Long COVID and Returning to Exercise

What is Long COVID?

Long COVID or “post-COVID-19 syndrome” refers to the presence of symptom(s) over 4 weeks after a COVID infection and that cannot be explained by an alternative diagnosis.1 It can be continuous or relapsing and remitting (at times worse and other times improved or better). There can be the persistence of the same one or more symptoms of your acute COVID-19 experience, or the appearance of new symptoms. And typically those with Long COVID are PCR negative. (1, 2)

About 25% of people who have had COVID-19 will experience symptoms for up to 4 weeks and 10% will experience symptoms for more than 12 weeks. Recovery of Long COVID can occur with studies showing symptom reduction within 1 year, but symptoms can persist longer. (1)

The pathophysiology behind Long COVID is not widely understood. Many hypotheses refer to inflammation, immune system activation, endothelial dysfunction, deconditioning, and viral persistence.(2)  As Long COVID is a new disease, knowledge and treatments are still evolving, and the long-term impact has yet to be fully understood.

Caption: Virus and red blood cells in arteries. Stock image by Adobe



Having Long COVID can be debilitating and limit a person’s ability to carry out their everyday tasks. Long COVID is a multi-system disorder that can impact the cardiopulmonary, neuropsychiatric, dermatologic, gastrointestinal (GI), and musculoskeletal systems and more. Most common reported symptoms include: (1, 3)

  • Fatigue 
  • Cardiopulmonary: shortness of breath, exercise intolerance, cough, palpitations, fainting, and chest pain
  • Neuro/psych: headaches, anxiety, depression, disordered sleep, persistent loss of smell or taste, and brain fog or difficulty concentrating
  • Musculoskeletal: muscle pain, joint pain, weakness
  • GI: abdominal pain, nausea, vomiting
  • Dermatologic: rashes

Given the variety of symptoms and poor understanding of the mechanism behind Long COVID, it is recommended that treatments be symptom-based and patient care coordinated by multidisciplinary teams of primary care clinicians, specialists, and physical therapists.1 Coordinating with appropriate medical providers can assist with addressing symptoms and identify if follow-ups are needed. 


Who is at risk?

Long COVID can occur in people of all ages and severity of COVID-19. There have been more diagnoses of in people younger than 50 years old, and in mild acute cases in non-hospitalized patients. (1, 5) Some studies show that those at higher risk  include females, high BMI, smoking/history of smoking, prior hospitalization from COVID-19, and co-morbidities such as diabetes, cancer, pre-existing pulmonary conditions (like asthma), and cardiovascular disease. In terms of COVID-19 reinfections, multiple infections can increase your risk as well. (1, 5) 

What does returning to exercise look like?

Currently, there are no evidence-based guidelines to return to exercise after a COVID-19 infection or following Long COVID.6 Several organizations, such as the British Journal of Sports Medicine (BJSM), created symptom-based guidelines to assist with safe progressions to return-to-play after an acute COVID-19 infection. (7)  However, little is known about return-to-play following Long COVID.

During an active infection, rest and quarantine are highly recommended. Detraining might occur depending on the length of an active infection, so it is important to be cautious with training intensity and volume when resuming exercise.6 Keep in mind that your body might feel tired or sluggish.

Because the onset and variety of Long COVID symptoms can vary, it is important to take note of symptom improvement or worsening and the presence of new problems during and after a COVID-19 infection. Keep a log of your nutrition, sleep, activity, stress, and symptoms to learn if there are any triggers. The key to returning to exercise is monitoring your symptoms, paying attention to your fatigue and exertion levels, and progressing gradually without flare ups. (6)

Image by © myreha.ai/schlaganfall-ratgebe


With Long COVID:

    • For patients presenting with prolonged fatigue, pacing is highly recommended instead of graded exercise therapy. Pacing is an activity-management strategy that disperses activities throughout the day with rest to prevent overexertion and exacerbation of symptoms. Think of it like budgeting your energy to avoid a crash after. Graded exercise therapy is controversial due to its provocation of symptoms and flares while increasing physical activity levels.
      • For pacing, everyone’s work-to-rest ratio will be different based on activity and symptoms onset. For example, if you’re a runner and have been fatiguing after 15 minutes of moderate intensity running, start with low-intensity jogging for 5 minutes and resting for 5 minutes x 3 cycles before increasing duration and intensity of activity. When resting, you’re not recovering from a flare up but rather taking a break before symptoms develop. (6, 8)
    • For patients with cardiopulmonary symptoms or demonstrating exercise intolerance, cardiac evaluation is recommended before returning to exercise. Additionally, if you have any underlying cardiovascular or pulmonary condition(s), a consultation with a physician prior to returning to exercise is recommended.
    • Using the Stanford Hall Guidelines, those with persistent cardiovascular symptoms and are cleared to exercise should limit activities to mild-moderate intensity (60% of HR max) until 2-3 weeks after symptoms resolve. Then, they can progress to Stage 2 of BJSM guidelines.
    • It is recommended that for patients with persistent mild symptoms, start with low intensity exercise like walking and use symptoms to guide duration. The goal is to complete 20 minutes of walking without an increase of symptoms to progress to Stage 3 of BJSM guidelines. 
    • Avoid high-intensity exercises initially. 
  • Stop any activities if fever, breathlessness, or muscle aches develop.

After a COVID-19 infection, the BJSM provided guidelines following multiple stages of progression for return-to-play. (7) 

  • Duration of each stage depends on the person’s age, severity of infection, comorbidities, and activity goals.
  • When prescribing exercises in patients, general recommendations include increasing frequency first, followed by duration, and then intensity. And it is recommended that training intensity or volume can increase no more than 10% per week or every three to five training sessions. (6)
Created by BJSM. https://bjsm.bmj.com/content/54/19/1174 

Regarding strength training after a COVID-19 infection, modifying the volume/workload and work-rest ratio is encouraged by the National Strength and Conditioning Association (NSCA) and the Collegiate Strength and Conditioning Coaches Association (CSCCa) of the United States.6 

  • A 50/30/20/10 percent reduction in weekly total lifting volume or workload is recommended, ie. “During the first week back to weight training, the volume or total workload is reduced by at least 50 percent, during the second week by at least 30 percent, etc.” 6 
  • Additionally, increasing the rest is recommended in the first week back with a minimum work-rest ratio of 1:4. By the second week, the ratio can improve to 1:3, and then to 1:2 for the two weeks after. 


Take Home Points

  • Long COVID or “post-COVID-19 syndrome” is a multi-system disorder that occurs 4 weeks after an acute COVID-19 infection. Symptoms can include: fatigue, shortness of breath, body aches/pains, palpitations, cough, headaches, brain fog, and more.
  • The pathophysiology continues to be studied, but treatment involves symptom-based approach with a multidisciplinary team consisting of primary care physicians, specialists, and physical therapists.
  • Return-to-exercise involves close monitoring of symptoms and medical clearance in the presence of cardiopulmonary symptoms or history of cardiopulmonary conditions. It is important to gradually progress return-to-activity levels as tolerated, utilize pacing strategies if needed, and avoid any high-intensity exercise initially.
  • Because Long COVID is a new condition, more knowledge about returning to exercise will develop as more data and evidence come out.

Long COVID can be a debilitating condition, and it is important to have a good understanding of your symptoms before returning to prior activity levels. With the right approach and guidance, you can achieve your health/fitness goals. 

At Perfect Stride, our Doctors’ of Physical Therapy work with you to meet your individualized training needs and help you feel stronger and better with your everyday and recreational activities. Reach out to us to discover more about our rehabilitation and performance services at info@perfectstridept.com.

  1. Chippa V, Aleem A, Anjum F. Post Acute Coronavirus (COVID-19) Syndrome. In: StatPearls. Treasure Island (FL): StatPearls Publishing; June 19, 2022
  2. Raveendran AV, Jayadevan R, Sashidharan S. Long COVID: An overview. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2021;15(3):869-875. doi:10.1016/j.dsx.2021.04.007 
  3. Lindsay RK, Wilson JJ, Trott M, et al. What are the recommendations for returning athletes who have experienced long term covid-19 symptoms? Annals of Medicine. 2021;53(1):1935-1944. doi:10.1080/07853890.2021.1992496 
  4. Gluckman TJ, Bhave NM, Allen LA, 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. Journal of the American College of Cardiology. 2022;79(17):1717-1756. doi:10.1016/j.jacc.2022.02.003
  5. Davis HE, McCorkell L, Vogel JM, Topol EJ. Long covid: Major findings, mechanisms and recommendations. Nature Reviews Microbiology. 2023. doi:10.1038/s41579-022-00846-2
  6. O’Connor F, Franzos M. COVID-19: Return to sport or strenuous activity following infection. UpToDate. https://www.uptodate.com/contents/covid-19-return-to-sport-or-strenuous-activity-following-infection#! Published January 2023. Accessed February 19, 2023.
  7. Elliott N, Martin R, Heron N, Elliott J, Grimstead D, Biswas A. Infographic. graduated return to play guidance following covid-19 infection. British Journal of Sports Medicine. https://bjsm.bmj.com/content/54/19/1174. Published October 1, 2020. Accessed February 19, 2023.
  8. Giusto E, Asplund CA. Persistent covid and a return to sport. Current Sports Medicine Reports. 2022;21(3):100-104. doi:10.1249/jsr.0000000000000943

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