Clinical Criteria Help Guide Return to Activity After Mono


VANCOUVER, B.C. — Physical findings, laboratory values, and imaging results are of little use in determining when it is safe for young athletes with infectious mononucleosis to return to play. Ultimately, the decision on how long to keep them away from physical activity is a clinical one, according to Dr. Chris G. Koutures.

Young athletes with mono may experience fatigue and weight loss, but the issue of greatest concern is enlargement and increased fragility of the spleen, Dr. Koutures said at a meeting on pediatric and adolescent sports medicine sponsored by the American Academy of Pediatrics.

“Most documented splenic ruptures—but not all—take place within 4–21 days of symptom onset,” he noted, adding that rupture can occur even with minimal activity and in the absence of trauma.

Palpable splenomegaly can be helpful, Dr. Koutures said. “That, in combination with mono symptoms, is an absolute contraindication to sport activity.” But on the flip side, the absence of palpable splenomegaly is not informative and does not clear the athlete for sports participation.

“My standard approach is to tell them right away, I don't want you going back to any exertion until you are feeling better,” said Dr. Koutures, a pediatric sports medicine specialist in private practice in Anaheim, Calif.

At the first visit, physicians should document in the chart the day of symptom onset, because athletes and their parents may later try to backdate this event to permit earlier return to play, he cautioned.

The literature recommends holding athletes out for anywhere from 2 to 24 weeks from symptom onset, but the most common recommendation is about a 3-week period of no activity, Dr. Koutures said.

The first few weeks should be easy because athletes feel so unwell, but by the third week, they often feel normal and are eager to get back to play. However, he said this week still lies within the window during which most splenic ruptures occur.

After the 3-week period, athletes who are afebrile, have had resolution of palpable splenic or liver enlargement, and are back to school or work may try some light, noncontact conditioning activity for a week, with the aim of offsetting fatigue and weight loss, Dr. Koutures said. “This has not been shown to aggravate or prolong the course of mononucleosis,” he observed. If that week goes well, the athlete may gradually progress to contact and impact activities.

'My standard approach is to tell them right away, I don't want you going back to any exertion until you are feeling better.' DR. KOUTURES

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