Returning to Running after COVID-19: How concerned do we need to be in mild COVID-19 cases?

Returning to Running after COVID-19: How concerned do we need to be in mild COVID-19 cases?

Returning to Running after COVID-19

Its six months into the world-wide global COVID-19 pandemic. During that six months, the pandemic thas resulted in marathons and other running races being cancelled across the world, including the Boston Marathon for the first time in its illustrious history as the oldest continually held marathon. 

Now that the spread of the virus has slowed in some areas, this slowing may allow some running races to slowly return with limited race entries. Many runners are eager to resume their normal training for races. However, what should you do if you’ve been diagnosed with COVID-19 and want to resume normal marathon training or simply recreational running?

Sports medicine physicians typically recommend the “neck check” for advising athletes if they should work out with a viral infection. If the symptoms are localized above the neck, such as mild runny nose or sore throat then running and other workouts are acceptable. If the symptoms are below the neck, meaning cough, wheezing or fever or chills, we’ll recommend to hold off on running and other exercise until the “below the neck” symptoms resolve.

However, we don’t know if the “neck check” criteria also applies to runners and other athletes if they are recovering from a COVID-19 infection.

The reason is that COVID-19 infections are not limited to a respiratory infection like influenza or the common cold. Instead, the SARS-CoV2 virus that causes COVID-19 has also been shown to affect the heart, kidneys and even cause neurologic issues, even in otherwise young and healthy people. 1

There’s been individual and case reports of athletes having significant symptoms after a COVID-19 infection. Major League Baseball pitcher Eduardo Rodriguez was diagnosed with a viral myocarditis (infection and inflammation of the heart) after he had COVID-19 prior to the restart of the MLB season in July 2020. 

NFL linebacker Von Miller was also diagnosed with COVID-19 and while not hospitalized, had significant fatigue and shortness of breath that limited his initial workouts post-infection. 

In Italy, one of the first patients diagnosed and hospitalized with COVID-19 was a 38 year old marathoner 2. He did survive after a long hospitalization, but the point being that even younger and athletic people can have severe complications with COVID-19.

Running after COVID-19: Myocarditis and heart inflammation

As a sports medicine physician, my concern is potential heart involvement due to COVID-19 infection. 

There was a recent (July 2020) study published in the JAMA Cardiology journal 3 that evaluated 100 German patients recovering from COVID-19 infections. The researchers were studying potential long-term heart issues after COVID-19 infection.

These post-COVID-19 patients all had blood tests and cardiac workup that included cardiac magnetic resonance imaging (cardiac MRI).  Cardiac MRI is more sensitive for detecting cardiac inflammation the either an EKG or cardiac ultrasound (echo).

The patients in the study had an average age of  49 years old and had their cardiac testing done on average, just over 2 month after they were first diagnosed with COVID-19. The actual timing of the cardiac MRIs ranged between sixty-four (64) and ninety-two (92) days after diagnosis with COVID-19, so all of these test subjects were well into their post-COVID-19 recovery phase.

The most concerning finding in the study which could impact runners with COVID-19 infections was that 78 of the 100 patients had abnormal cardiac MRIs. More importantly, sixty percent (60 of 100)  of the patients had some amount of cardiac inflammation on the cardiac MRI.  

Now remember that these cardiac MRIS weren’t done either during their COVID-19 infection or shortly afterwards. These MRI scans were done, on average, seventy-one (71) days after the patient was first diagnosed with COVID-19.

 So these findings of cardiac inflammation on the cardiac MRI scans were not an acute phase, still infected with COVID-19,  finding. These scans should that a majority of patients still had documented cardiac inflammation over 2 months after their COVID-19 infection. In some cases, cardiac inflammation was still present three months after they were originally diagnosed with COVID-19

I know that most runners think of themselves as healthier than the typical 49 year old German and while that may be true for some runners, I think these findings do mean we need to carefully monitor runners that have had COVID-19 as they return to running.

As colleges start back to campus, we are just starting to see the impact of COVID-19 on younger and healthier college athletes. Last week, (September 11,2020) The Ohio State University recently published their initial data as a research letter  in JAMA Cardiology 4.

The researchers at Ohio State described their findings on college athletes with prior COVID-19 infection that had cardiac MRI done as part of the college’s return to play medical evaluation. 

Twenty-six (26) college athletes that had previously tested positive for COVID-19 during the summer were enrolled in the study. None of the athletes had COVID-19 symptoms requiring hospitalization 

Out of 26 college athletes studied, a total of 4 (15%) of those Division 1 college athletes had abnormal cardiac MRI findings consistent with myocarditis or inflammation of the heart. Two of the athletes with myocarditis on MRI had no symptoms whatsoever and also had normal EKG and cardiac ultrasound. The other two  athletes were symptomatic with complaints of mild shortness of breath.

There are some details in this study that could impact their findings.  One factor affecting the results could be the short time frame between when the athletes were diagnosed with COVID-19 and when they had their cardiac MRI. In most cases, the cardiac MRI was done around 2 to 3 weeks after diagnosis, but in some cases, as soon as 11 days after diagnosis. 5 This shorter interval from time of positive COVID-19 test to the time of the cardiac MRI may demonstrate more acute response to COVID-19 rather than prolonged cardiac issues. 

We don’t yet know if this cardiac inflammation seen on the cardiac MRI is an acute phase reaction due to viral load and ACE-2 receptors on the heart or if this is an indication of possible longer term issues in these athletes. The four athletes that had cardiac MRIs consistent with myocarditis were tested at days 11,12, 17 and 23 from diagnosis of COVID-19. But with the German study showing continued cardiac inflammation past 2 months, this is an area of concern that needs further followup.

There have been otherindividual cases reported of other college athletes diagnosed with myocarditis following COVID-19 infection. Indiana University freshman football player Brian Feeney was diagnosed with COVID-19 during summer football practice and spent two weeks battling the virus (https://www.indystar.com/story/sports/college/indiana/2020/08/03/iu-football-players-mother-posts-covid-19-diagnosis/5577215002/))

The Ohio State study also found that 12 of the 26 athletes other signs of heart involvement from their COVID-19 infection. These twelve athletes all had some signs of late gadolinium enhancement (LGE) on cardiac MRI. Gadolinium is a dye injected into the vein during cardiac imaging tests where the damaged heart cells take up the gadolinium, but healthy heart cells won’t take up the dye t. 6 Late gadolinium enhancement on cardiac MRI is considered to be an indication of possible heart damage. The positive LGE group included the 4 athletes with myocarditis changes on cardiac MRI as well as 8 additional athletes. 

Return to running for runners after COVID-19 guidelines

Evidence of cardiac inflammation and damage in otherwise young and healthy college athletes is obviously worrisome. These findings may mean that  COVID-19 infections causes more damage in otherwise healthier patients that previously thought.

While there are published guidelines on return to play for athletes after COVID-19, 

7 as well as expert opinion pieces published 8 9 these guidelines may need to be updated as we find out more about long-term effects of COVID-19

If you have had COVID-19, even if asymptomatic, I’d recommend seeing your doctor for medical clearance prior to a return to running. If you have had significant symptoms from COVID-19 (with or without hospitalization) then discuss with your doctor the potential need for cardiac workup that may include a cardiology consult and cardiac testing.

The JAMA Cardiology guidelines 7 from earlier in the year offer a starting point for possible workup including an electrocardiogram (EKG), cardiac echocardiogram and potentially cardiac MRI in some cases.

Stay tuned, COVID-19 has definitely made us rethink how we clear runners and other athletes to go back to exercising after a COVID-19 infection. Prevention of COVID-19 in runners is still important!

Research
  1. https://jamanetwork.com/journals/jama/fullarticle/2762130[]
  2. https://www.thesun.co.uk/news/11139314/italys-coronavirus-patient-one-38-finally-taken-off-life-support-18-days-after-marathon-runner-was-struck-down/[]
  3. https://jamanetwork.com/journals/jamacardiology/fullarticle/2768916[]
  4. https://jamanetwork.com/journals/jamacardiology/fullarticle/2770645[]
  5. Table from the research letter. []
  6. https://www.ahajournals.org/doi/10.1161/CIRCIMAGING.113.001144[]
  7. https://jamanetwork.com/journals/jamacardiology/fullarticle/2766124[][]
  8. https://blogs.bmj.com/bjsm/2020/04/24/the-resurgence-of-sport-in-the-wake-of-covid-19-cardiac-considerations-in-competitive-athletes/[]
  9. https://www.acc.org/latest-in-cardiology/articles/2020/05/13/12/53/exercise-and-athletics-in-the-covid-19-pandemic-era[]

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