Injury fears, greater cardiac risk: What life is like for athletes after COVID-19

Mandeep Singh (right) says it took him about six weeks to return to full training after recovering from COVID-19. PA Wire/PA Images

Badminton player HS Prannoy suffered extreme fatigue in his recovery from COVID-19. So did Satwiksairaj Rankireddy, one half of India's top men's doubles pair, who could barely stand for even 10 minutes. India hockey player Mandeep Singh needed six weeks after resuming training before he could train as he used to pre-COVID-19.

However the virus attacks you -- asymptomatic, a mild infection or severe, full-blown episode -- the longer-term impact can be as damaging, if not more, than the actual period of illness. This is especially so for top athletes, most of whom have never dealt with serious illnesses and who would tend to treat this as any other kind of post-injury recovery.

Studies conducted by the British Medical Journal of Sports Medicine [BMJSM] and the European Heart Journal caution against myocarditis, or inflammation of the heart muscle, reducing the organ's ability to pump, triggering arrhythmias (rapid or abnormal heart rhythm) and leading to sudden cardiac death, in COVID-recovered persons. Viral replication, it is understood, can be enhanced during vigorous activity, resulting in greater structural damage of the heart tissue.

One BMJSM study includes recommendations to evaluate the cardiorespiratory system of elite athletes who've recovered from COVID-19. It mentions a 12-lead ECG and Echo (echocardiogram) in general for recuperated elite athletes and, irrespective of their current recovery, those who've been hospitalised with COVID-19 are advised full cardiac and respiratory work up, including cardiac MRI (Magnetic Resonance Imaging), CPET (Cardiopulmonary Exercise Testing), 24-hour ECG Holter and repeat chest imaging.

"The cardiac risk is actually more in athletes, even if they've had mild symptoms," says Dr. Daminda Attanayake, who works with the Sri Lanka cricket team and most recently was central to monitoring the 20-day Lanka Premier League.

"Even after joining the core group, we didn't train full sessions. It was not until around six weeks after resuming training that we were allowed to hit our maximum heart rate or play or train for a longer duration." Mandeep Singh

That's why athletes diagnosed with COVID-19, with or without any symptoms, are advised to refrain from intensive physical workouts for at least two weeks.

That's what happened with Prannoy, who felt fatigued even 10 days after he resumed training at the Pullela Gopichand Academy in Hyderabad. "During the first week I only trained for one session, just trying to move around the court and do basic strengthening. In the next, I pushed myself a little more to see how my body responds. After full sessions for a couple of days now, my body felt tired and lethargic.

"When you say you're feeling tired, people may not always fully comprehend. Only someone who's recovered from the virus can relate to it. The heavy dosage of medicines can weaken you and you may feel like your arms and limbs don't have any muscle mass in them anymore. We've all heard crazy, scary stories of the virus, so you can only count yourself lucky if nothing goes wrong in the two weeks."

There's no standard protocol on how to resume training for athletes, says Dr. Munesh Kumar, consultant physiotherapist with Olympic Gold Quest, who works closely with wrestlers. "Some athletes recover quicker and show fewer symptoms while others take longer. We have to treat each case on its own merits. One athlete I worked with had fever, chills, cough and loss of taste and smell. Another was training even the day he was tested and showed completely normal parameters. Wrestlers usually have a very high pain tolerance and the ability to wrestle through injuries and illnesses but COVID-19 is a very different kind of disease."

He explains why, despite wrestling being a contact sport that mandates humans being in close proximity to each other, the number of cases and the rate of spread in the sport have been low. "I think it helps that most wrestlers are usually at a very high fitness level. They already have a healthy diet, along with a good dose of vitamin and mineral supplements so their immunity is naturally quite high. Even when they contract COVID-19, they tend to recover relatively sooner."

For Indian hockey player Mandeep Singh, hearing the ambulance sirens coming to get him from the SAI campus in Bangalore in August was a grim feeling. Six national men's team players, including Mandeep, had tested positive after they'd assembled for the national camp following a 45-day break.

"After testing positive, we were in isolation at the SAI campus and had regular tele-consultations with the doctor," Mandeep says. "It so happened that during one such evening consultation, my oxygen level dropped to 94 and I reported it to the doctor and our coaching staff. As a precautionary measure, they advised I be moved to the hospital. I panicked when I heard the ambulance arriving to take me to hospital. I began worrying what would happen next."

Though they had very mild symptoms, it took the hockey players two to three weeks to return to basic activities. Their return to training was carried out in a phased manner and they weren't allowed to push themselves more than 60-70 per cent of their actual potential, says Mandeep.

"The coaching staff was very cautious at first when we began basic workouts and we trained in isolation, separate from the rest of the group for two weeks or so. Even after joining the core group, we didn't train full sessions. It was not until around six weeks after resuming training that we were allowed to hit our maximum heart rate or play or train for a longer duration."

"When you say you're feeling tired, people may not always fully comprehend. The heavy dosage of medicines can weaken you and you may feel like your arms and limbs don't have any muscle mass in them anymore." HS Prannoy

Prannoy's COVID-19 diagnosis was through a cough in early December. This, after he had re-joined training at the national academy in Hyderabad and attended the wedding of fellow player, RMV Gurusaidutt. Four players - Prannoy, Gurusaidutt, Parupalli Kashyap and Pranav Jerry Chopra, tested positive. After her initial negative test, Saina Nehwal's results too returned positive.

All five of them got on a WhatsApp group, and it's what, Prannoy says, saw him through the two weeks of living alone in his Hyderabad apartment. That, and food delivered from academy coach and close friend Vishnu Prasanna's home on most days. "We constantly shared what we were going through, or were on call with one another. A COVID isolation is very different from every other kind of isolation we've experienced through the year. There's this anxiety at the back of your mind at all times, linking even the slightest signs of discomfort or pain to the virus. You always feel like you want to talk to a doctor. I was all by myself in my flat so it was even more depressing. It was a relief to just be part of a group where you know people are experiencing a similar condition and are always there for you."

Dr. Attanayake, too, talks about the impact of isolation, especially on top-level athletes. The LPL reported three COVID-19 cases and she worked closely with the affected athletes and other support staff towards their recovery and rehabilitation. "Athletes are really reluctant to stay indoors," she says. "They don't want to eat their meals in their rooms, so you may have to fit that in and also allow for some sort of group training to take place at the place of accommodation. One thing we did do was arrange for a barber to come over and give the boys haircuts since the tournament was quite a long haul.

"Also, the intent of a bio-secure bubble may not always be fully grasped by venue management personnel so that has been a hurdle we've had to overcome through patient and simple briefs and also explaining consequences of any breach. What I learnt is that in my kind of role, you can't be popular and do your job well. Of course, later I received lots of messages from those who were part of LPL, expressing gratitude for what we did," she says.

While the long-term effects of COVID-19 are still unclear, chances of picking up an injury, Prannoy says, is a fear that lurks. "Your body is weak and (if) you end up taking up the kind of training load it isn't ready for, injury is almost certain. The only way is to be patient and if you feel you can't keep up, you should back off from your normal schedule, take a break and then come back."

While Mandeep is waiting to play again before a packed stadium, Prannoy has more tempered goals. "It's happened to me too many times that I've touched close to my peak fitness and then something came out of nowhere and totally took it away," he says. "This time too I returned to Hyderabad after 10 months in Kerala, in great physical shape, before I tested positive. If anything, all these experiences have taught me not to plan too much. I know most players probably think of tournaments, but for me now, it's just about getting on the court during a session and knowing that I feel good. Everything else will follow."