When Can Young Athletes Return to Sport After Illness?
Signs, symptoms, and feelings that can help athletes, parents, and coaches determine when it’s time to get back in the game.
Returning to sport from illness of any kind can be tricky, and with the COVID-19 pandemic, it’s only gotten more difficult. But even a simple cold or stomach bug can leave an athlete sidelined without a clear idea of when it’s safe or advisable to return to sport.
Here, Dr. Michele LaBotz, TrueSport Expert and sports medicine physician, will dig into the signs, symptoms, and feelings that can help athletes, parents, and coaches determine when it’s time to get back in the game.
Before we dive into specific ailments and illnesses, it’s important to note that even when an athlete is no longer infectious or isn’t running a fever, they may still not be ready to return to play. “Even something like an ear infection can be really difficult when it comes to returning to play,” says LaBotz. “An athlete may technically be cleared to return to practice, but I think it’s critical to understand that an athlete’s comfort and capacity to be fully engaged with the sport are just as important as a fever being gone. If a player is distracted because their ear hurts too much or because their tooth hurts too much, they're potentially risking injury. An athlete has to be feeling well enough that they can perform effectively.”
Assuming your athlete is ready to get back on the field, here’s what you need to know:
We’ve written about returning to sport after COVID in the past, but as LaBotz points out, the recommendations are changing constantly. Unfortunately, it’s not as simple as getting a negative test—there also needs to be a complete resolution of even mild symptoms, and an all-clear from a physician before an athlete comes back. “Once symptoms have resolved, it is recommended that they touch base with their primary care provider,” says LaBotz. “Many primary care providers are doing a phone call follow up to make sure that there are no other factors that need to be considered.”
Approach an athlete’s comeback the same way you would progress an athlete with a concussion, LaBotz says: “Take a stepwise approach, starting with low intensity activity, and then gradually building back up to sport-specific and higher intensity training over the course of five to seven days.”
“For moderate symptoms, the current recommendation is that athletes get seen by their primary care provider before returning to play,” says LaBotz. “In the United States, the recommendations are that an EKG be done, and the doctor may decide to order additional tests looking at the health of the heart muscle.”
With severe symptoms, it is presumed that an athlete has myocarditis, which is an inflammation of the heart muscles. “For them, it's a three-to-six-month time period before they can get back to sport,” says LaBotz. “The recommendation is that all of those children with severe symptoms get cleared by a cardiologist before going back.” (If you want to learn more about how COVID-19 can impact heart health, check out this article.)
Cold / Flu / Bronchitis
You may have heard of the ‘neck rule’ in the past, and LaBotz is a firm believer in it when it comes to dealing with colds and flues. “If you have symptoms that are isolated to above the neck, like an earache, a runny nose, or a sore throat, then generally speaking, you can return to sport safely if you feel okay,” she says.
However, anything below the neck—a fever, vomiting, diarrhea, lung symptoms, a significant cough, wheezing, or shortness of breath—then those need to be addressed before an athlete can go back to sport. “For fevers, you need to be fever free for 24 hours before being able to return to sport,” she adds. To check your athlete’s temperature, LaBotz recommends a digital thermometer that goes in the mouth. Forehead thermometers—popularized during COVID-19—are much less accurate.
“If an athlete is on an antibiotic for an ear infection or for a strep throat or a similar illness, once the fever is gone and they're feeling okay, they can go back,” says LaBotz. “They don't have to wait until they're done with antibiotics to go back to training.” (Just be aware that athletes may experience some gut issues like diarrhea because of antibiotics, and in that case, may want to wait until those gut issues resolve.)
LaBotz adds that it’s a great idea to ensure your athlete gets a flu shot this year. “If you're part of a team, you put not only yourself at risk, but you also put your teammates at risk if you're not vaccinated. So, making sure that athletes get their influenza vaccine is important,” she adds.
Mononucleosis is one of the scary high school illnesses that can set an athlete back for a full season in some cases. LaBotz notes that first and foremost, before even considering fever or spleen status, an athlete should be feeling better and their energy level should be coming back before return to play should be considered. Once an athlete is feeling energetic and their fever is gone, it’s still important to check with a doctor to get the all-clear to return, though.
“The biggest concern, especially with contact sports, is the risk for splenic rupture. Splenic rupture will most commonly happen within the first three weeks of illness, so that's when the risk is highest,” LaBotz says. “For most young athletes, there will be the recommendation that even if they're feeling a lot better, they stay out for that period of time. Return to sport is largely based on how the patient feels, as well as if there's any tenderness to palpation over the spleen area.”
LaBotz notes that “Kids can end up in a vicious cycle with mono. Symptoms may take a while to resolve, but after they do, kids are still feeling a lack of energy because they’ve been doing nothing for weeks.”
Generally, LaBotz recommends starting a low impact activity like walking or yoga once symptoms subside and it’s been a few weeks, even if energy levels are low. “It's also a good time to focus on rehabilitation, flexibility, and other lower intensity stuff,” she says. “When you're coming back from a serious illness like that, a slow progression is helpful.” It can also help them mentally get back in the game. (The same applies for athletes coming back from long bouts of the flu.)
For stomach bugs, food poisoning, and any tummy trouble that includes vomiting, diarrhea, or stomach pain, it’s important to stay away from practice until it resolves—both for the sake of the athlete and the team. Especially in high contact sports or sports with shared equipment, stomach bugs can easily pass between players.
“These days, we’re all talking about respiratory transmission and wearing masks, but when it comes to gastrointestinal illnesses, it’s all about hand washing,” LaBotz says. “And those bugs are not just spread by hands, they spread by contact with the basketball and the gymnastics equipment and the wrestling mat. So, it’s important to be cautious.”
“If there's still active diarrheal episodes or vomiting, stay out of practice,” she adds. “Not only because of transmission, but because with both vomiting and diarrhea, athletes are at higher risk for dehydration. And with some of these illnesses, the virus can affect muscle as well—in particular the heart muscle—so myocarditis is another concern.”
Knowing when it’s safe to return to sport after illness can be tricky and depends not only on how the athlete feels, but also the potential for spreading the illness to others. Particularly when athletes have been away from sport for more than several days, return to sport is not “all or nothing” but should include a few days where activity is gradually increased based upon the athlete’s energy and performance. Following the above guidance from Dr. LaBotz can help your athlete and their teammates stay healthy and return to sport safely if they do get sick.
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