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Updated AAP COVID-19 sports guidance includes return-to-play algorithm

September 21, 2021

Editor’s note: The guidance in this article has been updated since the time of publication. Please visit Return to Sports and Physical Activity. For the latest news on COVID-19, visit

A new algorithm provides straightforward steps to clear athletes to return to play after COVID-19 infection. The resource is part of the updated AAP COVID-19 interim guidance Return to Sports and Physical Activity.

The updated guidance also reviews the ongoing repercussions of the pandemic on physical activity for youths and explains the importance of risk mitigation strategies and COVID-19 vaccination for eligible individuals.

Return-to-play algorithm

Guidance on clearing athletes to return to play is divided into three categories based on symptom severity.

  • Youths who are asymptomatic or have mild symptoms require at least a telehealth or phone assessment by a primary care physician. During the assessment, the physician should discuss how long the athlete should quarantine, advise against exercise during quarantine and conduct the American Heart Association 14-element screening evaluation, focusing on symptoms of myocarditis. The next steps depend on whether the patient has symptoms.
  • Those with moderate symptoms should have an in-person visit with a primary care physician after their symptoms resolve and they have completed quarantine. The physician should perform the 14-element screening evaluation and a complete physical examination and electrocardiogram (EKG). The patient should be advised not to exercise until cleared. The next steps depend on whether the patient has a normal evaluation or has a positive symptom screen, abnormal examination or abnormal EKG.
  • Those with severe symptoms include those who required an intensive care unit stay and/or intubation or had multisystem inflammatory syndrome in children. They should not exercise for three to six months and get cardiology clearance before resuming training or competition.

The algorithm also outlines when and at what pace to return to play. Physicians should advise patients who have been cleared to stop immediately and see their primary care physician for an in-person examination if they experience any chest pain, shortness of breath out of proportion to upper respiratory infection, new-onset palpitations or syncope.

In support of masks

The interim guidance includes updates on mask use during sports. Sports performed outside are lower risk for transmission of SARS-CoV-2, and a mask may not be necessary for all sport-related activities. However, the AAP supports universal masking as an additional layer of protection. Recommendations include:

  • Face masks are strongly recommended for all indoor sports training, competition and on the sidelines for people who are not fully vaccinated and for all athletes, regardless of vaccination status, in counties with substantial or high transmission according to the Centers for Disease Control and Prevention criteria.
  • Masks are encouraged for athletes who play outdoor sports and are not fully vaccinated, including on the sidelines and during all group training and competition in which there is sustained close contact..
  • Masks worn by coaches, volunteers, officials and spectators help model positive behavior. Coaches and other club/school officials should monitor proper use and encourage all athletes to wear a well-fitting face mask in accordance with AAP guidance and local regulations.



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