Post-COVID-19 return to sport: an update

Soccer Football – Bundesliga – May 18, 2020 Werder Bremen players wearing protective face masks in the stands, as play resumes behind closed doors following the outbreak of the coronavirus disease (COVID-19) Stuart Franklin/Pool via REUTERS DFL 

Athletes are slowly returning to sport with the lifting of restrictions, as evidenced by the comeback of the Bundesliga and NASCAR this past weekend. Some of these athletes may have previously tested positive for the novel coronavirus or may contract it as their social interaction increases. Therefore, it’s essential to understand the latest guidelines concerning post-COVID-19 return to sport.

Cardiac injury is a known sequela from severe cases of COVID-19. Numbers now indicate that up to 22% of hospitalized patients with COVID-19 suffer damage to their heart(1). What remains unclear is how much damage occurs to those who convalesce from COVID-19 at home. Many of these patients are quite sick, with continuous symptoms for up to two months. Others may test positive for the novel coronavirus and yet remain asymptomatic.

Some of the cardiac damage sustained with COVID-19 is due to viral myocarditis. Myocarditis is implicated in anywhere from five to 22% of the sudden deaths of athletes under the age of 35(2). Thus, an athlete who returns to play post-COVID-19, whether asymptomatic or symptomatic, should do so with caution.

A group of sports cardiologists published recommended guidelines this past week(1). As professional sports teams are frequently testing their players, up to two times per week, it increases the likelihood that asymptomatic athletes will test positively(3). The new guidelines recommend that athletes who have a positive test for coronavirus but remain asymptomatic, rest without exercise for two weeks. This restricted activity limits contact with other athletes during a time when they may shed the virus, allows the team’s medical personnel to monitor the disease’s progression, and decreases the likelihood of the proliferation of the virus in the heart muscle. Even if athletes continue to feel well, experts recommend they slowly return to supervised exercise after an initial two-week rest.

Those who suffer mild symptoms at home should rest for a full two weeks after symptoms resolve. Symptom resolution is an individualized phenomenon, with patient reports of varying periods of recovery. Before physical activity, all athletes in this category should undergo screening tests by a physician, including a 12-lead electrocardiogram (ECG), an echocardiogram, and perhaps a pulmonary function, cardiorespiratory endurance, or blood test. Athletes with normal heart function should introduce graded exercise with close supervision. Those with elevated high-sensitivity troponin levels, an indication of damage to the heart muscle, should proceed under myocarditis return-to-play guidelines. This protocol suggests another three to six months of abstaining from exercise while the heart heals(4).

Hospitalized athletes should undergo appropriate cardiac testing while in hospital. If not, then the experts recommend cardiac screening as above. If the heart retains normal function, they should progress exercise under supervision once they’ve achieved two full weeks without symptoms. Those who have abnormal cardiac testing while in hospital should also follow myocarditis return-to-play guidelines, adding supervised graded exercise after three to six months.

Athletes with COVID-19 antibodies but who don’t recall being sick should also progress with graded exercise under supervision. Because the novel coronavirus is also know to affect coagulation, vascular, and kidney function, these athletes should also consider a full work-up by their physician as the implications for the mildly ill and asymptomatic are not yet know.

As evidenced by the injuries incurred this past weekend in the professional opening events, physios and trainers will be needed as athletes return to sport. Minor and recreational athletes may lack the support team to emphasize these guidelines. The physio may be the first medical point of contact for an athlete that only suffered a mild case or was hospitalized but not given return-to-play guidance. Therefore, now is the time to revise intake questionnaires to reflect the need to know the extent of prior COVID-19 exposure and pathology, and develop protocols for testing and referral.


  1. JAMA Cardiol.Published online May 13, 2020. doi:10.1001/jamacardio.2020.2136
  4. European Heart Journal. 2019 Jan 01;40(1):19–33


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