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Returning the High School Athlete Back to Sports Following COVID
When a student athlete tests positive for COVID, a lot of strain and stress is put on them as well as on their parents, coaches and physicians in regards to when they can return to play. In addition, many questions arise as to what the next steps are in helping the student athlete safely return to play once their illness subsides. Dr Greg Rowdon from Franciscan Health Sports Medicine discusses the protocols that he and his team adopted to help determine when it is safe for an athlete to return to their sport following a COVID diagnosis.
Featuring:
Greg Rowdon, MD
Dr Greg Rowdon is the Medical Director for Franciscan Health Sports Medicine (Western Division) and Purdue University Team Physician. Transcription:
Scott Webb (Host): For those hospitalized with COVID-19, it appears the virus has a predilection for the heart leading to an inflammatory process called myocarditis. Myocarditis is also a known cause of sudden death in young, healthy exercising athletes. Because of these two associations, physicians became concerned about athletes who were relatively symptom free or with mild symptoms returning to sports after infection. And joining me today to discuss myocarditis and how we can get our athletes back on the courts and fields is Dr. Greg Rowdon. He's the Medical Director for Franciscan Health Sports Medicine, Western Division, and Purdue University Team Physician. This is the Franciscan Health Doc Pod. I'm Scott Webb. So, Doctor, thanks so much for joining me today. Before we get rolling here and start talking about COVID-19 and the heart and myocarditis, I just want to have you tell listeners a little bit about yourself. What do you do? Where do you work?
Greg Rowdon, MD (Guest): My background originally was internal medicine. And I did that at Indiana University, down in Indianapolis, and then completed a Sports Medicine Fellowship following that and worked for several years in a private Sports Medicine Practice in Indianapolis, before I came up to West Lafayette and became the Team Physician for Purdue. Now I am working part time as the Team Physician at Purdue, as well as the Director of Sports Medicine for our local hospital system, Franciscan Physician Network. I've been doing that for about three years now.
Host: How does COVID-19 affect the heart and specifically what is myocarditis?
Dr. Rowdon: The virus appeared to have a like for attacking the heart. So, it became apparent to us from people that became very sick with the virus and were hospitalized, that the virus liked to have heart effects. And these heart effects are midterm myocarditis. And what that means is inflammation of the heart muscle itself. So, the virus gets in and affects the muscle of the heart causing the heart muscle not to be able to function normally. Well we were seeing in these hospitalized patients were mostly elderly, number one, or people with pre-existing conditions, such as diabetes or pre-existing heart disease or other types of pre-existing conditions.
And so we knew that the virus liked to affect the heart, but we didn't know how the virus affected young, mostly healthy individuals, like high school, college aged kids, that were athletes. And so because of this combination of the virus affecting the heart and young healthy people also getting the infection, but having much less severe disease, most of the time, they're either symptom-free or they have mild symptoms that do not require anything more than symptomatic treatment and staying at home. We didn't know how their hearts were being affected. So, we became concerned about that. And the reason we had that concern is because we know that young exercising athletes, myocarditis is a cause of sudden death in those athletes. And we had some anecdotal cases at the college level.
We've had some studies done mostly at the division one level and at the professional level where we've actually taken MRI scans of the heart, which is a way of looking for that inflammation caused by the virus and seeing if it was causing issues in these young athletes. And what we found was, and we did not know this initially, but studies have since been done and we've got numbers that have come out. And now that we're further along in the pandemic that it looks like it's about 2%, of young healthy athletes demonstrate this myocarditis. So, we again, very concerned about okay, we've got all these high school kids that are student athletes that are trying to get back to their sports and that may have had the infection.
And so what are we going to do to make sure those kids could go back safely to their sport, given that the resources we have for evaluating them are much less than at the professional, at the college level, you can't easily get an MRI scan of a, of an athlete's heart based on having an infection without much else other than at the professional and division one level. So, there are several groups across the country have looked at the same question and they've come out with some recommendations. And these included the National Federation of High Schools and the American Medical Society for Sports Medicine and the American Cardiology Section of Sports Medicine, all came out with some recommendations that we think should be put in place before we allow these athletes to just resume their sports after they're through with their 10 days of isolation. When they came out with the recommendations, we took these recommendations and we cover in our area probably about 25 high schools, but statewide, we have upwards of 50 plus high schools that we cover across the state, within the Franciscan System.
And so we came up with guidelines to help the primary care physicians and the other sports medicine physicians around the state, determine how best to allow the student athlete to get back to their sport. And what we came up with was that we were going to have the student athlete, after they came out of their isolation period of 10 days, be evaluated by a physician. And that physician was given some guidelines as to things to look for as far as concerning factors. One, they had to complete their 10 days of isolation. They had to have fairly mild symptoms. And by that, I mean, they were not hospitalized or had a severe infection that they were maybe able to stay home and not be hospitalized with, so they had to have fairly mild symptoms.
They had to be symptom free by the time they got out of their isolation period of 10 days, and they couldn't have had a fever within the proceeding 24 hours. And so if they met those conditions, then we, as physicians who were seeing those patients and going through a history with them to make sure that there was no concerning historical markers, that would tell us that the heart was not functioning normally. Those were essentially getting shortness of breath just doing the activities of daily living or getting chest pain with doing activities of daily living, having excessive fatigue, just again, doing daily activities.
If those were met that they were not having those symptoms, then they would get an examination looking mainly at the heart and lungs, checking their blood pressure, checking their heart rate, checking their oxygen saturation, at the time of their visit and listening to their heart and lungs. And if those were all okay, given all those factors, the student athlete could be checked and allowed to begin a gradual return to exercise. And this gradual return to exercise also came to us, from national recommendations, but in the state of Indiana, if you miss 10 days of practice, which you were in isolation for 10 days. So, if you miss that amount of time, you had to go through six days of recovery before competing. And so Indiana already had a six day lag, in return to competition after a 10 day missing sport. So, we took that and over those six days, we gradually increased the activity level under the supervision of the high school athletic trainer. And by the way, I just want to at this time say that it is the national athletic trainers month, for this month. And these individuals have had a tremendous amount of work placed upon them because of the COVID and making sure that everything is done appropriately as far as cleaning of facilities and taking care of their athletes.
And they're just an unsung group of individuals that do a great job taking care of these kids out at the high schools. We definitely could not do this without them and how appreciative we are for their efforts. But these individuals then supervised the return to exercise. And again, if that went without problem, if the student athlete could gradually step up their exercise intensity over the six days, then they could be returned to competition safely in that matter. If they became symptomatic, or if they couldn't pass the initial physician evaluation, at that point, they usually were referred on to cardiology for the cardiologist to take a look at them and make sure that they did not have issues.
And that evaluation at that time, by the cardiologist, would be blood work and EKG testing and a cardiac MRI scan for the most part, maybe a stress exercise tests. All those things would go into, looking at that student athlete closer if they were having symptoms to make sure that they could return to their sport and they didn't have an ongoing issue such as myocarditis. And so, we have put that into place. We have sent out the information to all the primary care doctors that might be seeing these young athletes coming into their clinic for this evaluation. We see a fair number of them in our Sports Medicine Clinic that come in to get clearance to get back to sport. And it's been well received, I think from the athletic administration at the high schools, the athletic directors and the coaches, as far as getting these kids back and playing safely.
Host: And so doctor, based on the recommendations and the protocols and everything you've explained here, how do you feel about things? Are things going well?
Dr. Rowdon: Most of the infections that we've seen at least at the high school level and much at the college athlete level also have been very mild. I think we've had one individual at the college level that did end up requiring hospitalization, but we've not had those types of things happening at the high school level. Most of the time it's like, I didn't even know I was sick and I may have lost my taste or smell sense. And that was the only thing I had and or a family member got sick and they got tested because of the family member found that they had it. So, most of the infections in this age group has been mostly minimal. And because of that, most of the kids have come in no symptoms, normal examination. They pass through the exercise return to play without any issues whatsoever. And I don't have specific numbers on what the percentages are. We've had a few individuals that have become symptomatic when they've tried to go through. And mostly it was a fatigue issue and their cardiac evaluation has mostly been normal again, showing that they just were not ready to return to a full activity because of a fatigue factor rather than a specific cardiac issue. And so I think, as far as this group has been going very well, as far as putting this in place and having these checks that they need to go through. And most of the time that it is not been a significant problem.
Host: And you mentioned fatigue and that's something that I've heard about COVID-19 that some of the lasting effects for people? Well, after the initial symptoms has really just been a fatigue or fogginess. Is that been your experience?
Dr. Rowdon: That this age level fatigue seems to be if they're going to have anything, it seems to be that, but I think that's fairly infrequent that we're seeing like I said, I would say that it's less than 10% of individuals that we've cleared and had to have them go through this protocol that have had any issues other than just being fatigued. And that has usually cleared up within a few weeks. So, they've gotten back, it's just taking them longer.
Host: Doctor as we wrap up today, this has been really educational. Anything else you want to tell folks about COVID-19, the effects on the heart, myocarditis and really everything you're doing to make sure that if and when the high school athletes get back on the fields and the courts that they're really ready.
Dr. Rowdon: I just want to stress the importance of having some type of a check in place to try to prevent horrific ending of this happening and that's a sudden death episode. And we hear across the country, this person was on the court and died. And those are the serious things we are trying to prevent, as far as putting all these things in place. And even though sudden death of any kind at the student athlete while they're exercising is a very rare thing, if we can prevent it relatively easily, then those efforts I think, should be made.
And in the face of the pandemic where we've had such a large number of individuals contract this virus and potentially having an increase or a spike in these possible sudden deaths, I think we should try to do everything we can to prevent this. And I think by putting this in place, this is a very reasonable way to go about it without putting a lot of extra costs in the medical system itself such as doing, EKGs, doing blood work, doing cardiac MRI scans, all of which are very expensive, and can also lead us down other roads of testing when you have false positive tests. So, by putting something in place that we have, I think it's a very cost-effective way and a very safe way, for us to allow these individuals to get back to their sport.
Host: Definitely. That's a great word you used a reasonable. It seems very reasonable, very doable and certainly prudent. So, Doctor, thanks so much for your time today. You stay well.
Dr. Rowdon: You're very welcome. Thank you for having me.
Scott Webb (Host): For more information, go to Franciscan health.org/blogs and search general health and wellness.
Host:
And if you found this podcast helpful, please share it on your social channels and be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.
Scott Webb (Host): For those hospitalized with COVID-19, it appears the virus has a predilection for the heart leading to an inflammatory process called myocarditis. Myocarditis is also a known cause of sudden death in young, healthy exercising athletes. Because of these two associations, physicians became concerned about athletes who were relatively symptom free or with mild symptoms returning to sports after infection. And joining me today to discuss myocarditis and how we can get our athletes back on the courts and fields is Dr. Greg Rowdon. He's the Medical Director for Franciscan Health Sports Medicine, Western Division, and Purdue University Team Physician. This is the Franciscan Health Doc Pod. I'm Scott Webb. So, Doctor, thanks so much for joining me today. Before we get rolling here and start talking about COVID-19 and the heart and myocarditis, I just want to have you tell listeners a little bit about yourself. What do you do? Where do you work?
Greg Rowdon, MD (Guest): My background originally was internal medicine. And I did that at Indiana University, down in Indianapolis, and then completed a Sports Medicine Fellowship following that and worked for several years in a private Sports Medicine Practice in Indianapolis, before I came up to West Lafayette and became the Team Physician for Purdue. Now I am working part time as the Team Physician at Purdue, as well as the Director of Sports Medicine for our local hospital system, Franciscan Physician Network. I've been doing that for about three years now.
Host: How does COVID-19 affect the heart and specifically what is myocarditis?
Dr. Rowdon: The virus appeared to have a like for attacking the heart. So, it became apparent to us from people that became very sick with the virus and were hospitalized, that the virus liked to have heart effects. And these heart effects are midterm myocarditis. And what that means is inflammation of the heart muscle itself. So, the virus gets in and affects the muscle of the heart causing the heart muscle not to be able to function normally. Well we were seeing in these hospitalized patients were mostly elderly, number one, or people with pre-existing conditions, such as diabetes or pre-existing heart disease or other types of pre-existing conditions.
And so we knew that the virus liked to affect the heart, but we didn't know how the virus affected young, mostly healthy individuals, like high school, college aged kids, that were athletes. And so because of this combination of the virus affecting the heart and young healthy people also getting the infection, but having much less severe disease, most of the time, they're either symptom-free or they have mild symptoms that do not require anything more than symptomatic treatment and staying at home. We didn't know how their hearts were being affected. So, we became concerned about that. And the reason we had that concern is because we know that young exercising athletes, myocarditis is a cause of sudden death in those athletes. And we had some anecdotal cases at the college level.
We've had some studies done mostly at the division one level and at the professional level where we've actually taken MRI scans of the heart, which is a way of looking for that inflammation caused by the virus and seeing if it was causing issues in these young athletes. And what we found was, and we did not know this initially, but studies have since been done and we've got numbers that have come out. And now that we're further along in the pandemic that it looks like it's about 2%, of young healthy athletes demonstrate this myocarditis. So, we again, very concerned about okay, we've got all these high school kids that are student athletes that are trying to get back to their sports and that may have had the infection.
And so what are we going to do to make sure those kids could go back safely to their sport, given that the resources we have for evaluating them are much less than at the professional, at the college level, you can't easily get an MRI scan of a, of an athlete's heart based on having an infection without much else other than at the professional and division one level. So, there are several groups across the country have looked at the same question and they've come out with some recommendations. And these included the National Federation of High Schools and the American Medical Society for Sports Medicine and the American Cardiology Section of Sports Medicine, all came out with some recommendations that we think should be put in place before we allow these athletes to just resume their sports after they're through with their 10 days of isolation. When they came out with the recommendations, we took these recommendations and we cover in our area probably about 25 high schools, but statewide, we have upwards of 50 plus high schools that we cover across the state, within the Franciscan System.
And so we came up with guidelines to help the primary care physicians and the other sports medicine physicians around the state, determine how best to allow the student athlete to get back to their sport. And what we came up with was that we were going to have the student athlete, after they came out of their isolation period of 10 days, be evaluated by a physician. And that physician was given some guidelines as to things to look for as far as concerning factors. One, they had to complete their 10 days of isolation. They had to have fairly mild symptoms. And by that, I mean, they were not hospitalized or had a severe infection that they were maybe able to stay home and not be hospitalized with, so they had to have fairly mild symptoms.
They had to be symptom free by the time they got out of their isolation period of 10 days, and they couldn't have had a fever within the proceeding 24 hours. And so if they met those conditions, then we, as physicians who were seeing those patients and going through a history with them to make sure that there was no concerning historical markers, that would tell us that the heart was not functioning normally. Those were essentially getting shortness of breath just doing the activities of daily living or getting chest pain with doing activities of daily living, having excessive fatigue, just again, doing daily activities.
If those were met that they were not having those symptoms, then they would get an examination looking mainly at the heart and lungs, checking their blood pressure, checking their heart rate, checking their oxygen saturation, at the time of their visit and listening to their heart and lungs. And if those were all okay, given all those factors, the student athlete could be checked and allowed to begin a gradual return to exercise. And this gradual return to exercise also came to us, from national recommendations, but in the state of Indiana, if you miss 10 days of practice, which you were in isolation for 10 days. So, if you miss that amount of time, you had to go through six days of recovery before competing. And so Indiana already had a six day lag, in return to competition after a 10 day missing sport. So, we took that and over those six days, we gradually increased the activity level under the supervision of the high school athletic trainer. And by the way, I just want to at this time say that it is the national athletic trainers month, for this month. And these individuals have had a tremendous amount of work placed upon them because of the COVID and making sure that everything is done appropriately as far as cleaning of facilities and taking care of their athletes.
And they're just an unsung group of individuals that do a great job taking care of these kids out at the high schools. We definitely could not do this without them and how appreciative we are for their efforts. But these individuals then supervised the return to exercise. And again, if that went without problem, if the student athlete could gradually step up their exercise intensity over the six days, then they could be returned to competition safely in that matter. If they became symptomatic, or if they couldn't pass the initial physician evaluation, at that point, they usually were referred on to cardiology for the cardiologist to take a look at them and make sure that they did not have issues.
And that evaluation at that time, by the cardiologist, would be blood work and EKG testing and a cardiac MRI scan for the most part, maybe a stress exercise tests. All those things would go into, looking at that student athlete closer if they were having symptoms to make sure that they could return to their sport and they didn't have an ongoing issue such as myocarditis. And so, we have put that into place. We have sent out the information to all the primary care doctors that might be seeing these young athletes coming into their clinic for this evaluation. We see a fair number of them in our Sports Medicine Clinic that come in to get clearance to get back to sport. And it's been well received, I think from the athletic administration at the high schools, the athletic directors and the coaches, as far as getting these kids back and playing safely.
Host: And so doctor, based on the recommendations and the protocols and everything you've explained here, how do you feel about things? Are things going well?
Dr. Rowdon: Most of the infections that we've seen at least at the high school level and much at the college athlete level also have been very mild. I think we've had one individual at the college level that did end up requiring hospitalization, but we've not had those types of things happening at the high school level. Most of the time it's like, I didn't even know I was sick and I may have lost my taste or smell sense. And that was the only thing I had and or a family member got sick and they got tested because of the family member found that they had it. So, most of the infections in this age group has been mostly minimal. And because of that, most of the kids have come in no symptoms, normal examination. They pass through the exercise return to play without any issues whatsoever. And I don't have specific numbers on what the percentages are. We've had a few individuals that have become symptomatic when they've tried to go through. And mostly it was a fatigue issue and their cardiac evaluation has mostly been normal again, showing that they just were not ready to return to a full activity because of a fatigue factor rather than a specific cardiac issue. And so I think, as far as this group has been going very well, as far as putting this in place and having these checks that they need to go through. And most of the time that it is not been a significant problem.
Host: And you mentioned fatigue and that's something that I've heard about COVID-19 that some of the lasting effects for people? Well, after the initial symptoms has really just been a fatigue or fogginess. Is that been your experience?
Dr. Rowdon: That this age level fatigue seems to be if they're going to have anything, it seems to be that, but I think that's fairly infrequent that we're seeing like I said, I would say that it's less than 10% of individuals that we've cleared and had to have them go through this protocol that have had any issues other than just being fatigued. And that has usually cleared up within a few weeks. So, they've gotten back, it's just taking them longer.
Host: Doctor as we wrap up today, this has been really educational. Anything else you want to tell folks about COVID-19, the effects on the heart, myocarditis and really everything you're doing to make sure that if and when the high school athletes get back on the fields and the courts that they're really ready.
Dr. Rowdon: I just want to stress the importance of having some type of a check in place to try to prevent horrific ending of this happening and that's a sudden death episode. And we hear across the country, this person was on the court and died. And those are the serious things we are trying to prevent, as far as putting all these things in place. And even though sudden death of any kind at the student athlete while they're exercising is a very rare thing, if we can prevent it relatively easily, then those efforts I think, should be made.
And in the face of the pandemic where we've had such a large number of individuals contract this virus and potentially having an increase or a spike in these possible sudden deaths, I think we should try to do everything we can to prevent this. And I think by putting this in place, this is a very reasonable way to go about it without putting a lot of extra costs in the medical system itself such as doing, EKGs, doing blood work, doing cardiac MRI scans, all of which are very expensive, and can also lead us down other roads of testing when you have false positive tests. So, by putting something in place that we have, I think it's a very cost-effective way and a very safe way, for us to allow these individuals to get back to their sport.
Host: Definitely. That's a great word you used a reasonable. It seems very reasonable, very doable and certainly prudent. So, Doctor, thanks so much for your time today. You stay well.
Dr. Rowdon: You're very welcome. Thank you for having me.
Scott Webb (Host): For more information, go to Franciscan health.org/blogs and search general health and wellness.
Host:
And if you found this podcast helpful, please share it on your social channels and be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.