Is the COVID-19 pandemic another reason why tennis may be the healthiest sport?

If you're like me, I've been wondering about whether or not it's safe to go outside and hit some balls around. I think this article, while a bit long, sums it up nicely.

“Why this global game may be the right sport for this global pandemic” 

By: Neeru Jayanthi, MD, USPTA, PTR

STMS

Society for Tennis Medicine and Science

I recently stepped off the court playing tennis with one of my good friends in the neighborhood. Like many of you, we often do this to relieve the stress of our usual very busy work weeks.  However, this time it was different as we are playing during a time where much of the world has been shut down due to the impending and ongoing COVID-19 pandemic.  While as a tennis player I see the many reasons why it was good to finally get a “hit” in; as an academic sports (and tennis medicine) physician and a researcher, I question whether or not it is prudent to be playing tennis or not now.  I know I am not alone as a lot of tennis players and tennis coaches around the world are asking themselves (and me) the question of whether it is safe to play tennis during the pandemic.

“Right now, my coach and I have lightly hit a few times in the last week.  I’ve been maintaining my fitness and workouts but really using this time to socially distance and keep healthy” said Catherine Harrison, a woman’s professional tennis player in the top 300 in the world who currently trains in Austin, Texas.

But this has not been the case for other players and coaches.  “I haven’t had a single private lesson cancel on me during this, although we have recently cancelled all groups and other programming” said Amy Pazahanick, Tennis teaching professional, and CEO of Agape Tennis at Dekalb Tennis Center in Atlanta, Georgia.  “I believe in balance, and we follow all CDC (Center for Disease Control) social distancing guidelines (https://www.cdc.gov/coronavirus/2019-ncov/downloads/2019-ncov-factsheet.pdf) and allow our coaches to do some teaching in a relatively safe environment.”

With many millions of players around the world and thousands of elite/professional players, tennis has yet to find its place during this pandemic.  The postponement of both WTA and ATP tours as well as major tournaments, grand slams, and Olympics has sent a shock wave through the tennis world.  It is now obvious that those postponements were all the correct decisions to avoid a massively accelerated spread of the virus through a mass spectator event.  However, most organizations such as USTA (United States Tennis Association https://www.usta.com/en/home/stay-current/national/usta-statement-on-suspension-of-events-.html) and many local leagues and clubs have also appropriately cancelled organized leagues and tournaments, which has also made people wonder if it is safe to play tennis during the COVID-19 pandemic at all.  I have sought to provide the best objective and informed answers to the common questions about your health and tennis during this pandemic.

“Unfortunately we just do not have enough research studies to make any definitive decisions.  But, the likelihood of transmission [in singles tennis] is probably at the same risk level (arguably less) than picking up a to-go order of food at the restaurant”, said Mark Kovacs, PhD, executive director of the ITPA (International Tennis Performance Association) who also sits on a couple of COVID-19 task forces.  Naturally, nearly all the data we have is on treatment and containment of the sickest victims of this virus with very little data in the sports world except a few anecdotal cases.

This has made it difficult to guide many individuals in the sports world, so Aspen Institute has put out a statements on youth sports participation and the coronavirus based on expert opinion (https://www.aspenprojectplay.org/coronavirus-and-youth-sports/reports/2020/3/13/what-themes-are-emerging-in-communities).  While the research efforts need to continue in the way it has from a medical and public health perspective, perhaps I can shed some light on tennis and the novel coronavirus.

Tennis health benefits have already been shown:

Tennis has already been considered the sport with some of the greatest health benefitwith improvements in cardiovascular, bone, and psychological health to name a few.  Tennis has benefits for young players as well as adults.  Specifically, tennis players (and those in racket sports) live an average of 9.7 years longer than sedentary behavior even when adjusting for many other factors (https://www.mayoclinicproceedings.org/article/S0025-6196(18)30538-X/fulltext).  Jogging only improved life expectancy 3.4 years.  Perhaps this is not just the obvious aerobic and cardiovascular physical benefits but the benefits of regular social interaction, psychological health and stress reduction that reduces mortality and extends life expectancy.

What are the real risks during the COVID-19 pandemic?

Before answering the question of whether one should play tennis, it is important to have facts regarding the individual and societal risks of COVID-19 (https://www.cdc.gov/mmwr/volumes/69/wr/mm6912e2.htm).  It is important to realize that this novel virus has many unknowns, and the information is evolving each day as communities and countries gather more data from outcomes of those with the disease.

·      Personal Health:  The overall risk of exposure to COVID-19 may actually be to hundreds of millions of Americans and perhaps much of the world, but the individual risk of getting infected and developing symptoms is largely unknown.  Of that group, approximately 80% of people whom are infected have mild symptoms, while 14% have severe symptoms, and 1-6% may die.  The primary mode of infection is through respiratory droplets, while other studies have suggested surfaces and in particular recently aerosolized (but in large part, that is when changing ventilators and using inhalers when hospitalized).

·      Age distribution Initial reports suggested that this was largely a disease of the elderly, but while the highest mortality rates (approximately 15% in those >80 years old), in the US, the CDC warns that people 20-44 years old comprise 29% of the people infected with COVID-19 and approximately 20% of hospital admissions.

·      Asymptomatic carriers:  Children (under 18 years old) do not often get symptoms, but are most likely to be asymptomatic carriers where they may shed virus unknowingly to others (and potentially infect them, including those vulnerable populations. Young people (under 18) are more likely to be asymptomatic carriers while most healthy adults mostly have mild symptoms.   This may actually be the most concerning group because bringing them into a group environment with exposure to other individuals and then also at home allows for an easy vector for rapid escalation of transmission.

·      Social Responsibility If there was ever a time to do something for the greater good (of humanity) it would be now.  There has never been a time in my lifetime where so many people’s decisions affected so many other’s outcomes.  With regards to tennis, each time you add a person to a tennis environment, the risk of contamination increases exponentially (i.e. it includes all of the contacts of the player).  So, playing doubles with 3 additional players versus playing singles with 1 player carries exponentially GREATER risk.  Obviously, group settings are even exponentially more risk of transmission.  Also, the key point through this is that with an expected “surge” in cases and subsequently rapid increase in those that need to be hospitalized and perhaps intubated, there is a finite set of health care resources that can handle this.  To put it more bluntly, if there are 20 ICU beds in your community, and they are all occupied to capacity (which many of them are already) and even if you are younger and healthier (<50 years old) and you need a ventilator, but there is none available, there would be some difficult decisions to be made.

·      Flattening the curve (community spread):   This is the newest phrase that describes the important concept of trying to distribute the spread of the virus over time to allow healthcare workers and hospitals to not get too overwhelmed at once, and at the same time, give time to research innovative treatments and vaccines.  Simply put, the more aggressive social distancing, the more effective (exponentially) the containment of the virus can be. For example, if there are no changes in social distancing and the community has made no interventions, that would be the highest risk decision to do during a pandemic.  Approximately 50% social distancing in a community may perhaps flatten the curve somewhat with some benefit (but with likely increased infections and death), while a Wuhan style complete lockdown has the most effective containment (combined with isolating those with coronavirus) during the pandemic.

This issue of understanding the community spread is an important issue in determining the viability of tennis in your area.  Few areas have been hit harder than Northern Italy.  Donato Campagnoli who is PTR and USTPA teaching professional with Federazione Italiana Tennis (FIT) and lives 10 km from Lombardy, the hardest hit region (to date 80,589 COVID-19 infections, and 8,215 deaths  (accessed Mar 26, 2020):  https://www.worldometers.info/coronavirus/#countries) has some very strong words of caution for those considering playing in regions of high community exposure (or “hot spots”). “STAY AT HOME.  You are not aware of the dangers that you, your family and the older people of your entourage are exposed to.  It's called DEATH.”  In regions hardest hit such as this, the initial casual approach has led to a more stringent and restrictive approach that he believes may last until at least July 31st.  “We can't leave home. We can do physical activity, but we have to stay in a 200 meters range from home.”

Other regions of the United States for example, may not have much penetration of the virus and so it may be difficult to really see and predict whether it will be a hot spot or not.  It is vitally important to have a good grasp of your community prevalence of COVID-19 cases, a high rate of growth of cases, hospitalizations, and case fatality rates (number of deaths/number of COVID-19 cases.  At the low end, this is 1% and it is nearly 10% in Italy, where the traditional flu is approximately 0.1%).  You should be aware of your tennis community and neighborhoods that will help you understand what type of situation you are in. 

Can you play tennis during the COVID-19 epidemic?

Many health and sports medicine experts do recommend maintaining a healthy exercise schedule that improves cardiovascular, pulmonary health as well as may improve your immunity to infections.  It should be noted that for elite players, overtraining may potentially reduce immune responses and make you more vulnerable to respiratory infections.  Assuming your community is not an emerging “hot spot” with high cases, hospitalizations, or and seems spared from this virus, you may wonder if you can play tennis.  Why not tennis?  It is not a team sport like basketball or soccer, and there are many ways to keep appropriate social distancing.  Other individual sports such as swimming may be difficult with community-based pools and contamination, while golf offers little aerobic activity with increased likelihood of social contact in a typical foursome.  Most importantly, aside from the benefits of aerobic exercise, tennis offers something that is so needed in today’s “new world”: safe social interactions with people with a shared passion.  The combination of healthy aerobic exercise and safe social interactions for physical, emotional, and psychological health is like no other sport.  Running can provide the aerobic portion, but may not offer the much-needed opportunity to stop, smile, laugh, joke about a point or a clean winner.

CDC offers many recommendations for healthcare environments, COVID-19 exposure, symptomatic individuals but no specific guidance with regards to appropriate exercise activities.   Without any clear data, we are left to extrapolate non-sports data and make our best conclusions with select experts in the field.

Dr. Kovacs also states that “the transmission of the virus in a tennis environment has to be considered very low. First, it is assumed that both people on the court do not have the virus to start with. Then if an individual unknowingly has the virus, many of the suggestions above will significantly reduce the risk of transmission. However, like anything with this virus, anything above complete isolation does have a very slight risk to it.”

Additionally, University of Oregon’s Indoor research center states “Exposure to ultraviolet light reduces the ability of some viruses to survive” which may indicate why outdoor tennis is a preferred activity and may be better than indoor tennis.  There is some information on the presence of the virus on surfaces such as steel, plastic, and even cardboard, however, needless to say, there is no actual data on transmission through tennis balls (or theoretically, aerosolized).

Other viruses (such as the typical flu) are seasonal and often abates during warmer temperatures, so the theory is that the same would hold true.  However, this is not clear yet with the nature of this virus, and currently, there is no indication yet that COVID-19 risks are significantly lowered in hot or humid temperatures.  This may be exemplified by the rapid increases in places like Australia, Florida and California which are all seeing exponential increases in COVID-19 cases. Tennis players and coaches in warm weather climates should not expect lower risk in viral transmission at this time.

When you try to answer this question of whether you can play tennis during the pandemic, you should actually realize it is not a question of yes or no, but rather it is a question of how much risk you, your coach, your club or organization, and community are willing to manage.  Perhaps the best way is to evaluate a number of tennis-playing scenarios and rate the relative risk of each of these scenarios based on the best information available.

Let’s also assume that anyone whom is planning on playing tennis would not answer yes to any of the following screening questions (which are standard medical questions) and therefore should not consider playing at all:

1.     Have you been diagnosed with or been exposed to COVID-19 in the last 3 weeks?

2.     Do you have a cough, fever (>100.0 degrees), shortness of breath, sore throat, body aches, nighttime sweating, diarrhea, or loss of smell in the last 48 hours?

3.     Are you over the age of 65 years old and/or have any co-morbid health conditions such as diabetes, hypertension, cardiovascular disease, or COPD (chronic obstructive pulmonary disease), or smoke or vape?

4.     Do you have any medical condition that causes you to be immunocompromised?

5.     Have you traveled internationally in the last 21 days?

(Please do not take the following as medical recommendations, but rather general principles of risk, and each individual should consult with their physician to assess their own risk prior to engaging in any physical activity)

Additionally, these recommendations may change quickly based on the community, spread, government mandates for isolation either locally, statewide, or perhaps even nationally.

So, when is it an acceptable risk for you to participate in any of the following tennis activities?

The less tennis balls listed (between 0 and 10) the less risk there is for COVID-19 transmission and the morbidity associated with it, while the more tennis balls, the more risk.  These risks are personal risks, risks of transmission and risks to the community.

Appropriate social distancing measures include (but not limited to): 

Always staying at least 6 feet apart, do not sit on benches or touch the fence, doorknobs or net if possible.  Limit the amount of time you touch the ball with your hands, except perhaps when you are feeding the ball or serving.

Dr. Kovacs also recommends for appropriate hygiene:

·  Using wipes with at least 60% alcohol.

·  Using new balls on a very regular basis is highly encouraged.

·  Using a ball machine for the Tennis Coach is a great option to give lessons. Allows for the balls to not be touched by a human while still providing great instruction. Using ball tubes, basket pickups etc. to pick the loose balls up after a ball machine rotation also limits any human to ball contact.

 Is it possible to teach tennis during the pandemic?

“From a teaching standpoint, I have some mixed feelings”, says Mark Faber, the Director of Tennis Twos Athletic Club and USPTA National Vice-President.  “If you are to teach, you need to do it in the most controlled environment possible, which would be a private lesson.  We are all part of the food chain”

It is a really tough paradigm for coaches whom need to maintain some semblance of a business, be a source for much needed exercise and even perhaps training for some players and the social responsibility of limiting personal and community transmission of the virus.

Faber gives a lot of deference to the medical and scientific community in his message to tennis teaching professionals: “We as tennis professionals do not like it when someone (parents, players and so forth) come into our world and start to tell us how to do our jobs for we are the experts in our world.  So, we as professionals need to respectfully understand and do the same when medical experts are telling us what needs to be done to help with all of this when they are the experts in their world.”

Pazahanick, whom has continued to follow the situation closely, initially was asked by her county to stay open for the community, then stopped all programming to do just privates understands that this is a fluid situation.  However, in her environment, and perhaps in others, there may be a middle ground to finding those select situations with minimal risk such as low risk private lessons to provide that necessary outlet for tennis for at least some of the players.

Possible additional solutions (A and B teams):

As a sports medicine physician, many of us have been asked to stop all elective visits to reduce the potential risk of transmission to patients, staff, and even to myself.  This may reduce in-person visits by about 90% and use telehealth (video) for visits, in an effort to reduce the potential for health-care associated transmission.  Additionally, some healthcare staff has been divided into 2 “teams” such as “A” and “B” teams where one team works for two weeks, while the other goes into self-quarantine to stay healthy upon their return to work environment.  Perhaps a similar alternating schedule for tennis teaching professionals to allow for monitoring of development of any symptom development during the two-week quarantine can be reassuring upon return to work and limit transmission to the clients.

What is the future?

It is not clear, even from the experts what the future holds for the impact of the virus.  In modest estimates, it may infect millions and millions of people, but hopefully the mortality of the virus declines with appropriate social distancing, people may develop some herd immunity and the medical advances will find some working treatments and vaccinations.  The most optimistic predictions may suggest that we’ll be back to normal activities in the next 1-2 months.  However, more realistically, there may be some short-term resolution, but as some of these viruses act, we may have to manage another wave over 12-18 month period of time.

The future for tennis during this pandemic does not necessarily need to be so bleak.  We have survived a number of other novel viruses and it is likely this will happen with this one.  There WILL be a return to normalcy, matches, tournaments, leagues and coaching.

Kovacs feels that “In the first few months back, professional tennis may play events without fans in the stands. In the long run, it will likely have a series of adjustments that focus on general hygiene and better public health situations.”

“I have faith that my coach and I will find a way to keep the momentum going after this is all over and I’ll pick up where I left off,” Harrison, (who had just peaked at 256 in the WTA Tour) says optimistically.  But perhaps for most of us players who just crave that on court exercise and social interaction, maybe there is a reasonable path during this pandemic while still maintaining appropriate social distancing.

Remember, tennis IS a lifetime sport.  While many of us may have some short-term tennis goals, we should all feel comforted that we can have a lifetime of tennis even through the greatest pandemic of our lives.

Neeru Jayanthi MD, USPTA, PTR

Dr. Jayanthi is a sports medicine and tennis medicine physician at Emory Sports Medicine, immediate past-president of STMS (Society for Tennis Medicine and Science), advisor to a number of tennis organizations, chief medical advisor to PickUp Sports, and a competitive USTA league player and team captain.

 

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