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Infographic. Clinical recommendations for return to play during the COVID-19 pandemic
  1. Herbert Löllgen1,2,
  2. Norbert Bachl1,3,4,5,
  3. Theodora Papadopoulou1,3,6,7,
  4. Andrew Shafik7,
  5. Graham Holloway7,
  6. Karin Vonbank8,
  7. Nigel Edward Jones7,9,
  8. Xavier Bigard1,10,
  9. David Niederseer11,
  10. Joachim Meyer12,13,
  11. Borja Muniz-Pardos14,
  12. Andre Debruyne1,3,
  13. Petra Zupet1,15,
  14. Jürgen M Steinacker1,3,16,
  15. Bernd Wolfarth3,17,
  16. James Lee John Bilzon3,7,18,
  17. Anca Ionescu1,19,
  18. Michiko Dohi3,20,
  19. Jeroen Swart3,21,
  20. Victoriya Badtieva3,22,23,
  21. Irina Zelenkova14,22,
  22. Maurizio Casasco1,3,24,
  23. Michael Geistlinger3,25,
  24. Luigi Di Luigi3,26,
  25. Nick Webborn27,
  26. Patrick Singleton28,
  27. Mike Miller28,
  28. Fabio Pigozzi1,3,29,30,
  29. Yannis P Pitsiladis1,3,31
  1. 1 European Federation of Sports Medicine Associations (EFSMA), Lausanne, Switzerland
  2. 2 Cardiology Practice, Remscheid, Germany
  3. 3 International Federation of Sports Medicine (FIMS), Lausanne, Switzerland
  4. 4 Institute of Sports Science, University of Vienna, Vienna, Austria
  5. 5 Austrian Institute of Sports Medicine, Vienna, Austria
  6. 6 Lower Limbs-ADMR Hip & Groin, Defence Medical Rehabilitation Centre Headley Court, Loughborought, UK
  7. 7 British Association of Sport and Exercise Medicine, Doncaster, UK
  8. 8 Department of Pulmology, Medical University of Vienna, Vienna, Austria
  9. 9 University of Liverpool, Liverpool, UK
  10. 10 Union Cycliste Internationale (UCI), Aigle, Switzerland
  11. 11 Department of Cardiology, University Heart Center Zurich, Zurich, Switzerland
  12. 12 German Respiratory Society (DGP), Berlin, Germany
  13. 13 Lungenzentrum (Bogenhausen-Harlaching), München Klinik, Munich, Germany
  14. 14 GENUD (Growth, Exercise, Nutrition and Development), Department of Physiatry and Nursing, University of Zaragoza, Zaragoza, Spain
  15. 15 Institute for Medicine and Sport, Ljubljana, Slovenia
  16. 16 Division of Sports and Rehabilitation Medicine, Ulm University Hospital, Ulm, Germany
  17. 17 Department of Sport Medicine, Humboldt University and Charité University School of Medicine, Berlin, Germany
  18. 18 Department for Health, University of Bath, Bath, UK
  19. 19 Sports Medicine, "Carol Davila" University of Medicine, Bucharest, Romania
  20. 20 Sport Medical Center, Japan Institute of Sports Sciences, Tokyo, Japan
  21. 21 UCT Research Unit for Exercise Science and Sports Medicine, Universisty of Cape Town, Cape Town, South Africa
  22. 22 I.M. Sechenov First Moscow State Medical University (Sechenov University), Ministry of Health of Russia, Moscow, Russian Federation
  23. 23 Moscow Research and Practical Centre for Medical Rehabilitation, Restorative and Sports Medicine, Moscow Healthcare Department, Moscow, Russian Federation
  24. 24 Italian Federation of Sports Medicine (FMSI), Rome, Italy
  25. 25 Department of Public, International and European Law, Unit of International Law, University of Salzburg, Salzburg, Austria
  26. 26 Movement, Human and Health Sciences, University of Rome Foro Italico, Rome, Italy
  27. 27 School of Sport and Service Management, University of Brighton, Eastbourne, UK
  28. 28 World Olympians Association, Lausanne, Switzerland
  29. 29 Sports Medicine Unit, University of Rome Foro Italico, Rome, Italy
  30. 30 FIFA Medical Center of Excellence, Villa Stuart Sport Clinic, Rome, Italy
  31. 31 Collaborating Centre of Sports Medicine, University of Brighton, Eastbourne, UK
  1. Correspondence to Professor Yannis P Pitsiladis, Collaborating Centre of Sports Medicine, University of Brighton, Eastbourne BN20 7SN, UK; Y.Pitsiladis{at}

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COVID-19 and return to play

The world of sport has recently returned to training and competition following suspension due to the COVID-19 pandemic. It is concerning that a number of athletes have tested positive for COVID-19 after returning to competition.1 Numerous authors have attempted to address return to play given the importance and complexity of the issue, with notable attention on possible cardiac implications.2–6

Scope of the infographic

The specific recommendations shown in the present infographic (figure 1) have been generated by a panel of international experts and represent a compilation of the numerous approaches used to inform resumption of regular sports during the COVID-19 pandemic. Despite the different regulations around the world and the particular characteristics of each sport, it is essential to provide informative, consistent and specific guidance for safe return to training and competition at this most difficult time.

Figure 1

Recommendations for return to sport during the COVID-19 pandemic. BNP, brain natriuretic peptide; CRP, C-reactive protein.


COVID-19 is a systemic disease affecting the endothelium and all organs, especially the heart and lungs with more severity and clinical significance. Therefore, our recommendations for safe return to sport are based on a comprehensive clinical evaluation (ie, cardiac and respiratory) and have been designed for six different groups according to the level of exposure to COVID-19. These groups are based on a previous report by Phelan et al,3 which are applicable to both leisure time and professional athletes. It is imperative that group allocation is determined beforehand through a medical examination performed in cooperation with a respiratory physician and/or cardiologist. Specific recommendations for each group are provided based on current evidence and expert opinion (see table 1).

Table 1

Clinical recommendations for testing individual groups

Special considerations

The resumption of sporting activity should be determined on a case-by-case basis and consider the individual situation of the athlete, including pre-existing conditions, as well as the type of sport and the risk of infection from other athletes (eg, increased risk in contact/team sports). Ideally, the final decision to return to play will be based on the results of the individual assessment in consultation with the sport and exercise medicine physician, specialists in pulmonary medicine and sport cardiologists (or extended multidisciplinary team), coaches and training specialists. After a prolonged period of interruption in sport caused by more severe health issues, increments in training should be gradual, individualised and supervised by periodic monitoring of cardiac and respiratory markers to detect potential signs and symptoms. Although the present recommendations are focused primarily on pulmonary and cardiac assessments, given the wider health-related issues caused by COVID-19, more comprehensive evaluation including psychological status, examination of muscular function and other suspected collateral issues should be considered to provide more detailed and thorough information for safe return to play.

Further essential reading

For more detailed description of the risk factors and symptoms that could inform the decision to return to sport as safely as possible, consult Baggish et al, 5 Carmody et al 7 and Niess et al.8



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  • Correction notice This article has been corrected since it published Online First. Ref 8 has been corrected.

  • Contributors All authors contributed significantly and in line with the instructions to authors to merit publication.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.