John P. Prodoehl, William Johns, Marcos Areas Marques, Marcone Lima Sobreira, Sommer Hammoud.

Response/Recommendation: There is no consensus regarding the optimal management of venous thromboembolism (VTE) in athletes. Treatment of active VTE consists of early mobilization and uninterrupted anticoagulation for at least 3 months with abstinence from contact sports during the entire treatment duration. The choice of pharmacologic agent should be tailored according to patient-, physician-, and sport-related factors. However, some authors favor direct-acting oral anticoagulant agents (DOAC), which may allow earlier return to sport in athletes requiring prolonged anticoagulation. Athletes receiving treatment for active VTE may begin low-risk exercises (e.g., swimming) 3 weeks after initial diagnosis, progressing to full participation in non-contact sports at 6 weeks.

Strength of Recommendation: Consensus.

Rationale: While athletes are believed to have a low risk of VTE¹, this population is uniquely exposed to pro-thrombotic factors such as oral contraceptive use, prolonged travel, and immobilization after injury², often placing them at a higher risk than expected. One study by Erickson et al., demonstrated an 8% incidence of deep venous thrombosis (DVT) in athletes after arthroscopic anterior cruciate ligament (ACL) reconstruction³, and another cited VTE as a major cause of death in adolescent athletes across the United States⁴. While there is no official recommendation for DVT prophylaxis in athletes with a lower extremity injury without prior history of VTE, some authors recommend anticoagulation with low-molecular-weight heparin (LMWH) along with physical antithrombotic measures such as sequential compression devices (SCD) for immobilized, recently injured athletes or high-risk athletes undergoing long-distance travel^5–7. A Cochrane review recommended that all adults with injuries requiring low or above knee casts or braces should receive LMWH for the duration of immobilization⁸.

Therapeutic anticoagulation regimens for athletes after VTE diagnosis of VTE also lacks consensus, although the current recommendations follow the same guidelines for non-athletes as listed in the American College of Chest Physicians 10^th Edition of the Antithrombotic Guidelines and comprises the use of established VTE risk prediction scores to determine the appropriate prophylactic agent, dosage, and duration^1,9,10. Individualized anticoagulation regimens should consider type of anticoagulation, the athlete’s sport and preference, and expert opinion⁹. The most common treatment described involves initiating LMWH or unfractionated heparin, followed by a vitamin K antagonist such as warfarin until a target International Normalized Ratio (INR) of 2.0 – 3.0 is reached¹. DOAC such as rivaroxaban or apixaban may be preferred due to greater convenience and shorter half-lives that offer the possibility of intermittent dosing during sport participation⁹. Nahza et al., recommended an individualized approach to DOAC prescribing in high-risk patients after return to non-contact sport, which was analogous to the periprocedural management of DOAC use in the general population. This approach consists of limiting DOAC use in the days leading up to sporting events with the aim of ensuring low physiologic levels of anticoagulant use when an athlete is competing, and then returning to higher levels of DOAC use outside of competition^9,11,12. Although there is no consensus recommending one DOAC over another, one study showed that apixaban had shorter thrombin inhibition compared to rivaroxaban. This may favor apixaban for intermittent anticoagulation due to its shorter half-life relative to rivaroxaban¹³. Treatment with uninterrupted anticoagulation and abstinence from contact sports for three months during active treatment is the standard management for athletes receiving chemical anticoagulation for VTE treatment^7,14. Additionally, early mobilization (within 24 to 48 hours of starting anticoagulation) and compression stockings may be used for lower extremity DVT to reduce the rate of post-thrombotic syndrome^1,10,15.

There is currently no literature comparing the efficacy of various anticoagulants in the treatment or prevention of VTE in athletes. Despite a growing trend towards aspirin (ASA) use for VTE prophylaxis in total joint arthroplasty, recent studies in athletes have demonstrated no postoperative benefit with ASA use after arthroscopic surgeries^16,17. Additionally, a meta-analysis of randomized controlled trials by Zhu et al., demonstrated nearly 5-fold decrease in VTE rate after ACL reconstruction with the use of prophylactic LMWH. Despite these findings, a recent survey highlighted that the majority of arthroscopy surgeons still prescribe ASA for postoperative DVT prophylaxis¹⁸.

Return to sport following VTE should follow a gradual progression of increasing activity after the initiation of anticoagulation^19,20. Several randomized trials and observational studies have recommended that patients may begin ambulation within 24 hours of anticoagulation initiation if they do not have any evidence of active pulmonary embolism (PE) or cardiopulmonary compromise¹⁹. During the first 3 weeks, athletes should be limited to walking and activities of daily living. After 3 weeks, athletes may begin low-risk activities such as swimming, and gradually intensify activity participation to include low-impact exercises such as cycling, followed by running at 6 weeks^15,19,20. Athletes in non-contact sports may return to full sports participation within 6 weeks, while contact athletes should wait till 3 months after anticoagulation treatment is complete and coagulation labs are within their reference ranges^1,15,20. Return to contact sport can be permitted gradually while monitoring for VTE recurrence and treating post-thrombotic symptoms¹⁴.

References:

1.         Grabowski G, Whiteside WK, Kanwisher M. Venous thrombosis in athletes. J Am Acad Orthop Surg. 2013;21(2):108-117. doi:10.5435/JAAOS-21-02-108

2.         Elikowski W, Małek M, Montewska D, Kurosz J, Wróblewski D, Zawilska K. [Venous thromboembolism triggered by spinning in a young woman with thrombophilia]. Pol Merkur Lek Organ Pol Tow Lek. 2011;30(175):29-31.

3.         Erickson BJ, Saltzman BM, Campbell KA, et al. Rates of Deep Venous Thrombosis and Pulmonary Embolus After Anterior Cruciate Ligament Reconstruction: A Systematic Review. Sports Health. 2015;7(3):261-266. doi:10.1177/1941738115576927

4.         Boden BP, Breit I, Beachler JA, Williams A, Mueller FO. Fatalities in high school and college football players. Am J Sports Med. 2013;41(5):1108-1116. doi:10.1177/0363546513478572

5.         Eichner ER. Clots and consequences in athletes. Curr Sports Med Rep. 2014;13(5):287-288. doi:10.1249/JSR.0000000000000089

6.         Hilberg T, Jeschke D, Gabriel HHW. Hereditary thrombophilia in elite athletes. Med Sci Sports Exerc. 2002;34(2):218-221. doi:10.1097/00005768-200202000-00006

7.         Mont MA, Jacobs JJ. AAOS clinical practice guideline: preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. J Am Acad Orthop Surg. 2011;19(12):777-778. doi:10.5435/00124635-201112000-00008

8.         Testroote M, Stigter WAH, Janssen L, Janzing HMJ. Low molecular weight heparin for prevention of venous thromboembolism in patients with lower-leg immobilization. Cochrane Database Syst Rev. 2014;(4):CD006681. doi:10.1002/14651858.CD006681.pub3

9.         Nazha B, Pandya B, Spyropoulos AC, Kessler CM. Treatment of Venous Thromboembolism in Elite Athletes: A Suggested Approach to Individualized Anticoagulation. Semin Thromb Hemost. 2018;44(8):813-822. doi:10.1055/s-0038-1673690

10.       Singh A, Foster M, Chapman P, Hattab Y, Alhassan S, Bajwa O. Special Circumstances and Populations. Crit Care Nurs Q. 2017;40(3):276-287. doi:10.1097/CNQ.0000000000000166

11.       Kichloo A, Amir R, Wani F, Randhawa S, Rudd B, Rechlin D. Anticoagulation and antiplatelet therapy in contact sports: is it career limiting? J Investig Med Off Publ Am Fed Clin Res. 2021;69(3):781-784. doi:10.1136/jim-2020-001658

12.       Moll S, Berkowitz JN, Miars CW. Elite athletes and anticoagulant therapy: an intermittent dosing strategy. Hematol Am Soc Hematol Educ Program. 2018;2018(1):412-417. doi:10.1182/asheducation-2018.1.412

13.       Kreutz R, Persson PB, Kubitza D, et al. Dissociation between the pharmacokinetics and pharmacodynamics of once-daily rivaroxaban and twice-daily apixaban: a randomized crossover study. J Thromb Haemost JTH. 2017;15(10):2017-2028. doi:10.1111/jth.13801

14.       Berkowitz JN, Moll S. Athletes and blood clots: individualized, intermittent anticoagulation management. J Thromb Haemost JTH. 2017;15(6):1051-1054. doi:10.1111/jth.13676

15.       Meyering C, Howard T. Hypercoagulability in athletes. Curr Sports Med Rep. 2004;3(2):77-83. doi:10.1249/00149619-200404000-00005

16.       McIntire SC, Bernstein EM, Tompane TM, et al. Aspirin for Deep-Venous Thrombosis Prophylaxis After Anterior Cruciate Ligament Reconstruction. Mil Med. 2021;186(7-8):656-660. doi:10.1093/milmed/usab025

17.       Kaye ID, Patel DN, Strauss EJ, et al. Prevention of Venous Thromboembolism after Arthroscopic Knee Surgery in a Low-Risk Population with the Use of Aspirin. A Randomized Trial. Bull Hosp Jt Dis 2013. 2015;73(4):243-248.

18.       Keller RA, Moutzouros V, Dines JS, Bush-Joseph CA, Limpisvasti O. Deep Venous Thrombosis Prophylaxis in Anterior Cruciate Ligament Reconstructive Surgery: What Is the Current State of Practice? Sports Health. 2018;10(2):156-159. doi:10.1177/1941738117730576

19.       Depenbrock PJ. Thromboembolic disorders: guidance for return-to-play. Curr Sports Med Rep. 2011;10(2):78-83. doi:10.1249/JSR.0b013e318214d828

20.       Roberts WO, Christie DM. Return to training and competition after deep venous calf thrombosis. Med Sci Sports Exerc. 1992;24(1):2-5.