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Issue: January 2021
Source: Andreato LV, et al. Strength Cond J. 2020;doi:10.1519/SSC.0000000000000563.

Disclosures: Ahmad, Belanger, Stracciolini, West and Zachazewski report no relevant financial disclosures.
January 14, 2021
9 min read

Physicians tackle return to play issues in COVID-19 pandemic

Issue: January 2021
Source: Andreato LV, et al. Strength Cond J. 2020;doi:10.1519/SSC.0000000000000563.

Disclosures: Ahmad, Belanger, Stracciolini, West and Zachazewski report no relevant financial disclosures.
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The COVID-19 pandemic caused the postponement or cancellation of amateur and professional sporting events in 2020, which raised concerns among the medical community once athletes eventually returned to sports.

A primary concern among orthopedic surgeons and sports medicine physicians was the athletes’ increased risk of injury after prolonged periods of physical inactivity.

Christopher S. Ahmad

“What we were fearing is when you have been shut down for a period of time and then the world opens up to sport, that the combination of deconditioning along with intense enthusiasm could lead to the high injury risk,” Christopher S. Ahmad, MD, professor of orthopedic surgery and chief of sports medicine at Columbia University, New York Presbyterian Hospital, told Orthopedics Today.

Without appropriate preparation and conditioning, athletes can have an increased risk of shoulder and elbow injuries, including ulnar collateral ligament and Tommy John injuries, as well as lower extremity injuries, such as soft tissue injuries, hamstring strains, quadriceps strains and gastrocnemius strains, Ahmad said.

Teenage athletes also may be at an increased risk of soft tissue and other injuries due to growth spurts they experienced during periods of inactivity during the pandemic, according to Robin V. West, MD, who is president of Inova Musculoskeletal Line and chair of Inova Sports Medicine.

“We are seeing a lot of soft tissue injuries, including ankle sprains, hamstring injuries and ACL tears. The soft tissue injuries are likely due to a period of inactivity along with a concurrent growth spurt. These younger athletes are developing in so many different ways and trying to get back to play with decreased body awareness,” West said.

Progressive return to play

To reduce risk of injury when they eventually return to play, West said youth athletes should undergo a “preseason” physical with an orthopedic surgeon or a physician who is fellowship trained in sports medicine.

“When athletes go to the pediatrician for their physical, they routinely get their heart and lungs evaluated, but they do not typically get a full assessment of their overall range of motion, strength and flexibility,” West said. “This is where a sports medicine physician can assist with a full orthopedic exam to help identify areas of weakness, decreased range of motion or asymmetry. A well-trained physical therapist, strength and conditioning coach or athletic trainer can also be valuable in assessing for muscular imbalance.”

Athletes of all levels can also prepare prior to the sporting season with a home exercise program specific to the sport they play, according to Ahmad.

Cross-training encouraged

Andrea Stracciolini

For younger athletes, Andrea Stracciolini, MD, director of medical sports medicine at Boston Children’s Hospital, said cross-training is important, and young athletes are encouraged to revisit free play and sample different sports.

“A lot of people think that athletes should just play sports, but if you send them outside for free play and they develop different muscle groups, it can be quite helpful in terms of injury prevention down the line,” Stracciolini told Orthopedics Today. “It maintains their physical fitness, it builds different muscle groups, it develops different skills,” she said.

As the sporting season begins, West said transition back to normal practice and normal play during a 21-day period is essential.

“Start with a half-hour practice and then ramp it up over that period of time instead of jumping into a 2-hour practice and then into back-to-back games,” West, an Orthopedics Today Editorial Board Member, said.

James E. Zachazewski

This progressive return to play is especially important for young athletes who were diagnosed with COVID-19, according to James E. Zachazewski, PT, DPT, ATC, athletic trainer in the department of orthopedic surgery at Brigham and Women’s Hospital.

Athletes diagnosed with COVID-19 should undergo a return to play program similar to one designed to help athletes return to play after injury, he said. With an individual who has been out for 1 week or 2 weeks, “that is no different in terms of their overall condition and physical capacity to get back to their sport than if they had been injured and out with a sprained ankle for 1 week or 2 weeks,” Zachazewski said.

Impact on overall health

In addition to concerns about athletes’ musculoskeletal health, it is also important to focus on their overall health and well-being, Stracciolini said.

“Re-entry [to sport], even in normal times, for some athletes who are injured is hard. Now with the pandemic, not knowing what the future holds in totally abnormal times, re-entry can be stress and anxiety provoking,” Stracciolini said.

Michael J. Belanger

According to Michael J. Belanger, PT, MSPT, ATC, an athlete’s psychological well-being may decline due to not being able to meet high expectations in their return to play performance.

“A lot of [restrictions due to COVID-19] can lead to general frustration, an athlete thinking they should be at one level, but actually performing at a level below that,” Belanger, clinical supervisor of athletic training in the department of orthopedic surgery at Brigham and Women’s Hospital, said. “I think that would be one specific concern I would advise my athletic trainers to be aware of and to look out for, that athlete who could be struggling in that respect, and [we should be] doing our best to make sure we are offering them the best resources we can.”

Recognize signs, symptoms

While it may be beneficial for athletes impacted by the pandemic to see a sports psychologist, West said education of athletes, coaches and parents about the signs and symptoms of anxiety and depression is an effective way to identify athletes who are in need of support and mental health care.

“There are kids who do not have access to [a sports psychologist], so how do you adjust for that? Parents, coaches and athletic trainers are going to have to try to recognize these signs and symptoms,” West told Orthopedics Today.

Education is helpful, especially if you “give some specifics to help parents and athletic trainers recognize and support these athletes,” she said.

Robin V. West, MD, said youth athletes who return to play during the pandemic should undergo a “preseason” physical to identify any areas of weakness, asymmetry or decreased range of motion.

Source: Washington Football Team

Stracciolini said young athletes can use the time off from sports during the pandemic to focus on their sleep and nutrition.

“These athletes are playing multiple sports and their energy balance often can be brittle and their energy intake often does not meet their output at times of high athletic demands,” she said. “This is a good time to look at overall health and well-being, good sleep, nutrition, mental health, stress and anxiety management, etc.”

Guidance on return to play

Following consistent guidance from governing bodies can also reduce the risk of injury among athletes who return to play after lengthy periods of inactivity during the pandemic, according to Belanger.

“We see consistency for return to play with issues such as concussion. I think that is a good parallel to this because after sustaining a concussion, there is a graded return to play that you need to go through in order to prove you are game worthy,” Belanger told Orthopedics Today.

In terms of return to physical activity considerations among high school and collegiate athletes, the Korey String Institute at the University of Connecticut published pandemic-related consensus information about the unique risks of physical distancing among athletes, which identifies various risk profiles and ways to mitigate risk using available tools and resources. It also addresses pre-participation evaluations, return to physical activity and conditioning, heat acclimatization, injury prevention and education for related items.

Gradual return to play

Guidance has also been published in the British Journal of Sports Medicine on graduated return to play for athletes who have been diagnosed with COVID-19. It recommends athletes be able to complete activities of daily living and walk without excessive fatigue or breathlessness, have at least 10 days of rest, be symptom-free for 7 days and conclude all COVID-19 treatment before returning to sport.

With concerns of COVID-19 cardiovascular sequelae that may lead to multisystem inflammatory syndrome in athletes, guidance published in JAMA Cardiology recommends athletes with prior moderate or severe cases of COVID-19 infection undergo a comprehensive cardiovascular risk stratification that includes clinical evaluation, electrocardiogram, high-sensitivity cardiac troponin assessment and echocardiography. Athletes with asymptomatic COVID-19 infection should also abstain from exercise for 10 days from the date of their first positive test.

Mitigate cardiac issues

“All our athletes who have tested positive for COVID-19, whether they are a [New York] Yankee player, a [New York City Football Club] NYCFC player or even staff, were tested according to a cardiology protocol to make sure they do not have myocarditis that can result in a cardiac problem with exertion,” said Ahmad, who is the Section Editor, Shoulder & Elbow for Orthopedics Today. “We have rolled that out to even amateur athletes and younger athletes to make sure that they have the same access to that type of care.”

However, Stracciolini said it is hard to generalize return-to-play guidelines and strategies for all athletes in the setting of the pandemic because each athlete is different with regard to baseline fitness and their level of activity during quarantine. She said some athletes may have taken advantage of the pause in sports to rest, recover and heal before slowly progressing back to play.

“Some athletes ... may in fact do well with re-entry. I think it is to be determined with regard to the injury profile in the younger athlete as they return to sport,” she said.

Teamwork supports return to play

Developing clear and consistent guidance on return to play after the pandemic and making sure athletes can return to play safely is a team effort, according to Zachazewski who said it is important to work collaboratively with whomever sees athletes on a day-to-day basis.

Although such care initially falls on the team physician and athletic trainer, physicians in the high school and collegiate sectors should also seek support from the school administrator when working with high school and collegiate athletes, according to Belanger.

“Being able to identify an athlete who may be struggling and identify what needs to be done with that athlete, a lot of that starts initially with good communication to administration so that you have their support when you do want to pull somebody out of competition for a particular reason,” he said.

Work with school health officials

Belanger said high school nurses and physicians may be better equipped to handle respiratory illnesses compared with orthopedic surgeons, athletic trainers and physical therapists.

“[School nurses and physicians are] going to bring that skillset to the table that is certainly going to complement what we have and they should be the ones helping us define how to [treat athletes],” he said.

For athletes who participate in recreational sports, Zachazewski told Orthopedics Today orthopedic surgeons, physical therapists and athletic trainers should work in collaboration with the athletes primary care physician.

“Reach out to the professional who is dealing with the child athlete on a day-to-day basis and say, ‘Here is what I am hearing from mom and dad, tell me what you are seeing. Let’s talk collaboratively about where we go and how do we progress this’,” he said.

During the COVID-19 pandemic, it may be beneficial for orthopedic surgeons to work with a sports cardiologist or cardiopulmonary physical therapist, Belanger said.

Enlisting help from a sports psychologist may also be needed for some athletes’ return to play issues, Zachazewski said.

“It may well mean bringing in a sports psychologist with a kid who is able to return but is having a tough time psychologically returning because they had to deal with COVID-19. How did it affect their season? Or they dealt with COVID-19 and are not back to where they want to be in the timeframe they want to be there and we cannot necessarily give them a timeframe because we are still learning about COVID-19 and how long it may take to return,” he said.

Share information moving forward

Regardless of which specialists are included in the care of athletes as they return to sport during the pandemic, communication remains a mainstay of that care, according to Zachazewski.

“We spent a lot of time prior to school starting back up and athletics starting back up meeting with the athletic directors and the nurses and/or school physicians ... to articulate the need for everybody being on board with the same policies, so there is no team splitting, if you will, with this, and everybody is in agreement that the child’s health and welfare comes first, not necessarily their time and date of return to play,” Zachazewski said.

Members of the medical community also need to share information about return to play issues related to COVID-19, especially with individuals who have limited resources or support, Belanger said.

“My suggestion moving forward would be to continue to share whatever information we have,” he said.

However, Belanger said athletic trainers who find themselves with limited resources and support from their administration should do their best to reach out to colleagues and try other resources available in their geographical area as a way manage this as best as they can.

But, overall, Zachazewski said the medical community must be patient as the care of athletes and other patients during the COVID-19 pandemic progresses and improves.

“[COVID-19] is something that is evolving, that we do not know everything about,” Zachazewski said. “We do not know some of the impact of this on a long-term basis down the road. It is a ‘be patient’ aspect, taking it step-by-step and working with the best interest of the individual in mind.”