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Pre Participation Physical Part 1

Matt Baird, MD and Matthew DeLaney, MD
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Almost all athletes should undergo a pre-participation physical. While there is significant variability in terms of what may occur during this exam, the ultimate goal is to identify high risk historical or physical exam findings that could increase the risk that the athlete has a bad outcome.

Pearls:

  • Pre-participation exams (PPE) are screening exams and any concerning findings warrant referral for further evaluation before providing full clearance. 
  • PPEs serve as one of the few points of contact with the health care system for generally healthy adolescents and offer an opportunity for counseling about health topics. 
  • A thorough personal and family history of symptoms and illnesses will reveal the vast majority of concerning findings that preclude sports clearance. 
  • Pay attention to vital signs, most notably blood pressure and visual acuity, because abnormalities here need to be addressed before full clearance.
 
  • Pre-participation/sports physical are intended to identify life-threatening or potentially disabling conditions affecting or resulting from sports participation such as ligamentous laxity and organomegaly. 
  • Sports physicals offer an opportunity to examine and counsel adolescents who are otherwise healthy and likely have little other contact with the healthcare system. 
  • It is not a typical well child visit and a pre-participation exam (PPE) should not replace this.
  • Guidelines change and PPEs can serve to clear children who may have previously been told they have a condition that prevents them from playing sports.
    • Well controlled asthma and childhood heart murmurs should not preclude sports participation in most cases. 
    • Guidelines no longer recommend GU/hernia exams. 
  • Virtually all college and high school athletes are required to have a PPE. 
    • The recommended frequency of PPEs varies by organization. The American Heart Association recommends one every 2 years. . 
    • The NCAA recommends athletes have a PPE when they first begin at a new school and if there is a significant change in health at any point.
  • PPEs should ideally be performed 6 weeks before the athlete is scheduled to start playing. 
  • Sports physicals are controversial because they’ve never been shown to decrease mortality in athletes and it can lead to unnecessary testing and expense.
    • Screening EKG is a major area of debate because non-specific findings are common which lead to more downstream testing without clear benefit. 
    • Sudden death in athletes is rare, so proving a mortality benefit of PPEs is statistically very difficult, but high risk findings can be identified when this standard practice is applied over millions of athletes. 
  • The history will provide the most useful information. Physical exam tends to be less revealing. 
    • Standardized PPE history forms can be found online, but tend to be overly lengthy. 
    • Cardiovascular (including vital signs) and neurologic evaluation (including visual acuity) are the most important systems to review. 
  • High Risk Considerations:
    • Cardiovascular
      • Hypertrophic Cardiomyopathy (HCM) - systolic murmur which increases in intensity with valsalva.
      • Blood pressure over 140/90 should be rechecked prior to participation.
        • Blood pressure over 160/100 should be restricted from play until they can be further evaluated.
      • History of chest pain or syncope (especially during exertion)
      • Marfan’s Syndrome - based on habitus and family history
      • Family history of sudden Cardiac Death
    • Neurologic
      • History of concussions - number, duration for recovery
      • Seizure disorder history - especially for aerial and water sports
      • Spinal injuries - especially recent “stingers” 
      • Visual acuity worse than 20/40 in either eye or both eyes require further evaluation before being fully cleared to play. 
        • Visual screening is also an opportunity to discuss wearing eye protection.
    • Hematologic
      • Abnormal bleeding - screening for hemophilia and von Willebrand’s Disease
      • Sickle cell disease - patients are severely restricted from intense sports.
        • The NCAA mandates sickle cell screening for all athletes. 
        • Sickle cell trait patients can usually participate in most sports with monitoring.
          • Restrictions for sickle cell trait include avoiding heat stress and high altitudes. 
      • History of severe allergy (ie: anaphylaxis) - Screening questions could include use of EpiPen or previous treatment by EMS etc.
    • Respiratory
      • Asthma, including exercise induced, is the primary respiratory disease that providers will encounter when performing PPEs. 
        • There are no restrictions for well controlled asthma. 
  • Organ injury considerations
    • Patients with a solitary kidney are generally not permitted to play contact sports.
    • Patients with a single testicle are only permitted to play contact sports if wearing a protective cup at all times. 
    • Patients with recent mononucleosis should be examined for splenomegaly and restricted from contact sports until this resolves.
  • Musculoskeletal 
    • Inquire about prior injuries and surgeries and if recently post-op, ensure they have reached the milestones in recovery to participate (or refer them back to their surgeon).
    • Perform a brief screening exam for laxity and ROM of each joint.
    • Screening for scoliosis is only recommended for symptomatic patients. 
  • PPE is also an opportunity to screen for mental health disorders including depression, anxiety, and suicidal ideation. 
    • Asking about menses in female athletes is important, especially in endurance athletes.
      • Amenorrhea in female athletes portends risk of osteoporosis.
  • PPE can also serve as an opportunity to discuss basic nutrition and diet. 
    • Eating disorders are also common in athletes and eating habits should be explored, especially in underweight endurance athletes.

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