Sports after Covid-19


Sports after Covid-19

Return to activity and training

The number of corona cases has increased enormously, especially in the winter months. The disease is insidious and has a varying degree of severity – often without symptoms and completely unnoticed by those affected. How do you get back to physical activity and movement after recovery – also taking into account possible long-term consequences?

The corona pandemic is putting the world to a tough test. Not only the health systems, but all areas of public life are faced with major challenges. With a view to restoring performance, our doctors and sports scientists are now asked to systematically organize the “return to work and sports” after a Covid 19 infection.

In Germany there are currently around 1.6 million recovered Covid 19 patients (as of January 20, 2021) – the number is steadily increasing. Soon there will be more than two million people who want to return to their usual performance after recovering from illness.

Long-term damage

Recent studies indicate that a variety of complications and long-term damage can occur after a Covid 19 infection. Many patients who have recovered from acute illness have some persistent symptoms. Health authorities are still trying to estimate the frequency of such long-term effects in Covid-19 patients. Some of the most commonly reported symptoms are:

  • Chest pain,
  • To cough,
  •  Pain in the joints,
  • recurring fever,
  • Muscle pain,
  • Fatigue,
  • Depression and anxiety

Among the many health complications associated with Covid-19, the most common is inflammation of the heart muscles called myocarditis. In addition, diarrhea, nausea, and shortness of breath are the main effects that hinder exercise increase.

The cardiological examination is of the utmost importance for the protection of those affected due to the frequent secondary problems affecting the heart. One of the most important tests in the medical assessment of athletes is a long-term EKG to rule out cardiac arrhythmias and diseases. Other examinations that are urgently recommended in the event of a longer course of the disease are the transthoracic echocardiogram, spiroergometry and, in the case of severe courses or missing previous findings, cardio-MRI.

Return-to-Work & Sports

In order to keep the cardiac and respiratory risks after an infection low, it is recommended that you resume training in accordance with these guidelines systematically and under medical and / or sports science supervision. You can refer to the guidelines of the research group Elliott et al. orientate – a scientific group that has focused on the re-integration of athletes after Covid-19 diseases with its Return-to-Work & Sports protocol.

Diagnostics before the start of the increase in exertion: The Return-to-Work & Sports is primarily aimed at those suffering from mild and moderate disease. But even after these supposedly milder courses, the risk of damage to the heart muscle, or myocarditis, must be taken very seriously. The case of the national ice hockey player Janik Möser, who suffered from corona-related myocarditis, was reported in the media. There are now more confirmed cases of myocarditis as a late consequence of a corona infection.


Myocarditis is inflammation of the heart muscle that is not due to ischemia (lack of blood). The most obvious symptoms include:

  • Shortness of breath,
  • Joint pain,
  •  Chest pain,
  • Swelling in the legs and / or feet
  • Fatigue.

The diagnosis of coronavirus-associated myocarditis is medically very demanding. Myocarditis is usually caused by a viral infection. It is therefore assumed that it is due to a direct infection of the heart (myocardium) by the novel coronavirus in Covid 19 patients. A study shows that SARSCoV-2 attacks the heart muscle and can cause both inflammation and cell death.

Patient history:The first step in diagnosing myocarditis is to analyze the full history of symptoms. Although symptoms vary from person to person, people often report chest pain and tightness with activity and exertion. Decreased exercise tolerance and recurring chest pain are two major symptoms. Severe cases even show signs of existing heart damage (heart failure or cardiogenic shock).

Electrocardiogram (EKG):An electrocardiogram is very often used to see changes in the heart. It is an easy procedure to perform thanks to the new mobile EKG devices. An electrocardiogram gives doctors an insight into the heart’s PQRST curve (cardiac current curve). This test will help cardiologists identify signs of myocarditis. These mainly include:

  • increased thickness of the heart walls,
  • Expansion of the ventricles,
  • Pericardial effusion.

Imaging: Cardio-MRI is a successful screening method for myocarditis. This procedure is
recommended by the task force of the German Ice Hockey Federation and the DEL if the diagnosis is not reliable.

The most important recommendations summarized:

  • Absolute rest Even asymptomatically infected patients should refrain from physical activity for at least ten days.
  • Freedom from symptoms required To start training, the patient should be absolutely symptom-free for at least seven days.
  • Slow increase The activity level should be increased slowly: first the frequency, then the duration and finally the intensity of the training units.
  • More diagnostics in advance after severe courses After severe disease courses, further medical examinations (especially the cardiological tests) should be carried out before starting training.

Step by step

From a medical point of view, the following diagnostic measures are urgently recommended before resuming intense physical exertion:

1. Physical examination: Listening to the heart and lungs, rough neurological examination
2. Apparative diagnostics: resting pulse, blood pressure, measurement of body temperature, resting ECG (ideally in comparison on previous findings before infection with Covid-19), gladly also data from wearables for progress control, including heart rate and sleep data, if necessary long-term ECG, lung function test
3. Laboratory diagnostics: blood values ​​(CRP value, LDH, troponin, D-dimers, liver values, urea , Creatinine
In the event of severe Covid disease progression with hospitalization, the following examinations should also be carried out:

  • Laboratory diagnostics for the parameters ferritin, PCT, IL-6 and
  • Apparatus diagnostics using echocardiography, spiroergometry (ideally compared to previous findings before Covid-19), body plethysmography (the so-called “large lung function”), possibly also a cardio MRI.

4. Step-by-step: Return-to-Work & Sports Management is a systematic program for gradually returning to sporting activity and performance after a Covid 19 illness. Before starting the gradual increase in performance, the patient should

  • have rested completely for at least ten days,
  • be symptom-free for at least seven days at a time,
  • be able to do simple everyday activities without feeling tired or short of breath,
  • stop taking any medication to treat the condition.

The way back to training

Attention: If symptoms recur or symptoms of exhaustion are noticed, you should refrain from continuing the training and go back to the resting phase! During the entire period, the resting heart rate should be documented daily, and possible symptoms and the subjective feeling of stress should be observed. A moderate return to training is ideally divided into the following four phases:

1st phase (immediately after the onset of symptoms or after a positive test): Rest (at least ten days). Here you should avoid any kind of physical strain. Health-promoting measures such as a balanced diet, plenty of sleep and drinking enough fluids support the recovery process.
Practical example: At the U20 Ice Hockey World Championship 2020/21 in Canada, a symptom diary was kept of all players and the resting heart rate was recorded every day, and the temperature and blood pressure were also measured. A slight mobilization was possible for the players, for example yoga. In addition, a new type of 1-channel 24-hour ECG was used. A measuring system was used to test how the cardiovascular system, breathing, HRV and sleep react to the infection and later to the slow reloading – because the symptoms also include an increased resting heart rate and faster breathing. The HRV was decreased and the quality of sleep decreased, as expected. Obtaining second opinions using telemedicine was important.

2nd phase (after seven symptom-free days): light activity for at least two days. Daily activities such as walking, cycling or light jogging can be resumed. Make sure you have a moderate heart rate and a short exercise time of approx. 15 minutes.
At the Ice Hockey World Championships, the players were subjected to a 15-minute load on a spinning bike to see how the body reacts to this load. The load was increased up to a maximum of 70 percent of the maximum heart rate. In order to have a good comparison, previous values ​​from the training were necessary. The heartbeat of each player was carefully monitored and the values ​​were set. In addition, the one-minute regeneration of the pulse was observed, because the more productive and healthy someone is, the faster the pulse calms down. All of this was then linked to the athlete’s subjective assessment, for which the so-called Borg scale is available as a reference. In the end it was rated whether the 70 percent maximum heart rate actually corresponded to a 70 percent load. This phase lasted two days.
In the positive case, the athlete moves on to the next phase – if not, he stays there or may be downgraded.

3rd phase: increase activities (at least four days). Simple exercise routines that stabilize and mobilize the body, or light training units in the type of sport that was performed before the illness can be integrated. The duration of the activity should first be increased (from 30 to a maximum of 60 minutes) and only then should the intensity of the activity be increased.
At the World Championships, the athletes were exposed to an interval load of up to 80 percent of the maximum heart rate twice for 22 minutes, as a 45-minute uniform load does not correspond to the sport-specific load. After the exercise, the 1-minute and 2-minute regeneration pulse (HRR) were determined.

4th phase: return to normal activity. The body is sufficiently recovered from the 17th day at the earliest to return to full physical exertion. So don’t start too zealously to avoid possible relapses and damage to your health.

The bottom line

All in all, a full medical evaluation combined with gradual reloading is the best way to plan for returning to activity after a Covid-19 infection. Since the virus is undoubtedly highly contagious and anyone can unwittingly become a carrier, a thorough and regular medical examination is a must for every athlete. Ideally, there are preliminary findings from times of excellent health for all important biomarkers and parameters

Dr. Lutz Graumann & Katharina Brinkmann

Katharina Brinkmann

Health scientist MA, lives and works as a yoga teacher in Munich. She is also known as a multiple book author (all published by Riva Verlag). She works as a speaker and has specialized in the areas of yoga, relaxation and stress management in recent years.

Dr. Lutz Graumann

is a sports physician and looks after the military, top athletes and clients from industry. He is the current president of the International Association of Performance Medicine. His publications appear regularly in national and international specialist magazines.

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