Getting Ready for Fall Sports

As the heat of summer begins to build, athletes around the country start planning and training for their fall sports season. Many will be preparing for the physical demands of football and soccer. Dedicated athletes are likely already in good physical condition due to their regular, uninterrupted exercise routines. However, with many routines interrupted over the past 2 years by the COVID-19 pandemic and the restrictions designed to minimize COVID-19 transmission risk, it is inevitable that some athletes are behind in their preparation for sport.

There are significant benefits to training in the heat of summer, but the risks should not be taken lightly. ⁹ Heat acclimation takes 10 to 15 days, more than most training programs allow for. Failing to take adequate precautions can have severe consequences. Unfortunately, some athletes lack the motivation and discipline to stay in good condition but nevertheless still want to participate in their favorite sports. An interesting study with GPS monitoring technology in an Australian football league demonstrated that players were at the highest noncontact injury risk during the precompetition period. Low preseason cumulative workloads suggest that strength and conditioning coaches should emphasize achieving at least moderate training loads leading to competitive play. ⁵

Before beginning any intense physical activity, however, it is imperative that athletes take the preparticipation physical evaluation (PPPE). The PPPE is crucial to the health of the athlete at the high school and college levels, as well as for anyone who anticipates a large uptick in physical activity, regardless of age. The older the athlete and the more rigorous the activity, the more risk escalates. Although imperfect, when thoroughly performed, the PPPE is still a fundamental precautionary step to progressive athletic training. This is especially true at the adolescent and high school levels, where resources are often not available for advanced screening and testing of athletes before training. Many “red flags” can be detected during the PPPE while obtaining a patient and family history of cardiac murmurs, exertional chest pain, syncope, or personal and family histories suggestive of other cardiac conditions. ⁴

Truly, a good preseason evaluation by a well-informed clinician is the most efficient, cost-effective way to progress an athlete to full participation in a physically demanding sport. If “red flags” are noted during the examination, further evaluation by a specialist, along with imaging and testing, may be indicated. However, even the most complete history, physical examination, and additional screenings will not be able to detect 100% of all potential hidden medical issues, emphasizing the need for a monitored approach to progressive conditioning that may expose those at risk.

Strenuous physical athletic activities usually rely on a combination of speed, power, and endurance. All of these depend on a certain level of air aerobic fitness. The best indicator of aerobic fitness is maximal aerobic capacity (VO₂ max). In a publication in this issue of Sports Health, Boden et al ² report a wide range of VO₂ max in high school and college football players, with greater than a 3-fold difference between the best and worst aerobic performances on testing in high school athletes (19.1-60.6 mL kg^-1 min^-1) and a 2-fold difference in college players. These numbers demonstrate the need to individualize conditioning programs, as this range in aerobic fitness reveals how vastly different fitness profiles can be in the same sport at the same level of competition.

Despite this disparity, I’d venture to say that almost all high school, and many at college level, teams will not be using aerobic capacity testing (VO₂ max) in their preseason evaluation before conditioning begins. This raises the need for other indicators. An excellent surrogate for aerobic fitness is body mass index (BMI), which is easily determined. ² As Boden et al ² report, BMI is a good measure for estimating aerobic fitness and developing progressive training modules while minimizing risks of a medical event. Boden’s ² report demonstrates that most obese football players and approximately 50% of normal weight football players had poor aerobic fitness levels. Those in the lower levels of aerobic fitness will benefit from additional time and training to reach a fitness level appropriate for their sports.

Adding to the challenge of evaluating athlete health this preseason will be the number of athletes returning to competition that were infected by COVID-19. I anticipate that many athletes will not even know that they were infected, either because they were asymptomatic or they simply never got tested.

Respiratory illness and pulmonary complications are still the most common clinical presentation for COVID-19; however, cardiovascular complications of COVID-19 may be the most significant complication in pediatric patients. COVID-19 has produced full-blown myocarditis, ventricular arrythmias, and pulmonary hypertension in previously healthy kids. ⁷

COVID-19 has infected at least 100 million people in the world and is known to produce cardiac sequelae in mild and asymptomatic cases. ¹ Children constitute between 2% and 14% of all cases worldwide.^3,8,10 Interestingly, the novel COVID-19 variants appear to be more infectious in children. ¹ The viral injury from COVID-19 can be a direct result of the virus or due to subsequent immune response to the virus. The most significant cardiac risk may be in individuals with undiagnosed congenital heart disease. The most common major congenital anomaly, congenital heart disease, affects nearly 1 in every 100 live births and is a leading cause of sudden death in young athletes. ¹ COVID-19 and multisystem inflammation syndrome-children (MIS-C), ⁶ also referred to as pediatric inflammatory multisystem syndrome, have complicated these clinical issues because of their known cardiac involvement potential. Children with congenital heart disease are at a higher risk of death when they are infected with COVID-19. ⁸

A meta-analysis of 16 articles was formatted mostly from small case series of MIS-C. MIS-C affects mostly previously healthy, school-age kids and adolescents, with multisystem failure affecting primarily the heart, and it accounts for most pediatric COVID-19 fatalities. ⁷ This report emphasizes the need for cardiac workup in kids with COVID-19 severe enough to require hospitalization. The immune response can affect multiple organ systems (MIS-C), presenting with ongoing fever, stomach pain, diarrhea, vomiting, skin rash, bloodshot eyes, and dizziness associated with cardiac dysfunction, ¹ making it difficult to differentiate from other pathologies. While still relatively rare, there were 95 confirmed cases in New York state alone between 2019 and 2020 in patients 21 years and younger. ⁶ The dermatologic signs were most frequent among children up to age 5 years, with myocarditis highest among adolescents. Both groups had a high prevalence of gastrointestinal symptoms.

Recognition of MIS-C after COVID-19 should result in blood pressure monitoring, with electrocardiogram and echocardiography evaluation informing supportive care. ⁶ Sports medicine personnel must be aware of these COVID-19 complications and should monitor athletes to detect potential cases. In suspicious clinical cases, physical activity should be restricted until diagnosis can be confirmed or ruled out.

In summary, clinicians need to suspect that some athletes returning to sport this fall may not be aerobically fit enough to safely train. They may need additional time to progress to full participation.

Second, the PPPE should focus on identifying those at risk for cardiac complications from COVID-19, whether diagnosed or not. Clinicians should take extra care in determining which athletes may be most vulnerable due to congenital heart problems that have not previously been diagnosed.

Finally, careful attention should be given to monitor the progress of athletes through their conditioning programs and identify those struggling to progress. These situations may be the result of COVID-19 cardiac sequelae. Those that present with bloodshot eyes and dermatologic signs may be in MIS-C and in need of urgent medical attention.

Consequently, team physicians and primary care physicians may require additional time and resources to adequately address the complications of the COVID-19 pandemic.

Edward M. Wojtys, MD
Editor-in-Chief