What NFL, NBA, and MLB COVID Protocols Taught Us

Robert D. Glatter, MD; John P. DiFiori, MD; James Kinderknecht, MD; Kathryn D. McElheny, MD


February 05, 2021

Editorial Collaboration

Medscape &

This transcript has been edited for clarity.

Editor's note: This interview is intended to reflect the current state of medical care for athletes in the era of COVID-19, given the experience of Major League Baseball (MLB), the National Basketball Association (NBA), and the National Football League (NFL). The goal is to highlight protocols for testing, isolation, and quarantines, and what seems to work best in light of the current outcomes in the professional leagues this past season.

Robert D. Glatter, MD: Hi. I'm Dr Robert Glatter, medical advisor for Medscape Emergency Medicine. Today we'll be discussing the care of athletes during the COVID-19 pandemic.

Joining me today is a distinguished panel of sports medicine physicians from the Hospital for Special Surgery who provide care to professional athletes. Dr John DiFiori is currently the director of sports medicine for the NBA, Dr James Kinderknecht is a team physician for the New York Giants and the New York Mets, and Dr Kathryn McElheny is a nonoperative medical director and associate team physician for the New York Mets.

Welcome, everyone.

I want to talk about league protocols for the NFL, MLB, and the NBA. Kat, let's start with you. Can you talk to me a little bit about the protocols at MLB that you're using to test players?

Kathryn D. McElheny, MD: I think that our protocols will be adjusted prior to next year. I know that the NFL and NBA have taken different approaches in certain aspects of their protocols based on emerging data as the year has gone on. For the 2020 season, if someone were to test positive on a routine serial monitoring type of test that we did with saliva (every other day), they were to go home, isolate, and quarantine. They had to be completely asymptomatic for a full 72 hours before they were permitted back to the field, and they needed to have two negative PCR tests that were separated by 24 hours.

That became somewhat problematic as the season went on because we learned that players can continue to shed viral genetic material for quite a while without being infectious. We had other ways around that ─ other laboratory evidence that we would obtain (eg, cycle times, antibody presence) to try to get players back when we felt that they truly weren't an infectious risk to other people in the clubhouse.

Because of the cardiac screening that we did, the earliest anyone could really come back to game activity was after 14 days. Oftentimes it was longer than that, but typically it was about a 14-day minimum.

Glatter: James, your protocols for the NFL?

James J. Kinderknecht, MD: I'm a team physician with the Giants, so I'm kind of on the end game of it all. The protocols are all developed by the league and then we're left with complying with them.

We have daily testing, so if somebody tests positive, there's a rerun of that positive. There were some cases of false positives early on, and that was more on the lab-error side of things. First and foremost, we confirm that they have COVID. Then at that point, we start the contact tracing and we talk to the athletes about their symptoms.

They are protocoled out for 10 days. You can free somebody from quarantine after 5 days and two negative tests, although we haven't pushed that so much because breaking quarantine is one thing, but returning to play is another. The league protocol, as it relates to the concern with some of the cardiac involvement, was to hold people for 10 days. At the 10-day mark, we do further testing that included an ECG, an echo, and troponin. Any abnormality on any of these three tests would lead to a cardiac MRI. If those are negative, then they're cleared for a 3-day ramp-up. We do submaximal exercise and we progress them over a 3-day period. Earliest return to play is in 14 days.

Everything gets pushed back if somebody is symptomatic. Fortunately, in the ones I've dealt with, we've had minimally symptomatic to not symptomatic with short duration of symptoms. We get everybody pulse oximetry and quarantine. We have a hotel situation; all their food is delivered and they're in constant contact with the medical personnel while they're quarantined. Typically, we take them away from their home and quarantine them in these situations, but if they live alone, then we let them stay at home.

Glatter: At the end of 14 days, they are PCR-tested again and that's the end of it?

Kinderknecht: Once they test positive, we don't PCR-test them again for 90 days. They get a 90-day holiday because of all the issues. That's basically in concordance with the CDC recommendations. We've seen that people will test positive for out to 3 months after an infection. We saw that early on, where we would have people that would come in, they'd have had antibodies for 2 months, and they were still PCR positive. We don't really use follow-up testing. Early on when we're trying to clear people, quarantine, or confirm the diagnosis, we will do multiple tests. But once we've made the diagnosis, we don't do PCR for 90 days.

Glatter: John, if you want to go through your NBA protocols to just outline your approach as James did.

John P. DiFiori, MD: All positive tests must be confirmed. They're isolated until it's confirmed one way or the other. We initiate the contact tracing right away so that we're prepared to move forward if we need to quarantine others. The CDC criteria are applied in terms of when isolation is discontinued. We do test individuals who have recovered from COVID-19. We have a slightly different approach. We haven't implemented a test holiday following a recovered case yet, but we may.

One of our concerns, at least in the early phase, is following recovery. Because we are testing every day, we are in a zone for which the CDC doesn't really account. We may be detecting infections much earlier than is accounted for in the CDC's criteria. Our concern is that there may be persistent infectious shedding after that 10-day mark. We have a little more cautious approach with that.

Once they clear isolation, they undergo — like Dr Kinderknecht mentioned — a cardiac evaluation and then a gradual return to play. That's kind of it in a nutshell. There's a lot of contact tracing, obviously, as we get concerned about household members in particular. But that's been our general approach.

Rapid Antigen Testing

Glatter: Was there any thought to doing daily rapid antigen viral testing, being that the more often you test (although they're often less sensitive) it could be a good bellwether if there was any degree of infectiousness among the players?

McElheny: It's a good question. I don't know what the higher-level conversations were surrounding that. We developed a unique set-up where our antidoping lab was transitioned into a COVID testing lab dedicated to baseball. I think we achieved pretty impressive sensitivity and specificity with saliva PCR testing. We were reliant upon that methodology overall.

In terms of the rapid antigen testing, all teams were offered by MLB the opportunity to acquire portable rapid test machines for stadium use. [Most clubs opted to utilize point-of-care testing at some point throughout the season.]

We didn't use it to make sure that we had daily testing because that would have been really difficult to do from a logistical perspective; you have to do one sample at a time, and so on. If there was ever a concern or a pending lab result — for instance, if the saliva monitoring lab hadn't come back for someone that day, or if there was someone who had recently gone to a doctor's appointment or something along those lines — we would supplement with rapid antigen testing with the Sofia.

Player Bubbles

Glatter: Going forward to next season, is there any thought about using a bubble, based on the success of the NBA and the issues of the beginning of the season and throughout the season with multiple teams?

DiFiori: Well, in the bubble, we did daily PCR testing with a 12- to 14-hour turnaround time, and that worked very well for us. Obviously, the bubble is a different setting. Basketball is a different sport. We knew we had to test pretty much every day due to the frequency of competition. Plus, the fact that the players are exposed to each other on the court, close contact for extended periods of time, it's a little different from baseball and from football and hockey. We knew what was going to be needed was a daily test.

We also know, and probably apropos to your earlier discussion, that testing doesn't prevent infection. We have a big emphasis on all of the personal protective measures: wearing face masks, face coverings, social distancing, washing hands, not eating around each other unless it's quite distant. All of those things are very important. We had a very detailed infection protocol for all the facilities. The idea with the testing that you're asking about is really that it's designed to detect a case as early as possible. You're trying to prevent a campfire from becoming a forest fire. That's really the goal of the testing protocol.

Now we're in a quite different situation as we begin our preseason games. We're in a completely different scenario — we're not in a bubble. The pandemic is at its current height and hasn't reached its peak. We did experiment with point-of-care PCR testing in the bubble. We're in close contact with our colleagues in the NFL and their experience with the same platform. Because of the current situation, not being in a bubble, the prevalence of the virus in the community is now so high that we're basically going to do twice-daily testing regularly every day to try to narrow our window to no more than 12 hours where we're not knowing what the status is in terms of PCR.

That'll be our approach moving forward. Again, emphasizing that the most likely way for anyone within an organization to become infected is going to be in the community. They're probably less likely to become infected within the training facilities or on the court. Certainly it can happen, but the community introduction is really the main source of introduction that we feel we will be trying to guard against.

Glatter: But with your bubble during the season, you really didn't have the community to worry about. When you're saying the community as a whole, you controlled for that. It obviously raises the question, should all of the leagues embrace the bubble? You had a great outcome.

DiFiori: You have to remember that it's a different sport. We only had to complete 24% of our season. Normally we have an 82-game schedule. Trying to do an 82-game schedule in a bubble would be incredibly difficult from any number of standpoints, the least of which would be mental health. It's incredibly difficult for players and coaches to be away from their families. It's a mental endurance test to be in a bubble for any length of time.

The same is true with the National Hockey League. They were in a very similar circumstance and just needed to complete the season. When you've got a full season in front of you, it would be extremely difficult to expect to be able to have that kind of success in a bubble over a long period of time. It's quite challenging from many aspects. We're entering a 72-game season now. It's possible that we could revert to some sort of hub system or bubble system depending upon how things go. Maybe even down the road we would consider that if we got to playoffs or something like that.

But there are other things that are going to happen along the way. The vaccine, as you know, is on its way and we're not sure exactly how much that will impact us as we proceed halfway through the season. There are many factors.

I think one of the main things that we've learned is to collect data as we go forward and to review and analyze that data, adapt our protocols, and be nimble with that.

The same will hold true now as we start using twice-daily testing. What are we going to learn from that as the pandemic continues to increase? Are we going to be successful even with twice-daily testing? Or are we going to have multiple introductions, teams needing to shut down, facilities being shut down, and then we're going to recalibrate?

We're already considering what that means for us. You've seen in the NFL where San Francisco had to move to Arizona because of local public health ordinances. We are always prioritizing player health and safety — that's paramount, that's first. The next thing is that we do not want to detract resources from the public health effort. We won't do that. The third is that we will always fall in line with whatever the public health guidance is. Everything follows from those three priorities and then we go from there.

Glatter: Kat, I want to bring you into the discussion. You obviously did not have a bubble in MLB. This whole discussion we just had raises the question of whether MLB would entertain a hub system or a similar approach vs what happened this season.

McElheny: Similar to what Dr DiFiori mentioned, I think it's going to be really tough in these sports that involve a full, longer season. Our typical season is 162 games. If you're looking at doing an 8-month season in a bubble, I think that would be a really big ask for players and families from a logistical and mental health perspective.

From a baseball perspective, it's really logistically hard just because of the surface on which we play. If you look at basketball or hockey, for instance, you can reuse that court time and time again, and it's not going to cause an issue. If you play three games per day every day on the same field, you may have to completely redo that field partway through the season. That takes quite a bit of time.

Glatter: In terms of player embracement of these mitigation measures, was there any resistance — not just among the Mets but among other teams? What role does leadership and buy-in play in this?

McElheny: I think you had a mixed bag with every team. There definitely were people who believed in it and bought into it more than others. That's for certain. But in general, our team overall had a great attitude and they wanted to keep each other healthy.

We had a code of conduct; it was recommended by Major League Baseball that each team develop their own code of conduct. I liked that because I felt like the players were able to formulate that on their own. It wasn't something that they shared with the front office or shared with us as medical staff. In general, everyone was a really good sport; they had to be in order to play the sport that they loved. I think that the leadership was absolutely crucial in inspiring that.

When you look at baseball, we obviously got off to a little bit of a rocky start at the beginning of our season. I think that those two outbreaks with the Cardinals and the Marlins really showed us a few important factors.

One thing that we learned that was somewhat more positive is the relative lack of evidence supporting on-the-field transmission. While we did learn that there was spread through indoor spaces and through our clubhouses, and some of the shared facilities that our players were utilizing off the field, it seemed like on the field we actually did a pretty good job of not spreading COVID-19. They looked at about 40 different game hours, 11 of those being on-field play with five games where there were unknowingly asymptomatic, positive people. There was no transmission to other teams and no transmission to umpires. That helped us reshape our protocols and focus on containment and indoor prevention, social distancing, and mask usage, but also just where to focus our efforts.

Player Injuries

Glatter: I want to talk about the delays in starting the seasons and whether the shortened time spent in training camps has had an impact on the players, and specifically if you're finding injuries to be more of an issue this year as a result of the delays. James, let's start with you in the NFL.

Kinderknecht: Obviously, this was a big concern with the players' union, and appropriately so. Then based off that, our training camp started a couple of weeks late. Then we eliminated preseason games and it was a very prescribed, gradual ramp-up. It really was an attempt to recondition people because the problem is that nobody had resources through the summer. There were many off-season conditioning things that were just not performed. It really was a slow ramp-up to the start of the season.

The injury surveillance in the NFL is quite high. We're going to have that data to answer it scientifically and not anecdotally. On our team, and just talking to the other team physicians, we really didn't see that as a real problem where we had more soft tissue injuries (eg, hamstring injuries and the like). I think it was partly because by design, there was a prescribed ramp-up early on in terms of practice volume and intensity.

Glatter: John, if you want to weigh in on that too.

DiFiori: I think that was a concern, as Dr Kinderknecht was alluding to, because it wasn't that players had time off because the leagues shut down; it was that they couldn't even train. Everything was locked down. Gyms and facilities were closed and obviously we were concerned. We didn't want them trying to train in a public setting because of the risk of becoming infected.

We were trying to overcome de-training and so it wasn't even like a normal preseason. We tried to account for that as best we could. From the time they first arrived at the pre-resumption of season training in June, there were about 5 weeks before the first official game. We tried to incorporate conditioning, with each team having their own program for conditioning and getting players back into resilient shape.

We haven't fully analyzed the data from the bubble in terms of injuries yet, but our impression was that the players did very well. As we move forward into this season, the training camp is more consistent with the usual preseason training camp in terms of time. It's too early to tell right now, obviously, for what we're going to see. Overall, the teams and the players did a fantastic job in getting ready for these very unusual circumstances. We're very focused on their fitness, and I think the medical staffs for the teams did a great job in preparing them. It probably went better than we had expected.

Glatter: That's good to hear. Kat, if you want to just finish this up with what you know.

McElheny: I think that if you just look at the objective numbers, it does appear that we had more injuries during the shortened season. Whether that actually correlates with a specific increase in injury incidence is to be determined.

I think there were some differences in terms of our sport. First of all, throwers need to throw. During quarantine, if you don't have a throwing partner or someone to go out and do that with, it's really challenging.

We received news that we had the green light to proceed with the regular season on June 23rd, and we reported to spring training on July 1st. So we really had a pretty short window to prepare for spring training, and then an abbreviated training of about 2-3 weeks when it's typically 4-6 weeks.

Maybe those things contributed, but it's hard to interpret the data as well. We had a taxi squad right down the road (which was unique to this year), and the use of the [injured list] was probably slightly different because of the shortened season, the utilization of that practice squad, and the availability of those players. It will be challenging to interpret some of this data completely and objectively, given these confounding variables.

Postseason Monitoring of Players

Glatter: It would be interesting to look at the data, maybe at some point later on, on whether that's just an internal issue.

I'd like to get everyone's approaches about how we're going to monitor patients in the postseason, not only for the effects of COVID but also looking at their injuries and making a very clear pattern or approach in terms of follow-up. Does each team or league have a protocol in place for this at this time?

Kinderknecht: I would say we haven't gotten as far as what we are going to do in terms of monitoring of our known COVID-positive patients in the postseason. The protocol is in place. We follow these guys quite closely and they get more physicals than any healthy person in any other setting. They get frequent labs. They all get an ECG each year. I would anticipate that we probably will be more symptom driven. In terms of 3 or 4 months out, I don't think we're going to repeat the cardiac testing. I do think it will probably become protocol that troponin may be part of our screening labs in this specific population that has been COVID positive. I don't think it's going to change much of what we do in terms of other than monitoring symptoms.

Glatter: Right, just a basic approach of looking at symptoms more so than looking at imaging tests in terms of making decisions.

Kinderknecht: It's not a whole lot different from what we'll be doing with the general population. What we knew from early on is that 20% of hospitalized patients had cardiac involvement. What we still don't know is what percentage of people in a nonhospitalized population, either asymptomatic or minimally symptomatic, have cardiac involvement. In a few of the leagues we can produce some data, and we're going to try to for everybody. We've had a robust testing protocol for this special population of COVID-positive patients, who are typically healthy, active, minimally symptomatic people. I do think we're going to have data for the general public and all physicians to utilize, but right now it's still so evolving that we don't know.

Glatter: When we saw the Big Ten cancel the season in light of this concern for myocarditis, that was a big scare not only to the players and staff but also to the public — to hear that these young athletes could have an arrhythmia and die. The data don't show that, and certainly going forward we can think about that.

Kinderknecht: We all have to be careful with stating things that aren't proven, because it can create hysteria and paranoia. That was pushed out there and then reeled back. The problem is that when those comments were reeled back, the paranoia and hysteria had already been developed. Everybody needs to be patient while we collect solid data that we can then share with providers to help make decisions.

Glatter: Exactly. Kat, I just wanted to get your thoughts on that too.

McElheny: In terms of our postseason monitoring, we are a pretty tight bunch. Everyone knows to reach out to our head athletic trainer or to me personally if they have any concerns or symptoms. We've had a few situations that have arisen in the off-season where you talk them through the process remotely.

Sometimes you help them arrange for testing if they have a concern, or testing for their family members. If for any reason someone were to test positive, we arrange for cardiac testing for them. Our physical therapists and athletic trainers have a group of guys that they check in with regularly. In terms of their return to play following any potential infection, that would also be closely monitored from a workload perspective.

In terms of the cardiac piece, I think it's challenging, especially the interpretation aspect to which Dr Kinderknecht alluded. Many of the tools that we have to assess the cardiac concerns are really reliant on a high pretest probability of that being true.

The issue is that with some of our screening modalities, in a relatively healthy and borderline asymptomatic population, the pretest probability is much lower. It affects the quality and the interpretation of the tests that we have available. It seems like there are emerging expert opinion consensus statements that are slightly different from some of the initial ones that came out.

It will be interesting to see what the leagues adopt for next season. I'm sure that will be a topic of discussion. In the off-season, at least, we're continuing to recommend the same sort of protocol that we had during the season: the cardiac-specific troponin, ECG (which has a low sensitivity for detecting myocarditis in isolation), and echo.

Glatter: One other thing I want to talk about is the mental health effects of all this on the players. Have any of you seen any depression or anxiety?

McElheny: From an organizational perspective, we certainly tried to be proactive. We have two people on staff; one is a psychologist and the other is an addiction health specialist. They work together to try to confidentially be available for all of our players and staff.

I would echo the staff mental health component too, because with reduced travel party size and trying to pull off this season, you're doing twice as much work with half the bodies. Many people were mentally and physically fatigued — players and staff alike. By the end of the season, everyone's comment was, "Man, we did it. I'm glad we made it through. That was tough. It would be really tough to do this for 162 games."

Sense of Community

Glatter: Right. Among the different NFL, MLB, and NBA leagues, do you feel that there's some community now, that everyone's gone through this and they can all join in this together?

DiFiori: I think that's actually one of the silver linings of all of this. Early on in March, when we shut down the league — and even before that, back in February — we were actively communicating with colleagues internationally who are involved in professional soccer, Australian football, and rugby. It did seem to really galvanize the medical community.

As we moved forward in March, April, and May, there's been regular communication with the major professional leagues, the NCAA, and other associations.

Kinderknecht: I think that's the biggest example of how galvanized the league became — not our team, the whole league. It wasn't until maybe 10 weeks into training camp, combined with the season, before the NFL had its first case. Clearly, we could create an ecosystem that really diminished risk. But we've been talking about the community spread, and that's really where the risk is. If our players and our staff were doing less than smart things — exposing themselves to the crowd, not social distancing, not wearing the mask and the whole bit — we would have had cases all over the place. To me, what really was obvious is how much buy-in there was that individuals do have to sacrifice some things outside this ecosystem to really make it work.

I personally did not think that could happen. I was pleasantly surprised because you're talking about staff so close to the players. In training camp, it's 90 players. We went to teams of 80 players. You then talk about equipment, coaches, medical staff, and that goes up to about 140 people, easy. Any one of those 140 screwing up is going to bring down the house of cards. To me, that was really the evident answer that people did galvanize and work together. There was this collective "I have to do my part to make sure this works."

McElheny: I agree with everything that's been said so far. I think the last piece I would add is that now with baseball being on the flipside of our season, there was a sense of camaraderie from having survived it. We all went through uncharted waters together. We navigated it together, both in the medical community but also the players and staff members. That travel party of 60 guys will always have that experience of battling through it together. It brought them closer as teammates. Don't get me wrong — it was challenging and tiring at times for everyone involved, but I think that piece was also potentially a positive to come out of all of this.

Glatter: I want to thank everyone for joining us today. It has been very informative, and I think our audience will truly appreciate this. Not only people who practice sports medicine, but all providers in general, because I think it's an important part of understanding how athletes are cared for and how we're approaching sports going forward during the pandemic.

Robert D. Glatter, MD, is an attending physician at Lenox Hill Hospital in New York City and assistant professor of emergency medicine at Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York. He is an editorial advisor and hosts the Hot Topics in EM series on Medscape. He is also a medical contributor for Forbes.

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