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Outbreaks, Alerts and Hot Topics

September 2021

COVID-19 and Sport; Fall 2021 Update


Co-author: Brian S. Harvey, DO | Associate Program Director of Primary Care Sports Medicine Fellowship | Assistant Professor of Orthopedic Surgery, UMKC School of Medicine

Co-author: Natalie C. Stork, MD 

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Column Editor: Angela Myers, MD, MPH | Director, Division of Infectious Diseases | Professor of Pediatrics, UMKC School of Medicine | Medical Editor, The Link Newsletter


SARS-CoV-2 has transformed the sports world from youth sports leagues to professional sports. Safe return to sports and physical activity continues to be a topic debated among sports physicians, cardiologists, primary care physicians and infectious disease specialists. The return-to-play process after a COVID-19 infection will depend on the severity of infection, duration of symptoms in the context of any concerning past medical history, and/or family history.1

Between the National Federation of High Schools2 and the American Academy of Pediatrics,1 there are some conflicting guidelines. At this time, we recommend that the work-up and evaluation be individualized for each athlete. We encourage shared decision-making between the athlete, parents/guardians and physicians involved in their care. If the patient is at the elite level, late adolescent, OR has any concerning cardiopulmonary signs with exercise, there should be an in-person evaluation by a primary care physician or cardiologist. 

In the asymptomatic athlete, defined as no symptoms with a positive test, as well as mild symptoms, defined as fever 100.4 less than or equal to four days, <one week of chills, lethargy, myalgias, the American Academy of Pediatrics (AAP) recommends at minimum a telehealth visit or a phone call with the primary care physician prior to returning to participation in sport.1 During the screening process, if there are any concerning symptoms by history, an in-office evaluation should be performed. This evaluation should consist of a full AHA 14-point cardiac screen questionnaire and a physical exam should be conducted. An ECG may be considered pending the history and exam.1 If there are any abnormalities or concerns, a referral to cardiology is warranted.1

For a moderate illness in the athlete, defined as symptoms greater than or equal to four days of symptoms, greater than or equal to one week of chills, lethargy, myalgias OR non-ICU hospitalization, an in-office evaluation should be performed prior to the return to sport. This would include the 14-point AHA cardiac screening questionnaire, physical exam and an ECG.1 If there are any concerns or abnormalities, the patient should be referred to cardiology.1

For severe COVID-19 infections, defined as an ICU stay, intubation, or diagnosis of MIS-C, athletes should be followed clinically by pediatric cardiology.1 Cardiology will direct further work-up and could include laboratory evaluation, ECG, echocardiogram, Holter monitor, cardiopulmonary stress testing, and/or cardiac MRI.3 Athletes should not participate in any sports or any other physical activity for a minimum of three to six months as directed by pediatric cardiology.

If an athlete has been diagnosed with COVID-19, they should not participate in sports or physical activity for 10 days after the positive test OR symptom onset, AND 10 days after symptom resolution without fever reducing agents.1 Athletes may begin the COVID-19 return-to-play progression once they are able to complete activities of daily living without symptom exacerbation and they have been cleared by a health care provider for exercise or sports activities.1 Over a seven- to 10-day period, athletes can slowly return into activity adapted from Elliot et al.4

Phase 1 At least two sessions of light aerobic activity (up to 70% maximum heart rate) for up to 15 minutes. Sessions should be at least 24 hours apart. Activities may include brisk walking, light jogging or using a stationary bike. No strength training.
Phase 2 At least one session of aerobic exercise (up to 80% maximum heart rate) for up to 30 minutes. Simple movement activities such as running drills may be added to increase the level of difficulty. No strength training.
Phase 3 At least one session of exercise (up to 80% maximum heart rate) for up to 45 minutes. May add some simple sport-specific activities and strength training to increase the level of difficulty.
Phase 4 At least two sessions of sport-specific training (up to 80% maximum heart rate) for up to 60 minutes. Sessions must be at least 24 hours apart.
Phase 5 Resume normal training activities and duration for at least one session.
Phase 6 Return to competition with no restrictions.




  1. AAP. COVID-19 interim guidance: Return to sports and physical activity. Published 2021. Updated September 2021. Accessed Sept. 23, 2021.
  2. Drezner JA HWM, Asif IM, Batten CG, Fields KB, Raukar NP, Valentine VD, Walter KD, Baggish AL. Cardiopulmonary considerations for high school student-athletes during the COVID-19 pandemic: Update to the NFHS-AMSSM guidance statement. Published 2021. Accessed Sept. 5, 2021.
  3. Phelan D, Kim JH, Elliott MD, et al. Screening of potential cardiac involvement in competitive athletes recovering from COVID-19: An expert consensus statement. JACC Cardiovasc Imaging. 2020;13(12):2635-2652.
  4. Elliott N, Martin R, Heron N, Elliott J, Grimstead D, Biswas A. Infographic. Graduated return to play guidance following COVID-19 infection. In. BJSM2020.