Key points you should know:
- In the lead-up to this year’s Olympics, dozens of professional athletes have been sidelined by long COVID.
- The disease has a wide spectrum of severity. Elite athletes could be more likely than most people to notice more mild presentations of long COVID, which some experts think is much more widespread than currently acknowledged.
- Long COVID can be a particularly frustrating hurdle for athletes to deal with because, unlike an injury or surgery, it lacks clear management guidelines and can be unpredictable.
- Emerging evidence suggests that long COVID makes returning to endurance sports particularly difficult. Studies show that it lowers VO2 max, weakens lung muscles, and causes muscle fibers to die off after long bouts of exercise.
- Some treatments may provide some relief for long COVID. However, some athletes may never regain their pre-COVID fitness.
Jordan Mann was used to suffering — but not like this. The elite distance runner was training for the upcoming Olympic Trials steeplechase — a grueling 3,000 meter-long track race that involves both running and jumping over barriers into water — when he contracted COVID-19 in September 2023. A month after clearing the acute infection, something was obviously off.
“Everything felt terrible,” he said. He found himself struggling to make it through short, light runs; he was totally unable to hit the paces and miles he would need to qualify for the Paris Olympics.
After a few more weeks passed and the symptoms persisted, it became clear: Mann had developed long COVID, and it was destroying his ability to compete at the top level.
Long COVID is a multisystemic disease with a broad spectrum of severity that affects more than 400 million people around the world. Some people with the disease are able to work full-time, while others have had their lives radically altered and can no longer work, exercise, or partake in life as they used to. Some with severe long COVID and myalgic encephalomyelitis (ME) are entirely bedbound.
For people whose livelihoods and identities are tied to excelling in sports, even a less severe case of long COVID can be devastating.
“It can be hugely problematic when an elite level athlete can’t train,” said Todd Davenport, a physical therapist at University of the Pacific and chair of Long COVID Physio.
Since the start of the COVID-19 pandemic, millions of people have had their careers thrown into question by seemingly unshakable long COVID symptoms. The disease has cost working Americans an estimated $170 billion in lost wages, and athletes, many of whom rely on contracts, prize money, and sponsorships, are among those taking an economic hit.
Scientists are working to unravel the mechanisms behind the disease, and some have turned to studying sports competitors to better understand how it affects intense physical performance. Now, their efforts are beginning to shed light on why long COVID hits some athletes — especially those in endurance sports — so hard.
A hurdle for athletic careers
Even years into the pandemic, medical professionals are still figuring out how best to treat people with long COVID, let alone advise athletes on managing it (if they are still able to exercise at all). What we do know: resting during a COVID-19 infection can help reduce the risk of long COVID. Some experts also recommend avoiding strenuous exercise for up to six weeks after COVID-19.
Top-tier athletes, however, are rarely incentivized to follow this protocol. For some professionals, the inability to compete can have serious financial repercussions. Around the time professional runner Drew Hunter began developing long COVID symptoms two years ago, he and his wife welcomed their daughter into the world. Soon after, his wife was laid off from her job, leaving Hunter the family’s sole breadwinner. There was just one problem: he was physically unable to race to his full potential.
“I was reduced in my contract because I wasn’t performing,” said Hunter. Many athletes have certain performance standards written into their contracts; if they don’t meet them, their sponsors may dock pay or benefits. “My job and my financial situation are tied to how I perform,” he said.
The fear of losing sponsor support can make long COVID difficult for some athletes to talk about, or even acknowledge. In addition to pros, Davenport has spoken with collegiate athletes who have had their scholarships threatened. Coaches, trainers, physical therapists, and sports medicine physicians sometimes accuse athletes of exaggerating their symptoms or faking them altogether. “There is so much denial in athletic spaces,” Davenport said.
The desire to be mentally and physically “tough” can also drive athletes to keep pushing through symptoms, often making their condition worse.
“There’s this psychology that athletes have that if they just buckle down and grit their teeth, it’ll be ok,” said Liam Keane, a rower for the Canadian National Team who wrote a thesis about top-level athletes’ experiences of long COVID while at Dartmouth College. Keane stresses that living with long COVID is not a matter of toughness — and in fact, that old-school grin-and-bare-it mentality can further exacerbate symptoms, a phenomenon known as post-exertional malaise (PEM).
Some studies have found that after people with these conditions work out, a significant volume of their muscle fibers die off. “Literally, exercise is toxic for people with long COVID and PEM,” said Isabell von Loga, an MD/PHD at University Hospital Zurich in Switzerland and member of the organization Long COVID Deutschland.
Many people with the most debilitating long COVID symptoms also meet the diagnostic criteria for other diseases, like ME or dysautonomia– but these diseases have historically been dismissed or under-researched by the greater medical community.
Finding a doctor who is familiar with the nuances of long COVID, takes them seriously, and knows how to treat high-level athletes can be a struggle. Though Mann understands why, like many with long COVID he was frustrated by the contradictory advice and lack of clear guidance he received from doctors and physical therapists early on. He told me about sitting through a battery of blood tests, only to have them come back “normal.” The experience threw him through a mental loop.
However, as researchers learn more about long COVID, they are beginning to gain a better idea of how to detect disease in the body. It can cause elevated levels of certain inflammatory cytokines and c-reactive protein, as well as decreased hemoglobin, for example. It can also affect heart rhythms, especially during and after exercise.
Von Loga tries to emphasize these lab numbers when working with athletes experiencing long COVID, like two-time Olympian Nathan Ikon Crumpton. But she said many medical professionals still don’t know which tests to run, and some end up dismissing long COVID symptoms based on inadequate diagnostics.
“It is physiologically measurable,” she said. “If only doctors used the right tests.”
Interfering with endurance
Research also suggests that for endurance athletes like Mann, Keane, and Hunter, long COVID may make the return to training especially difficult — if they are able to do so at all. The disease can affect most organ systems, and some studies have found that it does a number on endurance-oriented systems in particular.
In 2022, Daniel Śliż, a cardiopulmonary researcher at the University of Warsaw, examined 49 endurance athletes before and three to six months after SARS-CoV-2 infection. He and his team found that after recovering from their initial infection, study participants were still able to lift weights or sprint at roughly the same level they could pre-COVID-19 — their strength and speed were not severely impacted. (The study also did not assess whether participants developed long COVID.)
However, their performances suffered in another area: VO2 max, or the body’s ability to absorb oxygen. “We found that even if it was mild COVID, it significantly decreased VO2 max,” Śliż said. This metric is especially important for endurance sports, like cycling, rowing, cross-country skiing, and distance running, which require athletes to maintain steady blood oxygen levels. A recent Italian study found that athletes also have reduced lung function after experiencing COVID, along with a higher likelihood of hyperventilating during hard exercise — both of which could impact aerobic capacity.
And a 2024 study published in Nature found that people with long COVID not only had a lower VO2 max, but also had lower maximal ventilation (the amount of air a person can hold in their lungs) and peak power output during exercise. The longer a bout of exercise lasted, the more these factors decreased. To experience these worsened metrics, “we think you have to exercise above a certain threshold, which is time-dependent,” said Rob Wüst, a physiologist at Amsterdam University Medical Center and co-author of the study.
Śliż, Wüst, and their colleagues can’t say for certain why long COVID causes this drop. But Śliż speculates that it could be some combination of fibrosis — a type of scarring associated with chronic inflammation — and reduced mitochondrial activity. Klara Komici, a cardiopulmonologist at the University of Molise in Italy, adds that weakened respiratory muscles could be a contributing factor.
Like other clinicians who treat long COVID, von Loga points out that there is probably more than one underlying cause for long COVID symptoms. “The literature agrees that there must be different subtypes,” which may impact athletes differently and influence which treatments will or won’t work for them, she said.
This certainly seems to track with athletes’ lived experiences. Every athlete Keane spoke with for his thesis had their own unique experience of long COVID, as did each of the athletes I interviewed for this piece. Hunter’s initial infection was severe, and his long COVID symptoms manifested as shortness of breath and a cough he couldn’t shake.
“My life became this cycle of run, rest as much as you possibly can, and then survive to get to the next run,” he said. For Crumpton, the first round of COVID was relatively mild. But the subsequent discomfort and malaise have made it challenging to carry out daily tasks, let alone train. In Mann’s case, long COVID has hung around as a cloud of extreme fatigue. “My body is just like, W.T.F?” he said.
Hopes for treatment
For now there is no “cure” for long COVID, though immunoglobulins and low doses of opioid antagonists like naltrexone have provided relief for some people with the disease. Crumpton has seen some improvement with hyperbaric oxygen therapy (HBOT), the same technique scuba divers use to decompress from the bends. But von Loga cautions that the scientific literature is preliminary, and even after more studies come in, researchers likely won’t have a one-size-fits-all treatment that works for every person. Not to mention, HBOT is expensive and not accessible to most.
In the last few months, Hunter said his long COVID symptoms have finally begun to abate. He strung together a high-quality training cycle that culminated in a fourth-place finish at the U.S. Olympic Trials 10,000 meters, one spot away from making the team. Now, he is feeling optimistic about running for the first time in years.
But many are still grappling with the disease, which may remit and relapse, especially after subsequent COVID-19 reinfections. Long COVID has ended some athletes’ competitive careers altogether, including rower Oonagh Cousins, tennis prodigy Tanysha Dissanayake, and hockey player Brandon Sutter.
Crumpton’s symptoms sidelined him from making a third Olympic team this summer, likely his last shot at the summer games. He describes this reality as “a bitter pill to swallow.” Meanwhile, Mann is contemplating his future in the sport. With no set path to full recovery, he feels stuck in limbo, unsure whether to continue his career or hang up his spikes for good.
First and foremost, he said, “I’d like to be able to get to a point where I can run without suffering again.”
Joanna Thompson is a science journalist and part-time pro runner based in New York. When she isn’t writing, she enjoys reading science fiction, baking, and trying to identify weird bugs.
This article was published by The Sick Times, a website chronicling the long COVID crisis, on August 16, 2024. It is republished with permission.
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