Unintentional Consequences

The onset of COVID-19 in winter 2020 brought many changes to the world of sport at almost every level of play, from youth to the major leagues. In an attempt to slow the viral spread and keep athletes of all ages safe, many winter sports seasons, including college basketball, were suddenly halted as the lockdowns were enforced. Uncertainty followed because never before in recent history were college and professional sports halted in midseason.

As the shock of the pandemic took hold, spring sports seasons were delayed. Major League Baseball (MLB) postponed the season with the hopes that the warm weather would help diminish the viral risk. Unfortunately, the risk did not abate in April and May, and the MLB, National Hockey League (NHL), and National Basketball Association (NBA) were forced to make drastic reductions in playing time and alternate venue arrangements. The NBA chose a bubble format restricting player and personnel movement in hopes of salvaging a shortened season. They were successful in completing the playoffs, which yielded a championship for the Los Angeles Lakers. TV interest was down for the NBA, but there are many theories as to why.

The NHL chose 2 Canadian cities for their shortened season format, which minimized travel for teams but avoided the bubble approach. Both the NBA and the NHL face challenges as to when to start the 2020-2021 season after the 2019-2020 season stretched far beyond the usual time frame.

The NFL tried to play an entire 16-game regular season after all preseason games and minicamps were canceled, and 3 weeks of preseason conditioning were required before contact practices began. Some NFL games were postponed due to COVID-19 flare-ups. College football was drastically changed as many schools opted out of playing (Ivy League) while the Big Ten and Pac-12 started late yet planned to run right up into the holidays. Training schedules were on-again-off-again as school officials struggled to balance the desire to play with safety. By mid-October, a number of contests were canceled as outbreaks occurred among players, coaches, and staff. Some players chose not to play this season, forcing their teams into awkward situations. The relative risk was not clear.

At the high school level, many seasons were postponed until spring. Some of those allowed to play Fall Ball had to don masks in an attempt to keep players safe. Decision making was, at best, haphazard with many administrators unsure of the safest route forward. The negative impact of decreased physical activity on students is well-known and highlighted in a publication in this issue of Sports Health.⁶ Many athletes saw their hopes and dreams crushed by canceled schedules. In an attempt to guide decision making regarding return to play (RTP), Sports Health convened a panel of experts for a Webinar in July 2020¹ to address best practices, challenges, and ethical dilemmas related to RTP. The question of whether high school sports should be played proved difficult to decide. Trying to balance the mental health needs and physical education benefits against what was known about COVID-19 was not easy.

Did high school administrators, sports officials, medical professionals, and college presidents choose correctly? At the time of this writing, nobody knows for sure. While there were many professional and college players who tested positive, forcing quarantines and canceled contests, there were no serious cases with dreaded complications of COVID-19 reported among the young and healthy college or professional athletes in the fall. That’s great news for those players, but it will take many more months and maybe years to know the full long-term consequences of contracting the virus.

Thus far, a large percentage of positive cases of COVID-19 have shown electrocardiographic changes and evidence of myocarditis, as shown in an article by Raukar and Cooper.⁵ Are these findings irrelevant and of no concern or will they hint at future issues still unknown? A JAMA Cardiology publication reported that there was cardiac involvement in 78% of recovered patients.⁴ While these were not athletes, many questions arose on the medical risks being posed. Myocarditis is a known cause of death in athletes, and as such, considering the myocardial effects of COVID-19 in RTP discussion is essential. Healthy athletes are probably more resistant to these viral complications but not immune. Of those nonathlete patients hospitalized with COVID-19, 10% to 27.8% demonstrate cardiac injury with a mortality rate approaching 70%.² Those recovering from COVID-19 with cardiac involvement often experience ventricular arrhythmias (78%)³, requiring further monitoring with electrocardiograms and echocardiograms. Cardiac magnetic resonance imaging and myocardial biopsy may be indicated.

In the NFL on the musculoskeletal side, the effect of some factors, such as the lack of organized football preparation and minicamps, should be evidenced soon. There seemed to be a lot of injuries in the first few weeks of the season but until the entire season can be evaluated, it is difficult to speculate on the musculoskeletal injury rates for the year.

Was the delay of much of the college football season until the traditional start of the flu season in October the worst decision for college football? Many colleges chose to start the semester for students early so that they could be sent home by Thanksgiving and not return when the flu risk would be rising. If the regular season and championships are completed without major illness problems, the discussions of who was right or wrong may be of minor importance. However, what if the worst was yet to come? By the time most read this editorial, some of these questions may be answered.

At the high school level where injury and illness reporting and monitoring is quite cursory compared with the college and professional level, the answers to these questions may not be found at all.

Much will be learned from the COVID-19 pandemic for athletes and nonathletes alike. Unfortunately, only the introduction to that book of medical facts has been written and it may be some time before the chapters and data are complete. Hopefully, the right decisions were made.

—Edward M. Wojtys, MD
Editor-in-Chief