Streams of mucus, inflammation and broken sleep: How hay fever affects elite sports performance

Professional golfer Jill McGill stood over the ball and prepared to take her shot. Grip? Check. Foot placement? Check. Ball position?

As she lowered her head to check that one off, she felt it; a stream of mucus grabbing its gravity-given opportunity to escape from her nostrils.

“I thought I was going to have to withdraw from the event,” recalls McGill of the tournament in Corona, Mexico, “because the drainage from my nose was so bad that I couldn’t have my head down.”

Instead, she stuffed some tissues up her nose and carried on.

“My poor playing partners,” laughs McGill, speaking to The Athletic from her home in Dallas, Texas, “they had to listen to me sneeze all the way around the golf course and try to hold in the sneezes when they were swinging.”

McGill, who played on the LPGA Tour for more than 15 years and won the US Senior Women’s Open in 2022, has suffered from hay fever since childhood, although she didn’t discover her exact allergies until later in life, when she was already plying her trade as a professional golfer. When the allergist who tested her (using a skin-prick test) delivered her results, he reeled off a long list of trees, pollens and grasses that she was reactive to.

“You’re in the wrong profession,” he chuckled.

“I feel like it’s one of those things that people just kind of get on with and hope that they figure out a way to deal with it,” she says of fellow athletes who suffer from hay fever. “But I do think it’s underestimated. Really, it can be a knockout punch.”

While sport does not cause hay fever, there are certain sports that can make it harder for athletes who struggle with it.

Before The Masters last year, US golfer Scottie Scheffler revealed he had been suffering with hay fever from the moment he touched down in Augusta: “I get out of my car in the morning, my eyes start watering,” he said. “It’s a little bit worse than normal years.”

And former British athletics star Colin Jackson, who was twice a world champion (1993, 1999) in the 110m hurdles, has told how he gave up cricket for athletics as a teenager because of his struggles with hay fever. A talented all-rounder who played under-15s for his county, Jackson said the symptoms became “unbearable”.

“We were always in parks and green areas surrounded by trees. Being in a field from May onwards when you suffer from hay fever is bound to be a problem — but I was opening the bowling and batting at No 5 — and there was not enough time to get my itchy, streaming eyes under control.”

“Track and field athletes spend a lot of time outdoors, training and competing, and as a result of that, they inhale huge amounts of air at high intensity,” he says. “Middle distance athletes approximately ventilate 10 to 20 times more air during exercise than at rest and, of course, when they do that, if they’re exposed to pollen, it increases the exposure into both the upper airways (the nasal area) but also into the lower.”

It’s a similar story in sports like tennis and cycling, where athletes are exposed to the elements for lengthy periods of time.

“It’s a big issue,” says EF Pro Cycling head doctor Jon Greenwell, who explains that there are two time periods when it becomes particularly problematic for riders. The first is around the Ardennes Classics, a prestigious trio of mid-April one-day cycling races held across the Dutch Limburg and Belgian Wallonia regions. Greenwell says it’s the last of those, the demanding Liège-Bastogne-Liège, that is the worst for hay fever symptoms. At that time of year, it’s tree pollen causing the issues.

The second is around late June, when preparation races for the Tour de France are taking place, and that’s due to grass pollen. By the time the Tour actually begins in July, Greenwell says it’s not so much of an issue.

In some cases, the time of year can combine with environmental factors to worsen the impact on athletes.

Take the Madrid Open in tennis, for example. Played on clay courts in late April, when tree pollen overlaps with the arrival of grass pollen, players can struggle as a result of the combination of clay, dry air, wind, and pollen.

“These can stack on top of each other,” explains Dr Robby Sikka, who is medical director for the Professional Tennis Players Association. “It is not just one exposure — it is the cumulative airway burden.”

While people often think of allergies as itchy eyes or a runny nose, they can be seriously debilitating for athletes looking to perform at the highest level.

“It’s actually an inflammatory airway disease,” says Brown. “The classic early phase symptoms are sneezing, itchy, runny nose, watering eyes, but it can also trigger a later inflammatory phase, which causes swelling inside the nose and therefore nasal obstruction.”

The nose is a critical part of the respiratory system, filtering, humidifying and conditioning the air we breathe through it. If it becomes inflamed and blocked, causing athletes to mouth-breathe more, that can irritate the lower airways, says Brown, “and it can worsen exercise-induced respiratory symptoms like asthma, for example”.

During long, high-intensity tennis matches, players are breathing huge volumes of air. If they are mouth-breathing, and thus bypassing some of the nose’s natural filtering system, Sikka says “more pollen and irritants can reach the lower airways. That can trigger inflammation, coughing, chest tightness, or exercise-induced bronchospasm (when the muscles that line the airways in your lungs tighten, causing chest tightness and shortness of breath).”

It’s not just breathing that’s affected. Eyes can also be impacted by excessive watering, itching and swelling. “It’s actually allergic conjunctivitis, which is an inflammatory response in the eyes, causing watering and blurred vision, says Brown. “It can also cause the eyes to swell right up.”

When it comes to athletes, he explains, these eye symptoms can affect visual tracking, reaction time and concentration.

One of the key ways in which hay fever can impact performance is through its effect on sleep, with nasal inflammation and blockage causing athletes to wake more often, feel more tired and recover less effectively. They can then experience “impaired concentration and impaired decision-making,” says Brown, “and at the elite level, you can see that even small impairments to sleep and/or breathing can really affect performance”.

There is also the knock-on effect of mouth breathing at night time, caused by a blocked nose. That means you lose the natural defence that your nose gives you by filtering the air and are then breathing unfiltered, dry air straight into your lungs.

“They can then go on and start to have problems with coughs, colds and bronchitis,” says Greenwell.

What can athletes do about it, then?

Before loading up on medications, they need to be aware of the anti-doping regulations, says Professor John Dickinson, a leading exercise respiratory physiologist who lectures at the University of Kent and runs a respiratory clinic at the Marylebone Health Group.

“Antihistamines aren’t a problem and nasal glucocorticoid steroids (steroid nasal sprays) aren’t restricted either. What we need to avoid is athletes using stronger stuff.”

He mentions British cyclist Bradley Wiggins, who received a therapeutic use exemption (TUE) for injections of a powerful corticosteroid called triamcinolone before the 2011 and 2012 Tour de France and the 2013 Giro d’Italia. Though triamcinolone is banned in-competition by the World Anti-Doping Agency (WADA), it can be used by an athlete if they are granted a TUE on the understanding that, without the drug, they would experience significant health problems, and the medication is simply returning them to “normal” health, rather than providing a performance boost.

Wiggins has always said that this was the case, and that he had been suffering from pollen allergies affecting his performances since 2003.

“Triamcinolone is a much stronger medicine that you really only give in very severe cases of allergy,” says Dickinson. “So you want to avoid teams providing that stuff unless it really, really needs to be administered.”

Greenwell, who worked for UK Sport before moving into professional cycling, says the impact of the fallout over Wiggins’ TUE is a lasting one.

“Certainly UK Anti-Doping and WADA wouldn’t issue a TUE for triamcinolone now,” he says. “I don’t think there will be any anti-doping bodies that would give a TUE for corticosteroids (injected) or even tablet corticosteroids. It just doesn’t happen anymore, partly because of some of these cases, but also because the anti-doping authorities have tightened up on the use of corticosteroids generally.”

If someone is suffering badly from hay fever symptoms then, what are their options?

Greenwell reels off a list: “Titrating up oral antihistamines until you’re on the maximum dose (although if you go really high, you can end up feeling quite sleepy with it, so we don’t tend to go over the recommended prescribed dosage) and optimising the nasal antihistamine and nasal corticosteroid spray. If they’ve been on one nasal spray for a while, we’ll switch them to another one and sometimes that will make a big difference.”

There are also practical measures, like training earlier in the morning before the pollen levels are highest.

Using a saline nose rinse twice a day, first when athletes come home from training to wash all the pollen out and then before they go to bed to keep the nose clear at night. Changing out of their clothes straight away after training to prevent the pollen being released into the house. And if they’re really struggling, putting Vaseline up their nose to trap the pollen before it’s ingested.

“Often the things that make the biggest change are just the day-to-day things” says Greenwell. “Because there isn’t a rescue steroid that you can use anymore.”

Even away from strong medications like triamcinolone, there are reasons for athletes to be cautious when it comes to combination cold remedies or decongestants.

Greenwell says they don’t allow riders to use nasal decongestants if they contain Sudafed, as some of these products contain pseudoephedrine, which is prohibited by WADA in-competition above a certain urinary threshold.

“Because of that, we won’t use oral decongestants and there are certain nasal decongestants we won’t use either because they could potentially result in a failed test as well. If you’ve been using Sudafed for a cold, even if you’ve taken the normal dose and you were dehydrated, you would probably tip over to a positive test.”

All the experts The Athletic spoke to for this story say that the key aspect of treating hay fever is to be proactive with it, rather than reactive.

What that looks like for Greenwell is screening every rider to establish who is at risk of symptoms. He uses the Allergy Questionnaire for Athletes (AQUA) and once he’s established who is at risk, carries out skin-prick tests against all of the tree pollens, grass pollens, dust mites, cats, dogs, and a few molds as well.

“Then we can build up a profile as to: Are they really allergic (because there is so much overlap in the symptoms with respiratory infection)? And if so, when is their risk period?”

Greenwell is speaking to The Athletic via a video call from his home in Yorkshire and at this point holds up a book to the screen: “And we have this,” he says proudly.

Inside the book are pages containing colour-coded maps of all the races the team will compete in, showing the pollen distributions based on location and time of year. It was put together by a PhD student and shows which pollens are high (in red), which are low (yellow) and which are not present at all (white).

It allows him to plan the team’s preventative medication strategy at those key points.

“The thing with all the hay fever tablets is they work best if you take them at least one week, if not two weeks, before you’re exposed to the pollens,” he explains. “If you start the day before or if you start with symptoms, it’s almost too late.

“We use a three-pronged approach: anti-allergy tablets, a nasal corticosteroid often in conjunction with an antihistamine — we like to use combined inhalers, which are not prohibited. You have to write them down if you get tested but you don’t need a TUE. Potentially, we’ll use anti-allergy eye drops as well to manage the eye symptoms.”

At some races, the team will also have air purifiers placed in every rider’s bedroom to try and keep the air they’re breathing at night as clean as possible.

One of the worst locations for hay fever in track and field is around Eugene, Oregon where one of the sport’s most famous meetings, the Prefontaine Classic is held at Hayward Field. It also hosted the World Athletics Championships in 2022.

It’s a big grass-seed producing region and so levels of grass pollen are notoriously high, particularly at times of US Championships and Olympic trials.

When he’s had athletes training or competing there, Brown says the focus is on reducing exposure by modifying training times, showering after sessions, changing clothes, saline nasal rinsing and wearing wrap-around sunglasses. Plus, starting medication at least a week before exposure.

Of course, modifying training times is not applicable during competition when races are not subject to change based on pollen counts. That’s what led to the famous moment at the 1972 U.S. Olympic Track and Field Trials in Eugene, when American miler and severe hay-fever sufferer Jim Ryun (1500m silver medallist at the 1968 Summer Olympics, and the first high school athlete to run a mile in under four minutes), warmed up for his race in the next town and was flown in by helicopter to avoid excessive exposure to grass seed.

It sounds a lot, but he won the race, so might argue it was justified.

What determines which athletes suffer from hay fever and which don’t comes down to a combination of factors, says Brown, explaining that it develops through an interaction between “genetic predisposition, immune sensitisation, environmental exposure, and then airway inflammation”.

That is the case for any individual, not specifically athletes. But what is specific to the athlete population, says Brown, is that elite athletes “expose their airways to enormous environmental loads through high ventilation rates, prolonged outdoor exposure, pollution, cold air, chlorinated environments and repeated airway stress.

“It doesn’t necessarily cause allergy on its own, but it may amplify the inflammation in the airway. And therefore, in somebody who is more predisposed, they can go on and develop this issue.”

Is it getting worse?

“I think the landscape is kind of changing,” says Brown. “We are seeing longer and more intense pollen seasons, which we think is linked to climate change. So athletes are becoming symptomatic even earlier in the spring and also late into the summer than they were previously.”

“People who don’t suffer from allergies don’t understand how debilitating it can be,” says golfer McGill. “I would equate it to, if you have a very bad common-cold virus, where you just feel beat down and all you want to do is sleep because your body is fighting it so hard.”

For tennis players, even small changes matter, adds Sikka: “If your eyes are irritated, your sleep is worse, your breathing is less efficient, or you cannot recover as quickly between points, that can absolutely affect performance.

“At the elite level, allergies are not just a nuisance,” he continues. “They can be the difference between feeling normal and feeling like every rally takes more out of you than it should.”

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