Return to Training After Acute Respiratory Infections in Athletes: Performance Impairment, Red Flags and a Graduated Return-to-Sport Approach - A Narrative Review
DOI:
https://doi.org/10.12775/QS.2026.78.76521Keywords
acute respiratory infection, athletes, return to sport, athletic performance, exercise tolerance, sports medicineAbstract
Background: Acute respiratory infections can disrupt training and competition in athletes, while decisions about returning to sport vary between individuals.
Aim: To review the effects of acute respiratory infections on performance, the risks associated with exercise during illness, clinical red flags, and return-to-sport strategies.
Materials and Methods: A narrative literature review was conducted using PubMed searches and reference-list screening. Publications from 2014 to 2026 were considered, with priority given to relevant consensus statements, systematic reviews, meta-analyses, and original studies.
Results: The effects of infection on performance and training depend on illness severity and clinical presentation. Evidence from studies with pathogen-confirmed infections suggests that return to training, full training, and full performance may occur at different times, with longer recovery associated with greater illness severity and certain viral pathogens. Cardiopulmonary or systemic symptoms and an abnormal response to exercise warrant reassessment. A gradual increase in exercise load, guided by tolerance and symptom monitoring, may help athletes resume training.
Conclusions: Return-to-sport decisions should account for clinical recovery, warning signs, and exercise tolerance. Progression should follow the athlete’s response to exercise rather than a fixed timetable.
References
1. Derman W, Badenhorst M, Eken MM, Ezeiza-Gomez J, Fitzpatrick J, Gleeson M, et al. Incidence of acute respiratory illnesses in athletes: a systematic review and meta-analysis by a subgroup of the IOC consensus on ‘acute respiratory illness in the athlete.’ Br J Sports Med. 2022 Jun;56(11):630–40. doi:10.1136/bjsports-2021-104737
2. Kaulback K, Pyne DB, Hull JH, Snyders C, Sewry N, Schwellnus M. The effects of acute respiratory illness on exercise and sports performance outcomes in athletes – A systematic review by a subgroup of the IOC consensus group on “Acute respiratory illness in the athlete.” Eur J Sport Sci. 2023 Jul;23(7):1356–74. doi:10.1080/17461391.2022.2089914
3. Snyders C, Pyne DB, Sewry N, Hull JH, Kaulback K, Schwellnus M. Acute respiratory illness and return to sport: a systematic review and meta-analysis by a subgroup of the IOC consensus on ‘acute respiratory illness in the athlete.’ Br J Sports Med. 2022 Feb;56(4):223–32. doi:10.1136/bjsports-2021-104719
4. Schwellnus M, Adami PE, Bougault V, Budgett R, Clemm HH, Derman W, et al. International Olympic Committee (IOC) consensus statement on acute respiratory illness in athletes part 1: acute respiratory infections. Br J Sports Med. 2022 Oct;56(19):1066–88. doi:10.1136/bjsports-2022-105759
5. Jooste M, Sewry N, Valtonen M, Dyer M, Jordaan E, Schwellnus M. Clinical manifestations of different viral respiratory infections in athletes: implications for risk assessment and return-to-sport - AWARE VII study in 116 cases. Phys Sportsmed. 2026;54(1):1–10. doi:10.1080/00913847.2025.2518748
6. Luoto R, Waris M, Valtonen M, Ruuskanen O. Respiratory viral infections - impact on sport and exercise medicine. Exerc Immunol Rev. 2023;29:7–21. PubMed PMID: 37358372.
7. Snyders C, Dyer M, Jordaan E, Scholtz L, Du Plessis A, Mpe M, et al. Number of Symptoms During the Acute Phase of SARS-CoV-2 Infection in Athletes Is Associated With Multiorgan Involvement: AWARE III. Clin J Sport Med. 2026 Jan;36(1):6–13. doi:10.1097/JSM.0000000000001347
8. Derman W, Badenhorst M, Eken M, Gomez-Ezeiza J, Fitzpatrick J, Gleeson M, et al. Risk factors associated with acute respiratory illnesses in athletes: a systematic review by a subgroup of the IOC consensus on ‘acute respiratory illness in the athlete.’ Br J Sports Med. 2022 Jun;56(11):639–50. doi:10.1136/bjsports-2021-104795
9. Svendsen IS, Taylor IM, Tønnessen E, Bahr R, Gleeson M. Training-related and competition-related risk factors for respiratory tract and gastrointestinal infections in elite cross-country skiers. Br J Sports Med. 2016 Jul;50(13):809–15. doi:10.1136/bjsports-2015-095398
10. Hellard P, Avalos M, Guimaraes F, Toussaint JF, Pyne DB. Training-Related Risk of Common Illnesses in Elite Swimmers over a 4-yr Period. Med Sci Sports Exerc. 2015 Apr;47(4):698–707. doi:10.1249/MSS.0000000000000461
11. Valtonen M, Grönroos W, Luoto R, Waris M, Uhari M, Heinonen OJ, et al. Increased risk of respiratory viral infections in elite athletes: A controlled study. PLOS ONE. 2021 May 4;16(5):e0250907. doi:10.1371/journal.pone.0250907
12. Luoto R, Laatikainen-Raussi V, Mjøsund KE, Valtonen M, Uhari M, Ihalainen JK, et al. Viral acute respiratory illnesses in elite athletes: A 12-month controlled follow-up study. Wade TJ, editor. PLOS One. 2025 Jun 2;20(6):e0322283. doi:10.1371/journal.pone.0322283
13. Valtonen M, Waris M, Luoto R, Mjøsund K, Kaikkonen M, Heinonen OJ, et al. Non–SARS-CoV-2 Respiratory Viruses in Athletes at Major Winter Sport Events, 2021 and 2022. Emerg Infect Dis. 2022 Oct;28(10):2096–9. doi:10.3201/eid2810.220478
14. Grönroos W, Uhari M, Ruuskanen O. Occurrence of acute respiratory illnesses in athletes: a systematic review and meta-analysis. Exerc Immunol Rev. 2025;31:6–18. PubMed PMID: 41408785.
15. Deng S, Deng J, Yin M, Li Y, Chen Z, Nassis GP, et al. Short-term effects of SARS-CoV-2 infection and return to sport on neuromuscular performance, body composition, and mental health — A case series of well-trained young kayakers. J Exerc Sci Fit. 2023 Oct;21(4):345–53. doi:10.1016/j.jesf.2023.08.002
16. Van Tonder A, Schwellnus M, Swanevelder S, Jordaan E, Derman W, Janse Van Rensburg DC. A prospective cohort study of 7031 distance runners shows that 1 in 13 report systemic symptoms of an acute illness in the 8–12 day period before a race, increasing their risk of not finishing the race 1.9 times for those runners who started the race: SAFER study IV. Br J Sports Med. 2016 Aug;50(15):939–45. doi:10.1136/bjsports-2016-096190
17. Mäki-Heikkilä R, Karjalainen J, Parkkari J, Huhtala H, Valtonen M, Lehtimäki L. Acute respiratory infections hamper training and competition in cross-country skiers, especially in those with asthma. Int J Circumpolar Health. 2023;82(1):2223359. doi:10.1080/22423982.2023.2223359
18. Grönroos W, Valtonen M, Lindblad N, Hänninen T, Luoto R, Heinonen OJ, et al. Respiratory viral infections in professional ice hockey teams-a one-season observational study. Front Sports Act Living. 2026;8:1832991. doi:10.3389/fspor.2026.1832991 PubMed PMID: 42416341; PubMed Central PMCID: PMC13337772.
19. Gordon L, Schwellnus M, Swanevelder S, Jordaan E, Derman W. Recent acute prerace systemic illness in runners increases the risk of not finishing the race: SAFER study V. Br J Sports Med. 2017 Sep;51(17):1295–300. doi:10.1136/bjsports-2016-096964
20. Svendsen IS, Gleeson M, Haugen TA, Tønnessen E. Effect of an intense period of competition on race performance and self‐reported illness in elite cross‐country skiers. Scand J Med Sci Sports. 2015 Dec;25(6):846–53. doi:10.1111/sms.12452
21. Deng S, Yin M, Chen Z, Deng J, Wang Z, Li Y, et al. SARS-CoV-2 infection decreases cardiorespiratory fitness and time-trial performance even two months after returning to regular training — Insights from a longitudinal case series of well-trained kayak athletes. J Exerc Sci Fit. 2024 Oct;22(4):350–8. doi:10.1016/j.jesf.2024.05.003
22. Roczniok R, Terbalyan A, Pietraszewski P, Mikrut G, Zielonka H, Stastny P, et al. Impact of SARS-CoV-2 on Aerobic and Anaerobic Capacity in Professional Ice Hockey Players. J Clin Med. 2025 May 16;14(10):3478. doi:10.3390/jcm14103478
23. Raysmith BP, Drew MK. Performance success or failure is influenced by weeks lost to injury and illness in elite Australian track and field athletes: A 5-year prospective study. J Sci Med Sport. 2016 Oct;19(10):778–83. doi:10.1016/j.jsams.2015.12.515
24. Dick NA, Diehl JJ. Febrile illness in the athlete. Sports Health. 2014 May;6(3):225–31. doi:10.1177/1941738113508373 PubMed PMID: 24790692; PubMed Central PMCID: PMC4000470.
25. Tyson HC, Zurawlew MJ, Robinson MR, Hemingway R, Corbett J, Tipton MJ, et al. Infection as an Exertional Heat Illness Risk Factor: A Prospective Cohort Study. Med Sci Sports Exerc. 2026 Sep;58(9):2101–10. doi:10.1249/MSS.0000000000004012
26. Ruuskanen O, Valtonen M, Waris M, Luoto R, Heinonen OJ. Sport and exercise during viral acute respiratory illness—Time to revisit. J Sport Health Sci. 2024 Sep;13(5):663–5. doi:10.1016/j.jshs.2023.12.002
27. Gluckman TJ, Bhave NM, Allen LA, Chung EH, Spatz ES, Ammirati E, et al. 2022 ACC Expert Consensus Decision Pathway on Cardiovascular Sequelae of COVID-19 in Adults: Myocarditis and Other Myocardial Involvement, Post-Acute Sequelae of SARS-CoV-2 Infection, and Return to Play. J Am Coll Cardiol. 2022 May;79(17):1717–56. doi:10.1016/j.jacc.2022.02.003
28. Petek BJ, Moulson N, Baggish AL, Kliethermes SA, Patel MR, Churchill TW, et al. Prevalence and clinical implications of persistent or exertional cardiopulmonary symptoms following SARS-CoV-2 infection in 3597 collegiate athletes: a study from the Outcomes Registry for Cardiac Conditions in Athletes (ORCCA). Br J Sports Med. 2022 Aug;56(16):913–8. doi:10.1136/bjsports-2021-104644
29. Kim JH, Baggish AL, Levine BD, Ackerman MJ, Day SM, Dineen EH, et al. Clinical Considerations for Competitive Sports Participation for Athletes With Cardiovascular Abnormalities. J Am Coll Cardiol. 2025 Mar;85(10):1059–108. doi:10.1016/j.jacc.2024.12.025
30. Jooste M, Sewry N, Valtonen M, Dyer M, Jordaan E, Schwellnus M. Factors associated with return-to-sport outcomes following pathogen-confirmed acute respiratory infections in athletes: AWARE X study. Br J Sports Med. 2026 Jul;60(14):1028–35. doi:10.1136/bjsports-2025-111446
31. Schwellnus M, Sewry N, Snyders C, Kaulback K, Wood PS, Seocharan I, et al. Symptom cluster is associated with prolonged return-to-play in symptomatic athletes with acute respiratory illness (including COVID-19): a cross-sectional study—AWARE study I. Br J Sports Med. 2021 Oct;55(20):1144–52. doi:10.1136/bjsports-2020-103782
32. Snyders C, Schwellnus M, Sewry N, Kaulback K, Wood P, Seocharan I, et al. Symptom Number and Reduced Preinfection Training Predict Prolonged Return to Training after SARS-CoV-2 in Athletes: AWARE IV. Med Sci Sports Exerc. 2023 Jan 1;55(1):1–8. doi:10.1249/MSS.0000000000003027 PubMed PMID: 35975934; PubMed Central PMCID: PMC9770013.
33. Hull JH, Wootten M, Moghal M, Heron N, Martin R, Walsted ES, et al. Clinical patterns, recovery time and prolonged impact of COVID-19 illness in international athletes: the UK experience. Br J Sports Med. 2022 Jan;56(1):4–11. doi:10.1136/bjsports-2021-104392
34. Hull JH, Williams Z, Wootten M, Ranson C, Heron N. Recovery from COVID-19 in athletes and impact on sporting participation. J Sci Med Sport. 2023 Oct;26(10):528–9. doi:10.1016/j.jsams.2023.07.011
35. Jansen Van Rensburg A, Janse Van Rensburg DC, Schwellnus MP, Janse Van Rensburg C, Jordaan E. Days until return-to-play differ for sub-categories of acute respiratory tract illness in Super Rugby players: A cross-sectional study over 5 seasons (102,738 player-days). J Sci Med Sport. 2021 Dec;24(12):1218–23. doi:10.1016/j.jsams.2021.06.010
36. Snyders C, Dyer M, Sewry N, Jordaan E, Schwellnus M. Increased number of symptoms during the acute phase of SARS-CoV-2 infection in athletes is associated with prolonged time to return to full sports performance—AWARE VIII. J Sport Health Sci. 2024 May;13(3):280–7. doi:10.1016/j.jshs.2023.10.005
37. Kaulback K, Schwellnus M, Sewry N, Jordaan E, Wood P. Rating of Perceived Exertion Associated With Acute Symptoms in Athletes With Recent SARS-CoV-2 Infection: Athletes With Acute Respiratory InfEction (AWARE) VI Study. J Athl Train. 2024 Jan 1;59(1):90–8. doi:10.4085/1062-6050-0632.22
38. Kaulback K, Schwellnus M, Sewry N, Lombard C, Jordaan E, Wood P. The cardiovascular response to exercise in athletes recovering from SARS-CoV-2 infection: A prospective cohort study with repeated measures over 16 weeks – AWARE IX. J Sports Sci. 2023 Dec 2;41(23):2077–87. doi:10.1080/02640414.2024.2312054
39. Wang J, Lin L, Jiang L, Tan C, Cao G, Yin J, et al. Characteristics of symptoms during athletes’ COVID-19 infection and return to training: A descriptive study. Medicine (Baltimore). 2025 May 9;104(19):e42380. doi:10.1097/MD.0000000000042380
40. Widmann M, Gaidai R, Schubert I, Grummt M, Bensen L, Kerling A, et al. COVID-19 in Female and Male Athletes: Symptoms, Clinical Findings, Outcome, and Prolonged Exercise Intolerance—A Prospective, Observational, Multicenter Cohort Study (CoSmo-S). Sports Med. 2024 Apr;54(4):1033–49. doi:10.1007/s40279-023-01976-0
41. Ruuskanen O, Luoto R, Valtonen M, Heinonen OJ, Waris M. Respiratory Viral Infections in Athletes: Many Unanswered Questions. Sports Med. 2022 Sep;52(9):2013–21. doi:10.1007/s40279-022-01660-9
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Copyright (c) 2026 Katarzyna Garbacz, Natalia Wiczuk, Michał Siwko, Szymon Kanadys, Kamila Satławska, Artur Goc, Julia Drzewiecka, Karolina Laskowska, Lidia Jasielska, Karolina Dąbek
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