Sports in America are and always have been an important part of the fabric of our society, with participation continuously on the rise. This year, nearly eight million boys and girls will take part in interscholastic sports, and an additional half million are competing at the collegiate level.1,2
This growth in participation has also led to a rise in sudden death in athletes, the vast majority of which being attributed to congenital or acquired cardiovascular disease involving male athletes participating in football and basketball.3-5 Other causes include heat stroke, cerebral aneurysm, asthma, commotio cordis and sickle cell trait.4.5
As increased sport participation continues and greater attention is paid to catastrophic deaths in athletes, the medical community should adopt a standardized pre-participation examination aimed at improving the safety of sports participants at all levels. In organized athletics, the pre-participation physical examination (PPE) has been routinely used in an attempt to identify those conditions that may place an athlete at increased risk and affect safe participation.
When properly administered, there is ample evidence of the effectiveness of the PPE. However, lack of standardization has created confusion, and failure to define its objectives has led to the consensus that, in its current form, it does not address the goal of protecting the health and safety of the participant.
It has been shown that the PPE represents the sole source of medical evaluation for 30% to 88% of children and adolescents annually,6,7 leading to the identification of conditions that, while not necessarily related to or requiring restriction from athletic participation, nonetheless call for additional follow-up.
The National Athletic Trainers' Association (NATA) recently published a new position statement in the Journal of Athletic Training titled "Pre-Participation Physical Examinations and Disqualifying Conditions,"8 which provides recommendations to equip the sports medicine community with the tools to conduct the PPE as effectively and efficiently as possible using available scientific evidence. In addition, the recommendations identify those conditions that may threaten the health and safety of participants in organized sports, may require further evaluation and intervention, or may result in potential disqualification.
Medical and Family History
The medical and family history serves as the cornerstone of the PPE, having been shown to identify approximately 75% of problems that affect initial athletic participation.6,9 While there is little evidence to suggest the PPE will reliably identify important but clinically silent conditions such as hypertrophic cardiomyopathy (HCM), there is consensus that a comprehensive, uniformly applied approach to the PPE offers the best opportunity to meet this objective.10 Furthermore, the information obtained from the athlete and parents/guardians should always be reviewed carefully as they may not provide reliable historical information on which to base participation decisions.11
A limited general physical examination is recommended for the PPE to include vital signs (e.g., height, weight, and blood pressure) and visual acuity testing as well as a cardiovascular, neurological, general medical (e.g., pulmonary, abdominal, skin, and male genitalia), and musculoskeletal examination. Further examination should be based on issues uncovered during the history.10,12 An effective screening test satisfies two major requirements to be considered effective: 1) the test must be accurate, and 2) be effective for early detection.13
Auscultation of the heart should be performed with the patient in both the standing and supine positions, and also during various maneuvers (e.g., squat-to-stand, deep inspiration) as these may clarify if a murmur is present.14 Murmurs are commonly found, occurring in over 30-50% of athletes, and may not warrant further evaluation in the asymptomatic athlete.15
Electrocardiography, echocardiography and exercise stress testing are not considered routine aspects of the PPE unless warranted by findings from the medical and family history.10 These tests are not cost effective in a population at relatively low risk for cardiac abnormalities and cannot consistently identify athletes at actual risk.16-20
At present, the common cardiac conditions that limit athletic participation are rarely detected during the PPE.21 Even when cardiac abnormalities are detected, the findings leading to disqualification are most often rhythm and conduction abnormalities, valvular abnormalities, and systemic hypertension that are not the cardiac abnormalities noted to be associated with sudden cardiac death in athletes.22,23
Echocardiography and stress testing are the most commonly recommended diagnostic tests for patients with an abnormal cardiovascular history or examination. Unfortunately, echocardiography lacks specificity in terms of diagnosing HCM and determining those patients with HCM who are at risk for sudden cardiac death.
Furthermore, some patients with HCM are able to tolerate vigorous exercise for many years, and even maintain high levels of achievement without incurring symptoms, disease progression, or sudden death.20,24
Athletes who report having sustained a previous neck injury should undergo a complete neck evaluation to establish the presence of symptoms in addition to full range of motion and strength.
Neck pain and/or any symptoms that radiate down into the arms, hands, or legs should prompt cervical X-rays including flexion/extension views. Additionally, concerns related to cervical stenosis (narrowing) should be further evaluated through diagnostic imaging.25
Recent attention brought to the seriousness of concussions has led to the inclusion of a review and assessment of head injury history during the PPE. NATA, at the fifth annual Youth Sports Safety Summit in mid-March, issued a new position statement updating well-defined guidelines for the management of sport-related concussions,26 and sports organizations such as the National Collegiate Athletic Association (NCAA) and the National Football League (NFL) have followed suit by developing concussion management plans for athletes who suffer concussions.
These also include recommendations for establishing baseline normative values prior to the beginning of a sport season that can be used following an injury to determine recovery and aid in return-to-play decisions.
Abnormal musculoskeletal findings are the major cause of restriction of sports activities, the most common being knee injury followed by ankle injury.14,27-29 The orthopedic screen should be used to determine conditions that would make sports participation unsafe, giving specific consideration to the sport for which the athlete is being screened and to facilitate conditioning programs for injury prevention.25
The first component of the orthopedic portion of the PPE is a complete history of previous injuries and surgeries; this is followed by the physical exam. If the athlete has either a history of previous injury or other signs and symptoms of injury with the basic exam, then the screening should be supplemented with a more comprehensive site-specific examination.28,30,31 Follow-up treatment can take the form of referral to a sports specialist, diagnostic testing, or implementing a rehabilitation program.
General Medical Screening
The use of routine laboratory or other screening tests such as urinalysis, complete blood count, or spirometry during the PPE is not supported in the current literature.10,28,32,33 Under certain circumstances, however, diagnostic studies should be considered based upon results gathered in the medical and family history.
Conditions such as anemia, sickle cell trait, diabetes mellitus and exercise-induced brochospasm (asthma) can pose a threat to safe athletic participation and, when warranted, should be further investigated when reported or uncovered. Treatment and management plans should also be implemented according to available scientific evidence and best practices.
The PPE also offers the opportunity to establish the impact, if any, of medication usage, nutrition, heat and hydration and mental health considerations on the ability of the athlete to train and compete safely. Specific questions in the medical history will direct the discussion as to how these factors can affect the athlete's health and performance.
The American Academy of Pediatrics has developed a very thorough document that should minimally serve as the template for a standardized PPE instrument.10 It is recommended that a physician (MD or DO) with clinical training in dealing with potential problems or risk factors associated with athletic participation be the responsible party in coordinating and/or conducting the PPE.
Certified athletic trainers, physical therapists, nutritionists and exercise physiologists may also be of considerable value to conduct various administrative tasks, collect vital signs, administer patient education, provide consultation on rehabilitative exercises, and help with organization and flow of the process.
It is recommended that the PPE should ideally be conducted four to six weeks prior to preseason practice. Residual injuries and further evaluation of abnormalities can be addressed during that time period.
All data documented from the PPE should be handled carefully, thoroughly, accurately, and privately to ensure the screening process is complete and that any follow-up testing or additional information necessary to complete the PPE has been performed and reviewed by the examining physician in order that an appropriate judgment can be made regarding the athlete's status for participation.
Determination of Clearance
Occasionally, an abnormality or condition is found that may limit an athlete's participation or predispose to further injury. In these cases, the team physician should review the following questions as the athlete's ability to meet the criteria for participation is being determined:10
Does the condition pose an unacceptable risk or place the athlete at increased risk for further injury? Does the condition place other participants at risk for injury? Can the athlete safely participate with treatment (e.g., medication, rehabilitation, bracing, padding)? Can limited participation be allowed while treatment is being completed? If clearance is denied only for certain sports or sport categories, in what activities can the athlete safely participate?
The determination of clearance to participate in a particular sport should be based on previously published guidelines. Participation recommendations are based on the specific diagnosis, though multiple factors such as the classification of the sport and the specific health status of the athlete affect the decision.
In terms of excluding an athlete from participation based upon medical concerns, a team physician and institution have the legal right to restrict an individual from participating in athletics as long as the decision is individualized, reasonably made, and based on competent medical evidence.
References are available at www.advanceweb.com/pt under the Toolbox tab.
This article was produced in cooperation with the National Athletic Trainers' Association (NATA), the professional membership association for certified athletic trainers and those who support the athletic training profession. Visit www.nata.org
Kevin M. Conley is associate dean for undergraduate studies in the School of Health and Rehabilitation Sciences and associate professor and program director for athletic training education at the University of Pittsburgh.