By Sarah Kinsella, MD, CAQ, FAAP, and William O. Roberts, MD, MS, FASCM, FAAFP
COVID-19 has upended almost every aspect of our lives, and youth sports are no different. In March 2020, many sports organizations were shut down due to the pandemic, and the Minnesota State High School League (MSHSL) canceled its winter state tournaments with two days remaining in the girls’ basketball tournament. Throughout the summer and fall, sports leagues at every level strategized how to navigate safer sports participation during this pandemic. As more people are exposed to and infected with SARS-CoV-2, physicians need to consider how athletes can safely return to sports once they have recovered.
As we learn more about the potential sequelae of COVID-19, particularly the risk of post-viral myocarditis, various national organizations are working together to come up with guidelines and cardiopulmonary considerations for returning athletes to sports during the pandemic based on the best evidence currently available. The National Federation of State High School Associations (NFHS) and the American Medical Society for Sports Medicine (AMSSM) formed a task force and published a guidance statement, and the American Academy of Pediatrics (AAP) updates recommendations on their COVID-19 specific website. The MSHSL recently established their own “Post COVID-19 Graduated Return to Sport Protocol” based on these guidelines which can be found on their website. When a student-athlete has been diagnosed with, or tests positive for COVID-19, a medical evaluation is recommended prior to returning to physical activity. General pediatricians will likely see this Minnesota-specific form during clinic visits this winter.
The MSHSL medical form prompts providers to ask specific questions about the patient’s diagnosis, treatment history, and current symptoms including a more detailed cardiopulmonary symptom history. COVID-19 induced myocarditis may predispose patients to arrhythmia and sudden cardiac arrest with activities. Given this concern post infection, certain criteria should be met before an athlete returns to sports. Athletes should be at least 14 days symptom free without medications and able to tolerate activities of daily living without cough, shortness of breath or fatigue. They should not have any cardiac symptoms including chest pain or tightness, unexplained syncope, dyspnea or fatigue with exertion, palpitations with activity, or a new heart murmur on exam. For athletes with a positive response to a cardiac screening question or a history of moderate to severe symptoms including hospitalization, additional cardiac evaluation is recommended which could include cardiology consultation, ECG, echocardiogram or other investigations. The AAP specifically recommends that those patients with severe illness, including organ failure, intubation or multisystem inflammatory syndrome (MIS-C), be treated like they have myocarditis and restricted from exercises for 3-6 months.
When an athlete is ready to return to sports, the protocol outlines a graduated return progression based on international recommendations. An activity progression is important to provide an athlete with a gradual increase in cardiac load. If cardiac symptoms develop during the progression, additional medical evaluation is needed. The protocol recommends a 7-day return to sport protocol starting with stage 1 of light activity, like walking, and progressing through more complex training at a minimum of 1 week. If symptoms develop with advances in activity, the athlete should return to the previous asymptomatic level for 24-48 hours before attempting the next level of activity.
At the high school level, athletic trainers can help guide athletes through this protocol. For younger or non-high school athletes, this protocol is a good template for pediatricians to educate parents on how to return their children to activities after COVID-19.
1) Drezner, et. Al. Cardiopulmonary Considerations for High School Student-Athletes During the COVID_19 Pendemic. Sports Health 2020; 12(5), 459-461.
2) American Academy of Pediatrics “COVID-19 Interim Guidance: Return to Sports” updated 9/18/2020: https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid-19-interim-guidance-return-to-sports/
3) Minnesota State High School League (MSHSL):
4) Elliott N, et al. Infographic. Graduate return to play guidance following COVID-19 infection. Br J Sports Med, 2020.