Covid-19: Advice for Athletes

An article like this would usually start with a summary of the events of the last 2 years. Unless you have been living on the international space station, and even then, you know what has gone on. Covid-19, caused by SARS-CoV-2 infection, has changed the world. As an Intensive Care Consultant and Triathlon Coach I have been asked a lot of questions about Covid-19 and training. Below is a summary of these questions and the answers as I see them. These are based on the evidence we have, expert opinion and from views including my own. I hope you find it helpful.

Can I keep training with Covid? Maybe just at a lower intensity?

No. Pure and simple. Why? Because of the risks Covid-19 infection brings, even if the infection is mild or asymptomatic.

Inflammation of the heart (Myocarditis) was reported early in the pandemic in athletes infected with Covid-19 but who were asymptomatic and continued to train.1 A further study in 2021 of nearly 1600 collegiate athletes demonstrated myocarditis in 2% (1 in 50) athletes following Covid-19.2 Myocarditis can be mild with full recovery, or severe, resulting in cardiac scarring or the most serious (but extremely rare) complication; sudden cardiac death. Put simply, continuing to train is simply not worth the risk.

The other point here is that Covid-19 is an inflammatory illness. At best, continuing to train will simply prolong the illness or any symptoms you have and make it even longer before you can get back to training properly.


How soon after Covid can I start training?

The big question. There is a lot of different advice out there and this will also depend on the individual. But let's just take a step back and look at why this is important.

 

The very purpose of training is to stress and fatigue the body so that it rebuilds stronger and faster. Training has a significant impact on the immune system with very hard training or a hard race suppressing white-blood cell production and severe other key mediators of our response to infection.3 So resuming hard training while your body is still trying to clear infection is going to slow that process.

 

So what's best to do? Well firstly it depends how ill you have been. If you have been more than mildly symptomatic, the illness has been prolonged or you suffer with other medical conditions (particularly heart problems) then it would be a good idea to seek medical advice prior to re-starting training.

 

For athletes who have been asymptomatic or only mildly symptomatic my advice based on the medical evidence the expert guidance I have seen would be as follows:

 

•  No exercise during the 7-10 day isolation period. That means at least 7 days off from the positive test even if asymptomatic

•  Only resume exercise after 7 days of being symptom free (so if you were unwell for 5 days, wait another 7 before resuming training – so 12 days in total)

•  Ease back into training slowly. Start with short easy sessions and see how you feel.

•  Listen to your body. Everyone will respond differently to re-starting training.

•  See how you feel both during the session and later in the day. If you're finding that getting back into training is wiping you out and you're overly tired that is your body telling you you need to back off.

•  Assuming you feel ok, slowly build the volume and intensity back to your usual level.

 

I would also advise wearing a heart rate monitor for all activities as you ease back in. If you are seeing abnormal heart rates compared to what you would expect (high or low) STOP and if it persists you should seek medical advice. The same goes for any other unusual effects as you re-start exercise such as chest pains, palpitations or shortness of breath out of proportion to the effort you are making. If these do occur you need to be checked out before resuming any form of training.

 

For more details on this, a summary article based on the current medical evidence can be found below (reference 4 – summarised in algorithm one).

Can I train when I have the vaccine?

There is different guidance on this too, from different organisations even different countries. Again, let's take it back to basics. The idea of the vaccine is to trigger an immune response so your body forms antibodies to the virus. For some the only side-effect may be a sore arm. Others may feel rough for a day or so with headaches and fevers. Either way, what your body doesn't need while it's busy making antibodies is a hard threshold session. My advice, combining expert opinion as well as guidance from other organisations would be:

 

•  Train as normal the day before but nothing too hard that will leave you wiped out.

•  If your vaccine is late in the day you could consider an easy session in the morning but once you've had the vaccine take the rest of that day off.

•  Take a day off training the day after the vaccine.

•  Then go on feel. If you are feeling completely well two days after the vaccine, ease back into training. Listen to your body as outlined above.

•  If you are still having symptoms after the vaccine, for example temperature headache or feeling in any way unwell do not restart training until these have been fully resolved for at least 24-48hrs then ease back in gently. Again, monitor yourself as above.

I've just tested positive for Covid but I have an Ironman in three weeks I'll be okay to race won't I?

No. For all the reasons outlined above this is simply not worth the risk. An Ironman takes a huge toll on the body, risks all of the above and will without doubt suppress the immune system for several days afterwards. Likewise any major endurance event. It is simply not worth the risk. There will be other Ironman's but you only have one body.

 

With my coach hat on it is also worth pointing out that after a recent infection such as Covid you simply aren't going to perform to your best. If you do race, not only are you putting your long-term health at risk but you will almost certainly not perform anywhere near your best or achieve what you hoped for. Far better to rest, recover and re-focus on the next race.

But Omicron is far milder so I'm okay to crack on aren't I?

Early studies are reporting that Omicron does indeed appear to cause milder infection but this is with regards to not becoming seriously ill or dying.4  However it is still a viral infection and as far as we are aware at the current time, carries similar risks to the athlete as those discussed above. There are still many thousands of people in hospital

with omicron requiring oxygen even if the demand for intensive care has reduced with this variant.5  My advice; treat all variants the same with regards to training.

 

Again with my triathlon coach hat on I would point out that it is January. Many people’s target races are still many months

away and a few days off followed by easing gently back into training is unlikely to have any significant impact on performance in the racing season. However if you do try to return to training too soon without properly recovering

you are likely to lengthen the illness and prolong the time when you’re unable to train hard. That is far more likely to have an impact come the summer.

I don't really need the vaccine do I? I’m an athlete and fit and well so I'll be fine even if I get Covid?

As an intensive care consultant I have to declare bias on this one. Since May 2021 by far the majority of covid admissions to Intensive Care have been unvaccinated patients.5 Whilst few in number, we have still had young, relatively well patients die from Covid-19 and its complications.

 

I am also aware of several athletes who have had Covid infection and whilst they have not required intensive care, they have been very ill. In some cases they have needed hospital treatment, and have not recovered to anywhere near their baseline following the infection. ‘Long covid,’ fatigue and breathlessness can all follow infection with covid and can impair performance for many months. This is perhaps the most compelling argument for athletes to get the vaccine.

 

There is also the debate about the social responsibility of being vaccinated if you run, bike and swim (or indeed participate in any other sport) with groups of people on a regular basis. I’ll leave that one for you to consider.

Summary

In summary; as athletes we should take covid-19 seriously. As fit and well people it is easy to be blasé but Covid-19 still comes with its risks. Don’t try and train through it. Professional athletes aren't and neither should you. Listen to your body, be sensible and stay safe. Then go smash 2022. It’s going to be a good year.

Tom

Dr Tom Williams

MBChB (Hons) MRCP FRCA FFICM

Consultant in Critical Care & Anaesthesia

References

1.    Cardiovascular magnetic resonance findings in competitive athletes recovering from COVID-19 infection. Rajpal S, et al. JAMA Cardiol. (2020). 

2.    Review of COVID-19 Myocarditis in Competitive Athletes: Legitimate Concern or Fake News. Zulqarnain Khan et al. Front. Cardiovasc. Med., 14 July 2021

3.    Immune function in sport and exercise. Gleeson, M. Journal of Applied Physiology. Aug 2007.

4.    COVID-19: Return to play or strenuous activity following infection. O’Connor, FG. https://www.uptodate.com/contents/covid-19-return-to-play-or-strenuous-activity-following-infection

5.    Covid-19: Early studies give hope omicron is milder than other variants. BMJ 2021;375:n3144

6.    Intensive Care National Audit & Research Centre. https://www.icnarc.org/our-audit/audits/cmp/reports