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When Jordan D. Metzl, MD, and his colleagues at the HSS Sports Medicine Institute published their guidelines to returning to activity after recovering from COVID-19 in August, he never imagined the response he’d get from patients.
“I’ve been surprised at how many people have reached out to me,” says Dr. Metzl. He calls these individuals long haulers, people who are still having mild to moderate symptoms three to five months later. “Maybe they just didn’t know where to go, people weren’t talking about it. There are more people out there with these issues than I even realized.”
After working with athletes in their own practices, the HSS team knew it was important to create a framework for recreational athletes who had mild to moderate coronavirus, to understand how to best return to activity safely. This was especially important after realizing how recovery looked vastly different for different individuals, with some recovering quickly and others taking months even if they only had mild symptoms. Similarly, the American College of Cardiology Sports and Exercise released their return to play guidelines back in May and an update late in October, directed at competitive athletes and highly active recreational athletes.
The update comes backed up with more information. During springtime, most of the country was locked down on stay at home orders. By summer sports leagues began up again and elite-only and virtual races started to spring up, giving doctors actual experience in helping athletes return to their sport after recovering from the virus.
These consensus recommendations can be helpful for runners who are unsure how to navigate getting back to training after their COVID-19 diagnosis, especially if they were asymptomatic or only had mild symptoms. “We’re trying to find a balance between people feeling safe when they’re back to strenuously exercising while also not overdoing it with unnecessary testing,” says Jonathan Kim, MD, a sports cardiologist and co-author of the ACC return to play guidelines.
Because of the unpredictable nature of the virus, these guidelines take a cautious stance.
What You Need to Know
According to the CDC, scientists have learned “that many organs besides the lungs are affected by COVID-19 and there are many ways the infection can affect someone’s health.” In particular, they are watching how the virus interacts and causes damage to the heart. The inflammation and damage they are worried about is called myocarditis.
“We’re still not entirely sure about the underlying mechanisms as it relates to all the cardiac injury that we’re seeing in hospitalized patients,” says Dr. Kim.
To avoid putting stress on the heart before it’s ready, runners shouldn’t plan to pick up where they left off in their training. In the guidelines for competitive and highly active recreational athletes from the ACC, a minimum of 10 days of full recovery is recommended with slow return to activity and evaluation by a medical professional if your symptoms are moderate or lingering.
If you experienced no symptoms or mild symptoms, the updated ACC recommendations state that you are okay to navigate returning to running on your own. “One of our takeaway points is that you want to take your time getting back up to regular training levels, but you’re probably okay to do that on your own and you don’t need to go see a cardiologist and worry about getting all these tests,” says Dr. Kim.
And of course, while you are still sick, regardless of severity, you should abstain from exercise. “If you test positive in the setting of being exposed, the idea is to wait because we know that when symptoms evolve they can sometimes evolve pretty dramatically after the first week. Once you know you have it, you need to socially isolate and not exercise,” says Dr. Kim.
He also recommends runners pay attention if clear cardiac symptoms arise when they return to running after COVID-19, such as new chest tightness, excessive shortness of breath, feeling winded during a workout that is normally easy, feeling lightheaded, or passing out. Those are all indications that you are not ready to be running again.
The guidelines for recreational athletes vary slightly based on the types of symptoms the individual may have had (pulmonary, cardiac, musculoskeletal, etc.), but in general, they recommend returning to running after COVID-19 using the 50/30/20/10 rule. In your first week back, reduce your normal training load by 50 percent. If that is comfortable and you’re not experiencing new symptoms, the next week reduce by only 30 percent, followed by 20 percent, and 10 percent in the fourth week. By the fifth week, you can resume your regular training.
“If you have a body system that’s been infected, it’s important to gradually tax that system to see where you are,” says Dr. Metzl.
“If you try to run too hard too soon, you are only doing yourself a disservice,” says Emily Stoneman, MD, a physician and infectious disease expert at the University of Michigan. “Giving your body time to heal will offer much more benefit in the long term than trying to push yourself when you are not fully recovered.”
Both these groups that set out guidelines for returning to activity recognize that, with the current uncertainty, their recommendations will likely change in the future. “I think we all submit that these recommendations will change,” says Dr. Kim.
While the return to play guidelines fill a void right now, the ACC author panel hopes to one day be able to provide a data-driven approach to ‘return to play.’ “That takes time,” says Dr. Kim. “You obviously have to build up the numbers and as fast as we work on that, these athletes are coming to our clinics now and need guidance.”
Lessons Beyond Coronavirus
Some of this advice can also be used to take us into flu season. “Even before COVID I was always giving the advice that when you’re under the weather, that’s the time when you shouldn’t be going out and pushing yourself to the limits and very hard. There’s a whole new introduced variable with COVID-19, but it emphasizes the point that you always need to let your body recover if you have a viral infection,” says Dr. Kim.
Dr. Metzl points out that it can be tough convincing runners, who are used to pushing through illness, bad weather, and stress, to take a break. “We’re just programmed to run through everything,” he says. “Which honestly, in life in general, is probably a great attribute. We get stuff done. We don’t let stuff stand in our way.” But he emphasizes that now is not the time to just do what runners do. It’s important to be methodical in your approach to running after COVID-19. “As a sports doctor who’s seen patients that have all different issues as well as some of these post-COVID issues, I think this is a time where you need to really temper that runner mindset and put it in context with the fact that that’s not necessarily the best thing for runners right now. You want to be mindful, you want to be careful. You want to be more careful than you’ve been before.”
Runners can take this as an opportunity to tune into what their body is telling them, to practice being aware. “I think the most important advice is to listen to your body and back off if necessary,” says Dr. Stoneman.
But if you genuinely feel good and have no reason to believe you are sick, there should be nothing that stops you from getting out and enjoying a socially distanced run. “Keep on running,” Dr. Stoneman urges. “Even though most of the races are canceled, we are all training for life and our own sanity during these challenging times.”
This article has been updated with new information. We will continue to update this story as we receive new or expanded advice from experts. Please visit the CDC or World Health Organization websites for more information.