Doctors Recommend Caution When Returning to Exercise Post-COVID-19

Stephen Day was very fit, very healthy. At 49, he’s a three-time Kona finisher, once in the top ten in his age group. Went to the doctor maybe every five years, had never had a course of antibiotics. Then he got coronavirus.

“I’ve been to the doctor five times in the last month,” Day said by phone from his home outside NYC. “It’s been three months and I just feel like I’m back to full health. I’ve lost a bunch of fitness, but that’s fine.”

Looking back, Day knows exactly when he was exposed. It was the evening of Saturday, March 7, when he and his wife went to a birthday party held in a private room in a restaurant in New York City. Social distancing was not yet a thing, the food was served family style. “It was basically a science experiment for the virus,” he said.

On Tuesday, he had a bit of a cough but had done a hard workout that day so thought nothing of it. Wednesday he woke with a fever and headache and went to the doctor who said it was “something viral” but that his fever and oxygen saturation level didn’t meet criteria for COVID testing. Day was sent home and told to self-isolate. Later that day, a friend who’d been at the birthday party said a number of the guests had COVID symptoms. Eventually 17 of the 20 guests would experience symptoms. When the clinic still would not test him, Day and his wife drove to their weekend home about 90 miles from the city figuring it would be easier to isolate there.

He had some back pain, night sweats, but no breathing issues. Fatigue was probably the most onerous symptom—he napped to make it through the day. “But I could function. At the time, I thought I’d had worse colds. In hindsight, I’ve changed my mind.”

After a full two weeks with no training, Day went out for a short run. “I felt dreadful, really tired, my heart rate was high. I went straight to bed. It was clearly way too soon. Another week went by, and I’d try again. There was a lot of stop-starting. I’d feel okay, go out for a run, get a half-mile in, and have to walk home. My running pace in February was 6:45; in April, it was 8:30 and I felt terrible. No chest tightness; it was like I was completely unfit. But it was the mental part, too. Going from training 12 to 13 hours a week to walking home from a half-mile run was really hard. It affected my mood. I couldn’t focus on work.”

Two months of gradual improvement had Day cautiously optimistic. Then he got an infection on his elbow and his whole arm swelled. A week after that, and the first course of antibiotics in his life, he got a kidney infection. “Though it was not directly related to COVID, the doctor suggested that the virus had compromised my immune system,” Day said.

Day’s experiences highlight the insidiousness of the disease. The list of unknowns is long—why the course of the virus varies from asymptomatic to fatal, what organs are affected and how those changes impact the patient, both during the illness and afterward. Are changes temporary or permanent? And long-term? We haven’t even gotten there yet. Adding the athletic load of training to an already uncertain recovery protocol is, admittedly, an educated guess.

“Given the lack of an adequate database on this new disease and especially the lack of scientific knowledge on the sport-specific aspects of the disease, we understand this position paper as an initial expert consensus on the question of conception of the safest possible return of the athlete to competitive sport after an infection with SARS-CoV-2.”

That’s the caveat from a paper in the German Journal of Sports Medicine, one of several recently published giving guidelines for returning to sport after coronavirus. Including the Lancet, and JAMA Cardiology, all share a very conservative approach to return to training, ranging from two weeks of light exercise to three months off and cardiac testing. The Return To Play protocol is dependent on the severity of the symptoms—asymptomatic, mild to moderate, or requiring hospitalization.

“I lean toward the idea that your body will talk to you if you’re listening,” said Dr. Bill Roberts, professor of Family Medicine, Community Health and Sports Medicine at the University of Minnesota, of returning to exercise after Coronavirus. Roberts is also the medical director of the Twin Cities Marathon. “Wait until you feel well and gradually increase activity. For athletes, it’s important that they not start where they left off before getting sick. Assume starting from an inactive status, so even for an athlete who had been in good shape, that may mean building up to 30 minutes of walking before any running.”

For those who were asymptomatic, guidelines recommend light exercise for two weeks and close monitoring of symptoms. Those with mild to moderate symptoms, like Stephen Day, are advised to take an additional 10 days to two weeks of total rest after all their initial symptoms resolved, which might end up being four weeks off. That turned out to be accurate for Day. Anyone who has been hospitalized, though, needs to use extra caution.

“What we’re worried about is myocarditis,” Roberts said. Myocarditis, inflammation of the heart muscle caused by the virus, can weaken the heart, and cause arrhythmias that can be fatal. “It’s hard to tell who has had scarring of the heart muscle. Muscle aches, one of the symptoms of COVID, is the virus attacking the muscles, and if it’s attacking the skeletal muscles, we can assume it’s attacking the heart muscle too.”

Since it’s hard to tell who has experienced myocarditis and how that will affect the individual patient long-term, Roberts agreed with other experts that anyone whose symptoms were severe enough to require hospitalization should take extra time off from exercise and have cardiac testing before resuming training. If myocarditis is confirmed, the most conservative paper recommended three months of no exercise, cardiac testing, and careful monitoring by physicians as training is resumed.

While there’s no hard data on weakening of the immune system post-COVID, as Day experienced, it aligns with what’s known about other viral infections, Roberts said. The good news there is that it’s temporary, like the lapse in immunity after an intense workout.

Further confounding athletes’ return to training is that three or four weeks of total rest will result in some deconditioning. So is that feeling of being totally unfit, as Day described, deconditioning or a sign you’re not ready to work out?

“That’s part of the difficulty. There are not great markers,” Roberts said. “My guess is, if you exercise and feel fine the next morning, that’s okay. If you’re still tired the next day, if your heart rate or your morning pulse is high, you’ve probably done too much.”

Both the RTP guidelines in the German Journal of Sports Medicine and JAMA Cardiology recommended that athletes who have had mild to moderate viral symptoms have an electrocardiogram before returning to hard training. “This is controversial. I tend toward doing the study [ECG] if there is a symptom, but others would disagree,” Roberts said.

The red flag symptoms Roberts is talking about are chest pressure or pain, feeling like you can’t get your breath, racing or erratic heartbeat, or feeling like you just can’t get going, very heavy, for a few minutes at the start of exercise. If you experience any of these symptoms in your return to training, Roberts recommended being evaluated for possible myocarditis.

Ten days clear of his third bout of antibiotics, Stephen Day feels like a new man. Or rather, his old self. “My fitness has been ramping up like crazy. I think it didn’t really go away—it was just masked by illness. I really think I’ve turned a corner. Of course, I’ve said that a lot of times over the past three months.”