This is a 14-year old female who presents to the office for her sports physical. She is planning on participating in high school cross-country and track. She ran both in middle school last year, but this will be her first time participating in high school sports. She has a history of shin splints with cross-country last year. She did not have any problems in track in which she ran middle distance and relays. She has no other history of injuries last year, no medical history. She is not on any medications. Her onset of menses was 2 years ago. Her periods were irregular during cross-country season, but since then they have been monthly. She did the history portion of the PPE (preparticipation exam) form herself. The questions were reviewed with her mother for accuracy of the family history.
VS T37.0, P62, R16, BP 95/60, height 162 cm (5’4”), weight 46.3 kg (102 lbs), BMI 17.5 (25%ile)
General appearance: Alert, no distress, thin female. Head: Normocephalic. Eyes: PERRL, EOMI, vision 20/20 bilaterally. ENT: nares patent, TM’s clear, intact, no scarring, pharynx clear, good dentition, no oral ulcers, no gingival atrophy, normal enamel. Neck: supple, no masses, full range of motion. Breasts: deferred. Heart: +S1, +S2, regular rhythm, no murmur sitting, standing or squatting. Lungs: clear to auscultation bilaterally, good aeration, no prolonged expiratory phase. Abdomen: soft, non-tender, non-distended, no masses palpated. Genitalia: deferred. Back: spine straight, no curve on forward flexion. Skin: no lesions. Musculoskeletal: 14 point musculoskeletal exam normal (1). Neuro: DTR’s 2+.
She was counseled on the female athlete triad (irregular menses, poor bone health, and poor dietary intake) and the importance of monitoring for monthly cycles especially during cross country season. Preventative strategies for shin splints were addressed and she was cautioned about the risk of stress fracture if not treated appropriately. The expected lifetime of running shoes was discussed. She is cleared for full participation in sports.
The number of participants in sports has continued to rise over the past four decades. Many high school athletes undergo a preparticipation exam (PPE) prior to playing sports. Since less than 2% of athletes are actually disqualified from sports, the utility of the exam has come in question recently; however, most states have legislation that require an exam prior to sports participation. Aside from the medical utility of the exam, there is also consideration given to the administrative and coaching/athletic value of the PPE.
The primary goals of the PPE are to screen for conditions that may be life-threatening or disabling and to screen for conditions that may predispose an athlete to injury or illness. The secondary goals of the PPE are to determine general health, to serve as an entry point to the health care system for adolescents, and to provide an opportunity to initiate discussion on health-related topics.
The optimal timing for the exam is to have it completed about 6 weeks prior to the start of the season. It gives the athlete time for further work-up if necessary or to rehabilitate a previous injury. If done too soon, it may make the information out of date. The exam is typically done annually although some school districts have a requirement for a full exam every other year and updates in-between.
The history, like most things in medicine, is the most important part of the exam. Most red flags are detected with the history. The PPE Monograph (1) provides a sample of a history form that has been adopted in most states for the sports physical. The history must be reviewed with the patient and also the parent. It is not sufficient just to have the form filled out without ensuring that the questions were understood.
Essential information from the history includes updated demographic information, immunization status, excessive changes in weight, history of anaphylactic reactions, history of concussions, dizziness or syncope with exertion, family history of exercise related death, history of asthma, loss or dysfunction on one of a paired organ, menstrual history, use of contact lenses, dental appliances or other apparatuses (insulin pump, prosthesis etc.), recent or recurrent fractures/dislocations, and history of heat illness.
Physical exam should include a global exam with an orthopedic examination. Some complete a performance exam as well. Specific joint exams are done when there is a history or current complaints of pain or injury. Vital signs should be obtained including height, weight, BMI (body mass index), heart rate, respirations, and blood pressure. Most districts will calculate body fat for wrestlers in the school and not in the physician’s office. For pediatric patients, the blood pressure must be checked against sex and height matched norms. BMI must be plotted on a growth chart. Visual acuity should be completed. Inspect for skin lesions. On the eye exam, assess for anisocoria and the pupillary reflex. For the heart examination, listen to the heart sounds, rhythm, and any murmur. If a murmur is detected, assess in the sitting and supine positions and also with Valsalva and squatting. Hypertrophic cardiomyopathy is the leading cause of sudden cardiac death in the United States. The lungs should be assessed for prolonged expiratory phase, which may indicate asthma. The abdominal exam should assess for any masses. The musculoskeletal exam should include the 14-point exam (2).
There is no current evidence to support routine screening laboratory tests or ECG’s, at least in the United States. Further work up should be based on the history and physical exam.
Clearance is divided into four categories,
1. Cleared for all activities without restriction.
2. Cleared with recommendations for further evaluation or treatment.
3. Not cleared; clearance status to be reconsidered after completion of further evaluation, treatment, or rehabilitation.
4. Not cleared for certain types of sport or for any sports.
When an issue arises regarding clearance, the following must be considered. Does the problem place the athlete at increased risk of injury or illness? Is another participant at risk for injury of illness because of the problem? Can the athlete safely participate with treatment? Can limited participation be allowed while treatment is being completed? If the clearance is denied only for certain sports or sport categories, in what activities can the athlete safely participate? The purpose of the PPE is not to disqualify an athlete, but to ensure the athlete and the team is safe. The American Academy of Pediatrics (AAP) has a statement regarding medical conditions and sports participation. The AAP also has a classification of sports according to contact to aid in appropriate clearance (3).
With regards to the athlete with special needs, the PPE is similar. However, it must address specific concerns of the athlete with special needs. The issues that pose the greatest concern include a history of seizures and how well controlled they are, hearing loss, vision loss, cardiopulmonary disease, renal disease or unilateral kidney, atlantoaxial instability (Down syndrome), heat stress, fractures and dislocations, prosthetic devices, indwelling catheter or intermittent catheterization, pressure sores or ulcers, previous level of competition, level of independence, medications, special diet, history of autonomic dysreflexia. For the physical exam, particular attentions should be given to visual, cardiovascular, musculoskeletal, neurologic and dermatologic systems. Clearance for sports participation is similar. Often times it will require multiple physicians, as the subspecialists that are treating the athletes will have to weigh in as well as other members of the medical care team, including therapists and educators.
For final clearance of any athlete, some schools employ a team physician that reviews the PPEs for the school. The athletic trainer in the school is an essential component of the medical/athletic team and is a very effective gatekeeper in ensuring the safety and health of the student athlete.
The PPE continues to evolve. For many adolescents, it may offer their only contact for medical evaluation. Although the evidence of effectiveness is lacking, it provides an opportunity to establish or continue a physician patient relationship that may not otherwise exist.
1. True/False: A 13 year old male comes to the clinic for his sports physical. His auntie brought him as both parents are at work. He filled out the history form on his own, he checked "no" for all the answers. Auntie does not know the family history, but states that his mom and dad are healthy. His exam is normal and reports no history of injury previously in football. Can he be cleared for sports?
2. True/False: The purpose of the PPE is to disqualify athletes from sports since there are too many athletes currently as it is.
3. True/False: The most important part of the PPE is the physical examination because it is more likely to pick up an abnormality that must be further evaluated.
4. True/False: The physical exam must include specific and extensive joint exams for the shoulders, knees, and ankles for football players as football is a contact sport.
5. True/False: Once the pre-participation exam is completed, the athlete is either cleared or disqualified from all sport activity.
1. Bernhardt DT, Roberts WO. PPE Preparticipation Physical Evaluation Fourth Edition 2010, American Academy of Pediatrics.
Answers to questions
1. False. He cannot be cleared for sports until the history is reviewed by one of the parents.
2. False. The purpose of the PPE is: to screen for conditions that may be life threatening or disabling; to screen for conditions that may predispose an athlete to injury or illness; to determine general health; to serve as an entry point to the health care system for adolescents; and to provide an opportunity to initiate discussion on health-related topics.
3. False. The most important part of the PPE is the history since further workup is typically a result of an issue recognized in the history.
4. False. A joint specific exam only needs to be performed if there are complaints regarding a joint or a recent history of injury.
5. False. Clearance falls into the following categories: cleared for all activities without restriction; cleared with recommendations for further evaluation or treatment; not cleared, clearance status to be reconsidered after completion of further evaluation, treatment, or rehabilitation; and not cleared for certain types of sport or for any sports.