What are the guidelines for returning to sports after mono?

Guidelines for Returning to Sports After Mononucleosis

Athletes with infectious mononucleosis should avoid participation in contact or collision sports for at least 4 weeks from symptom onset, with return to full activity only after clinical resolution and confirmation of normal splenic size. 1, 2

Understanding Infectious Mononucleosis

• Infectious mononucleosis (IM) is a viral syndrome primarily caused by Epstein-Barr virus (EBV), commonly affecting adolescents and young adults 2
• Classic symptoms include fever, pharyngitis, posterior cervical lymphadenopathy, and fatigue 1
• Laboratory findings typically show atypical lymphocytosis (≥10%) and lymphocytosis (≥50%) 1

Primary Concern: Splenic Rupture

• Splenic rupture is a rare but potentially life-threatening complication of mononucleosis 3
• Highest risk period for splenic rupture is within the first 4 weeks of symptom onset 4
• Young men under 30 years of age appear to be at highest risk for splenic rupture 4
• Splenic rupture can occur with minimal or no trauma in 86% of cases 4

Return to Sport Timeline

• Minimum restriction from contact/collision sports: 4 weeks from symptom onset 2
• Some evidence suggests extending restrictions to 8 weeks in high-risk cases, as ruptures have been documented up to 8 weeks after symptom onset 4
• Athletes should be completely asymptomatic before considering return to play 1

Evaluation Before Return to Play

• Abdominal ultrasonography at 1 month post-diagnosis can help determine if it's safe to return to contact sports 3
• Research shows approximately 84% of athletes have normal splenic dimensions at 1 month and can safely return to sports 3
• For those with persistent splenomegaly at 1 month, repeat ultrasonography at 2 months is recommended 3

Graduated Return to Activity

• Initial return should focus on low-intensity activities with gradual progression based on symptoms 1
• Patient's energy level should guide activity rather than enforced bed rest 1
• Full return to contact sports should only occur after:
  1. Complete resolution of clinical symptoms 1
  2. Normal splenic size confirmed by imaging (if performed) 3
  3. Minimum waiting period of 4 weeks from symptom onset 2

Special Considerations

• Athletes wishing to return to high-risk activities before the recommended waiting period should undergo ultrasound to ensure resolution of splenomegaly 4
• Patients should be educated about symptoms of splenic rupture (sudden abdominal pain, especially left upper quadrant) to ensure prompt medical attention if needed 4
• Persistent fatigue and need for additional sleep may continue for several months after acute infection has resolved 1

Treatment Considerations

• Management is primarily supportive with adequate hydration, analgesics, and rest 1
• Corticosteroids, acyclovir, and antihistamines are not recommended for routine treatment 1
• Corticosteroids may be considered only in cases of severe pharyngeal edema or respiratory compromise 1

By following these guidelines and using appropriate imaging when indicated, clinicians can make informed decisions about when athletes can safely return to sports following infectious mononucleosis, minimizing the risk of splenic rupture while allowing timely return to activity.