West Ham's Sophie Hillyerd is among a growing number of athletes dealing with POTS, a condition that has been linked with Long COVID patients. Alex Pantling - The FA/The FA via Getty ImagesWest Ham United goalkeeper Sophie Hillyerd says that the last 12 months have been like nothing she's ever experienced before.
"Nobody can tell," she told ESPN. "When you're having a bad day, they think, 'Why is she struggling today?' People are going 'come on Soph, run,' and I'm thinking, 'I can't.'
"They just won't know. They'll think, 'She's being lazy, she's unfit,' but no. I'm dealing with something that nobody else can see."
With physical injuries, "You know what it is, you have scans, and you know what to do to fix it.
"With this, it was so different. It was unknown."
In September 2021, Hillyerd was embarking on the beginning of her professional career, signing with Charlton Athletic from Manchester United in search of senior first-team football. A COVID outbreak impacted her and a large group of her teammates prior to the season starting. It was when the keeper returned to training that she realised something wasn't right.
"I was breathless, but it wasn't until three sessions in that I realised 'this isn't normal,'" Hillyer recalled.
"I'd heard of people struggling to return to play but there was nothing quite like how I felt with my heart going so fast. My heart rate got up to 224 [beats per minute], which is ridiculous."
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For context, Hillyerd's maximum heart rate at the time should have been 202 BPM. Despite her symptoms, the tests on her heart came back normal. At first glance, there was no physical reason to discontinue training. However, she soon knew that the situation was untenable.
"I did a session all about crosses. That's quite low intensity," she explained. "I'd fallen on the floor and I stood back up and I just thought 'God, I'm going to faint, I'm going to fall back over.'
"It was more than light-headedness. The dizziness -- I couldn't stand up without feeling faint. I knew that something wasn't right.
"As I was sitting in bed at night, I'd just have this excruciating chest pain and there was no explanation for it. It was so hard not knowing what's wrong and it being such a horrible thing, something to do with your heart."
The lack of answers is a common theme among patients who have Long COVID. In a Pultizer Prize-winning explainer on Long COVID by Ed Yong, patients describe the dismissal or disbelief of their symptoms by friends, family and even medical professionals. However, Hillyerd spoke glowingly about the medical team at Charlton, led by Dr. Chris Schoeb, and the way that they continued to pursue answers in the face of inconclusive tests.
"He never gave up," she said of Dr. Schoeb, and he helped her book an appointment for the specialist to confirm his suspicions of a condition known as POTS.
Even light training sessions left Hillyerd, an England youth international, exhausted. Alex Pantling - The FA/The FA via Getty Images
Postural orthostatic tachycardia syndrome -- POTS -- has some tell-tale signs. They can include dizziness, brain fog, chest pains, fatigue, and a heart rate that increases by over 30 when standing. It is also a common diagnosis for people experiencing Long COVID. Most people have never heard of the condition, let alone know what the signs are, and can go months or even years before diagnosis.
Exercise physiologist Carlo Sibulo works at the Wellness Station in Melbourne, Australia. He specialises in Chronic Fatigue Syndrome and Myalgic Encephalomyelitis, collectively known as ME/CFS. POTS is known to be related to ME/CFS.
"POTS relates to intolerances to postural changes and an inability to regulate blood volume," Sibulo told ESPN. "However, both POTS and CFS can originate from the same root cause, and hence can share risk factors."
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ME/CFS and POTS impact a variety of people. They are far from exclusive to Long COVID -- they precipitate from other viral infections as well. However, over the last 12 months, there has been a substantial increase in Long COVID cases in Sibulo's clinic. The most common symptoms that his patients are presenting with are fatigue, concentration, memory issues and exercise intolerance. He explains that this leads to "significant impact to daily life and function."
Risk factors for developing illnesses like ME/CFS and POTS include being exposed to a demanding or stressful environment, having high activity levels, and certain personality types including high achievers and carers. While anyone is at risk to developing a post-viral syndrome, these risk factors will inevitably capture a high number of athletes -- something that sports organisations are slowly becoming more aware of as effects of the COVID-19 pandemic continue to reverberate throughout the world.
Hillyerd's eventual POTS diagnosis provided her the answers that she was so desperately seeking, and an eventual path back to football.
While the science remains unclear as to the exact prevalence of POTS in Long COVID patients, there does appear to be a clear link. The severity of symptoms can vary. Some POTS patients report having to stop work or education due to their condition. However, the vast majority report an improvement of symptoms with treatment. Many do recover, either fully or to the extent that their quality of life is no longer affected.
Treatment options include increasing intake of salt, staying hydrated, and wearing compression garments. They can also include certain heart medications to help with low blood pressure. Hillyerd immediately began to notice improvements after implementing the recommendations from the specialist.
"It probably took about two to three months to get back into training since I had that appointment," she said. "It does sound long, but after having the unknown it was great for me."
There were several modifications required once she did re-enter the professional training environment.
"In training, I wore compression on my legs to help the blood come back up and the oxygen flow," she explained. "I also wasn't allowed to do isometric exercises, where you hold -- so I can't do a wall sit for example, because it just triggers it.
"If my blood is in the wrong place, it will cause me to feel faint."
It was with the help of these treatments and modifications that Hillyerd has recovered, to the extent that POTS no longer hinders her ability to perform as an elite athlete on a day-to-day basis. She is now fit and firing at West Ham, ready for her opportunity in the FA Women's Super League.