When is it safe for Covid-recovered athletes to return to competition?

A year ago, Divya Kakran was in irrepressible form. In February last year, she cruised through her bouts and won the gold medal in 68kg at the Asian Wrestling Championships in New Delhi. In an exhibition of power and determination that day Kakran pinned down four opponents from Kazakhstan, Mongolia, Uzbekistan and Japan in just a couple of hours in the round-robin format. She saved her best for Japanese junior world champion Naruha Matsuyuki in the decider.

Kakran’s feat came with the Asian Olympic qualifier just days away. She looked primed to fetch the 68kg Olympic quota for India. Then the pandemic struck, a lockdown followed and sports took a backseat.

In December last year, Kakran herself tested positive for Covid-19, just before she was set to travel to Serbia for her first competition in eight months.

She was down with high temperatures, cough and fatigue. Chest and lung scans showed the presence of infection. Since then, Kakran has made a comeback to the mat, but she is not the same wrestler. From complete domination in 68kg–winning medals at Commonwealth, Asian Games and three Asian Championships in the run up to Tokyo–she is now unable to make it to the team in her weight class. She lost in the first round of the Senior national championships, and in national selection trials for the Olympic qualifiers. She competed in the non-Olympic 72kg category at the Asian Championships this month and showed signs of improvement with a gold medal. But her hopes of making it to Tokyo are dashed.

As a second and more powerful surge of infection is sweeping through the country, it has also infected many athletes. Little is known about long-term implications of the disease among elite athletes. It is a predicament facing sports science expert, doctors and physios across the world dealing with getting athletes back on their feet post Covid-19.

“The main problem is that we never really investigated the relation between a virus and an athletes’ heart and we didn’t have the technique to investigate the sometimes subtle damage a virus could cause for a very long time and scars like those you get in Covid can only be found using MRI which of course is very expensive and time consuming and takes high level of expertise to interpret properly,” said Dr Harald T Jorstad, Cardiologist at Amsterdam University Medical Centre, who has been working with elite athletes.

Dr Jorstad’s research paper — Balancing act: when is an elite athlete who has had COVID-19 safe to return to play? — published in the British Journal of Sports Science last year is one of the first scientific papers trying to highlight the impact of Covid-19 in elite athletes and prescribing a safe return-to-play protocol.

“Elite athlete populations have a low prevalence of overweight and obesity, hypertension and smoking, and of lifestyle-related diseases, such as atherosclerotic coronary artery disease, congestive heart failure and obstructive lung disease, all of which are associated with severe Covid-19. However, from an athlete’s point of view, COVID-19 sequelae leading to even a small long-term decrease in physical performance capacity can be career limiting,” according to the research paper.

“The thing we are most worried about is myocarditis or inflammation of the heart muscle itself, because we know that myocarditis can cause up to 10 to 20 percent of sudden cardiac deaths in apparently healthy athletes,” said Dr. Jorstad over the phone.

Athletes push their bodies during training and have a higher threshold of pain and that is where they have to be careful while coming back to the sport. In case they have shown even moderate symptoms, an athlete is advised to take a battery of tests and return to the field while under surveillance of coaching support staff.

Post Covid was a challenging period for Kakran — be it stepping up intensity in training or maintaining her body weight. Her doctors and physio Munesh Kumar of Olympic Gold Quest closely monitored her progress in the last four months reminding her periodically not to push herself (the opposite of what an athlete usually hears).

“Though she has regained a lot of her ability, we have to keep a watch on her progress. We have to be very careful. Only an athlete knows how strong she feels from inside,” said Munesh. “We know very little about the post Covid effect on athletes. So, we have to carefully plan to bring an athlete back to competition mode.”

Among the very few studies done on the subject so far, the Journal of the American Medical Association published a study done at University of Wisconsin on 145 competitive student athletes — having mild to moderate symptoms or no symptoms during acute infection. As part of comprehensive screening, cardiac magnetic resonance imaging (MRI) was performed on the athletes. The MRI findings (at a median of 15 days after a positive test result for Covid-19) were consistent with myocarditis in only 2 patients (1.4%).

“On one side it is reassuring that it is not 20-25 percent. But even that one or two percent if you think of the population level, that’s a lot,” said Dr Jorstad. “The biggest questions are still not answered. This was just one MRI. Do they recover completely or does the scar remain and if they don’t recover completely, do they have a chance of arrhythmia (irregular heart beat) and can it be worsened by returning to play?

“We do know that Covid can involve the heart of an athlete with even minimal symptoms. Fortunately, in the best and biggest studies the percentage of involvement is low. I am optimistic that arrhythmias in athletes, at least until now, are not extremely common,” said Dr Jorstad.

While a host of top athletes in every major discipline in India was affected by Covid, most of them were either asymptomatic or showed moderate symptoms. Many of them have successfully returned to competition, including Vinesh Phogat and Deepak Punia.

“They also have to consider their hamstring and tendons because if you are in isolation, you haven’t been doing much sport,” said Dr Jorstad. “Don’t start from day one with 100 per cent training. Each sport has a different training regimen. They should start carefully and increase the training and intensity gradually two weeks afterwards. That is one of the keys to safe return to sport. It also makes the athlete more confident because then they can listen to their bodies and they have time to find out that if anything is wrong and whether they have recovered well.”

Dr Amol Patil, who is monitoring the training of Tokyo-bound boxer r Lovlina Borgohain, who had to be hospitalized last year with high fever and vomiting, said, “Our athletes have not been that significantly affected. In other countries, there have been cases of Covid complications even among athletes where changes have happened in lung capacity or abnormalities in overall cardiological evaluation.”

It is not only the physical but also the mental aspect that athletes have to cope with; used to running certain distances or performing certain exercises, they are often distressed to see that they are unable to do the basics. In Kakran’s case it was difficult for her to maintain her body weight. Wrestlers have to cut weight before competition which compounded her problem.

“There are multiple factors we have to monitor. The metabolic system has to work more to fight the virus. The training load is not of the same level and you have to eat well for that and cannot stop water intake. Usually, wrestlers take less water when they have to shed weight. So, it becomes difficult to maintain body weight without compromising on the strength. Eventually, it can affect strength, power and thinking ability during competitions. So, all these things have to be kept in mind,” said Munesh.

It is also important to keep monitoring Covid recovered athletes even after their successful return to competition, said Dr Jorstad.

“We do know that some athletes are hit very hard and that they have long-Covid symptoms which limits them. Fortunately, there are also many athletes who recover completely but we still have to see whether this recovery is durable. To address that we have established routines to follow-up with athletes,” he said.

“We have an ongoing study where we follow elite athletes year to year into their careers. We have to follow them very carefully at this moment. This is also a fantastic opportunity for us to learn and increase safety of athletes not only after Covid but also from other viral infections.”