Return to Track and Pole Vault After Mononucleosis
A teenager with infectious mononucleosis should wait a minimum of 4 weeks from symptom onset before returning to track and pole vault, but ideally should wait until 8 weeks or until splenomegaly has completely resolved as confirmed by ultrasound. 1, 2
Risk Assessment for High-Intensity Sports
Pole vault and track are particularly high-risk activities for teenagers recovering from mononucleosis because they involve:
- "Burst" exertion with rapid acceleration/deceleration, which should be avoided during recovery 2, 3
- Potential for abdominal trauma in pole vault landings, creating risk for splenic rupture
- Strenuous exercise that can worsen outcomes during active infection 4
The most feared complication is spontaneous splenic rupture, which occurs in 0.1-0.5% of patients and is potentially life-threatening. 4
Evidence-Based Return-to-Play Timeline
Minimum 4-Week Restriction (Mandatory)
- All contact sports, heavy lifting, and vigorous activity must be avoided for at least 4 weeks from symptom onset, regardless of how the teenager feels 1, 2
- This 4-week period represents the absolute minimum based on American Academy of Pediatrics recommendations 1, 2
Optimal 8-Week Restriction (Preferred)
- The safest approach is to wait 8 weeks from symptom onset before returning to full athletic participation 1, 4
- Current guidelines from recent literature recommend patients not participate in athletic activity for 3 weeks from onset of symptoms at minimum, with many experts advocating for longer periods 5
Clinical Algorithm for Clearance
At Week 4 Post-Symptom Onset:
Perform abdominal ultrasound to assess splenic size 1, 6
- If ultrasound shows normal splenic dimensions: May consider gradual return to play with medical clearance 1, 6
- If ultrasound shows persistent splenomegaly: Continue restriction and repeat ultrasound at week 8 1
Required Criteria Before ANY Return:
The teenager must meet ALL of the following before progressing 5, 7:
- Afebrile (no fever)
- Well hydrated
- Asymptomatic (no fatigue, pharyngitis, or other symptoms)
- No palpable liver or spleen on physical examination
- Normal splenic dimensions on ultrasound (if returning before 8 weeks)
Graduated Return Protocol:
Once cleared, use a stepwise progression 1:
- Light aerobic activity without contact (jogging, light running)
- Sport-specific drills (track workouts, pole vault technique work without full effort)
- Full contact practice only after medical clearance
- Full competition
Each step should take several days, and any return of symptoms requires stopping and re-evaluation. 1
Critical Patient Education
The teenager must be warned about splenic rupture symptoms that require immediate emergency evaluation 1:
- Sudden onset of left upper quadrant pain
- Left shoulder pain (Kehr's sign)
- Abdominal pain
- Lightheadedness or syncope
Evidence Quality and Nuances
The American Academy of Pediatrics guidelines provide the strongest recommendations, with the 4-week minimum being well-established. 1, 2 However, there is important nuance:
- 84% of athletes had normal splenic dimensions at 1 month in one ultrasound study, while the remaining 16% required 2 months for resolution 6
- No strong evidence-based information supports use of a single parameter to predict safe return, which is why the multi-criteria approach is essential 7
- Clinical judgment incorporating multiple criteria 1 month after diagnosis has been suggested as safe, but this does not guarantee the spleen has returned to normal size 7
Common Pitfalls to Avoid
- Do not rely on the teenager "feeling better" - fatigue may resolve but splenomegaly can persist 4
- Do not allow return based solely on physical examination - palpation can miss splenomegaly, especially in athletic individuals 7, 6
- Do not permit early return without ultrasound confirmation if returning before 8 weeks 1, 6
- Do not allow participation in pole vault before track running - pole vault carries higher risk due to landing forces 2, 3