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HSS Experts Release Evidence-Based Guidelines for Returning to Recreational Exercise After COVID-19

Sports medicine physicians at the Hospital for Special Surgery (HSS) Sports Medicine Institute in New York City have developed the first set of guidelines for helping patients return to recreational activity safely after mild to moderate infection with COVID-19. The guidelines provide a framework of considerations and recommendations based on the latest evidence regarding how COVID-19 affects different body systems.

COVID-19 is primarily a respiratory illness. Most individuals who become sick experience mild to moderate pulmonary symptoms, such as dry cough and shortness of breath lasting about six weeks. However, it has become increasingly clear that COVID-19 can have a significant impact on multiple body systems, most frequently the cardiac, musculoskeletal, gastrointestinal and hematologic systems.

For example, in addition to continued breathing difficulties, some patients experience extreme fatigue, irregular heart rhythms, inflammation of the heart muscle, muscle aches, gastrointestinal upset and blood clots. These symptoms have occurred even in previously healthy individuals and elite athletes who suffered mild to moderate COVID-19 and did not require hospitalization. Some individuals, called “long-haulers,” have lingering symptoms for weeks or even months after they clear infection by SARS-CoV-2, the virus that causes COVID-19.

“As sports medicine doctors we are always encouraging our patients to be active, but we realized that a one-size-fits-all plan for return to sport would not work well for those who had COVID-19,” said Jordan D. Metzl, MD, a sports medicine physician at HSS and lead author of the guidelines. “We’re excited to share this evidence-based framework to help recreational athletes resume activity safely.”

Dr. Metzl and five colleagues with experience treating recreational and professional athletes across various sports at the HSS Sports Medicine Institute created the new guidelines, published August 10, 2020, online in the HSS Journal.

According to the guidelines, patients who want to return to exercise should be aware that there is no typical recovery pattern after COVID-19. The severity of disease appears to affect the duration of recovery, but this has not yet been proven scientifically.

The guidelines recommend patients with COVID-19 should not resume exercise if they still have COVID-19 related symptoms. Those with an underlying cardiovascular or pulmonary condition should consult with their doctors before returning to any physical activity, even if COVID-19 symptoms have resolved.

Otherwise healthy patients who had mild or moderate COVID-19 and have not had symptoms for seven days may consider resuming physical activity by starting at 50 percent of their usual frequency and intensity. They should approach their return to exercise in a gradual, stepwise fashion, listen to their bodies, and speak with their healthcare providers if they develop chest pain, fever, palpitations or shortness of breath.

Physicians writing exercise prescriptions should take into account any symptoms affecting any of the involved body systems. They should carefully monitor patients who had respiratory symptoms. Patients with cardiac symptoms should rest for two to three weeks after symptoms resolve, except those with inflammation of the heart muscle (myocarditis), who should rest for three to six months and have their readiness to return to exercise confirmed with echocardiography, rhythm monitoring and exercise testing.

Patients with musculoskeletal issues can return to exercise after their symptoms resolve and gradually progress to normal activity levels. Low-intensity exercise and less time sitting may reduce the risk of blood clots in patients with mild clotting issues. Finally, fluid and calorie intake must be monitored carefully upon return to activity for patients who experienced gastrointestinal problems.

The guidelines are intended for recreational athletes of all ages. “I anticipate an increase in pediatric patients who will want to know when they can go back to organized sports after testing positive for COVID-19 as return to various forms of school and the availability of COVID-19 testing increases,” said guidelines co-author Kathryn McElheny, MD, a primary sports medicine specialist at the HSS Sports Medicine Institute who has a particular interest in the youth athlete. “These guidelines will serve as a useful tool for patient discussions and managing individual expectations for returning to play safely.”

“As a new disease, the landscape around COVID-19 has been changing rapidly,” said Dr. Metzl. “We plan to update these guidelines as our understanding of the disease evolves.”

About HSS

HSS is the world’s leading academic medical center focused on musculoskeletal health. At its core is Hospital for Special Surgery, nationally ranked No. 1 in orthopedics (for the 14th consecutive year), No. 2 in rheumatology by U.S. News & World Report (2023-2024), and the best pediatric orthopedic hospital in NY, NJ and CT by U.S. News & World Report “Best Children’s Hospitals” list (2023-2024). In a survey of medical professionals in more than 20 countries by Newsweek, HSS is ranked world #1 in orthopedics for a fourth consecutive year (2023). Founded in 1863, the Hospital has the lowest readmission rates in the nation for orthopedics, and among the lowest infection and complication rates. HSS was the first in New York State to receive Magnet Recognition for Excellence in Nursing Service from the American Nurses Credentialing Center five consecutive times. An affiliate of Weill Cornell Medical College, HSS has a main campus in New York City and facilities in New Jersey, Connecticut and in the Long Island and Westchester County regions of New York State, as well as in Florida. In addition to patient care, HSS leads the field in research, innovation and education. The HSS Research Institute comprises 20 laboratories and 300 staff members focused on leading the advancement of musculoskeletal health through prevention of degeneration, tissue repair and tissue regeneration. In addition, more than 200 HSS clinical investigators are working to improve patient outcomes through better ways to prevent, diagnose, and treat orthopedic, rheumatic and musculoskeletal diseases. The HSS Innovation Institute works to realize the potential of new drugs, therapeutics and devices. The HSS Education Institute is a trusted leader in advancing musculoskeletal knowledge and research for physicians, nurses, allied health professionals, academic trainees, and consumers in more than 165 countries. The institution is collaborating with medical centers and other organizations to advance the quality and value of musculoskeletal care and to make world-class HSS care more widely accessible nationally and internationally. www.hss.edu.