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CAQ Review

Athletes with Clotting and Bleeding Disorders

Clyde, Travis MD; Gordon, Christopher MD

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Current Sports Medicine Reports: December 2019 - Volume 18 - Issue 12 - p 427-428
doi: 10.1249/JSR.0000000000000656
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Treatment of athletes who encounter a venous thromboembolism (VTE) or have a bleeding disorder require appropriate care and management to minimize morbidity and mortality. Incidence of clotting and bleeding disorders in athletes are the same as the general population; however, athletes are susceptible to acquired thrombogenic risk factors (1,2).

Risk Factors

Competitive athletes have several factors that increase risk for VTE, which include endothelial injury with sports play, blood stasis seen with prolonged travel, bradycardia, postinjury immobilization, compression of vessels via muscle hypertrophy or other anatomic variants, and increased blood viscosity from dehydration and other factors (1,2). Athletes with protein C deficiency may have an increased clotting response and risk for thrombosis with exercise (2).


Clotting Disorders

VTE treatment recommendations are the same for athletes and nonathletes. Traditional management commonly includes initiating anticoagulation with a subcutaneous low molecular weight heparin bridge along with a vitamin K antagonist (VKA), such as warfarin. VKA dosing should be routinely adjusted to maintain an International Normalized Ratio (INR) between 2.0 and 3.0 (target of 2.5) for at least 3 months (1). Alternate treatment could include prescription of a direct oral anticoagulant (DOAC) (3). At least 3 months of anticoagulation is advised for athletes with their first unprovoked distal VTE (1); however, the average time lost for all forms of VTE in professional athletes is 6.7 months, substantially greater than the 3-month minimum treatment period recommended by the American College of Chest Physicians (2).

Though lacking in scientific studies, treatment with a DOAC “fast on/fast off” has been proposed (3). Pausing treatment before a competition may allow an athlete to compete when plasma drug concentration levels reach the level at which bleeding risk is considered minimal (3). Once the risk of trauma or bleeding normalizes after athletic competition, a single dose of medication quickly reestablishes therapeutic anticoagulation (3).

In conjunction with anticoagulation treatment, use of elastic compression stockings with an ankle pressure gradient of 30 mm Hg to 40 mm Hg may reduce incidence of postthrombotic syndrome in athletes with a lower-extremity VTE (1,2).

Surgical procedures should be reserved for athletes with upper-extremity VTE who fail initial therapy (1).

Bleeding Disorders

All athletes with hemophilia should receive prophylactic factor infusions per current recommendations with routine supervision and care of a hematologist and a primary care physician (4). Medications that increase bleeding risk should generally be avoided in athletes with hemophilia.

Sports Participation

Clotting Disorders

Athletes with a VTE have a high risk for clot propagation and pulmonary emboli. After initiating anticoagulation, early walking may reduce short- and long-term symptoms associated with VTE (1). Though there are no expert guidelines regarding return to physical activity while on anticoagulation treatment, 3 wk of gradual return to activities of daily living followed by a progressive return to training program is suggested (1,3). While anticoagulated, athletes should not engage in contact or collision activities (1).

Return-to-contact play may be considered once the athlete is treated for at least 3 months, medication treatment is discontinued, hypercoagulability laboratory results have returned to normal, and symptoms have resolved. A gradual increase in intensity is recommended with careful monitoring for recurrent VTE. Athletes who acquired a VTE should be educated regarding potential risk factors along with avoidance measures to reduce VTE risk (1).

Bleeding Disorders

The National Hemophilia Foundation (NHF) recommends athletes with a bleeding disorder participate primarily in safe and moderately risky sports: swimming, golf, sailing, rowing, kayaking, bicycling, archery, and table tennis (4); however, certain moderate-to-dangerous contact and collision activities, like basketball, racquetball or tennis, running, and soccer, may be acceptable with proper precautions, prophylaxis, equipment, surveillance by caregivers, and immediate access to care (4). The NHF recommends restriction from some of the most dangerous activities, including BMX racing, rodeo, wrestling, and boxing (4).

The authors declare no conflict of interest and do not have any financial disclosures.


1. Depenbrock PJ. Thromboembolic disorders. Curr. Sports Med. Rep. 2011; 10:78–83.
2. Howell C, Scott K, Patel DR. Sports participation recommendations for patients with bleeding disorders. Transl. Pediatr. 2017; 6:174–80.
3. Bishop M, Astolfi M, Padegimas E, et al. Venous thromboembolism within professional American sport leagues. Orthop. J. Sports Med. 2017; 5:232596711774553.
4. Berkowitz JN, Moll S. Athletes and blood clots: individualized, intermittent anticoagulation management. J. Thromb. Haemost. 2017; 15:1051–4.
Copyright © 2019 by the American College of Sports Medicine