Big Ten football has been canceled for the fall, and public enemy No. 1 seems to be an unrelenting underdog: myocarditis.
Within days of reports spreading to mainstream media about the risk of possible heartbeat following COVID-19 infections, the university football world has been turned upside down. But, is this all blown out of proportion?
Was myocarditis just the last straw for a decision that had already been made for the most part? Or is athlete safety suddenly more at risk than it was a week ago?
‘The bottom line is that we knew this. We were ready for it. ”– Dr. Aloiya Earl on myocarditis
Myocarditis is inflammation of the heart muscle that can occur after viral infections. To break it, Myo = Muscle. Card = heart. Itis = Inflammation.
With its recent clout and notoriety, myocarditis seems sure and understandable as a new phenomenon, but it is not. In the medical world, we have known about myocarditis since the beginning of the 19th century.
In clinical practice, we recognize it as a potential after-effect of many common viruses, such as the flu and other coronaviruses. If a patient recently had the flu as a common cold, and now complains of new chest pain or breathing problems, myocarditis has always been among the top potential causes to test for.
We have never necessarily screened for myocarditis before returning to play for a case of flu, but screening can be done if it is of greater concern with COVID-19.
As we learned more over the past few months about the novel coronavirus and its behavior, myocarditis was a known potential pursuit, and we prepared for it. It has also been the focus of medical literature in my world of sports medicine for two months.
The British Journal of Sports Medicine published on 19 June initial guidance on myocarditis in COVID-19 positive athletes. This article stated “ensuring the health of athletes will … test the use of electrocardiography as a blood biomarker to screen for occult myocardial injury and inflammation.”
The information in this publication prompted organizations such as the American Medical Society for Sports Medicine (a group that includes every team doctor) and the National Federation of State High School Associations to develop an algorithm to screen for myocarditis and other heart and lung conditions. COVID- 19 infections before athletes can play back. This last set of recommendations was published on July 9th.
To be even more careful, the return to play was planned to be a slow, controlled protocol over the course of several days – starting with light activity and eventually continuing to full contact.
The bottom line is that we knew this. We were ready for it.
‘We know how to look for it, we know how to catch it, and we had plans to screen for it before an athlete ever set foot on the playing field after testing positive for COVID-19. This is our bread and butter. It’s what we do. ”– Dr. Aloiya Earl on myocarditis
We had organized guidelines to help our derby. We have had this information much longer in our COVID-19 file than just the past 72 hours. So, why pull the plug on the season now?
I do not want to minimize the risk of myocarditis in any way. In the worst cases, it can cause the heart to have an abnormal rhythm during exercise, which can lead to cardiac arrest. It is not a trivial matter, and that is not a point of controversy.
But, we know to look for it, know how to catch it, and we had plans for screening for it before an athlete ever set foot on the playing field after testing positive for COVID-19. This is our bread and butter. It’s what we do.
Think of conclusions, a known risk for football and other contact sports. Of course not contagious as a viral infection, but for the sake of an analogy about risk mitigation, let’s talk back to gaming.
After a concussion, there are several risks to the athlete that we monitor and screen for prior to returning to the game: balance deficits, slow reaction time, poor control of body movements, altered eye tracking, and so on. There is also a second impulse syndrome, which is a rare and potentially fatal risk of returning an athlete to play prior to a complete recovery from one concussion, and the athlete receives a second compound concussion that causes a landing cascade of events in the brain, leading to irreversible damage.
Scary, of course. But we know about it. We screen for risk factors. We do various personal and computerized assessments before allowing athletes to return. That’s risk mitigation, and that’s sports medicine.
Why is coronavirus-related myocarditis different?
Even if we consider the possibility that myocarditis is more prevalent with coronavirus than other viral infections – which we do not yet know – we have the resources to screen it. Athletic trainers who check for symptoms is one part. A doctor’s exam is one part. Special testing is one part. Tests may include ECGs, blood tests, echocardiograms, exercise tests, and cardiac MRIs.
“I feel that the medical world of football was ready to handle this risk and navigate it successfully. It’s what we’re training for. We are champions of athletic safety. ”
Guess what? We have access to all of these things. Each team has a group of athletic trainers and at least one physician for sports medicine. Many teams, especially in Power 5, work with a cardiologist. ECGs are done as part of routine sports searches in many football programs, and they cost about $ 50 each.
Sources may not be the problem. Lack of medical expertise to navigate this risk safely and carefully screen, as it may not be the problem. Each Power 5 team was able to perform an ECG, blood work, echocardiogram, stress test (on a gold plated treadmill, no less), and MRI of heart on each athlete and still save money compared to the financial loss of canceling a season of football. Cost may not be the issue either. So, what is it?
I want to emphasize how much I agree that one life, one longing heart condition, is a far too high price to pay for football. My attitude is not “this is rare, so let’s take the risk and see how it goes.” Far from it.
After all, I feel that the medical world of football was ready to handle this risk and navigate it successfully. It’s what we’re training for. We are champions of athletic safety. That’s why novice quarterbacks are held out if they dominate them, or if they have mono (risk of spleen rupture), or if their injury is not yet strong enough to protect themselves in full contact. We do not cut corners with welfare in athletes, and risks related to COVID-19 are no exception.
If unknown long-term risks and myocarditis were the catalysts for canceling fall sports, I’m not sure when it’s considered safe to continue. We will not know long-term risks until, well, in the long run. I do not know that there is much more preparation we can do than a medical community that has not been planned in the last five months for us to be ready. A spring season seems random. Coronavirus and myocarditis will still be risks that we need to deal with effectively and completely in the spring.
What I can say with confidence is as a medical profession, we will be here with our stethoscopes and our heart tests when we get the green light – autumn or spring. Athlete safety will, as it always has been, be our top priority.
Dr. Aloiya Earl is a doctor of sports medicine in Dayton. After a writing hiatus upon completing her Ohio State residency and scholarship to the University of Alabama, she rejoined Eleven Warriors as a medical columnist. She will write informal articles on injuries, recovery, the implications of COVID-19 on university athletics, and various other topics of sports medicine and sports sciences.
