Sports in 2021

On this bright, sunny day in late February in Michigan, there is cause for great optimism. Not only is spring just around the corner after a cold, snowy winter but it looks like the United States has the pandemic on the run. Infection rates are falling, COVID-19 hospitalizations and deaths are declining, and the arms of Americans are getting vaccinated daily. The answers to all our viral infection disease questions are still not available, but we’ve been learning. Only time will tell the variant story, which remains a concern. In an effort to return kids’ lives back to normal, the Centers for Disease Control and Prevention (CDC) does offer guidance for youth sport administration.¹ Hopefully by the time this editorial is published, we’ll be on our way to normal.

There have been many hardships and lost opportunities over the past year, but it is time to look ahead. The lost athletic seasons at the high school level cannot be brought back. An unknown number of games were missed, experiences lost, and athletic scholarship opportunities dashed. If I were a 2021 high school senior, I’d probably be pretty unhappy and feeling cheated. I don’t think there’s any way to remedy that problem except to move on with life.

At the college level, the pandemic laid bare many truths about college sports. To start, almost all fall National Collegiate Athletic Association sports were delayed except football—why? It certainly seems like the revenue-generating capacity of football had something to do with the decision. Because of the on-again, off-again start, preparation for this highly physical sport was surely compromised. Were athletes placed at higher risk because of subpar preparation? We will have to wait for the injury reports to surface to know for sure. Because of the increased health risk athletes were asked to assume, several publications criticized college football as ruthlessly exploitive⁵ and distorted.¹³ Are these fair, realistic critiques or simply a case of more football bashing by those who dislike the sport?

Though numerous college games were canceled, many were played, allowing a playoff series and a national champion to be crowned. No doubt the public enjoyed this semblance of American normalcy, but at what cost? The toll remains to be seen, especially for players that tested positive. At least most college football players had the opportunity to play; some did not. The Ivy League canceled the entire season for all fall sports, and that order carried into the spring with all sports still on hold.³ Sad to see, there is much unhappiness at some of the nation’s most prestigious institutions.⁴

The loss of football revenue at the institutional level has produced significant fallout. Sports leader Stanford University plans to cut 11 nonrevenue sports.¹⁰ New Mexico State had to cancel nonconference games against Florida and UCLA, resulting in a loss of US$2.75 million or 85% of its athletic department deficit for 2020.¹⁶ Unfortunately, the University of Cincinnati had to eliminate its men’s soccer team to make up for a revenue shortfall of US$726,000, while its head football coach received a US$1.1 million raise.¹³ Last—and maybe the most interesting—Auburn University paid its head football coach US$21.45 million to just go away after a disappointing performance.¹³ As 2020 came to a devastating close, 116 Division I sports at 34 schools were scheduled to be eliminated.¹⁰ What does this mean for college sports in 2021 and beyond? Clearly, changes are coming. Football and basketball remain the major revenue-generating sports for all other college athletic activities. That fact is not going to change, but the vulnerability of college sports has been exposed. Will players who take on the risk of injury and disease transmission be further compensated beyond the costs of their education? The activists that have been pushing for higher compensation for college players have been buoyed by this pandemic.

At the pro sports level in North America, the National Basketball Association, National Football League (NFL), Major League Soccer, and National Hockey League made exhaustive efforts to salvage sports seasons while protecting the safety of players, personnel, administrators, and the public. Their recommendation for everything from venues, exposure, and protective equipment to practice and game protocols are outlined in a recent publication.² The efforts of those professionals should be applauded. In their multimillion-dollar-generating enterprise, they found the time and effort to aid the public by providing guidance based on their experience this year.

In particular, the NFL deserves applause for their COVID-19 efforts. Yes, the same league that took endless criticism for its medical approach to concussion has now collaborated with the CDC to answer important viral transmission questions.⁹ With the assistance of the NFL Players Association, the NFL was able to redefine a high-risk situation: confirming transmission of the SARS-CoV-2 virus after less than 15 minutes of cumulative interaction. Utilizing hundreds of thousands of viral tests and contact tracing devices, the NFL improved our understanding of viral transmission in sports. The result was a salvaged season despite numerous rescheduled games, leading to an exciting playoff series and a highly entertaining Super Bowl.

Looking ahead to 2021 at the high school, college, and professional level, it is critical to learn from our mistakes, remember the lessons learned, and keep in mind what we don’t know. From the NFL experience, we know that on-field transmission of COVID-19 did not happen, and those players were notably not wearing masks.⁹ This is good news for contact sports like soccer and basketball. It looks like these seasons can return to normal in 2021.

For athletes who did contract the virus, caution must be exhibited in returning to activity and play, as emphasized in a previous Sports Health editorial.¹⁵ In a recent study of 100 patients in Germany who recovered from COVID-19 infection, 78% revealed cardiac involvement on cardiac magnetic resonance imaging, with 60% demonstrating ongoing disease.¹² Coronavirus disease and the athletic heart^7,8 is now a known concern and is subject to screening protocols⁶ and return to sports play guidelines.¹⁴ At the upper levels of competition where diagnostic testing (electrocardiogram, echocardiogram, and cardiac magnetic resonance imaging) are usually readily available, detection of those at risk with acute cardiac inflammation is likely.¹¹ At the high school and other junior levels of competition, these resources are likely not available and are hopefully not needed for the young and healthy.

However, keeping in mind that viral myocarditis is one of the causes of sudden cardiac death due to arrhythmia, an emergency action plan should be in place where athletes who have either had or been exposed to the virus are returning to sports. It is doubtful that the screening procedures will be able to detect all who are at cardiac risk. Therefore, those who are responsible for the welfare of athletes need to be prepared for these unlikely events.

—Edward M, Wojtys, MD
Editor-in-Chief