.