Endurance Athletes and Recovery from COVID-19

In a world of 8 billion people, there are never any shortages of opinions out there.  When it comes to COVID-19, I think we can all agree that we have seen opinions that cover a very broad spectrum of views.

My intent with writing this article is to share my own experiences with COVID-19 and what I’ve learned over the last 24 months as it pertains to how this virus impacts endurance athletes and some practices that have worked well for athletes recovering from it.

As I shared in the fall of 2021, I had a moderately severe case of COVID-19 in January 2021 and was diagnosed with “long COVID” (commonly called “Long Haul”) in March 2021.  More than 14 months after my COVID-19 fever broke, I still live with the effects of the virus every day.  I didn’t go to medical school and I’m not a virologist, but I have accumulated a significant amount of first-hand experience of what it is like to be sick with, recover from, and live with the effects of COVID-19 as a human and as an endurance athlete.

As an endurance coach, I have accumulated a significant amount of experience coaching endurance athletes who have also contracted COVID-19.  At the time of this writing, more than 40% of the athletes I’ve coached since 2020 have tested positive for COVID-19 at one point or another while I was coaching them.

There’s a reason why the World Health Organization (WHO) has deemed COVID-19 to be a virus worthy of declaring a pandemic for.  Not only is this virus extremely contagious, its impact - both short-term and long-term - on people is quite a bit different than other viruses (even severe illnesses such as influenza) that the current world population has encountered in our lifetimes.

The impact that COVID-19 has on endurance athletes is pretty significant.  I’ve observed that many, many people think that COVID-19 is only a respiratory disease.  I can understand this thought process; the virus is transmitted through respiratory droplets and has respiratory symptoms.  

However, COVID-19 doesn’t just impact the lungs.  Researchers have learned that COVID-19 is effectively also a disease that impacts the circulatory system.  Specifically, the inflammation caused by the virus negatively impacts critical structures such as the lining of the blood vessels and heart, which is called the endothelium.  

The endothelium is a barrier between blood and the blood vessel itself and it controls the flow of fluid and other substances into and out of a tissue.   Among many things, it is involved in the process of transferring oxygen and other critical elements and nutrients into the blood.  In fact, capillaries, which are the blood vessels directly responsible for transferring oxygen, are composed only of endothelial cells; they do not have muscular or adventitial layers like other blood vessels do.  

While the endothelium provides a critical function for all humans, for endurance athletes, it’s a very critical function since an athlete’s ability to properly transfer oxygen into their bloodstream is essential to success in endurance sports.  COVID-19’s impact on the endothelium is thought to be one of the main things that leads to exercise intolerance and that causes the “sloggy” and fatigued sensation that so many athletes have described feeling as they return to activity after having the virus.  It can also cause a sensation of shortness of breath…literally because oxygen isn’t transferring into the blood in the same way that it did pre-COVID-19.

My colleague Dr. Manuel Delgado Gaona ran a COVID-19 clinic during the pandemic and has been studying viruses and their impact on athletes for a significant portion of his career.  Doctors like Dr. Manuel and other people much smarter than me have been recommending a specific protocol for athletes to follow when they resume activity after having COVID-19.  

At first glance, it often seems very severe.  Even Olympic Gold Medalist Gwen Jorgensen, who tested positive for COVID-19 in January 2021, shared that she felt this protocol was severe when she was first diagnosed, but came around to recognize that it’s a solid recommendation.  If a person like Ms. Jorgensen - whose full-time job is to exercise and perform and who rarely has a day off of exercise - can recognize the wisdom behind this, then those of us age-groupers - who lead busy lives that require us to work, care for our families, and contribute to our communities in addition to exercising - also certainly have the ability to embrace this wisdom.

I can attest from my personal experience coaching athletes through having COVID-19 that the athletes who follow this protocol fare better over the long haul (word choice is deliberate there ;) ) than those who disregard it and resume activity sooner or at higher levels of intensity than is recommended.  

That recommended protocol for return to activity following having COVID-19 is as follows (and currently applies to all variants of COVID-19 as of the time of this writing):

• No exercise at all for two weeks following your last day with a fever.

• If you never get a fever, the recommendation is no exercise at all for seven days following your last day of symptoms.

• If you don't have symptoms, the recommendation is no exercise at all for seven days following your positive test.

• Once you're clear of that timeline, a very, very gradual return to activity, building back over a minimum of 6-8 weeks.  For some people (I'm one of them), that timeline is significantly extended.

The protocol for “no exercise” includes any substantial walks (i.e. more than walking around than what you need to do to live your life).

As frustrating as it is to contract COVID-19, I have observed that it’s usually more frustrating for athletes to delay their return to activity and/or hold back once they don’t feel actively “sick” anymore.  Waiting two full weeks to resume exercise can feel over-the-top and unnecessary, but in my personal and observational experience, it’s very, very necessary so the body can start to heal itself - both entirely and on a cellular level - from having COVID-19.

There have been many studies conducted on the prevalence of long COVID.  Some suggest that more than 50% of people who contract COVID-19 will experience symptoms for six or more months beyond their illness even once they recover from their acute illness and test negative.   Other studies say that that number is around 33%.  As of March 2022, there isn’t any rhyme or reason as to who develops long COVID, but it’s been observed that stressing the body too quickly (via exercise) can definitely cause symptoms to linger longer.

Athletes who resume activity too quickly (and especially while they are still actively experiencing cardiorespiratory symptoms of COVID-19) have a significantly increased risk of developing myocarditis, which is an inflammation of the heart muscle, which is known as the myocardium.  Myocarditis can reduce the heart’s ability to pump blood as well as cause arrhythmias (irregular heart rhythms).  

Athletes have a higher risk of developing myocarditis after having COVID-19; COVID-19 on its own increases the risk of developing myocarditis by a factor of 16 over those who have not had the virus, but studies have shown that up to 15% of athletes who test positive for COVID-19 develop it.  This is especially concerning since it appears to happen irrespective of the severity of one’s symptoms; just having the virus is enough to raise one’s risk of developing this condition.

It’s important to remember that age-group athletes are not only resuming exercise when they are recovering from COVID-19.  They are also resuming daily life activities such as returning to work full-time, caring for children or other family members, doing the tasks necessary to operate their households, etc.  Resuming exercise is just another thing in a list of things that needs to be added back in after being sick.

As such, it’s even more important for age-group athletes to be mindful and patient with this process of waiting to resume exercising.  Just the experience of going back to work may be enough “extra” for several days to add in.  Once the body has time to heal and recover, it becomes more ready to “receive” or “accept” additional activities, such as exercise. 

A COVID-19 diagnosis is a frustrating one for any person, even if the symptoms are mild.  In my role coaching athletes who have had COVID-19, I’ve seen people who had severe cases recover well and within normal timelines.  I’ve also seen people who had mild cases develop long COVID.  For athletes, COVID-19 is certainly a frustrating diagnosis since exercise is not recommended for the duration of the illness.  Not being able to do what they love is unpleasant, to say the least.

However, two weeks off of exercise to give the body a chance to heal and come back is a much nicer alternative to having months and months of sub-par workouts, missed goals, or (worse) complications from the virus.  If you or your loved ones test positive for COVID-19, I encourage you to consider these data and these recommendations as you navigate your illness and recovery.