IOC Medical COVID-19 Hub

This IOC Medical Covid-19 hub has been created to help support staff provide good medical care of Olympic athletes. Over a year ago, the IOC brought together an international group of experts in respiratory illnesses to develop a Consensus statement on Acute respiratory illness in athletes led by Martin Schwellnus from South Africa.

The consensus group was divided into six sub-groups to cover different aspects of acute respiratory illness. A seventh subgroup has now been established focusing on COVID-19 to help medical support teams cope with the demands of the new situation. The IOC has created a large team primarily from the IOC research centres and representatives from International Federations to work on COVID-19 Scientific Evidence for Athlete management.

The IOC realises the challenges of finding, studying, and acting on the flow of current information. This hub will help all those involved in athlete care to decide whether news is real or fake and whether supposed scientific break-throughs are based on real data or are hypothetical extrapolations.

The IOC Medical COVID-19 Hub content will be a combination of the following:

  1. A repository of scientific advice, communications, links and relevant information that is gathered and provided by our colleagues in IOC Research Centres, Academic Sport Medicine Institutions, NOCs, IFs, and general sports medicine
  2. Disseminating ongoing literature searches for relevant scientific papers to add to the existing repository
  3. Provide a platform for publishing international Case Series to study the recovery of athletes from COVID-19

Latest News

Weekly updates on all COVID-19 resources can be found in this section. 


Evidence-based Research

The COVID-19 subgroup of the IOC Consensus group on “Acute Respiratory Illness in Athletes” is currently working in the following main areas. Please click on the area to access to the latest evidence-based resources on COVID-19 in athletes. To find out how the reviews are done, please follow this link

The focus of this section is on the incidence/prevalence of COVID-19 in athletes and specific risk factors associated with COVID-19 in athletes.

24 June 2020 reviewed by Lars Engebretsen

The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak

This paper presents basic early epidemiology of Covid-19. Be aware that this was written in February where the knowledge of consequences was still limited, but the paper represents the knowledge at that time.

Type of investigation: Review
Level of evidence: 3B
Practical guideline rating scale: B


18 June 2020 reviewed by Lars Engebretsen

Novel Coronavirus Infection (COVID-19) in Humans: A Scoping Review and Meta-Analysis. J Clin Med

A growing body of literature on the 2019 novel coronavirus (SARS-CoV-2) is becoming available, but a synthesis of available data has not been conducted. This study performed a scoping review of currently available clinical, epidemiological, laboratory, and chest imaging data related to the SARS-CoV-2 infection.

Qualitative synthesis and meta-analysis were conducted using the clinical and laboratory data, and random-effects models were applied to estimate pooled results. A total of 61 studies were included (59,254 patients). The most common disease-related symptoms were fever, cough, muscle aches and/or fatigue, dyspnoea, headache in 12%, sore throat in 10% and gastrointestinal symptoms in 9%. Laboratory findings were described in a lower number of patients and revealed lymphopenia and abnormal C-reactive protein. Radiological findings varied, but mostly described ground-glass opacities and consolidation. Data on treatment options were limited. All-cause mortality was 0.3%. Epidemiological studies showed that mortality was higher in males and elderly patients. The majority of reported clinical symptoms and laboratory findings related to SARS-CoV-2 infection are non-specific. Clinical suspicion, accompanied by a relevant epidemiological history, should be followed by early imaging and virological essay.

Type of investigation: Review
Level of evidence: 3B
Practical guideline rating scale: B


17 June 2020 reviewed by Alan McCall

Nowhere to hide: The significant impact of coronavirus disease 2019 (COVID-19) measures on elite and semi-elite South African athletes. Journal of Science & Medicine in Sport. 2020

This study surveyed 692 female & male elite and semi-elite athletes from both team and individual sports in South Africa. The response rate was 64% (602/1080 respondents). The survey aimed to collect perceptions and experiences on return to sport during the current COVID-19 pandemic and in particular relating to physical, nutritional and psychological perspectives. The most represented sports were soccer (26%), hockey (16%) and rugby (13%).

The survey revealed that the COVID-19 lockdown period may have resulted in adverse physical, nutritional and psychological consequences for athletes and these areas should be given particular focus by sports organisations and support teams working with athletes upon return to sport.

Despite some novel information in this study and common sense practical recommendations, some methodological concerns are present. We encourage the reader to interpret the results in this context. Firstly, the time from design to implementation of the survey is short and the rigour of survey development may have been affected. The methods are too short to allow critique. Additionally, the authors have adapted already validated questionnaires on ‘maintenance of activity, nutrition and mental state’. Adapting validated instruments can affect their validity.

Type of investigation: Other
Level of evidence: 5
Practical guideline rating scale: C

The focus of this section is on the pathology / pathophysiology of COVID-19 including possible involvement of organ systems other than the respiratory tract (e.g. what % cases have myo-pericarditis and other possible systemic organ involvement)

15 September 2020 reviewed by Katja Mjøsund

Cardiovascular Magnetic Resonance Findings in Competitive Athletes Recovering From COVID-19 Infection

Myocarditis is a significant cause of sudden cardiac death in athletes and some studies have raised concerns of myocardial inflammation and possible fibrosis after recovery from COVID-19. In this research letter the investigators performed cardiac MR imaging (CMR) in young competitive athletes after a mild or asymptomatic COVID-19 infection. The MRI was performed 8-53 days after a positive PCR test for COVID-19. Four of 26 (15%) athletes) had CMR findings consistent with myocarditis and 8 additional athletes (30.8%) exhibited late gadolinium enhancement, suggestive of prior myocardial injury.

The interpretation of the results in this small study is limited by the lack of baseline CMR, a possible selection bias and the variable timing of CMR. However, the possible myocardial involvement of COVID-19 infection even in mildly symptomatic or asymptomatic young athletes must be kept in mind when designing return to play strategies.
The possible myocardial involvement of COVID-19 infection even in mildly symptomatic or asymptomatic young athletes may influence the return to play strategies and may warrant cardiac screening.

The authors suggest that CMR may provide a risk stratification assessment tool for myocarditis in athletes recovering from COVID-19.

Type of investigation: Diagnostic accuracy
Level of evidence: 4
Practical guideline rating scale: C


24 June 2020 reviewed by Lars Engebretsen

The Stanford Hall Consensus Statement for post-COVID-19 Rehabilitation

This consensus statement provides an overarching framework assimilating evidence and likely requirements of multidisciplinary rehabilitation post-COVID-19 illness, for a target population of active individuals, including military personnel and athletes.

Type of investigation: Expert group consensus
Level of evidence: 3B
Practical guideline rating scale: C

The focus of this section is on the interaction between exercise, sport, training and risk of COVID-19.
13 August 2020 reviewed by Lars EngebretsenPre-existing immunity to SARS-CoV-2: the knowns and unknowns. Alessandro Sette and Shane Crotty, Nature July 20T cell reactivity against SARS-CoV-2 was observed in unexposed people; however, the source and clinical relevance of the reactivity remains unknown. It is speculated that this reflects T cell memory to circulating ‘common cold’ coronaviruses. It will be important to define specificities of these T cells and assess their association with COVID-19 disease severity and vaccine responses.In conclusion, it is now established that SARS-CoV-2 pre-existing immune reactivity exists to some degree in the general population. It is hypothesized, but not yet proven, that this might be due to immunity to CCCs. This might have implications for COVID-19 disease severity, herd immunity and vaccine development, which still await to be addressed with actual data.Type of investigation: Editorial
Level of evidence: 5
Practical guideline rating scale: Insufficient evidence to provide rating


13 August 2020 reviewed by Lars Engebretsen

Cell-Mediated Immune Responses to COVID-19 Infection. Frontiers of Immunology July 20. Amélie Guihot, Elena Litvinova, Brigitte Autran, Patrice Debré and Vincent Vieillard

This mini-review focuses on the cellular immune response to COVID-19 in human subjects, compared to other clinically relevant coronaviruses to evaluate its role in the control of infection and pathogenesis and accelerate the development of a preventive vaccine or immune therapies.

Current observations indicate that SARS-CoV-2 is particularly adapted to evade immune responses at the early stage of infection. Most mechanisms are linked to inappropriate type 1 IFN responses, massive inflammatory cytokine production, and possibly to a defect in NK-cell functions. Preliminary data also suggest adaptive immune evasion, as indicated by the exhaustion of T lymphocytes. However, current evidence strongly indicated that the Th1-type response is key to the successful control of human pathogenic CoVs, in the association with the presence of specific neutralizing Abs. Although there are clear relationships between the severity of the disease and immune responses, the role of protective immunity currently remains questionable.

Type of investigation: Review (narrative)
Level of evidence: 5
Practical guideline rating scale: Insufficient evidence to provide rating

08 September 2020 reviewed by Lars Engebretsen

Saliva or Nasopharyngeal Swab Specimens for Detection of SARS-CoV-2

Saliva may be used as an alternative to detection of the virus. Collection of saliva samples by patients themselves negates the need for direct interaction between health care workers and patients. This interaction is a source of major testing bottlenecks and presents a risk of nosocomial infection. Collection of saliva samples by patients themselves also alleviates demands for supplies of swabs and personal protective equipment. Given the growing need for testing, our findings provide support for the potential of saliva specimens in the diagnosis of SARS-CoV-2 infection.

Type of investigation: Diagnostic accuracy
Level of evidence: 3A
Practical guideline rating scale: B


08 September 2020 reviewed by Lars Engebretsen

Humoral Immune Response to SARS-CoV-2 in Iceland

Antibodies in the Iceland population. Little is known about the nature and durability of the humoral immune response to infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

The results indicate that antiviral antibodies against SARS-CoV-2 did not decline within 4 months after diagnosis. We estimate that the risk of death from infection was 0.3% and that 44% of persons infected with SARS-CoV-2 in Iceland were not diagnosed by qPCR.

Type of investigation: Diagnostic accuracy
Level of evidence: 3A
Practical guideline rating scale: A

The focus of this section is on special considerations in the management (pharmacological and non-pharmacological) of COVID-19 in athletes.

The focus of this section is on a number of areas including the following (please click on the area of interest) (by clicking – redirect to another webpage dedicated to this section)

22 August 2020 reviewed by Martin Schwellnus

Assessment of SARS-CoV-2 Transmission on an International Flight and Among a Tourist Group: JAMA Network Open

This study reports a case series of 7 international travellers on a commercial flight (4hrs:40min) who tested positive for SARS-CoV-2 RNA in a throat swab sample on arrival. Among a total of 102 passengers these 7 were part of a group of 24 tourists who, 7 days earlier, had contact with an individual who was later diagnosed with COVID-19. No member of the group had received a diagnosis of COVID-19 before the flight, and no measures to prevent transmission (e.g. wearing of masks) had been applied. The main finding was that with the 7 index cases on the flight, there were 2 likely SARS-CoV-2 transmissions on the flight, both seated within 2 rows of an index case. These transmissions may have also occurred before or after the flight.

This case series highlights the importance of preventative measures to reduce risk of transmission of SARS-CoV-2 during commercial flights for travelling athletes.

Type of investigation: Aetiology
Level of evidence: 4
Practical guideline rating scale: X


01 July 2020 reviewed by Lars Engebretsen

Possible indirect transmission of COVID-19 at a squash court, Slovenia, March 2020: case report. Cambridge University Press.

Since the beginning of the COVID-19 epidemic, there is an ongoing debate and research regarding the possible ways of virus transmission. An epidemiological investigation was conducted which revealed a cluster of five COVID-19 cases, linked to playing squash at a sports venue in Maribor, Slovenia. Acquired data raises possibility that the transmission occurred indirectly through contaminated objects in changing room or squash hall or via aerosolisation in a squash hall.

Type of investigation: Prevention
Level of evidence: 4
Practical guideline rating scale: Insufficient evidence to provide rating


01 July 2020 reviewed by Lars Engebretsen

Aerosol and Surface Stability of SARS-CoV-2 as compared with SARS-CoV-1. NEJM

The results indicate that aerosol and fomite transmission of SARS-CoV-2 is plausible, since the virus can remain viable and infectious in aerosols for hours and on surfaces up to days (depending on the inoculum shed). These findings echo those with SARS-CoV-1, in which these forms of transmission were associated with nosocomial spread and super-spreading events, and they provide information for pandemic mitigation efforts.

In the athletic and sport setting, this has potential practical implications for risk mitigation strategies e.g. when using sports equipment made from different materials.

Type of investigation: Prevention
Level of evidence: 3B
Practical guideline rating scale: Insufficient evidence to provide rating


1 June 2020 reviewed by Alan McCall

Returning to Play after prolonged restrictions in professional collision sports. Keith A Stokes et al. Int J Sports Med.

This narrative review provides a general insight into three key areas: (i) The potential impact of a period of restricted training in athletes from a physiological and psychological perspective, (ii) Provides some general considerations for returning to training and competition focusing mainly on physical/physiological qualities, including training interventions, progressions, basic training principles, and nutritional aspects, and (iii) Outlines considerations for athletes returning to sport after suspected or confirmed COVID-19 infection. The information may help sports science & medicine practitioners to plan restricted training and return to sport programmes from an exercise and nutrition perspective. The section on returning to sport following suspected or confirmed COVID-19 infection may need to be interpreted with caution as the section is based on early reports and recommendations/considerations are not backed up with a relevant scientific base and information may have changed/be changing compared to when this paper was accepted on 14th May 2020.

Type of investigation: Review
Level of evidence: 5
Practical guideline rating scale: C

01 July 2020 reviewed by Lars Engebretsen

Aerosol and Surface Stability of SARS-CoV-2 as compared with SARS-CoV-1. NEJM

The results indicate that aerosol and fomite transmission of SARS-CoV-2 is plausible, since the virus can remain viable and infectious in aerosols for hours and on surfaces up to days (depending on the inoculum shed). These findings echo those with SARS-CoV-1, in which these forms of transmission were associated with nosocomial spread and super-spreading events, and they provide information for pandemic mitigation efforts.

In the athletic and sport setting, this has potential practical implications for risk mitigation strategies e.g. when using sports equipment made from different materials.

Type of investigation: Prevention
Level of evidence: 3B
Practical guideline rating scale: Insufficient evidence to provide rating


25 June 2020 reviewed by Lars Engebretsen

Safety, tolerability, and immunogenicity of a recombinant adenovirus type-5 vectored COVID-19 vaccine: a dose-escalation, open-label, non-randomised, first-in-human trial. The Lancet

A vaccine to protect against COVID-19 is urgently needed. The aim of this study was to assess the safety, tolerability, and immunogenicity of a recombinant adenovirus type-5 (Ad5) vectored COVID-19 vaccine expressing the spike glycoprotein of a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) strain.
This is the first published article in a major journal on the vaccine research and shows that: The Ad5 vectored COVID-19 vaccine is tolerable and immunogenic at 28 days post-vaccination.

Humoral responses against SARS-CoV-2 peaked at day 28 post-vaccination in healthy adults, and rapid specific T-cell responses were noted from day 14 post-vaccination. Our findings suggest that the Ad5 vectored COVID-19 vaccine warrants further investigation. This is what you need to resume professional sports.

Type of investigation: Prevention
Level of evidence: 3B/4
Practical guideline rating scale: Insufficient evidence to provide rating


19 June 2020 reviewed by Tim Meyer

The resumption of sports competitions after COVID-19 lockdown: The case of the Spanish football league. Chaos, Solitons and Fractals 138 (2020)

The paper presents a modelling approach for disease transmission in a football league, in this case the Spanish one. Several assumptions (some of them questionable) are put into the model and parameters varied to demonstrate their effect on the outcome variable: number of infected players during the season. I am not the kind of expert to assess the modelling approach in detail. However, the more interesting part of this are the responses to varying parameters. The number of infections decreases when the time between matches is reduced (probably due to less chances of acquiring the infection in private life) and when the number of PCR tests is increased. The second result seems obvious, the first one a bit counterintuitive. The absolute numbers of infections are, of course, dependent on the assumptions about the likelihood of getting infected during training and match play. These estimations, however, seem very vague. Therefore, the prediction of the number of infections is probably a weaker aspect of the paper.

Type of investigation: Prevention
Level of evidence: N/A
Practical guideline rating scale: B


2 June 2020 reviewed by Paolo Emilio Adami

https://bjsm.bmj.com/content/early/2020/05/23/bjsports-2020-102539

The paper presents in detail the risk assessment tool developed by the World Health Organization (WHO) to evaluate stadium/venue-based sports mass gathering events. Through the practical examples of two football matches, it illustrates the potential different results that the tool could provide based on the mitigation actions the event organisers takes. Based on the sport’s characteristics and on mitigation actions taken, the risk of transmission can be significantly reduced, and the sport event staged. Close cooperation across sectors, in particular with public health authorities, is fundamental to coordinate actions and protect athletes and local communities.

Type of investigation: Other
Level of evidence: 5
Practical guideline rating scale: C

4 October 2020 reviewed by Lars Engebretsen

Return to sport for North American professional sport leagues in the context of COVID-19.

A paper on return to sports by the US professional leagues. COVID-19 is a respiratory illness that can spread from person to person. A range of clinical scenarios exist, from an asymptomatic disease course to SARS and death. This document describes important considerations for 5 North American professional sports leagues (Major League Baseball, Major League Soccer, National Basketball Association, National Football League and National Hockey league) assessing when and how to resume phased operations, including practices and games. Sports should prioritise and promote the health and safety of athletes, team and operational staff, and other participants, and should not unduly increase those individuals’ relative health risk while contributing to economic recovery, providing entertainment for the public and leading a responsible restoration of civic life.

Type of investigation: Expert group consensus
Level of evidence: 4
Practical guideline rating scale: B


2 June 2020 reviewed by Paolo Emilio Adami

https://bjsm.bmj.com/content/early/2020/05/23/bjsports-2020-102539

The paper presents in detail the risk assessment tool developed by the World Health Organization (WHO) to evaluate stadium/venue-based sports mass gathering events. Through the practical examples of two football matches, it illustrates the potential different results that the tool could provide based on the mitigation actions the event organisers takes. Based on the sport’s characteristics and on mitigation actions taken, the risk of transmission can be significantly reduced, and the sport event staged. Close cooperation across sectors, in particular with public health authorities, is fundamental to coordinate actions and protect athletes and local communities.

Type of investigation: Other
Level of evidence: 5
Practical guideline rating scale: C


1 June 2020 reviewed by Alan McCall

Returning to Play after prolonged restrictions in professional collision sports. Keith A Stokes et al. Int J Sports Med.

This narrative review provides a general insight into three key areas: (i) The potential impact of a period of restricted training in athletes from a physiological and psychological perspective, (ii) Provides some general considerations for returning to training and competition focusing mainly on physical/physiological qualities, including training interventions, progressions, basic training principles, and nutritional aspects, and (iii) Outlines considerations for athletes returning to sport after suspected or confirmed COVID-19 infection. The information may help sports science & medicine practitioners to plan restricted training and return to sport programmes from an exercise and nutrition perspective. The section on returning to sport following suspected or confirmed COVID-19 infection may need to be interpreted with caution as the section is based on early reports and recommendations/considerations are not backed up with a relevant scientific base and information may have changed/be changing compared to when this paper was accepted on 14th May 2020.

Type of investigation: Review
Level of evidence: 5
Practical guideline rating scale: C

14 September 2020 reviewed by Lars Engebretsen

COVID-19 and Review of Current Recommendations for Return to Athletic Play

In December 2019 a respiratory illness known as Coronavirus 2 (SARS-CoV-2, COVID-19) broke out in a region in China and rapidly spread to become a pandemic affecting all sporting events worldwide. The Summer Olympics scheduled to be held in Tokyo were postponed until 2021, and all professional leagues in the United States postponed or cancelled events. As the United States has begun to open up, there remains uncertainty of when sporting events can safely be held. Many professional leagues and the National Collegiate Athletic Association have established guidelines and recommendations for their athletes to compete safely. In this article, we review the protocols that have been established to allow athletes to return to play, and we review briefly the effects COVID-19 infection may have on athletes
Practical info and advice, primarily for US sports.

Type of investigation: Review (narrative)
Level of evidence: 3B
Practical guideline rating scale: A


03 September 2020 reviewed by Lars Engebretsen

Cardiorespiratory considerations for return-to-play in elite athletes after COVID-19 infection: a practical guide for sport and exercise medicine physicians

As infection rates drop and quarantine restrictions are lifted, the question how athletes can safely resume competitive sport is being asked. Given the rapidly evolving knowledge base about the virus and changing governmental and public health recommendations, a precise answer to this question is fraught with complexity and nuance. Without robust data to inform policy, return-to-play (RTP) decisions are especially difficult for elite athletes on the suspicion that the COVID-19 virus could result in significant cardiorespiratory compromise in a minority of afflicted athletes. There are now consistent reports of athletes reporting persistent and residual symptoms many weeks to months after initial COVID-19 infection. These symptoms include cough, tachycardia and extreme fatigue. To support safe RTP, we provide sport and exercise medicine physicians with practical recommendations on how to exclude cardiorespiratory complications of COVID-19 in elite athletes who place high demand on their cardiorespiratory system.

Type of investigation: Review (narrative)
Level of evidence: 4
Practical guideline rating scale: C


14 July 2020 reviewed by Martin Schwellnus

Persistent Symptoms in Patients After Acute COVID-19, 2020, JAMA

Information is lacking on symptoms that may persist after recovery from COVID-19. In this research letter, persistent symptoms following recovery from COVID-19 were assessed in 143 hospitalized patients that were discharged and followed up. The main findings are that a high proportion of individuals still reported fatigue, dyspnea, joint pain and chest pain at follow-up. Although this is a single-centre study, with a small number of older patients that were hospitalized (more severe illness), there is potential application of these results in athletes and active individuals that recover from COVID-19. In athletes with more severe COVID-19, medical staff need to be aware of persistent symptoms that may affect return to training.

In athletes with more severe COVID-19, symptoms such as fatigue, dyspnea, joint pain and chest pain may persist for weeks following recovery, highlighting the importance of continuous symptom monitoring following return to play.

Type of investigation: Prognosis
Level of evidence: 4
Practical guideline rating scale: C


24 June 2020 reviewed by Lars Engebretsen

The Stanford Hall Consensus Statement for post-COVID-19 Rehabilitation

This consensus statement provides an overarching framework assimilating evidence and likely requirements of multidisciplinary rehabilitation post-COVID-19 illness, for a target population of active individuals, including military personnel and athletes.

Type of investigation: Expert group consensus
Level of evidence: 3B
Practical guideline rating scale: C


24 June 2020 reviewed by Lars Engebretsen

Recommendations for altitude training programming to preserve athletes’ health after COVID-19 pandemic

Return to high altitude training and monitoring. This paper should be important in the coming year.

Type of investigation: Review
Level of evidence: 3B
Practical guideline rating scale: C


18 June 2020 reviewed by Lars Engebretsen

Training Restrictions in Professional Collision Sports. Int J Sports Med

With a focus on rugby league and rugby union, the purpose of this review is to examine the available evidence related to the following: potential changes to physical qualities and function during the period of modified training, strategies to mitigate this decline in function, and the time taken to return players and teams to “game ready” status. It is anticipated that many of the principles outlined in this review will be applicable to a broader range of collision sports (e. g. American football, Australian football). The final section provides practical recommendations that focus on restarting these sports after an extended break from training.

Type of investigation: Review
Level of evidence: 4
Practical guideline rating scale: C


3 June 2020 reviewed by Maarit Valtonen

Exercise in the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) era: A Question and Answer session with the experts. Endorsed by the section of Sports Cardiology & Exercise of the European Association of Preventive Cardiology (EAPC). Sanjay Sharma et al.

The publication offers practical recommendations for exercise in athletes based on symptoms and COVID-19 (viral RNA) test result. The authors propose a cardiac evaluation protocol of elite athletes prior to return to training and competitions. As the gaps in the literature still exists, the recommendations are based on the current understanding on possible cardiac involvement as a complication of the infection and potential implications for athletes, who push their cardiovascular system to the limits. The publication promotes safe participation in exercise in the COVID-19 era and offers a framework of management for physicians caring for athletes.

Type of investigation: Expert Group Consensus
Level of evidence: 5
Practical guideline rating scale: C


2 June 2020 reviewed by Andy Massey

https://www.germanjournalsportsmedicine.com/archiv/archive-2020/issue-5/position-stand-return-to-sport-in-the-current-coronavirus-pandemic-sars-cov-2-covid-19/

A position stand from an expert group from the German Society for Sports Medicine and Prevention and the German Olympic Sports Confederation looking at the potential presentation of SARS-CoV2/COVID-19 in the sporting population. The authors propose a model of investigation (in the form of a decisional algorithm), dependent upon symptoms affecting the cardiovascular and respiratory systems, prior to reintegration in sport.

Type of investigation: Expert Group Consensus
Level of evidence: 5
Practical guideline rating scale: B


1 June 2020 reviewed by Alan McCall

Returning to Play after prolonged restrictions in professional collision sports. Keith A Stokes et al. Int J Sports Med.

This narrative review provides a general insight into three key areas: (i) The potential impact of a period of restricted training in athletes from a physiological and psychological perspective, (ii) Provides some general considerations for returning to training and competition focusing mainly on physical/physiological qualities, including training interventions, progressions, basic training principles, and nutritional aspects, and (iii) Outlines considerations for athletes returning to sport after suspected or confirmed COVID-19 infection. The information may help sports science & medicine practitioners to plan restricted training and return to sport programmes from an exercise and nutrition perspective. The section on returning to sport following suspected or confirmed COVID-19 infection may need to be interpreted with caution as the section is based on early reports and recommendations/considerations are not backed up with a relevant scientific base and information may have changed/be changing compared to when this paper was accepted on 14th May 2020.

Type of investigation: Review
Level of evidence: 5
Practical guideline rating scale: C

1 June 2020 reviewed by Alan McCall

Returning to Play after prolonged restrictions in professional collision sports. Keith A Stokes et al. Int J Sports Med.

This narrative review provides a general insight into three key areas: (i) The potential impact of a period of restricted training in athletes from a physiological and psychological perspective, (ii) Provides some general considerations for returning to training and competition focusing mainly on physical/physiological qualities, including training interventions, progressions, basic training principles, and nutritional aspects, and (iii) Outlines considerations for athletes returning to sport after suspected or confirmed COVID-19 infection. The information may help sports science & medicine practitioners to plan restricted training and return to sport programmes from an exercise and nutrition perspective. The section on returning to sport following suspected or confirmed COVID-19 infection may need to be interpreted with caution as the section is based on early reports and recommendations/considerations are not backed up with a relevant scientific base and information may have changed/be changing compared to when this paper was accepted on 14th May 2020.

Type of investigation: Review
Level of evidence: 5
Practical guideline rating scale: C

15 September 2020 reviewed by Katja Mjøsund

Cardiovascular Magnetic Resonance Findings in Competitive Athletes Recovering From COVID-19 Infection

Myocarditis is a significant cause of sudden cardiac death in athletes and some studies have raised concerns of myocardial inflammation and possible fibrosis after recovery from COVID-19. In this research letter the investigators performed cardiac MR imaging (CMR) in young competitive athletes after a mild or asymptomatic COVID-19 infection. The MRI was performed 8-53 days after a positive PCR test for COVID-19. Four of 26 (15%) athletes) had CMR findings consistent with myocarditis and 8 additional athletes (30.8%) exhibited late gadolinium enhancement, suggestive of prior myocardial injury.

The interpretation of the results in this small study is limited by the lack of baseline CMR, a possible selection bias and the variable timing of CMR. However, the possible myocardial involvement of COVID-19 infection even in mildly symptomatic or asymptomatic young athletes must be kept in mind when designing return to play strategies.
The possible myocardial involvement of COVID-19 infection even in mildly symptomatic or asymptomatic young athletes may influence the return to play strategies and may warrant cardiac screening.

The authors suggest that CMR may provide a risk stratification assessment tool for myocarditis in athletes recovering from COVID-19.

Type of investigation: Diagnostic accuracy
Level of evidence: 4
Practical guideline rating scale: C


14 July 2020 reviewed by Martin Schwellnus

Persistent Symptoms in Patients After Acute COVID-19, 2020, JAMA

Information is lacking on symptoms that may persist after recovery from COVID-19. In this research letter, persistent symptoms following recovery from COVID-19 were assessed in 143 hospitalized patients that were discharged and followed up. The main findings are that a high proportion of individuals still reported fatigue, dyspnea, joint pain and chest pain at follow-up. Although this is a single-centre study, with a small number of older patients that were hospitalized (more severe illness), there is potential application of these results in athletes and active individuals that recover from COVID-19. In athletes with more severe COVID-19, medical staff need to be aware of persistent symptoms that may affect return to training.

In athletes with more severe COVID-19, symptoms such as fatigue, dyspnea, joint pain and chest pain may persist for weeks following recovery, highlighting the importance of continuous symptom monitoring following return to play.

Type of investigation: Prognosis
Level of evidence: 4
Practical guideline rating scale: C


24 June 2020 reviewed by Lars Engebretsen

The Stanford Hall Consensus Statement for post-COVID-19 Rehabilitation

This consensus statement provides an overarching framework assimilating evidence and likely requirements of multidisciplinary rehabilitation post-COVID-19 illness, for a target population of active individuals, including military personnel and athletes.

Type of investigation: Expert group consensus
Level of evidence: 3B
Practical guideline rating scale: C


1 June 2020 reviewed by Alan McCall

Returning to Play after prolonged restrictions in professional collision sports. Keith A Stokes et al. Int J Sports Med.

This narrative review provides a general insight into three key areas: (i) The potential impact of a period of restricted training in athletes from a physiological and psychological perspective, (ii) Provides some general considerations for returning to training and competition focusing mainly on physical/physiological qualities, including training interventions, progressions, basic training principles, and nutritional aspects, and (iii) Outlines considerations for athletes returning to sport after suspected or confirmed COVID-19 infection. The information may help sports science & medicine practitioners to plan restricted training and return to sport programmes from an exercise and nutrition perspective. The section on returning to sport following suspected or confirmed COVID-19 infection may need to be interpreted with caution as the section is based on early reports and recommendations/considerations are not backed up with a relevant scientific base and information may have changed/be changing compared to when this paper was accepted on 14th May 2020.

Type of investigation: Review
Level of evidence: 5
Practical guideline rating scale: C

04 October 2020 reviewed by Lars Engebretsen

Successful return to professional men’s football (soccer) competition after the COVID-19 shutdown: a cohort study in the German Bundesliga.

The objective was to evaluate the restart of the German Bundesliga (football / soccer) during the COVID-19 pandemic from a medical perspective.
Suspicious symptoms were reported for one player; an immediate additional PCR test as well as all subsequent diagnostic and antibody tests proved negative for coronavirus. Of 1702 regularly tested individuals (1079 players, 623 officials members), 8 players and 4 officials tested positive during one of the first rounds of PCR testing prior to the onset of team training, 2 players during the third round. No further positive results occurred during the remainder of the season. 694 players and 291 officials provided two serum samples for antibody testing. Nine players converted from negative/borderline to positive (without symptoms); two players who initially tested positive tested negative at the end of the season.

Type of investigation: Prognosis
Level of evidence: 2B
Practical guideline rating scale: A


03 September 2020 reviewed by Lars Engebretsen

Cardiorespiratory considerations for return-to-play in elite athletes after COVID-19 infection: a practical guide for sport and exercise medicine physicians

As infection rates drop and quarantine restrictions are lifted, the question how athletes can safely resume competitive sport is being asked. Given the rapidly evolving knowledge base about the virus and changing governmental and public health recommendations, a precise answer to this question is fraught with complexity and nuance. Without robust data to inform policy, return-to-play (RTP) decisions are especially difficult for elite athletes on the suspicion that the COVID-19 virus could result in significant cardiorespiratory compromise in a minority of afflicted athletes. There are now consistent reports of athletes reporting persistent and residual symptoms many weeks to months after initial COVID-19 infection. These symptoms include cough, tachycardia and extreme fatigue. To support safe RTP, we provide sport and exercise medicine physicians with practical recommendations on how to exclude cardiorespiratory complications of COVID-19 in elite athletes who place high demand on their cardiorespiratory system.

Type of investigation: Review (narrative)
Level of evidence: 4
Practical guideline rating scale: C

The focus of this section is on the mental health issues that athletes may face during the COVID-19 pandemic.

24 September 2020 reviewed by Lars Engebretsen

Mental health management of elite athletes during COVID-19: a narrative review and recommendations

Elite athletes suffer many mental health symptoms and disorders at rates equivalent to or exceeding those of the general population. COVID-19 has created new strains on elite athletes, thus potentially increasing their vulnerability to mental health symptoms. This manuscript serves as a narrative review of the impact of the pandemic on management of those symptoms in elite athletes and ensuing recommendations to guide that management.

The current pandemic provides an important opportunity for research on new methods of providing mental health care for athletes, and consideration for whether these new methods should extend beyond the pandemic.

Type of investigation: Expert group consensus
Level of evidence: 5
Practical guideline rating scale: B


27 July 2020 reviewed by Lars Engebretsen

Hosting the Olympics in Times of a Pandemic: Historical Insights from Antwerp 1920, Bram Constandt & Annick Willem

Postponing the Tokyo 2020 Olympics due to the global outbreak of COVID-19 marks a unique moment in the history of the Olympic Movement. For the first time since the cancellation of the Olympic Games during both World Wars, the Olympics will not take place as scheduled. This unprecedented postponement strongly impacts the Olympic Movement. Although only the future can tell exactly, the Antwerp 1920 Olympics can offer certain historical insights. Exactly 100 years ago, the Antwerp Olympic Games were the first Olympics organized after World War I and the Spanish flu pandemic. Their value in terms of rising the Olympic Movement from its ashes is vital.

Type of investigation: Prevention
Level of evidence: 5
Practical guideline rating scale: C

External Links: 

Areas of Resources