Play the long game: working out after COVID-19 infection
Written by: Dr. Rita Chorba DPT, ATC, SCS, CSCS and Dr. James Landis, MD, PhD
A Serious Setback
University of Houston defensive lineman Sedrick Williams, a JUCO All-American and conference MVP, tested positive for COVID-19 in July of 2020. Soon after, he began suffering from heart problems and could not continue practicing. Later, he announced he was opting-out of the football season due to ongoing viral complications.
Williams made his decision after learning the fate of pro basketball player Michael Ojo. While practicing with his team, Ojo had also tested positive for coronavirus in July. Ojo recovered and resumed practice, but then suffered an apparent heart attack during a training session and died. “I’ve had my mind made up,” Williams said, “but hearing this story made it even easier.”
The Rules Have Changed
As an athletic trainer, I learned the “neck rule” of return to play when one of my athletes felt sick. If they had a head cold (think runny nose), low-key workouts were acceptable. Research suggests that light exercise can help keep airways healthy and shorten the duration of some viral illnesses.
If my athlete had symptoms below the neck, such as coughing, body aches, or fever/elevated body temperature, we went into illness recovery mode. Sleep, fluids, rest, and de-stress protocols took top priority. After these symptoms subsided, a gradual increase in exercise followed – business as usual.
The rules have changed in the wake of the coronavirus pandemic. While the common complaints of COVID-19 infection include below the neck symptoms – cough, fever, and breathing difficulties – this novel virus makes its entrance with a wide variety of other indicators. Some patients with COVID-19 report the typical symptoms of colds and flu. Others have no symptoms at all.
A Hidden Killer
It needs to be made clear that a lack of symptoms does not mean a lack of effects on the body. A person can rapidly deteriorate days or weeks after infection, and the consequences can be unusually severe. Viruses, in particular, can exhibit numerous post-viral effects.
In the era of COVID-19, it is myocarditis – a rare inflammatory heart condition associated with some viral illnesses – that has garnered the most attention. Indeed, its occurrence is particularly striking because it is more common in younger, healthier Americans (e.g., less than 50 years old) once stricken with the coronavirus. Left unchecked, myocarditis can lead to permanent heart damage, stroke, or sudden cardiac death. Of particular importance is the fact that myocarditis is not generally obvious, and if there are no alerting symptoms, must be detected through electrophysiologic or echocardiographic testing.
Because the risk of myocarditis was deemed significant, the 2020 fall college athletic season was largely suspended. Several conferences, including the Big 10, PAC-12, and MAC, postponed their 2020 college football programs because of this risk. Over the summer, the NCAA had documented double-digit numbers of players diagnosed with myocarditis. Several professional sports organizations had announced cases in their athletes as well.
COVID-19 and You
In light of this new virus, poorly understood in even the most closely-monitored athletes, how can you “return to play” after being infected by COVID-19? Here are a few of the most frequently asked questions that have generated some consensus, based on the available medical information:
Who is most likely to struggle with workouts after a bout of COVID-19?
People of any age with underlying conditions are most at risk of complications and delayed recovery. These conditions include diabetes (Types 1 and 2), cancer, obesity, asthma, and heart or lung problems.
New evidence is emerging that people who smoke, are pregnant, or have a traumatic brain injury (TBI) are more likely to experience prolonged physical impairments. What’s more, there is now evidence that the virus can cross the blood-brain barrier and cause an encephalitis (brain infection). This encephalitis can manifest as anything from headaches to full neurologic deficits (like in a stroke).
When can I start working out again after COVID-19 infection?
The general guideline seems to be 2 weeks after a positive test result. Keep in mind, this only applies if you have been resting during that time, have no symptoms, and no other health factors.
In the Big 10 and other conferences, athletes without any symptoms are held from workouts for at least 14 days after a positive test result. They also receive additional medical workup during that time. If athletes begin to experience any symptoms – such as shortness of breath or increased fatigue – they are shut down from workouts to refocus on illness recovery. You should, too.
How should I get started?
Begin with low impact exercise for 20 minutes per day over at least the first 7 days after a positive test. If you have experienced COVID-19 symptoms, begin two days after your symptoms have entirely resolved.
Sample exercises that are appropriate for your first week back include walking, cycling, and swimming. These exercises promote immune system health and maintain steady oxygen levels while avoiding unnecessary inflammation. While rowing technically fits in this category, consider the other options if they are available to you. The posture of rowing creates chest restriction, which could interfere with optimal lung recovery.
But I feel great, why should I go slow?
Because the possibility of serious complications, including myocarditis, are still unknown with this virus. The greatest risks are for someone who develops myocarditis and doesn’t know it, especially if they perform strenuous activity.
The risk of developing heart problems after more common viral respiratory infections is about 1 in 100 people. Researchers have indicated that the risk for people infected with COVID-19 could be as high as 20%. Still, it could take several more years of study to understand more precisely the relative risk. By then, thousands of athletes could have sustained hidden heart damage, and have suffered complications.
Play the Long Game
Sedrick Williams, a once healthy and fit college athlete, is now cautiously dealing with heart complications resulting from COVID-19. In addition to daily monitoring by family, coaches, and trainers, he will likely undergo extensive medical testing to check for structural changes to his heart. His recovery plan could take months – or longer – until he is safe to return to the field.
If you have been infected by COVID-19, consider the hidden effects of inflammation that this virus can cause. It wouldn’t be unreasonable to double the amount of time you expect you’ll need to regain your fitness. Any attempts to make up for lost time could cost you down the road.
Think of it this way – exercise is a form of stress to the body. When done right and in the appropriate amount, it can make you stronger. But when your body is dealing with managing basic systems, the extra workload is not welcome. It can weaken your system far beyond its original state.
When it comes to getting back into workouts after COVID-19, play the long game.
Good judgment is your responsibility. No article can replace a healthcare professional’s advice who has examined you and knows your history and situation. Consider this information as a general overview of current evidence for informational purposes only. Consult your doctor if you think you’ve been infected with the COVID-19 virus.
Conway T. Houston DL Sedrick Williams Says He Has Heart Complications from COVID-19. August 10, 2020
Phelan D, et al. A game plan for resumption of sport and exercise after coronavirus disease 2019 (COVID-19) infection. JAMA Cardiology. May 13, 2020.
Coronavirus disease 2019: People with certain medical conditions. Centers for Disease Control and Prevention. August 14, 2020.