How a pandemic redefined athletics, transformed sports medicine, and changed our understanding of athlete health forever
On March 11, 2020, the World Health Organization declared COVID-19 a global pandemic. On that same day, the National Basketball Association suspended its season just minutes before tipoff in Oklahoma City, heralding what one editorial would later call "a seemingly endless series of cancelations or postponements of normal life activities and sporting events" 1 . This simultaneous response created a parallel evolution between a deadly virus and the world of sports—two seemingly disparate domains that became unexpectedly intertwined.
As the virus evolved, so too did athletic protocols, training methodologies, and our very understanding of athlete health. The pandemic didn't just interrupt games; it fundamentally transformed how we approach sports medicine, athlete safety, and the delicate balance between competition and well-being. This is the story of how COVID-19 and sports changed each other forever.
The first reaction to the pandemic was universal cancellation. The International Olympic Committee postponed the 2020 Tokyo Olympics, professional leagues suspended seasons, and community sports vanished overnight 4 . Athletes who relied on team-training facilities had to drastically reshape their approach to their craft, often training alone in confined home spaces without equipment, coaches, or training partners 3 .
of athletes could perform their main sport unrestricted during confinement 3
reported reduced time spent on sports during lockdowns 3
trained at reduced intensity levels 3
participants in worldwide survey on sports during confinement 3
The impact was immediate and measurable. A worldwide survey revealed that older athletes and those training in club settings were most likely to reduce their activity, while the availability of online training helped mitigate these decreases 3 .
This abrupt stop in organized athletics had unintended consequences beyond the immediate disappointment of canceled competitions. The stage was being set for a more insidious problem that would emerge when athletes returned to play too quickly.
As sports cautiously resumed, a disturbing trend emerged across competitive levels. The extended interruptions in training and competition led to a sharp increase in injuries when athletes returned to play.
The National Football League's public injury reports and Major League Baseball's transactions database revealed increased injury rates during modified 2020 seasons 1 .
A multistate study of 176 high schools found that the injury incidence ratio increased by 1.3 times between the prepandemic year and the initial year of COVID-19 1 .
This echoed a similar pattern observed in 2011 when an increased number of Achilles tendon ruptures were reported in NFL players after a 4-month lockout 1 .
This trend highlighted that the consequences of training disruption affected athletes at all levels, from weekend warriors to elite professionals.
One of the most significant medical concerns to emerge was the potential for COVID-19 to cause heart complications in athletes. Early in the pandemic, studies found that approximately 12% of hospitalized COVID-19 patients had elevated troponin levels, suggesting cardiac injury 4 . This raised alarms in the sports medicine community, given that myocarditis (inflammation of the heart muscle) has always been a concern following viral infections and can increase the risk of sudden cardiac events during intense exercise 4 .
A study of 1597 athletes in the Big Ten American Football Conference found that only 2.3% (37 athletes) exhibited clinical or subclinical signs of myocarditis 5 .
Another study indicated that approximately 6% of athletes showed cardiac abnormalities post-COVID-19 5 .
| Category | Symptoms | Return-to-Play Recommendation |
|---|---|---|
| Asymptomatic | No symptoms | 2 weeks of self-isolation and rest before gradual return 4 |
| Mildly Symptomatic | Subfebrile temperature (<38.5°C), mild cough, sore throat, slight malaise | Training only after 3 symptom-free days, then gradual progression |
| Moderate to Severe | Hospitalization required, cardiac or respiratory symptoms | Comprehensive multidisciplinary evaluation before beginning exercise 4 |
However, as research evolved, a more nuanced picture emerged. Larger studies revealed that while cardiac involvement was possible, the risk was comparable to other viral diseases .
In June 2020, as the world was grappling with the first wave of infections, researchers launched an ambitious international survey to assess the effects of the pandemic on sports participation. This study would provide one of the most comprehensive snapshots of how COVID-19 was transforming athletics worldwide.
The research team designed a retrospective study based on a self-administered questionnaire distributed in both German and English 3 . The survey was promoted by participating universities, sports organizations, and colleagues worldwide, though the majority of responses came from Europe (93.8%) 3 .
Participants were asked to classify themselves as recreational, competitive, or professional athletes and provide detailed information about their sporting activity before, during, and after pandemic-induced confinement. The survey collected data on three key areas: epidemiological information, sports activity patterns, and preventive measures adopted for safe return to community sports 3 .
The final cohort included 1,336 adults (30.5±11.7 years; 54.0% women), consisting of athletes (68.5%), coaches (10.1%), officials (2.1%), medical staff (4.3%), and others with regular sports involvement 3 .
The findings revealed dramatic changes in sports participation during confinement. Crucially, the study identified specific factors that influenced how the pandemic affected athletic activity:
Awareness Gap: Most participants (77.5%) were unaware of screening measures, and even larger majorities knew nothing about guidelines for dealing with infected athletes (80.0%) or for return to sports after coronavirus infection (88.6%) 3 .
| Factor | Impact on Sports Activity | Statistical Significance |
|---|---|---|
| Higher Age | Reduced sporting activity | p=0.004 3 |
| Club Setting Training | Reduced sporting activity | p<0.001 3 |
| Availability of Online Training | Increased extent and intensity | p=0.030 3 |
| Lower Age & Recreational Level | Decreased activity after confinement | p=0.001 (age), p=0.005 (level) 3 |
Studying the relationship between COVID-19 and sports required innovative approaches and specialized methodologies. Researchers employed several key tools to understand this complex interaction:
This became the gold standard for evaluating the cardiorespiratory and pulmonary health of athletes post-COVID-19 infection. CPET helped identify potentially detrimental symptomatology during exertion that wasn't apparent at rest 5 .
Multi-language questionnaires distributed across global networks allowed researchers to capture the widespread impact of the pandemic on sports participation and the effectiveness of various preventive measures 3 .
Detailed case studies of COVID-19 outbreaks in sports settings helped identify common transmission routes, revealing that most spread occurred through aerosol inhalation in indoor settings or social interactions outside of games 8 .
This computational technique allowed researchers to analyze large volumes of scientific literature (1,604 studies) to identify emerging research trends and knowledge structures at the intersection of COVID-19 and sports 7 .
As understanding of the virus improved, sports organizations developed increasingly sophisticated strategies to allow safe return to play. Research revealed that most outbreaks in individual sports like fitness classes were linked to poor ventilation and not wearing masks, while in team sports, the most common cause was interaction outside the game, such as social events 8 .
Notably, contact transmission during sports and exercise was found to be less important than initially feared, shifting the focus to aerosol transmission prevention 8 . This insight led to more effective protocols including improved ventilation, outdoor training relocation, and mask usage when appropriate.
The sports medicine community responded with unprecedented collaboration. An exemplary initiative was the examination of cardiac outcomes for collegiate athletes with COVID-19, which brought together institutions across the nation to pool data and insights 1 . This cooperative spirit accelerated the development of evidence-based return-to-play protocols that balanced athletic participation with health protection.
The parallel evolution of COVID-19 and sports has left a lasting imprint on athletic culture and sports medicine. The pandemic "widened the chasm between individuals or groups with different political agendas," yet simultaneously "served to foster more collaboration in the sports medicine community" 1 .
The comprehensive medical evaluations introduced for COVID-19 may become standard practice following any significant illness, leading to better long-term athlete health management.
The demonstrated effectiveness of online training components ensures they will remain part of athletic development, offering flexible solutions during travel restrictions or minor injuries.
The meticulous attention to respiratory transmission pathways has created new standards for indoor sports ventilation and outbreak prevention that may reduce all respiratory illnesses in athletic settings.
The recognition that extended interruptions require gradual return to avoid injuries has led to more scientific approaches to post-hiatus training progression.
As one editorial noted, "frequent headlines of athletes being disqualified after testing positive for COVID-19 serve as reminders of the ongoing threat of COVID-19—from which even multiple boosters cannot guarantee protection—and that the impact of COVID-19 may be seen for years to come" 1 .
The parallel evolution of virus and sport continues, each shaping the other in an ongoing dance between competition and safety, between pushing human limits and protecting human health. The pandemic transformed sports, but it also revealed the resilience and adaptability of athletic communities worldwide—a testament to the enduring human drive to play, compete, and move forward despite unprecedented challenges.