How the PGA Tour is trying to help its players avoid COVID-19 and the common injury

Courtesy of PGA Tour

This week's Memorial Tournament marks the sixth week since the PGA Tour's re-entry following the COVID-19 shutdown. Despite several positive tests and a few protocol modifications, the return of golf has been largely successful. Each tournament has been played as scheduled and both the at-home and on-site testing and screening measures have been executed without any major glitches.

While other sports struggle as they begin their own attempts at returns, how has golf managed to come back with barely a hitch amidst a pandemic that isn't slowing?

The answer is a multifaceted one. There are the months of preparation the PGA Tour and its medical staff, led by PGA Medical Director, Dr. Tom Hospel, spent creating health and safety protocols after consulting with infectious disease experts and the Centers for Disease Control and Prevention (CDC). There was also input as the plans were being formulated from the Players Advisory Council, which was key to getting buy-in to the plan from the players. They got a little assist from the structure of the sport itself, too.

As Andy Levinson, senior vice president of tournament administration for the PGA Tour said: "Our health and safety program, first and foremost, is built on this foundation that our sport lends itself to social distancing, which is by far the best defense we all have against this virus."

Natural social distancing aside, athlete health is a critical element of keeping a sport operational. These times require mitigating the risk of contracting COVID-19 as well as maintaining sport-related health and fitness.

Here is how the PGA Tour is tackling both of those:

Adapting in a COVID-19 world

Drafting health and safety protocols designed to function during a global pandemic is a daunting task. Factor into the equation that these athletes converge weekly in one location from multiple origination sites, maintain unique tournament schedules and prefer regimented routines and the task becomes infinitely more complicated.

With those concepts in mind, the Tour sought to implement COVID-19 testing that would be reliable and efficient for players, caddies and essential staff while allowing for evolution of the testing protocol as relevant information emerges. The result was a three-pronged testing regimen.

The first step is a pre-travel screen. Approximately three days prior to departure for the host city, players, caddies and staff perform an at-home test via a kit delivered through the mail. It is a saliva-based collection test performed under the supervision of a health care professional (HCP) via a Zoom link. The HCP observes the collection, answers any questions in real time and walks the individual through the process of properly packaging the sample and gives instructions on how to ship. The actual sample collection process takes about five minutes and results are returned within 24-48 hours.

The rationale for a pre-travel screen is to minimize the potential risk of viral spread by someone who is unknowingly infected. Additionally, since a positive test requires a subsequent isolation period, a positive result pre-travel allows an individual to remain home and isolate.

Given that travel presents another opportunity for exposure to the coronavirus, everyone is required to test again upon arrival in the host city.

According to Levinson, there were two overarching considerations as they developed an on-site testing program, one of which was result times. Given the short time players, caddies and staff are in any given city and given the preparation time players require pre-event, an extended wait time for results would be problematic. The second consideration involved potential impact on resources for the local community.

"We were not going to play if our health and safety program required us to utilize valuable resources in the communities in which we were playing," Levinson said.

The solution to both came in the form of a partnership with Sanford Health as the mobile COVID-19 testing partner for the PGA Tour. The mobile unit (including sample collectors, collection kits and lab technicians) sets up every Saturday in a designated testing area near the tournament site. Collectors walk samples collected via nasopharyngeal swabs from PGA players, caddies and staff to the mobile lab a few steps away. Results are then delivered within a few hours.

This Sanford Health mobile laboratory solves both of those problems," Levinson noted. "Not only can we get results back in a matter of hours, but we're also bringing the lab and the supplies with us."

Once an individual tests negative, he can then proceed to the course and can access facilities such as the clubhouse. Symptom screening questionnaires and temperature scans are required daily to gain entry to the course and everyone is asked to report any new symptoms to the medical staff. Testing can be repeated if there is suspicion of the virus.

There is also a third scheduled test during a competition week for those who choose to travel via the PGA-arranged charter flights to the next tournament location. A negative test result is required before boarding the flight.

Individuals who test positive in a tournament city are required to quarantine there unless they can drive home safely without stopping. Levinson notes that for anyone needing to quarantine, the PGA Tour has a plan. "We'll assist them in finding an appropriate place to do that and in getting the food and supplies that they might require. We're identifying an ID specialist in every tournament city, so if they are experiencing severe symptoms then they could see that person if they needed to and also show them how they might get follow-up testing as well. We're working closely with all of the local health departments and those would be notified of any positive tests as well and we'll comply with any regulations they have."

After clearing quarantine, individuals are permitted to travel to their next destination.

Trailer setup

Navigating the coronavirus pandemic may be front and center, but there is also ongoing care required for the athletes' sports-specific injuries, along with the requisite fitness and conditioning.

The requirement for players to be on a perpetual road trip throughout the season was the impetus for creating a traveling medical group to accompany them. The program dates back to the 1980s when Dr. Frank Jobe (yes, that Dr. Jobe, the surgeon who changed the career trajectory for numerous baseball pitchers after he successfully operated on Tommy John), then team physician for the Los Angeles Dodgers, had the idea that golfers should also have a dedicated medical group that traveled. Now that traveling facility is in the form of two expandable trailers -- one geared toward physical therapy and chiropractic treatment and the other functioning primarily as a mobile fitness center -- and their utilization has surged over the last decade as golfers have become more athletic, more fitness conscious and generally more proactive about their overall health.

Two years ago the PGA Tour purchased two brand new trailers, each offering more than 900 square feet of clinic and gym space and gave Tour players an opportunity to provide input into the equipment choices. According to Jason Stodelle, physical therapist for the PGA Tour, the response to the upgraded PGA Tour Player Performance Center has been extremely favorable, with each trailer accommodating between 50-70 players per day during a busy tournament.

The most common golf-related injuries are soft tissue in nature and often involve the spine and ribs, hips and wrists -- although no body part is immune. Golfers have come to rely on the consistency of care they receive from the physical therapists, chiropractors and athletic trainers who staff the trailers at each tournament, traveling the country just as the athletes do. Treatment may be ongoing as part of a chronic issue a golfer is working to manage while still competing or may address an acute injury that crops up during an event. The therapy trailer has a range of equipment, including tools for soft-tissue mobilization, dry needling, cold compression recovery, exercise and more.

Many athletes have a conditioning regimen they maintain via the fitness trailer which can also serve as a warmup venue prior to a round or a recovery area afterward. The fitness trailer has Peloton bikes, treadmills and elliptical machines as well as cables, Olympic weights, kettlebells and medicine balls. Both trailers are also equipped with multiple TVs. making it easy to keep an eye on the action.

Integrating the trailers and the personnel who staff them into the COVID-19 protocols was a top priority for both the PGA Tour and the athletes who rely on them.

But, how?

"We started those discussions about a month ago in anticipation that at some point we were going to return to golf," Hospel said. "We broke it down to the granular level of the athlete walking in, changing clothes, using shoes, how they enter the trailers -- essentially being an avatar and breaking down every single movement. With the PTs, chiropractors and athletic trainers, we had multiple Zoom calls and discussed every single event that might take place and then the best ways for us to reduce the risk of someone transmitting the virus from one person to the other.

Hospel added: "We're spacing our tables about 10 feet apart. But beyond that -- even in our initial evaluation we're maintaining a six-foot distance while taking their history, trying to limit the amount of time we're within that six-foot space while treating the athlete. Obviously at some point we're going to have to put our hands on them and treat them and try to do so in an effective and efficient manner. Maybe we're providing them instruction at times on how to do things on their own, whether it's a stretch or treatment; a lot of recovery things they can do on their own. It's really about being creative from a practitioner perspective and trying to limit that spacing while providing effective treatment."

Part of maintaining social distancing within the trailer meant limiting the number of players in the trailer at any one time.

"We decided to limit it to no more than five players in the trailer at any one time, so eight people total (including PTs and chiropractor)," said Stodelle. "Normally pre-round could have 10-12 guys. Guys might occasionally have to wait a bit, so they just need to allow a little more time.'

"There's a bench outside (waiting area), there are masks, hand sanitizer, wipes available. When a player comes to the truck, we scan their temperature, just to make sure they're under 100.4. Assuming everything else is good, then he can proceed into the trailer."

Players are to arrive dressed in workout attire as they are no longer allowed to change inside the trailer. All medical personnel are wearing masks and scrubs while working inside the trailer. The staff has marked-out quadrants using athletic tape as boundary markers so that the athletes can independently stretch or exercise while maintaining proper physical distancing.

Out of an abundance of caution, the tour made the decision to limit the first few weeks to having just the therapy trailer onsite in an effort to mitigate risk.

"Just like with most health facilities we're a little bit worried about individuals working out, huffing and puffing, and that respiratory droplet component is a little bit greater risk," Hospel explained. "It's inside, we have to worry about air circulation, so we thought maybe there would be a little increased risk initially, so we held the fitness trailer out a few weeks."

It wasn't just preparing for COVID-19 protection; there were also concerns about the golfers' competition readiness from a physical standpoint after being in a shutdown for multiple weeks. During the shutdown, the availability of workout facilities was far-ranging, depending on each athlete's circumstances.

"Some guys have home gyms, but others were going online to buy resistance bands and kettlebells because their facilities were closed," Stodelle said.

For his part, Stodelle conducted telehealth visits via FaceTime or Zoom with a number of golfers to discuss their workouts and answer questions; the video component allowed for real-time feedback to ensure proper performance of various exercises.

Still, there were concerns about what challenges might face the golfers who hadn't walked a course regularly in multiple weeks.

"As guys were asking me leading up to the [the Charles Schwab Challenge, the Tour's first even back last month] what I would recommend, the biggest thing was I would tell them just go out and walk 18 holes. Get used to that. Otherwise they get here and they're walking 18 holes potentially four days in a row, in extreme heat. This is when we see heat-related issues and, of course, the usual soft-tissue injuries."

So far, the injury culprits are what Stodelle and his colleagues expected to see: muscle strains, sore lower backs, an occasional rib sprain. And the treatment process has been smooth, even with the new social distancing requirements.

Stodelle gave an example of a player who stopped by with a rib injury. He said he talked with him for five or six minutes to get a brief history, then he evaluated him quickly, provided some hands-on treatment. Afterward he showed him an exercise (from an appropriate distance) that he could then do on his own.

"The total interaction might have been 25 minutes but we had only 10 minutes of hands-on contact," Stodelle said.

Lessons so far

Like everything, there will be updates and adjustments. Here's what the Tour has learned and changed:

COVID-19 testing
There has been one modification to the protocol algorithm that follows a positive test for players and caddies.

After an initial positive test result, if an asymptomatic individual subsequently has two negative tests (conducted at least 24 hours apart), then he may return to competition.

This modification helps avoid inadvertently penalizing someone whose test may have yielded a false positive result or someone who may be on the tail end of an asymptomatic infection.

Additionally, the following point of clarification for return to play for symptomatic individuals was recently highlighted by the PGA Tour:

Following an initial positive test result, individuals who continue to test positive can return to work if they have gone more than three days without fever or respiratory symptoms and if it has been at least 10 days since symptoms first appeared.

These two items were established in consultation with the tour's infectious disease experts and are consistent with the CDC recommendations for discontinuation of isolation and return to work.

Awaiting on-site testing results before entering golf course
Initially players were permitted to head to the tournament venue to hit balls on the practice range or be outside while awaiting the results of the on-site testing. However, they were not permitted to use facilities such as the clubhouse. Now everyone is required to obtain a wristband as evidence of a negative test result prior to arriving at the course.

Return of the fitness trailer
Originally the plan was to play the first four weeks without the fitness trailer, then re-evaluate. By the fourth week of competition, though, the fitness trailer had returned, making its first post-shutdown appearance at the Rocket Mortgage Classic in Detroit two weeks ago. Players are required to wear masks while exercising in the trailer. Having the trailer on-site guaranteed players a sanitized workout facility with controlled foot traffic as opposed to working out in a more public venue, such as a hotel gym.

Heightened awareness
While everyone was generally accepting of the protocols guiding the return of golf after the shutdown, there appears to have been more universal vigilance with regards to social distancing measures after the first few positive tests were revealed. According to Stodelle, several players and staff referred to the week at the Traveler's as a wake-up call -- seven players withdrew from that event because of issues related to the coronavirus. After that, they began dining in more frequently, avoiding high-fives more regularly and wearing masks everywhere.

Looking ahead

There will be no fans at the Memorial this year, nor will there be any for the remaining events comprising the 2020 PGA Tour season as the presence of the coronavirus still looms large in the United States. The U.S. Open (September) and the Masters (November) have not yet announced a position on fan attendance. By reacting swiftly and strongly to an emergence of a few positive tests early in their comeback phase, the PGA Tour and golf proved the necessity of maintaining fluidity in their process and, in doing so, may have provided a road map for other leagues to follow.

While the restart of golf has been viewed as generally successful by the Tour, Hospel notes there is no room for relaxation of the protocols.

"As we're seeing cases spike across the country, continued diligence is required. We continue to learn more about this virus as time goes on, so we need to be ready and remain flexible in our response."