As we envision a return to youth sports, we know this: It won’t be the same

With a wistfulness adults generally reserve for a lost lover or deceased parent, 13-yearold Abigail Cajuelan said, “I just really miss it,” of her Santa Clara, California, volleyball team.

About 150 miles to her north, Sarah Pinkerton coaches and serves on the board of the River Park Soccer Club. They’ve suspended registration and are “just sitting here waiting and seeing,” she said.

A decision on when and how youth sports will return to the United States is as eagerly anticipated as it is complex.

“A lot of people think we are just going to flip the switch and go back,” said William Schaffner, a professor in the division of infectious diseases at Vanderbilt University Medical Center, “but we are not going back to the old way. We are going to a new normal.” What that will look like for athletes depends on evolving knowledge about the virus that causes COVID-19.

Doctors now believe it is primarily spread via direct contact with infected respiratory secretions. For athletes, then, “the more intense the contact – in terms of spacing between individuals, duration of interaction, type of interaction and degree of ventilation – the higher the likelihood of infection,” said Sohil Sud, an associate professor of pediatrics at the University of California, San Francisco.

Different sports present different levels of risk, with “shared” sports such as gymnastics (shared beam, vault, etc.) tougher to make safe than “singular” sports such as golf (own clubs, own ball). Collision sports such as lacrosse present higher risk than softball and other limited-contact sports. Sports involving covered skin and faces such as fencing will need to be treated differently than those like wrestling.

To begin sorting it out, the U.S. Olympic and Paralympic Committee and the NCAA have issued initial guidance. Phase 3 of the USOPC’s five phases, for example, includes: “If a ball is being used (e.g., basketball), make sure only one player is using a specific region of the court and/or basket at a time, and the court in that region needs to be cleaned before another player uses the ball in that space to prevent indirect transmission from ball 1 to ground and from ground to ball 2.” The National Athletic Trainers’ Association will also post best practices in the coming weeks. Many sport-specific organizations, such as USA Basketball, as well as professional ones such as the NBA, are expected to issue guidelines as well.

But what is your average youth sports coach, a mom like Pinkerton, supposed to make of it all?

When it comes to high school, there’s a degree of clarity. The National Federation of State High School Associations writes the rule book, literally, as the organizing body for the 51 associations (each state and Washington, D.C.) that govern approximately 20,000 high schools and 8 million athletes. The long list of “return-tosport” issues NFHS has had to contemplate, and the degree of nuance required to resolve each, has produced an intellectual, logistical and moral puzzle.

Take, for example, physicals. States require pre-participation evaluations to try to catch conditions such as heart defects and asthma that could make athletic participation dangerous. Because many doctors have been only seeing patients with acute illnesses, there’s likely to be a backlog when that changes, so families may have a hard time getting appointments. Wealthier ones are likely to get access first. The NFHS therefore recommended that state associations be flexible and consider issuing one-year extensions for everyone except first-time athletes.

It sounds pragmatic and clear-cut, but the decision wasn’t easy. Cindy Chang, who has served as chief medical officer for Team USA, said physicals aren’t just about the risk of sudden cardiac death. Some children don’t get regular checkups, and for them the physical serves as a gateway to vaccinations and other essential medical and mental health care.

Tensions like these underlie pretty much every aspect of developing a return-to-activity plan for youth sports. Medical risk to individuals and public health concerns must be weighed against the value of sport in preventing weight gain and boosting mental health. Additional factors include the cultural value of sport, economics and the emotional cost of missing out on beloved athletics.

“Everyone wants an answer right now,” said Bob Colgate, the NFHS director of sports and sports medicine. “They are not getting an answer right now.” Though NFHS released initial guidance beyond physicals, it will take time for each state’s association to settle on specific rules, said Michael Koester, the Oregon-based chairman of the NFHS Sports Medicine Advisory Committee.

To do so, they have to tackle the expected issues with getting kids back on the field and things that won’t have occurred to most of us.

In that first category are “gatekeeping” protocols on who can join. There’s talk of temperature-taking and monitoring (asking kids about new symptoms and contacts). Mental health check-ins will also be essential, “especially for athletes of color,” said Chang, “as they may live in communities that have been hardest hit by COVID-19.”

Cleanliness is next on the list. Bart Peterson, an athletic trainer in Tucson, Arizona said, “Right now, it’s very possible that athletic facilities are not necessarily sanitized on a regular basis.” Locker rooms, weight rooms, courts, etc., will require more frequent and thorough cleaning. State guidelines for coaches could get as granular as telling athletes not to share mascara or lip balm. Water bottles will be more problematic. Communal hydration sources must go, the NFHS guidance says, yet Peterson doesn’t see how football players can find a specific bottle on the sideline without lengthening stoppages of play. “At the same time, we’d hate to have something where we took away the water bottle, and we have a kid who had a problem with exertion or heat stroke.”

Regarding cloth masks, Sud said, “The sports for which they might be the most helpful (those involving close contact) are likely the ones in which they are the least feasible. Also, anything that increases handto-face contact – such as adjusting a sweaty mask – may heighten the risk of infection.” Plastic face shields would work better for those purposes, but NFHS says they unacceptably increase risk of injury to the wearer and teammates.

Each of these decisions “is kind of a catch-22,” Peterson said.

Then there’s maintaining distance. Relatively easy fixes include shifts for drills and locker rooms. But minimizing infection could conceivably necessitate modifications to the rules for games, Koester said. For example, “seven-on-seven football might be perhaps something we may look at.” It would require fewer athletes at a time, and there would be neither a high-contact line of scrimmage nor tackling, plus no pads to sanitize.

One of the less obvious repercussions of social isolation is the need for a ramp-up period. Studies on collegiate and professional athletes show that deconditioned athletes can’t just be safely hustled back to sport.

Volleyball player Cajuelan says if she has to start slowly, practice bumps six feet away from a teammate or wear a face-covering, she’ll do it. Whatever it takes to play: “Volleyball was somewhere I could talk to my teammates about life, and my coach is really supportive. It was this place where

I felt relaxed.”

But what if a team like hers has to shut down for a few weeks after a player tests positive for the novel coronavirus? Rules on postseason eligibility might need to be altered.

“There is no shortage to the ripples from this,” Koester said.

A big one is financial. If the basketball court needs cleaning between shooters, who’s going to do that and execute other new sanitation procedures? High school athletic trainers manage an average of 15 sports, which equates to 285.5 students per trainer. Only 66% of high schools even have one, according to a report in the Journal of Athletic Training, and it’s unclear how many will continue to staff that position, because most models of their employment depend on sports revenue that has evaporated. Extra custodial hours will also be difficult to swing thanks to the coronavirus pandemic’s devastating impact on school budgets.

What happens if some teams can afford these precautions and others can’t? Will highand low-infection-rate areas of the same state operate on different timetables? “We’ve got more questions than answers right now,” NFHS’s Colgate said.

Two things are clear, however: When competitive sports first resume, there’s no way “those contests are going to be ... played before hundreds of people sitting side-by-side,” Koester said. Second, the phases of states’ return-to-activity plans are unlikely to function like a one-way ratchet. They’ll be designed so teams can backtrack to a prior phase as infection rates spike, then move forward again once things are safer.

When her team stopped practicing, Cajuelan said, “I thought it was dumb, that coronavirus wasn’t that big of a deal.” But now that her mother explained things and she has paid attention to the news, she gets it: “I’m still eager to go back, but I know that has to happen in a way that keeps people safe.”