Dr. Chris Koutures has tips for returning to the court after having COVID

volleyball after covid 3/20/2021

You are a volleyball player who had COVID illness or an exposure without symptoms.

Your goal is to make a return to the court.

What should you know and do to make as safe a comeback as possible?

Concerns about COVID in athletes
In many people who are exposed to COVID, there are no signs or symptoms of illness. For those who develop illness, there is a variety of symptoms that may include cough, elevated temperature, body aches, loss of taste/smell, fatigue, and chest pain. These symptoms maybe get better by themselves and last for just a few (2-3) days.  In a smaller number of people, they may last longer or become so intense that hospital care may be needed. 

Individuals who are exposed to COVID are recommended to quarantine at home for a minimum of 10 days. Those with symptoms are asked not to exercise until they are feeling better for at least 5 days (some mild fatigue or lasting loss of taste and smell is considered acceptable in allowing a return to exercise). If in quarantine due to exposure alone without development of symptoms, light exercise is allowed.

For most athletes, the time away from practice, strength training and games is the biggest downside of exposure to COVID. These athletes need time to build up general fitness, strength and volleyball-specific movements before being able to return to a high level of play. 

  • KEY POINT: EASY FATIGUE IS SOMETHING TO TAKE SERIOUSLY- NOTIFY YOUR MEDICAL TEAM IF YOU HAVE THIS AFTER COVID EXPOSURE

If there is any symptom that tends to stick around after COVID exposure, it is fatigue. We have seen patients that have had trouble walking across their apartment or doing basic schoolwork. This type of fatigue really gets a physician’s attention. Others are fine with regular life stuff but find themselves easy to tire when resuming exercise. This could be from that deconditioning, or perhaps from something more serious.

One of the most concerning challenges of COVID is the possibility of serious damage to the heart or lungs. Inflammation of the heart muscle, known as myocarditis, is a potentially life-threatening disease that can come after viral infections such as COVID. Some of the first studies looking at COVID illness found an alarmingly high number of cases of myocarditis. While follow-up studies have thankfully showed a relatively lower number of identified myocarditis cases, the risk is still high enough to require additional evaluation before athletes return to practice and competition. 

Inflammation of the small airways of the lungs, along with damage to other tissues, can also be a result of COVID exposure. This too can lead to easy fatigue as well as lasting cough and chest pressure. Athletes with previous lung issues, most namely asthma, might have more problems, including a worsening of asthma symptoms. 

After COVID, get a medical evaluation before returning to volleyball
Once symptoms are fully or mostly gone, players should be evaluated by a medical provider and get written medical clearance before resuming any training or competition. This is not just a formality for a team, club or school, but rather should be seen as an important opportunity to assess for lasting symptoms, the need for additional testing, and a sensible return plan.

The examination should be an in-person visit (telemedicine is not recommended) so that vital signs and a hands-on physical exam can take place. It is best to find a provider who has experience and the latest information in post-COVID return to sport evaluations.

Honesty is key during this evaluation. Don’t let the desire to get back to play silence any symptoms or concerns. Your immediate and long-term health are in play. Make sure your medical professional is well aware of exactly when you first got sick or exposed, any/all symptoms that came up, and how things are currently doing. Report any past illnesses, such as heart issues, asthma, or diabetes that could have an effect on your recovery. The same goes for any medications that you used or are using.

In addition to the history and physical exam, additional testing may take place. Decisions to do additional testing are based on the number and length of COVID symptoms, longer-lasting fatigue, age/level of volleyball play, and concerns found during the history and physical exam. The additional testing can include:

  • Electrocardiogram (EKG) that looks at heart rate and shape/timing of the heart rhythm
  • Troponin blood test (high in the event of heart muscle damage)
  • Echocardiogram (ultrasound looking at size/shape of heart chambers, valves and blood vessels, blood flow and pressures)
  • Treadmill stress test that measures vitals and heart/lung function before and during exercise
  • Cardiac Magnetic Resonance Imaging (MRI) that takes an in-depth look at heart anatomy and blood flow within the heart muscle

Step-by-step return to volleyball
Once the medical evaluation is completed, clearance is given not just to immediately resume full play, but rather that clearance is given to start a stepwise progression back to volleyball. This return is done in stages to allow for reconditioning and also to watch for signs or symptoms of concern that did not come up before starting exercise.

The stepwise return starts with lower-level conditioning and individual volleyball-specific skills before advancing to higher intensity activities, weight-training, and eventual group-based drills, scrimmaging and competition. Each stage should be done at least once with a minimum 24-hour period between each stage.

This is another time when that full honesty is absolutely vital. If things don’t feel right, especially that sense of easy fatigue, stop the progression and alert the medical team. Ideally, this return is watched over by a certified athletic trainer working with the team or school. The athletic trainer can adjust the intensity and speed of return stages, monitor for issues, and be an advocate for players in communication with coaches and other medical personnel.

Many athletes have found that using a heart rate monitor can assist in this return process. This may include wearable chest-based devices (probably the most accurate but more costly) or even watches that can detect the number of heartbeats per minute. Another monitoring option is using a Rating of Perceived Exertion (RPE) scale. .

Athletes can compare the reported RPE to coaches’ estimates for a certain level of activity. If the athlete’s RPE is much higher (2 or more points) above the coach estimate, then there should be an immediate re-evaluation of progress.

Here is a sample volleyball return progression:

PHASE HEART RATE MONITORING STRENGTH TRAINING VOLLEYBALL SKILLS
1 (done at least twice) Walk/jog/bike/elliptical up to 70% max heart rate for 15 minutes maximum None None
2 Walk/jog/bike/elliptical up to 80% max heart rate with 30 minutes maximum None Self-set, light wall ball or pepper, light serve
3 Practice skills at 80% max heart rate up to 45 minutes maximum Light, start with seated activities Serve-receive, pass, serve, hit without block, individual blocking drills 
4 (at least 2 sessions) Practice/training at 80% max heart rate up to 60 minutes maximum Full Full skills include serve, receive/pass, hit, dive and block
5 No limit on heart rate- can do full-length practice Full Full practice including scrimmage 
6 RETURN TO COMPETITION WITHOUT RESTRICTIONS Full Full participation

These guidelines and sample progression are only intended as a suggested guide following COVID. They should not replace an individualized assessment and clearance to start return progression created by an athlete’s personal medical team.

Dr. Chris Koutures is a dual board-certified pediatric and sports medicine specialist who practices at ActiveKidMD in Anaheim Hills, CA. He is a team physician for USA Volleyball (including participating in the 2008 Beijing Olympics), the U.S. Figure Skating Sports Medicine Network, Cal State Fullerton Intercollegiate Athletics, Chapman University Dance Department, and Orange Lutheran High School. He offers a comprehensive blend of general pediatric and sport medicine care with an individualized approach to each patient and family. Please visit activekidmd.com or follow him on Facebook (https://www.facebook.com/activekidmd/), Instagram (https://www.instagram.com/activekidmd/), or Twitter (@dockoutures).
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