COVID-19 is associated with significant mortality and morbidity, including adverse cardiovascular sequelae. Multidisciplinary teams are charged with developing both clinical and logistical protocols to foster safe return to play. Additionally, as public health policy has directed the reopening of recreational and competitive sport, clinicians are tasked with determining when competitive athletes who have been infected with COVID-19 and recovered are medically ready to return to play.
In 2019, the Premier Lacrosse League (PLL) launched a new tour-based model men’s professional lacrosse league. In the setting of the COVID-19 pandemic, the PLL formed a committee to create a safe and successful return to play. There are limited data establishing the protocols required to facilitate this process. Recognizing these limitations, members of the PLL COVID-19 Committee were tasked with developing a consensus expert opinion framework on return to sport in the era of COVID-19.
Developing the COVID-19 Committee
The COVID-19 Committee—comprised of four physicians, PLL leadership, and a PLL board member—developed a return-to-play plan focusing on a 20-game Championship Series in a quarantine bubble without fans. The physicians represented the disciplines of orthopaedic surgery, infectious disease, and internal medicine. The primary objective of the committee was to build a comprehensive, safe “COVID-19 Return to Play Operations Plan,” a document that eventually surpassed 100 pages.
Given the novel nature of COVID-19, national and local standards are being updated regularly, which necessitated integration of new scientific findings throughout the development process. The committee deliberated several bubble locations, taking into consideration a multitude of factors. For example, the committee considered local disease burden; site proximity to COVID-19 testing labs; location relative to players’ homes; and venue-specific details of housing layout, dining facilities, and locker room setup.
Once the venue was selected, detailed guidance within several categories was developed, including but not limited to COVID-19 testing requirements, pre-participation physicals, symptom surveillance, COVID-19 illness protocols, social distancing and grouping, personal protective equipment requirements, travel standards, emergency action plans for competition days, sanitation/cleaning protocols, dining regulations, and intergroup interaction parameters.
Lead-up to the bubble
In the lead-up to the Championship Series, an all-league virtual town hall was conducted to educate all players, coaches, and staff who would be traveling to the bubble. That large meeting was followed by individual team and staff question-and-answer sessions.
Twelve days prior to travel, daily symptom and temperature surveillance commenced, and the first round of COVID-19 testing was conducted 72 hours prior to departure. Any positive symptoms were reported to the head league physician, who directly contacted that individual to better understand context and determine necessity of further investigation.
Players who had a known, previous COVID-19-positive test and completed their Centers for Disease Control and Prevention (CDC)-defined isolation were required to undergo a thorough clinical cardiovascular examination and electrocardiogram. Further adjunctive exercise testing and imaging were included, depending on clinical course and initial testing. Two players tested positive for COVID-19 via saliva testing on pre-travel testing, and two additional players had known previous positive results. Those players were isolated per CDC guidance. After completing the recommended isolation period, any player on a travel roster who had known history of a positive COVID-19 test underwent cardiology clearance in addition to the standard pre-participation league physical prior to being cleared to play. Of the players who underwent additional cardiology testing, one player was deemed still recovering and unable to return to competitive play.
In all athletes returning to play, acknowledgment of training restrictions due to gym, field, and club closures was necessary. The league utilized online and app-based training modules as an alternative to traditional training to enable preparation for the upcoming spike in playing time and intensity. Once everyone was in the bubble, individual training progression was considered to minimize related injuries. Each team had a dedicated athletic trainer previously debriefed on athlete-specific injury history and pre-season training patterns.
Inside the bubble
COVID-19 tests were repeated upon arrival and at designated intervals or if symptoms were present. The PLL Championship Series bubble comprised 274 individuals (157 players, 21 coaches, and 96 staff). There were no positive COVID-19 tests or symptoms to suggest COVID-19 infection in the bubble, including among players, coaches, and staff.
Maintaining the bubble
During the previous season, epidemiologic data were compiled on the injuries sustained by players with respect to multiple factors such as age, position, and field surface. With those data, a plan was developed to best care for expected injuries while maintaining a safe bubble. As an example, a neurologist outside the bubble assisted the bubble medical team via telemedicine in conducting the league’s brain health protocol. The league also partnered with a mobile fluoroscopy company to enable radiographs to be performed safely and efficiently inside the bubble. If unexpected medications were needed, a contactless drop-off was organized with a local pharmacy. These tactics proved both efficient and effective. An emergency action plan included local emergency medical services on the field, socially distanced from staff and players, in case local transport was needed.
This case study describes the experience of the first successful quarantine bubble championship series in professional sports. The COVID-19 pandemic has presented clinicians and the sports community with unique challenges that affect all levels of sport, from youth to professional. Recommendations regarding resumption of high-intensity exercise and competitive athletics require careful planning and are best performed in a multidisciplinary manner. Attempts to mitigate risks for returning athletes should include complying with public health guidelines and adjusting recommendations as evidence evolves. Important steps include minimizing the risk of transmission, ensuring readily available testing, and accurately contact tracing. Additionally, although athletes are not generally considered at high risk for severe COVID-19 symptoms, the development of cardiovascular involvement must be considered, with formal evaluation by a cardiologist.
Catherine Logan, MD, MBA, is a sports medicine orthopaedic surgeon and partner at Colorado Sports Medicine & Orthopaedics in Denver. She is the head league physician for the Premier Lacrosse League and team physician for the U.S. Ski & Snowboard Association. Visit www.cosportsmedicine.com to learn more, and follow Dr. Logan on Instagram @cloganmd.