Returning Athletes Back to High School Sports in the COVID-19 Era: Preparing for the Fall

In the late spring of 2020, the number of cases of COVID-19 had stabilized throughout most of the United States, and conversations regarding the safe return of high school sports began. Given the unprecedented nature of this problem, and with no evidence to guide the decisions, current best practices were based on expert opinion or consensus recommendations. To that end, Sports Health convened a panel of experts for a webinar on July 16, 2020, to guide members of the athlete health care team in a discussion on best practices, challenges, and ethical dilemmas related to return to fall sports for high school athletes. We are also fortunate to have learned from the experience of other countries who were first affected with this virus and who have large databases available for analysis that helped inform our recommendations.

Since the conception of the idea, the landscape of COVID-19 has changed, with a rising number of cases and several states postponing their fall high school sports season. The rapid evolution of the knowledge, guidelines, and new outbreaks makes it challenging to answer questions definitively. Nevertheless, a synopsis of the 10 questions/answers discussed by the group are presented below to help offer guidance for those who may need it.

• 1. Should we be playing high school sports this fall?

This is a challenging question. Balancing the mental health needs and physical education benefits of exercise against what is currently known about this new virus is difficult, as information is rapidly evolving. While the idea of playing sports at the high school level amid a rising number of COVID-19 cases could be perceived or portrayed as irresponsible, especially when regional testing resources may be more limited than for the collegiate or professional athletes, it is important to weigh this against the evidence-based effects of COVID-19 on the different age groups. Furthermore, restrictions would affect education-based athletics, but since club sports or alternative leagues are not subject to the same oversight, athletes from more privileged backgrounds may find ways to continue sports participation. This would further exacerbate disparities in those from underserved settings who have no other means to stay physically active and increase the consequences, both physical and psychological, of a sedentary lifestyle.

The psychological aspects of the stay-at-home order and lack of activity have been explored. High school students across the country reported significantly more anxiety and depression after the stay-at-home order was implemented.

The general consensus was that it is prudent to provide guidance to local/state governments and athletic associations in developing policies and procedures aimed at keeping athletes safe. These organizations may lack the expertise needed for the difficult decisions posed by COVID-19. This may include infection control/prevention practices if sports are played, considering creative schedules such as moving high-risk sports from the fall to the spring when the virus is hopefully under better control, considering playing only low-risk sports for the fall, and other “out-of-the-box” solutions.

• 2. What should be done with regard to the preparticipation examination this year?

Guidelines for conducting the preparticipation examination (PPE) this year will be directed by state associations. When conducting the PPE, providers should strongly consider including additional questions in the history and review of systems that can identify those athletes who may have previously contracted COVID-19, as there may be cardiopulmonary, hematologic, and other risks that may need to be investigated prior to full clearance for sports participation. Providers should strongly consider asking whether the athlete was affected emotionally by a family member or close friend who was ill with COVID-19. Regardless of having a new PPE or not, routine health care and immunizations should not be delayed as part of an annual well-child check.

• 3. Are there any training programs for getting athletes back on the field safely after refraining from sports for a significant period of time?

Long periods without training or sports participation can lead to deconditioning and increased risk of injury. Given the extended layoff between sports seasons that has included closure of athletic facilities and weight rooms, it is important to work with coaching staff and athletic trainers to develop a plan with gradually increasing intensity to get acclimated to practice and high-level competition. Those who continue to report persistent exercise intolerance should be evaluated for occult myocarditis.

• 4. Are there things we should consider for COVID-19 prevention for our teams?

Centers for Disease Control and Prevention (CDC) guidelines for testing for COVID-19 are prioritized to those who are symptomatic, at high risk for complications, or who have had a recent exposure to someone known to be infected with the disease. State and local governing bodies and athletic associations should offer infection control/prevention guidance for practice, competition, and events that mirror recommendations from the CDC. Key recommendations include:

• a. Prioritize noncontact activity where physical distancing can be maintained

• b. Use face coverings when distance cannot be preserved, to and from the field of play, and also on the sidelines

• c. Instruct athletes to use appropriate handwashing and hand hygiene to minimize disease spread

• d. Frequently clean often-touched services

• e. Minimize the use of locker rooms or group gathering spaces

• f. Use isolated small groups to minimize disease spread within a team

• g. Require athletes to bring their own water bottles or food/snacks

• h. Avoid workout areas with poor ventilation

• 5. What are the cardiopulmonary considerations and testing after COVID-19 infection?

While the evidence on cardiopulmonary complications from COVID-19 on young individuals with mild disease is limited, there is evidence that 1 in 5 hospitalized patients suffer cardiac or thromboembolic complications.^3,5 Additionally, a recent JAMA Cardiology article revealed cardiac involvement in 78% of recently recovered COVID-19 patients.⁴ A task force from the National Federation of State High School Associations (NFHS) and the American Medical Society for Sports Medicine (AMSSM) provided recommendations for the assessment and management of high school athletes with COVID-19.² These include the addition of new screening questions for previous COVID-19 infections, a recommended medical evaluation with consideration of an electrocardiogram after a confirmed infection, and a comprehensive medical evaluation with cardiology consult for more severe infections.

• 6. How long are athletes out if they test positive or are a close contact to someone with COVID-19?

The evidence for return to play after a COVID-19 infection and even length of time to quarantine is still emerging. At this time, the CDC recommends that patients need 10 days of recovery from the onset of symptoms with 24 hours of remaining afebrile without the use of fever-reducing medications, such as ibuprofen or acetaminophen. Guidelines from the NFHS-AMSSM statement recommend no exercise for 14 days after symptom onset.² A recent document from the American Academy of Pediatrics¹ recommends that all exposures, including those who are asymptomatic, require a minimum 2-week resting period without exercise or competition. The document further outlines that individuals with symptoms should undergo a 2- to 4-week restriction from exercise and competition.

• 7. How do we return athletes back to the field after COVID-19 infection?

Athletes who test positive for COVID-19 may become deconditioned by both the illness and the time that is needed to be away from sport while they recover. As a result, a gradual return-to-play process is necessary and may follow guidelines that parallel a return-to-play progression after a concussion, which is likely more familiar to high school districts.

• 8. What is the impact of a positive test on an athlete beyond the inability to play sports?

Most individuals will focus on the effect of COVID-19 on an athlete’s ability to play sports or the athlete’s physical health related to COVID-19 symptoms. However, a positive diagnosis can have other implications, including psychological and mental health repercussions due to social isolation, inability to play sports as a form of stress relief, or stigma from team members for having a positive test and potentially affecting a team’s ability to play their season. It is important for the athlete health care team members to be aware of unintended consequences and provide support as needed for the athlete, teammates, and others who may be at risk for physical and mental health sequalae.

• 9. What has been the personal impact of COVID-19 on athlete health care team members?

COVID-19 continues to have an unprecedented and profound impact on our society, and the athletic community has not been immune. From the repercussions of lost jobs, including athletic trainers, to the inability to gather and appropriately disseminate the evolving evidence to protect the health and safety of our athletes, to evolving guidelines regarding return to play, the COVID-19 era has been stressful. This has influenced the personal and professional lives of our society as a whole. At this time, patience with the medical, research, and public health communities is necessary. Many individuals are enduring stressors that are not always apparent. Thus, society as a whole should be offering support to each other, as well as seeking support when required. We encourage everyone to seek help from others if they are unsure of how to proceed in certain situations or find it difficult to cope with their circumstances.

• 10. Any final comments?

We hope these comments serve as a framework to help guide individuals as they tackle key issues related to return to sport for high school athletes. The opinions are our own and we are doing our best to provide guidance while recognizing that the evidence for recommendations is currently evolving. New information will be available, which often builds or improves upon what has been performed in the past. We encourage everyone to keep an open mind and also to find ways to work together while managing the COVID-19 pandemic.