• The Renaissance Surgeon

How I Returned to Marathon Training After COVID-19

I was starting to think that I was completely immune to COVID-19. Early on, I was grateful to get my first dose of the Pfizer vaccine and got a booster when that became available. My kids all got COVID in September 2021. I was unaffected. Then vaccinated people started getting infections. It became apparent that the coverage from the existing vaccines was not iron-clad. Still, when COVID swept through my household a second time, I blithely carried on, despite young kids coughing and sneezing all over me. Bivalent booster? ‘I don’t seem to need it’, I thought. You can imagine my disappointment when, as the virus came through our house a third time, my immunity finally succumbed to the infection. The bivalent booster was only a couple weeks old, but I was about to get a natural booster.

Image: Fusion Medical Imagination via Unsplash

My experience of the infection was not severe. For me, it resembled the flu. I certainly did not feel up to much for a couple days as total body muscle pain temporarily engulfed my system. Grateful not to have had more severe involvement, my next concern was: ‘how will this affect my marathon training?’ I had already truncated a 16 week marathon training plan to 12 by lopping off the first four weeks. Now, just 8 weeks from race day, I had this wrench in the works. As an athlete, my first instinct was: ‘as soon as I feel fine, I can resume my training as usual.’ As a team physician, though, I knew this is not what we tell our athletes, who are mostly healthy (and younger than me).


A retired cardiologist (a.k.a. my dad), cautioned me that the virus infects the myocardium (heart muscle), even for those who don’t get clinical myocarditis (inflammation of the heart muscle). A quick review of the literature on return to sport for elite athletes was replete with what I thought was a potentially overly medicalized approach. For example, some articles recommended cardiac clearance and an electrocardiogram (EKG) or even an echocardiogram (heart ultrasound) as part of a return to play evaluation. Some recommended 10 days from onset of symptoms before resuming exercise. WellSpan’s protocol is more forgiving, but even with that, I was looking at five days of no exercise, followed by a doctor’s evaluation, possibly an EKG and then a seven day return-to-play protocol.*

WellSpan COVID RTP
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But even losing just 12 days out of my 12-week marathon training would result in a loss of 14% of my planned training. Eek!


The longer an athlete delays return-to-play after COVID, the safer it is for his or her heart, but the greater the risk of orthopaedic injury after resumption of training and competition. I was about to start the peak mileage portion of my training, so I needed to balance cardiac health against the risk of musculoskeletal breakdown. I went with the WellSpan protocol, it being the fastest and also quite reasonable in its approach. As always, I sought to double down on sleep during the recovery period and began strict avoidance of alcohol while sick. In contrast to a typical cold however, I decided to do an extended period of alcohol abstinence. Alcohol is a toxin to the heart (and a toxin in general). With my heart under assault from the virus, I decided not to ingest any unnecessary cardiotoxins. I thus decided to abstain from alcohol from the time of my COVID infection until at least after my marathon. Caffeine got shelved as well (but only during the return to play protocol time period).

Photo: Josh Olalde via Unsplash

Being a sports medicine physician, I excused myself from going to see a doctor (typical doctor move). Not having had any chest pain or shortness of breath, I excused myself from EKG consideration as well. Counting my positive test as day one, I planned to start my seven day return-to-play protocol on the following Sunday, day 6 after the positive test.


My RTP plan

After my symptoms passed, I did nothing more strenuous than walking or light hiking for the five day isolation period. To start the return to play protocol, I planned to run lightly, keeping my heart rate below 128 beats per minute. I had just run 10 miles with an average heart rate of 128 at a 6:40 pace the week before my infection, so I thought this would be easy. Not so. I set a heart rate alarm on my watch to ding any time I went over 128. Although I felt fine and had no symptoms, I couldn’t jog for more than 30 seconds without my heart rate shooting into the 150s. My planned light run thus became a walk/run. Fortunately, I had planned it as a trail run, so I had some decent surroundings.


On day 2, I rode a stationary bike. There, it was easier to control my heart rate and I was able to keep it in check. On day 3, I was determined to give running another try, now with a more relaxed heart rate maximum of 144 beats per minute. I was able to sustain running for longer than 30 seconds this time but I still had to resort to walk/run even on a short, 3-mile loop in my neighborhood. Day 4 saw me back on the stationary bike, but now adding back in resistance training, with a 30-minute, ‘Strength for Runners’ session on the Peloton app. Day 5, I took to the roads again on foot, now going for 4 miles, still aiming to keep the heart rate under 144. This time I was able to do it by slowing my pace to a jog rather than a walk, and didn’t have to resort to the walk/run until near the end. Day 6 I took as a rest day, with Day 7 as my planned, full return to play.


I made this run shorter than the marathon program prescribed though, keeping my miles for that week at 50% of peak. As a result, I did 6 miles instead of the 15 that the plan called for. I turned the heart rate alarm off and ran a refreshing, monitor-free six mile effort through the country roads of Gardiner, NY, feeling fine. Afterwards I looked at my watch to discover with chagrin that my maximum heart rate was 194! In the second half of the run, it had shot up around 190 and stayed there.

Red-lining it...

Humbled, but grateful that I had no exertional symptoms, I thus completed the 5-plus-7 day return-to-play protocol. I returned to regularly scheduled training the following week, though it took another week for my average heart rates to return to my normal range. Less than five weeks after the infection, I ran a personal best half marathon. Now I have just two weeks of marathon taper before race day. I’m sure there will be plenty of coughing and sneezing from my kids to usher me to the starting line!


*Views expressed on this blog are my own, and do not in any way reflect those of my employer or any institution.