Helping Patients Return to Recreational Activity After COVID-19

Individuals who participated in recreational activities before developing mild-to-moderate infection with COVID-19 may be anxious to return to these activities, but they need to do so safely, taking into account the multi-system effects of the infection.

Most infected individuals experience mild-to-moderate pulmonary symptoms, such as dry cough and shortness of breath lasting about 6 weeks. However, it has become increasingly clear that COVID-19 can have a significant impact on multiple body systems, most frequently the cardiac, musculoskeletal, gastrointestinal, and hematologic systems.

For example, in addition to continued breathing difficulties, some individuals experience extreme fatigue, irregular heart rhythms, inflammation of the heart muscle, muscle aches, gastrointestinal upset, and blood clots. These symptoms have occurred even in previously healthy individuals and elite athletes who suffered mild-to-moderate COVID-19 and did not require hospitalization. Some individuals, called “long-haulers,” have lingering symptoms for weeks or even months after they clear infection by SARS-CoV-2, the virus that causes COVID-19.

With that in mind, sports medicine physicians at the Hospital for Special Surgery (HSS) Sports Medicine Institute in New York City have developed the first set of guidelines for helping individuals who had mild-to-moderate COVID-19 return to recreational activity safely. The guidelines provide a framework of considerations and recommendations based on the latest evidence regarding how COVID-19 affects different body systems.

“As sports medicine doctors we are always encouraging our patients to be active, but we realized that a one-size-fits-all plan for return to sport would not work well for those who had COVID-19,” said Jordan D. Metzl, MD, a sports medicine physician at HSS and lead author of the guidelines.

Dr. Metzl and 5 colleagues with experience treating recreational and professional athletes across various sports at the HSS Sports Medicine Institute created the new guidelines, which have been  published online by the HSS Jounal.

According to the guidelines, patients who want to return to exercise should be aware that there is no typical recovery pattern after COVID-19. The severity of disease appears to affect the duration of recovery, but this has not yet been proven scientifically.

The guidelines recommend that patients with COVID-19 avoid resuming exercise if they still have symptoms related to COVID-19. Those with an underlying cardiovascular or pulmonary condition should consult with their physician before returning to any physical activity, even if COVID-19 symptoms have resolved.

Otherwise healthy patients who had mild-to-moderate COVID-19 and have not had symptoms for 7 days may consider resuming physical activity by starting at 50% of their usual frequency and intensity. They should approach their return to exercise in a gradual, step-wise fashion, listen to their bodies, and speak with their healthcare provider if they develop chest pain, fever, palpitations, or shortness of breath.

Physicians writing exercise prescriptions should take into account any symptoms affecting any of the involved body systems. They should carefully monitor patients who had respiratory symptoms. Patients with cardiac symptoms should rest for 2 to 3 weeks after symptoms resolve, except those with myocarditis, who should rest for 3 to 6 months and have their readiness to return to exercise confirmed with echocardiography, rhythm monitoring, and exercise testing.

Patients with musculoskeletal issues can return to exercise after their symptoms resolve and gradually progress to normal activity levels. Low-intensity exercise and less time sitting may reduce the risk of blood clots in patients with mild clotting issues. Finally, fluid and calorie intake must be monitored carefully upon return to activity for patients who experienced gastrointestinal problems.

The guidelines are intended for recreational athletes of all ages. “I anticipate an increase in pediatric patients who will want to know when they can go back to organized sports after testing positive for COVID-19 as return to various forms of school and the availability of COVID-19 testing increases,” said guidelines co-author Kathryn McElheny, MD, a primary sports medicine specialist at the HSS Sports Medicine Institute who has a particular interest in the youth athlete. “These guidelines will serve as a useful tool for patient discussions and managing individual expectations for returning to play safely.”

“As a new disease, the landscape around COVID-19 has been changing rapidly,” Dr. Metzl said. “We plan to update these guidelines as our understanding of the disease evolves.”

The full article can be accessed here.



Metzl JD, McElheny K, Robinson JN, Scott DA, Sutton KM, Toresdahl BG. Considerations for return to exercise following mild-to-moderate COVID-19 in the recreational athlete. HSS Journal. 10 August 2020.

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