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AAOS Now

Published 9/2/2020
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Kerri Fitzgerald

Return to Sports in America Creates Quite the Conundrum

AOSSM panel addresses return to sports amid and after COVID-19

As a result of COVID-19, sports in America came to a halt on March 11, just as much of the country began social distancing and following stay-at-home orders. Following a months-long interlude, the National Women’s Soccer League was the first team sport to return, with a 25-game tournament in Utah in early July. No significant problems were reported, but the Orlando Pride franchise withdrew from the tournament due to too many COVID-19 cases. In addition, the MLB resumed in late July, followed by the NBA and NHL. The MLB’s return has been plagued by COVID-19 outbreaks within teams. The NBA and NHL, however, took a different approach with a “bubble concept,” which has, to date, been without any delays due to COVID-19.

As many have wondered how and when sports would return in the United States in the early weeks and months of the pandemic, others have been involved in the logistics of how to bring sports back. During a panel discussion during the American Orthopaedic Society for Sports Medicine (AOSSM) Virtual Annual Meeting, Rick Wright, MD, FAAOS, chair of the Department of Orthopaedic Surgery at Vanderbilt University in Nashville, Tenn., asked many involved in the resurgence of sports at the professional and collegiate levels just how this would happen. The panel included Daniel E. Cooper, MD, head team doctor for the Dallas Cowboys and consultant for Real Madrid; Bert Mandelbaum, MD, associate chief medical officer of the MLS and a U.S. soccer physician; Dawn Aponte, JD, chief football administrative officer of the NFL; Brian Hainline, MD, chief medical officer of the National Collegiate Athletic Association (NCAA); Tory Lindley, ATC, president of the National Athletic Trainers’ Association; Drew Rosenhaus, a professional athletics agent from Rosenhaus Sports; and tennis star Venus Williams.

First, Dr. Wright provided an overview of the return to sports. He noted that the cancelation of most North American sports in early March “represented the most significant worldwide sporting impact since World War II. The sports global value is $756 billion annually, and millions of jobs are affected,” he noted.

From a physical standpoint, the World Health Organization recommends 150 minutes of moderate or 75 minutes of vigorous exercise per week, which has been difficult for the public to achieve, as most gyms, pools, and fitness studios have shuttered, as well as some parks and playgrounds, Dr. Wright said. “Many people may not have the ability to achieve this kind of physical activity within their homes and neighborhoods,” he said. “This lack of physical activity exacerbates the economic and psychological impact of a pandemic of this type.”

In addition, athletes, coaches, and team support staff have seen their careers be impacted by the cancelation of sports. Furthermore, “Kids and young adults need the socialization and physical benefits of sports participation,” he said, asking, “How and can we return to sports safely?”

Although COVID-19-related mortality appears to be relatively rare in young, fit people, it is not impossible for athletes to have moderate to severe disease, and asymptomatic spread adds a layer of difficulty in returning to sports, as COVID-19 could be unknowingly spreading throughout a team.

The long-term effects of COVID-19 are unknown, but the cardiovascular and physiological demands of elite athletes may be hampered by COVID-19, and long-term effects may impact their ability to excel and remain at the top of their profession. It is also unknown whether mild or asymptomatic cases mean no long-term effects in the future, Dr. Wright said. The Centers for Disease Control and Prevention and NCAA, among others, have provided recommendations for sports and sporting athletes. All guidelines emphasize social distancing, universal masking when possible, stringent disinfection, and symptom reporting, but it is difficult to consider every risk, said Dr. Wright.

What do the athletes want?

Dr. Wright noted, “It seems like the quietest voice has been the athlete.” He asked Ms. Williams about the athlete perspective on return to play. Although she plays an individual sport in which athletes have been given the decision on whether to play, for team sports, there is more of an obligation to play and the pressure that comes with that, she said. “I do believe you can come back safely; you have to take those measures, including testing and social distancing,” she said. “Until the time that it doesn’t become safe enough, we have to have the courage to come back.” When asked about pressure on athletes to play, Ms. Williams countered, “What’s interesting is there is some pressure from a lot of players who don’t want to play, who don’t think it’s fair if everyone can’t play.”

Mr. Rosenhaus talked about advising his athlete clients on whether to play: “Our clients are eager to play but are of course nervous, especially football players because it’s a contact sport [and is] a much bigger group of players. As much as we all want to play and everyone wants to continue their careers, make their salaries, and support their families, their safety is paramount.” Among his NFL clients who have had experience with the disease, the overwhelming majority have had minor cases. Still, he said, “Everyone is very anxious to see how we can make this work, but the vast majority of my clients want to give it a shot and want to play. It means so much to my clients. These careers are so short. To miss a year, you just can’t get it back. There are so many people who are impacted by professional sports. It is nerve-wracking, it’s a moving target, [and] things change every day.”

Logistics for game-day return

Ms. Aponte discussed the logistics of returning to football. She said the league is most concerned about the things it cannot control, “which is a long list.” Although player health and safety are paramount, she said, “This is a unique set of circumstances because it is a shared risk by all involved—trying to evaluate the overall ecosystem of everyone in the NFL, not just the individual players.” This effort has required assessing operations at facilities, during travel, on game day, with game officials, and any other area that impacts the sport. “What keeps us up at night? Our game officials,” she said. “I feel like we have a lot more control over the environments for the players and coaches, as they can travel in more of a ‘football bubble,’ whereas our officials are in a different situation in traveling to games from all over the country.”

Dr. Mandelbaum agreed, noting, “The balance has to be made by all stakeholders. This is a stakeholder-driven decision. Everybody has a risk here. It really comes down to maximal caution for all athletes at all times.”

Fan-free stadiums are also a likely possibility, Ms. Aponte noted, and in some states, including Pennsylvania and New Jersey, that decision has already been made.

As for college sports, Dr. Wright stated that some college conferences have canceled their seasons, and others may follow suit. He asked Dr. Hainline how this will impact safety. Dr. Hainline spoke about the decision in March to stop the NCAA championship. He said they pondered whether they could allow just one more game to safely occur in order to crown a champion. “The reason we couldn’t is because the infrastructure in our country to support testing was so poor that it was only available for critically ill patients, and the fastest turnaround time was 72 hours,” he said.

Now, he said, testing has been prioritized and the turnaround time is five to seven days. He said that controlling the environment for student athletes off the field is more difficult. “We don’t have the public healthcare infrastructure to support what we are supposed to be doing. Sports is in a pivotal moment where we can make a very strong moral statement. We have to awaken as a society and say, ‘How much do we really want to do this?’ and ‘Can sports help mobilize society so we can get ourselves back on track?’ There should be no one on a sideline without a mask. We are prepared to go very granular if we go forward with fall sports, and that will include a testing protocol.”

Mr. Lindley said that based on what he has heard, student athletes are happy to be back with their teams. Managing athletic trainer interaction with sometimes hundreds of players at the youth sports level and their safety in such interactions will be difficult. “It’s critical that the athletic trainers lean on their medical model and their team and ensure that their connection to the team physician is strong and develop protocols that include protective personal equipment (PPE),” he said. “PPE cannot be compromised. There cannot be a situation where an athletic trainer is asked to be in an environment where they do not feel safe or do not have the appropriate PPE.”

Dr. Cooper added, “We are certainly listening to the experts. I’m also listening to my own intuition as a physician. It’s a concern at all levels. I’m in an age group where I’m more at risk than my players in terms of severity of illness if I get it. Throughout my 30-year career in sports, I’ve always said it’s always safest to not play.”

Dr. Wright discussed the costly requirements surrounding return to sports and asked whether it would be too expensive for Division III schools to return to the fields this fall. “That’s a great metaphor for our society,” Dr. Hainline said. “Sports is not equal access, even at the youth level. To do things right at a societal level, it would be equal access and opportunity, and testing should be free. Right now, the best deal you can get is $100 a test. If you were to calculate how much a good testing program would cost a collegiate football team right now, it’s $400,000. Most schools cannot afford that, so now we are getting into this disparity. COVID-19 has laid bare all sorts of disparities in our society.”

Kerri Fitzgerald is the managing editor of AAOS Now. She can be reached at kefitzgerald@aaos.org.