Preparticipation Physical Examination

By admin Last updated Mar 23, 2024

Ovid: OSE Sports Medicine

Editors: Schepsis, Anthony A.; Busconi, Brian D.

Title: OSE Sports Medicine, 1st Edition

> Table of Contents > Section I – Special Issues > 2 – Preparticipation Physical Examination

Preparticipation Physical Examination

Vasilios Chrisostomidis

Brian D. Busconi

J. Herbert Stevenson

Thirty-five million children and young adults
participate in organized sports in the United States. There are 3.5
million injuries per year as a result. The preparticipation physical
examination (PPE) is designed to be specific for athletic endeavors.
Sporting events create specific concerns of which physicians need to be
aware. Different sports create different injuries that medical
personnel must be prepared to treat; for example, in football, trauma
is more common when compared with cross-country running, in which
overuse injuries are more common. The PPE will vary from a focused exam
to an extensive workup depending on the sport, strenuousness of
activity, or level of competition.

Nurse practitioners, physician assistants, and
physicians may perform the PPE. Primary care physicians should consult
specialty physicians when a problem requires further expertise.
Conversely, when specialists perform screening examinations, they
should contact a generalist regarding issues outside of their expertise.

OBJECTIVES

The primary goal of the PPE is to make sure that
athletes are safe—to ensure the patient’s health rather than to
disqualify athletes. The examiner has a chance to detect current
injuries that may require rehabilitation prior to the season beginning.
In addition, the physician has the opportunity to detect
life-threatening conditions that may preclude a person from
participating in certain or all athletics. The PPE also addresses legal
and insurance requirements, as well as fulfilling many schools’
requirements. Finally, it gives the physician the chance to develop a
rapport with the athlete.

TIMING

Ideally, the PPE should be performed 6 weeks prior to
preseason practice. This time interval allows for the diagnosis and
treatment of potential problems before the beginning of the season.
Appropriate rehabilitative plans may be instituted with the goal of
returning the athlete to his or her sport and having missed no
practices or game time. Because scheduling the PPE in the midsummer may
be difficult, one may consider performing evaluations at the end of the
preceding school year. The responsibility of reporting injuries or
illnesses that occur in the time between the PPE and start of the
season falls on the athlete. This information may then be relayed to
the athletic trainer or directly to the team physician.

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FORMAT

Office-based PPE

The office-based PPE is performed in a private setting
during a time that is convenient for both the patient and the health
care provider. One person does the entire physical examination in
contrast to the station-based examination, which requires multiple
examiners. This has the advantage of maintaining continuity of care for
the patient since it is performed by the athlete’s personal or primary
care physician in the office setting. There is added benefit if the
physician already knows the patient because medical records are
complete and the risk of “abnormalities falling through the cracks”
decreases. In addition, athletes may feel more comfortable discussing
sensitive issues, such as alcohol and drug use, birth control, and
sexually transmitted diseases.

There are some disadvantages to the office-based
approach, including increased cost to the athlete and availability of
appointments. The large influx of patients in a fixed amount of time
may overwhelm an already busy office practice.

Station-based PPE

This format consists of a series of “stations,” each one
devoted to a single part of the history or physical examination. The
patients proceed in a stepwise fashion from one station to the next
until all are completed. At checkout, the entire file is reviewed to
make sure all appropriate information has been obtained, as well as to
determine medical clearance.

The advantage to this system is that a large number of
people may be screened in a relatively short period of time since there
are multiple stations with multiple physicians. The disadvantages of
this include a lack of privacy and fragmented care. Additionally, this
requires a large number of trained medical providers to man the various
stations.

Single Physician Assembly Line

This consists of multiple medical providers who perform
the complete exam, often in the training room or locker room. This
defrays some of the cost that is incurred when an athlete has to go to
a physician’s private office. This may be more personal to the athlete
since one physician performs all the components of the PPE. A major
disadvantage includes not having sufficient personnel trained to
perform the complete exam.

MEDICAL HISTORY

In a PPE, the history plays a predominant role. A
complete history can usually identify 60% to 75% of the problems
affecting a patient. The history provides details regarding health
problems and injuries, allowing the physician to focus on problem
areas. A standard questionnaire may be used with further investigation
during the assessment.

Recent or Chronic Injury or Illness

It is important that the physician is aware of any injuries that have occurred recently.
This also helps stimulate the athlete’s memory so that a complete history can be done.

Hospitalizations and Surgeries

Questions about recent medical care will
alert the physician to previous serious medical problems, as well as
assess if current medical or surgical problems are properly being cared
for.
Athletes who have had recent surgery will need appropriate review of results and status of any rehabilitation if indicated.

Medications

An athlete’s medication list allows the
doctor to determine if chronic medical problems are being managed
appropriately (anticonvulsants, insulin, asthma, and cardiovascular
agents). More importantly, coaches and trainers may be alerted to
potential adverse effects and drug interactions.
Asking specifically about
over-the-counter (OTC) drug use is important because of its high
prevalence. Organizing bodies, including the National Collegiate
Athletic Association (NCAA) and the International Olympic Committee,
restrict many common OTC medications.
It is crucial to ask about nutritional
supplement use, including vitamins, protein supplements, amino acids,
as well as the use of ergogenic aids, such as anabolic steroids.

Allergies

Any allergic reactions to medications
should be recorded, and care should be given to make sure they are not
inadvertently administered to the patient.
Any reaction to insect bites or stings should be noted so that appropriate medications are available (subcutaneous epinephrine).
Any history of exercise-induced urticaria or anaphylaxis should be noted and prepared for.
Ultimately, it is the athlete who is
responsible for being prepared with allergy medications, though
trainers or physicians may choose to carry them as well.

Cardiovascular

Most sudden deaths in athletes under the
age of 30 are due to a structural defect in the heart. A careful
history should be taken to uncover those at risk.
- A history of syncope or presyncope might be a clue to hypertrophic cardiomyopathy, dysrhythmias, or valve problems.
- Chest pain with activity could be a sign of atherosclerotic disease (unusual under the age of 30).
- Shortness of breath with exertion may indicate valvular
  
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  problems, structural disease, or pulmonary disease.
- Palpitations may signify dysrhythmias or conduction abnormalities.
- For these problems, one may want to conduct further tests prior to clearance.
A history of heart murmur or elevated
blood pressure should alert the physician to a possible cardiac problem
and may also require further evaluation.
- Some cardiac problems are familial, so a careful family history should be obtained from the patient.
- Any patient who was denied clearance previously for a cardiac issue should be thoroughly investigated prior to clearance.
Any history of anabolic steroid or
illicit drug use, particularly cocaine, may damage the heart and
increase the risk of sudden cardiac death in athletes.

Skin

Infectious dermatologic conditions—such
as impetigo, herpes simplex, and molluscum contagiosum—are some of the
primary concerns during review of an athlete’s dermatologic history.
This is especially important in contact sports or in sports where
spread of an infection is possible through a fomite such as a mat or
helmet.
It is also important to note acne because it may be exacerbated from equipment.
The physician should take a moment to emphasize the importance of sunblock for athletes who play outdoor sports.

Neurologic

Any history of head injury, seizures, concussions, burners/stingers, or “pinched nerves” requires further scrutiny.
- It is important to note whether symptoms occur with exertion or from trauma.
- Any history of loss of consciousness,
  significant concussion, or repetitive concussion should prompt further
  inquiry, including the number of episodes, loss of memory, and length
  of full recovery.
- If the patient is still experiencing
  symptoms, one should consider a referral to a neurologist or someone
  skilled in caring for such athletes.
Burners/stingers occur as a result of
trauma to the brachial plexus or cervical nerve roots and may present
as unilateral numbness or tingling that may persist for several minutes
(but rarely permanently).
- A proper history should include the
  number of episodes and what has been done for treatment until the
  present. Athletes with such a history should be referred to coaches or
  athletic trainers for instruction on neck and upper extremity
  strengthening, protective equipment, and instruction of proper
  technique in tackling.
Cervical spinal cord neurapraxia with transient quadriplegia is an uncommon entity that may result from trauma.
- Usually, the patient will complain of burning pain, numbness or tingling, and weakness or paralysis of all four extremities.
- Recovery is usually within 15 minutes, although some cases gradually resolve over 36 to 48 hours.
Positive findings in the history may
direct further testing—such as radiographs or magnetic resonance
imaging (MRI)—to rule out instability or other anatomical problems
prior to clearance.

Heat Illness

Heat-related disorders represent a
spectrum of disease ranging from exercise-associated cramps to heat
exhaustion to heat stroke.
Often, heat illness is recurrent, so a detailed history may be helpful in preventing it in the future.
Certain substances, such as caffeine, methylphenidate, or antihistamines, may predispose to heat illness.
Pre- and postexercise weights are helpful to determine hydration status and help with pre-event hydration.
Proper acclimatization is important in preventing heat illness and should be stressed to athletes.

Pulmonary

Exercise-induced asthma is a commonly overlooked diagnosis, and an attempt should be made to identify it at the PPE.
Athletes will often describe feeling
“winded” or “out of shape,” despite appropriate training. Some will
complain of chest tightness or obvious wheezing. These symptoms may be
related to cold weather or seasonal allergies.
Treatment with albuterol prior to athletic activity will relieve many of these athletes’ symptoms.
One may consider formal pulmonary function or preand postexercise peak flow testing to make the diagnosis.

Eyes and Vision

It is important for the physician to be aware of any eye injuries or surgeries that an athlete has had in the past.
If an athlete wears glasses, one must ensure that the frames and lenses are safe for use in competition.
It is important to assess if any athletes
are “functionally one-eyed” (as determined by the American Academy of
Ophthalmology) because their best-corrected vision is less than 20/40
in one eye.
Anisocoria should be documented so a baseline of pupillary size is documented in case of head injury.

Musculoskeletal

The musculoskeletal history should focus
on injuries to muscles, bones, or ligaments and, as such, they should
be recorded by the physician. This includes fractures, dislocations,
instability, subluxations, sprains, or strains.
Treatments including physical therapy, braces, and surgery

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should be reviewed with the athlete, and plans for rehabilitation (if necessary) should be instituted.
If the athlete has any current complaints
or injuries, a thorough workup may be instituted immediately, including
radiographs and lab work as the physician sees fit.

Gastrointestinal

A history of mononucleosis is an
important piece of information since the athlete is at increased risk
of splenic rupture in the time following diagnosis.
Any history of vomiting or diarrhea may put an athlete at risk for heat illness.

Genitourinary

A testicular exam should be performed on
male athletes, and time should be taken to instruct patients on the
self-testicular exam for screening of testicular cancer.
- Absence of one testicle, undescended testes, and inguinal hernias may be detected on examination.
The female genitourinary exam is not
performed routinely as part of the PPE and, if warranted, it should be
conducted in a private setting.
The use of Tanner staging reflects skeletal maturity but is not recommended as a routine part of the PPE.

Protective Devices

A special pad or brace will alert the
physician to any problems that the athlete may have forgotten to
mention. Examples include a special neck roll for an athlete who has
experienced multiple brachial plexus injuries in the past or a knee
brace to protect against a previous knee injury.
Athletes should wear a mouth guard if they have orthodontia, whether or not it is required by their sport.

Eating Disorders

Because of the prevalence of eating
disorders and their impact on the athlete’s health, it is important to
determine if an athlete is exhibiting any signs of disordered eating.
This refers to any unhealthy behavior resulting in calorie deprivation,
whether it is through poor food choices, self-induced vomiting, or use
of laxatives or diuretics.
- Females are more likely to engage in such behaviors.
Disordered eating is often more common in
sports with weight classes, such as wrestling or rowing, or sports in
which leanness is emphasized, such as in track and field or gymnastics.
A nonthreatening way to ascertain
information about the presence of an eating disorder is to ask an
athlete, “How much would you like to weigh?” or “Are you happy with
your weight?”
It is important to determine whether the athlete has lost any weight and, if so, whether it was accidental or intentional.
The physician should look for any signs
of bulimia or anorexia, including skin changes, oral ulcerations, and
decreased tooth enamel.
Asking about any history of stress
fractures, menstrual irregularity, and excessive exercise habits may
alert the doctor to the “female triad” (amenorrhea, osteopenia, and
disordered eating).
Disordered eating can be a difficult
problem and often requires a multifaceted approach—including referral
to a nutritionist or dietitian, psychologist, and primary care
physician—if feasible. It is important to provide an ideal weight range
and close follow-up.

Psychosocial Concerns

The use of drugs and other illicit substances, such as ergogenic aids, is prevalent in the United States.
Alcohol intake is rampant across college
campuses, as well as in high schools. The PPE is an opportunity to
explain the potential adverse effects of alcohol on the body, as well
as its impact on athletic performance.
Smokeless tobacco is the most commonly
used tobacco product by athletes, particularly in baseball players. It
is known to cause oral neoplasms, among other mouth disorders.
- The NCAA has banned the use of tobacco by game personnel, as well as student athletes.
- The United States Olympic Committee (USOC) has not banned it because tobacco use provides no competitive advantage.
Illicit drugs such as cocaine or
marijuana are illegal, as well as harmful to the athlete. They do not
aid athletic performance. Intravenous drug use exposes the athlete to
diseases such as hepatitis and human immunodeficiency virus (HIV).
Performance-enhancing agents are a major
concern in competition and often have hazardous side effects. The PPE
provides an opportunity for the physician to discuss such issues.
Anabolic steroids, such as testosterone, may be ingested orally or intravenously and are used to gain an advantage.
- Side effects include liver disease, testicular atrophy, gynecomastia, menstrual irregularities, and sudden cardiac death.
- The NCAA, USOC, and various other organizations ban these supplements.
Nutritional supplements are used to
increase energy stores and decrease fatigue. These include, but are not
limited to, vitamins, minerals, amino acids, and electrolyte solutions.

Immunizations

Vaccinations are an important health care
maintenance issue that can be addressed at the PPE. Although delinquent
immunizations are not grounds for disqualification, they do allow the
physician to set up appropriate follow-up.
Most schools have certain immunization requirements that must be met before the student may matriculate.

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The Centers for Disease Control and Prevention can be accessed to provide a recommended vaccination schedule.

Menstrual History

For female athletes, a detailed menstrual history should be obtained regarding amenorrhea or oligomenorrhea.
Amenorrhea may be described as primary (absence of menarche by age 16) or secondary
(missing three consecutive periods in a previously menstruating
female). Either may require a referral to the primary care physician or
gynecologist.
Although irregular menses is not uncommon
in athletes, irregular menses or amenorrhea may be due to an underlying
eating disorder.
- One should rule out pregnancy prior to
  attributing this condition to poor nutrition or excessive exercise, as
  seen in the female triad.
This is also an opportunity for health
care maintenance regarding self-breast examination, Papanicolaou
testing, and a frank discussion regarding prevention of transmission of
sexually transmitted diseases, as well as the prevention of unwanted
pregnancies.

PHYSICAL EXAMINATION

A variety of PPE forms are available on the Internet, or use of an institutional or statewide form may be required.

General

Recording the height and weight of an individual may help determine if there are any underweight or overweight athletes.
- Underweight individuals may be questioned about eating habits or recent weight loss.
- Those who are overweight may be counseled on a proper diet and exercise routine.
One may consider body fat analysis as
part of the PPE, though it must be cautioned that it is sometimes
difficult to determine what the ideal body fat is for every athlete in
a given sport.

Head, Eyes, Ears, Nose, and Throat

Examination of the head, eyes, ears, nose, and throat may begin with testing of visual acuity using a standard Snellen chart.
- Vision should be at least 20/40 in each eye.
- Appropriate eye protection should be worn if the athlete has any history of significant eye trauma or surgery.
Anisocoria (asymmetry of pupil size)
should be documented so there is a baseline for the athlete. This may
become important in the event of head injury.
- Make sure that this information is readily available to the entire training staff.
The rest of the examination is to
evaluate for pathology in the athlete, including—but not limited to—a
deviated nasal septum, a perforated or scarred tympanic membrane, oral
ulcers, or decreased enamel as seen in bulimia.

Cardiovascular

Examination of the heart should begin with obtaining a blood pressure reading from the athlete.
- It is important to use the appropriately sized blood pressure cuff, and multiple readings may be required.
- If blood pressure remains elevated,
  despite multiple readings, one should refer the athlete to his or her
  primary care physician, as well as discuss the use of stimulants such
  as caffeine or nicotine that may contribute to elevated blood pressure.
  This is not necessarily grounds for restricting athletic participation,
  however.
Auscultation of the athlete’s heart
should occur in the sitting and supine position listening for any
murmurs, irregular heartbeats, or extra heart sounds (S3 or S4).
Various maneuvers can be performed to clarify the murmur type.
- Special attention should be paid to the
  murmur of hypertrophic cardiomyopathy because it is the most common
  cause of sudden cardiac death in the United States among young
  athletes. This murmur will decrease in intensity with squatting (as
  venous outflow decreases) and will increase in intensity on standing or
  if the athlete does an abdominal “crunch” (increased outflow
  obstruction).
- Systolic murmurs grade 3/6 in severity or
  greater, all diastolic murmurs, and any murmur that increases in
  intensity with Valsalva should be evaluated further before clearance
  with an electrocardiogram, echocardiogram, and exercise stress test.
If any other testing is required, one should consider referral to a cardiologist.

Pulmonary

The pulmonary exam should focus on good air movement with clear lung fields.
Findings such as crackles, rhonchi, and wheezes are pathologic and may require further workup or treatment.
Exercise-induced asthma may not be evident on physical examination.

Abdomen

Examination of the abdomen is done with the athlete supine and relaxed.
Abdominal masses, organomegaly, and abdominal pain may require further workup prior to clearance.
Rarely may an abnormal kidney be palpated on examination.

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Genitourinary

Palpation of the male genitalia should reveal two descended testicles.
- Any testicular masses, hernias, or irregularities should be noted.
- Absence of a testicle or presence of an
  undescended testicle requires counseling because there is an increased
  risk of testicular loss due to contact sports that is reduced, but not
  removed, with the use of a protective cup.
The self-testicular exam should be
described and performed monthly because young males are at increased
risk for testicular cancer. If there are any questions, the patient may
be referred to his primary care physician.
The female genitourinary exam is not routinely done in the PPE.

Dermatologic

The skin should be examined for any signs
of contagious infection, including herpes simplex, fungal infections,
carbuncles, impetigo, and scabies that may preclude participation.
Suspicious nevi should be noted and referred for removal.

Musculoskeletal

The goal of the musculoskeletal
examination is to determine whether an athlete has any strength
deficits, atrophy, or instability that may require rehabilitation or
preclude the athlete from participation.
The type of examination depends on both the examiner and the athlete.
- If the athlete is asymptomatic and denies
  any previous injury, it may be reasonable to perform a generalized
  musculoskeletal screening examination.
- If the athlete has a current problem or previous injury, it may be prudent to perform a joint-specific examination.
- History alone is 92% sensitive in detecting significant musculoskeletal injuries.

Generalized Examination

The generalized exam can quickly assess instability, range of motion, and strength.
The exam should begin with inspection of the athlete while he or she faces the physician. Ask him or her to do the following:
- Move the neck in flexion, extension, rotation, and side-bending.
- Shrug the shoulders against resistance from the physician (trapezius strength).
- Move the shoulders in internal and external rotation (range of motion).
- Flex and extend the elbow.
- Pronate and supinate the elbow (range of motion).
- Clench the fist and spread the fingers (range of motion).
Next, ask the athlete to turn and face the other direction, away from you.
- Check back extension (spondylolysis), flexion, rotation, and side-bending (range of motion).
- Assess the lower extremities for alignment and symmetry.
- Ask him or her to “duck walk” for four steps and assess the motion of the hip, knee, and ankle.
- Finally, ask the athlete to stand on his or her toes and then the heels (calves).
Any abnormalities on this exam should prompt a joint-specific exam of the area in question.
- The joint-specific exam requires more
  time and expertise, though it does give the physician more information
  than the generalized musculoskeletal exam.
- There is no evidence that this examination has a higher yield in the asymptomatic athlete than the general screen.

Complete Examination

The complete examination includes
inspection and range-of-motion testing of the spine, neck, shoulders,
elbows, wrist, hands, hips, knees, ankles, and feet. Appearance and
symmetry should be noted.
The examination should be done in a stepwise fashion in the same order every time so that no part of the exam is omitted.

Spine

Note alignment and test for range of
motion in flexion, extension, rotation, and side-bending, noting any
asymmetry or complaint of pain.
Evaluate the thoracolumbar spine for kyphosis/scoliosis and evaluate the scapulae for any asymmetry.
Finally, check range of motion in
flexion, extension, side-bending, and rotation of the lumbar spine.
Note any increase or decrease in lumbar lordosis.

Lower Extremity

Examination of the lower extremity begins with the hip exam.
- Inspect the athlete while standing, noting the level of the iliac crests bilaterally.
- Have the athlete lie down and evaluate flexion and internal and external rotation of the hip.
The knee exam begins with inspection, followed by palpation for any effusion, ecchymosis, contusion, or deformity.
- The normal knee range of motion is 0 to 140 degrees; any decrease may be an indication of underlying pathology.
- The ligamentous exam is often performed next to assess stability of the knee.
Place the patient’s knee in 20 degrees of
flexion and stabilize the femur with one hand as the other pulls the
tibia anteriorly. Compare the injured side to the unaffected side for
excessive anterior motion, as well as presence of a firm “end point.”
This is the Lachman test, and when performed properly, it is very sensitive and specific for injury to the anterior cruciate ligament.

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To evaluate the medial and lateral
collateral ligaments, place the knee in 20 to 30 degrees of flexion and
apply a valgus stress (to evaluate the medial collateral ligament) and
a varus stress (to evaluate the lateral collateral ligament). Assess
for pain or laxity with this testing. Once again, it is important to
compare the affected side with the unaffected side.
The anterior and posterior drawer tests are used to evaluate the anterior collateral ligament and the posterior cruciate ligament, respectively.
Bend the athlete’s knee to 90 degrees,
and then sit on the patient’s foot. Place your hands on the tibial
plateau and push posteriorly (posterior drawer test) and pull
anteriorly (anterior drawer test), looking for excessive motion or no
firm end point.
While the knee is bent at 90 degrees and
the foot flat on the table, check for joint-line tenderness both
medially and laterally. The McMurray test
is a very sensitive and specific test for meniscal tears. If there is a
pain or a pop felt along the joint line, there may be a tear of the
respective meniscus.
Examination of the ankle involves inspection while the athlete is standing and sitting.
- Palpation of any effusion or tenderness may be indicative of underlying injury.
- Strength, dorsiflexion (20 degrees), and plantarflexion (40 degrees) should be assessed.
- Ligamentous laxity may be assessed by the
  anterior drawer test (pulling on the heel while stabilizing the tibia
  looking for anterior motion with the foot in 20 degrees of plantar
  flexion) and the talar tilt test (inversion of the calcaneus with
  respect to the tibia). Excessive motion, compared with the other side,
  should trigger further evaluation.
Examination of the feet should focus on
cavus or planus deformity. Either may affect the athlete’s performance
by playing a role in lower extremity overuse problems, such as medial
tibial stress syndrome.
- Other deformities, such as bunions, may become painful in athletic footwear and should be noted.

Upper Extremity

Examination of the upper extremity begins
with inspection of the shoulder, looking for any asymmetry while the
athlete is in the upright position.
- Range of motion in abduction, adduction, flexion, and internal and external rotation should be assessed.
- Strength testing is done in the same planes of motion.
- The rotator cuff is assessed with the aforementioned strength testing, as well as with the empty can test.
  The patient abducts the arms to 90 degrees, flexes them to 30 degrees,
  and points the thumbs downward while actively resisting the physician.
  This specifically isolates the supraspinatus.
- To detect impingement, passively flex (Neer test) and abduct (Hawkins test) the shoulder, which will recreate the patient’s symptoms.
- Laxity in the glenohumeral joint is assessed by pulling the arm inferiorly (sulcus sign) and by the load and shift test for anterior instability, as well as the apprehension and relocation tests.
- Potential labral tears may be assessed by the crank test, as well as the active compression test.

Neurologic

A detailed neurologic exam is required in athletes with a history of burners/stingers, herniated disc, or concussions.
Testing involves evaluation of strength in the upper or lower extremities and evaluation of deep tendon reflexes.
In addition, the cranial nerves and
cerebellar and cognitive function should be tested if there is a
history of head injury. Abnormalities may warrant further workup and a
referral to a neurologist prior to clearance.

LABORATORY INVESTIGATIONS

Laboratory screening is sometimes
performed on certain diseases that are prevalent in a given area. A
high prevalence is necessary for the test to have a good yield, even if
it is highly sensitive and specific.
Urinalysis is sometimes performed on
athletes looking for asymptomatic proteinuria or glucosuria, which
would signify renal or metabolic abnormality, including diabetes.
- This has not been substantiated in any studies, and urinalysis is not currently recommended as part of the PPE.
Hemoglobin and ferritin tests may be
considered as screening tools for anemia. The results may be difficult
to interpret in an athlete, however, particularly if he or she has no
symptoms. For example, the increased plasma volume in athletes falsely
lowers the concentration of hemoglobin, resulting in pseudoanemia. In
addition, the use of ferritin does not necessarily predict who will
develop true anemia, and those who take supplemental iron do not
necessarily see an improvement in performance.
- These tests are therefore not essential parts of the PPE.
Cholesterol screening may be performed in an athlete if there is a significant familial history of hypercholesterolemia.
- It is not routinely recommended in young individuals and, as such, need not be done routinely on the PPE.

SPECIAL TESTING

Sudden cardiac death is an extremely rare
but tragic event with far-reaching ramifications to the medical
community. It often results in unrealistic pressures on the medical
community to detect and prevent these deaths in the future. This is the
reason for such a comprehensive cardiac history and examination in the
athlete.

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- Some have proposed the use of electro-
  and echocardiogram to screen all asymptomatic individuals as part of
  the PPE. However, the use of an electrocardiogram to screen for cardiac
  problems has never been proven useful. In addition, there is a wide
  variability of “normal” electrocardiograms in athletes (“athlete’s
  heart”).
- The use of an echocardiogram may be useful in screening for structural abnormalities but is costprohibitive.
- As such, these tests are recommended only
  if abnormalities are detected in the history or physical examination
  and not as part of the routine PPE.
Asthma may be readily diagnosed with the use of pulmonary function testing (PFT).
- Exercise-induced asthma may not be easily
  assessed with PFTs because they are performed at rest. The physician
  must maintain a high index of suspicion. Exercise PFTs may be performed
  but can usually only be done at large university centers.
- There is currently no evidence that PFTs should be performed routinely as part of the PPE.

CLEARANCE

The physician makes the final decision on whether the athlete may participate in sports.
- He or she may decide that no athletic
  participation is allowed, that the athlete may participate after
  certain conditions are met, or that the athlete may participate in
  athletics. The last category may be further broken down into
  participation in events based on classification by contact or
  strenuousness of the activity.
- Only 0.3% to 1.3% of athletes are denied clearance during the PPE, and only 3.2% to 13.5% require further evaluation.
Classification of sports by contact
allows for risk stratification based on potential for injury.
High-impact collision sports, such as football and ice hockey, have an
increased potential for injury than do low-impact sports, such as
tennis (Box 2-1).
Classification by strenuousness is important for any athlete who may have pulmonary or cardiac diagnoses.
- Sports vary widely in how they stress the athlete’s body.
- They are categorized by the dynamic and
  static demands they place on the athlete. Those with high static or
  dynamic demands may be inappropriate for certain athletes (Box 2-2).
Regardless of the type of evaluation
done, it is important that coaches and trainers understand restrictions
in participation or further workup in the athlete.
- Communication should be maintained with the athlete and his or her parents so that there are no misunderstandings.
- Documentation of clearance or need for
  rehabilitation may be provided using the attached standard PPE form.
  This may then be distributed to the school, as well as to the parents
  of the athletes.

P.28

Cardiovascular abnormalities require an
understanding of the demands of the sport, as well as the risk to the
athlete prior to making a decision on clearance.
- The guidelines established by the 26th
  Bethesda Conference cover the major cardiac abnormalities, including
  mitral valve prolapse, hypertrophic cardiomyopathy, hypertension, and
  dysrhythmias. One should follow these guidelines and, if any further
  questions remain, one should consider a referral to a specialist.
Acute illness may be grounds for temporary disqualification in the athlete.
- Cases should be addressed individually
  based on symptoms. It is important to consider any risk to the
  individual athlete, as well as any risk to any teammates.
- American Academy of Pediatrics guidelines
  disallow participation during febrile illness and with all but mild
  diarrhea. This decreases the risk of dehydration and heat illness.
- One may summarize the decision for
  clearance with the adage, “if symptoms are present from the neck up
  (i.e., sore throat, nasal congestion, mild headache) and there is no fever, then the athlete may participate.”
Bloodborne pathogens are of concern in athletics, especially hepatitis and HIV.
- Hepatitis B virus and hepatitis C virus
  are spread via sexual contact, exposure to blood or blood products, and
  contamination of open wounds or mucous membranes.
There has been one documented case of spread in high school sumo wrestlers in Japan in 1982.
Hepatitis does not have a higher prevalence in athletics.
Infection with hepatitis B virus or
hepatitis C virus should be viewed as any other viral illness. Athletes
may be able to participate, as long as clinical symptoms such as
fatigue and abdominal pain are not interfering. Cases should be
assessed individually.
- HIV is spread in the same manner as hepatitis.
HIV transmission has never been conclusively documented in any sporting activities.
The health status of the individual
should be taken into account prior to clearance. HIV infection alone
does not disqualify an athlete from participation. The type of athletic
activity, strenuousness of activity, and risk of transmission to other
athletes should all be considered.
One must stress that confidentiality should be maintained in all such cases.
Dermatologic conditions—such as herpes simplex, impetigo, or scabies—may preclude participation in certain sports (contact).
- This is especially important in sports
  that require the use of mats, such as gymnastics and wrestling, as well
  as in sports in which equipment is shared, such as baseball.
- Play may resume once the infection has cleared or is no longer contagious.
If pregnancy is suspected, clearance for
collision sports should be withheld pending appropriate testing or
clearance given by the physician after pregnancy.
Ovarian injuries are unlikely in sports, so that a female with only one ovary need not be restricted from activity.
Menstrual disorders are not usually grounds for disqualification and may be further investigated after clearance is granted.
- Amenorrhea should raise the concern for the “female athletic triad,” and a frank discussion regarding
  
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  disordered eating should follow. Athletic activity should be restricted
  if there is evidence of compromised performance, significant weight
  loss, or risk to the athlete. The road to recovery is often a lengthy
  one, requiring multiple disciplines to work in concert.
Functionally, one-eyed athletes (vision
in one eye less than 20/40) should not participate in athletics with a
high risk of eye injury when eye protection cannot be worn. Loss of the
remaining “good eye” from injury can be devastating.
Previous eye surgery or history of retinal detachment requires a referral to an ophthalmologist prior to clearance.
Organomegaly may stem from various causes
and may present a concern in athletes, especially those in contact
sports. It is important to determine what is causing the problem so
that appropriate treatment is instituted.
Hepatomegaly may stem from a neoplasm or
infection, such as mononucleosis. If the liver edge is palpable distal
to the rib cage, it is at increased risk for injury.
- Even though hepatic rupture is rare, the
  athlete with hepatomegaly should not be allowed to participate until it
  has been resolved.
Athletes with splenomegaly may not
participate in athletics because of increased risk of splenic rupture
until it has resolved. This is not limited to contact sports because
there have been reports of splenic rupture while engaged in
nonstrenuous activity.
- The physician may consider the use of
  ultrasound to follow organ size since the physical exam has a low
  sensitivity for detecting organomegaly.
Athletes with a history of heat illness are at greater risk for recurrence.
- The physician must try to determine any
  predisposing factors and keep it from happening again. Repeated
  occurrences may be due to medicines, medical conditions, poor
  acclimatization, or the environment.
- Prevention should focus on appropriate
  hydration throughout activity, proper conditioning, and avoiding
  medications, such as antihistamines or stimulants.
- Clearance may be restricted to participation under temperate conditions.
Diagnosis of an inguinal hernia does not
necessarily disqualify an athlete from athletics. It may intermittently
cause pain and affect performance but is emergent only if it becomes
incarcerated.
- One may consider a surgical referral because the patient will inevitably require treatment in the future.
- Cases should be assessed individually.
An athlete with kidney abnormalities,
such as a solitary kidney, may be at increased risk for rupture in
contact sports. The actual risk is small, but the consequences, such as
transplantation or dialysis, are quite severe.
- One may consider a referral to a
  specialist prior to clearance to make sure the remaining kidney is
  normal and does not show any evidence of hydronephrosis or other
  abnormalities. If the kidney is normal, the athlete should be counseled
  on the risks and then allowed to make his or her own decision in
  conjunction with family members or guardians.
Athletes with the diagnosis of asthma may participate, provided it is well controlled with medication.
- Athletes with poorly controlled asthma
  need to be seen by their primary care physician or pulmonologist and
  have their condition stabilized before participation.
- Exercise-induced asthma may be difficult to assess in the PPE but may be treated with a trial of betaagonist medication.
- If symptoms do not resolve themselves,
  one may consider an exercise test with pulmonary function testing or a
  methacholine challenge to rule out exercise-induced asthma.
Severe pulmonary dysfunction, such as in
an athlete with cystic fibrosis, is justification for referral to a
specialist for further testing prior to clearance.
Testicular disorders, such as a solitary
testicle or undescended testes, do not necessarily disqualify an
athlete. There is no consensus on whether or not an athlete with only
one testicle may participate in contact sports. The actual incidence of
injury resulting in orchiectomy in sporting events is quite low.
- The use of a protective cup, though
  cumbersome and uncomfortable, may decrease risk of injury. Ultimately,
  the risk of injury should be explained to the athlete, who may then
  make the decision on wearing protection.
- Undescended testes should be thoroughly
  evaluated secondary to the increased risk of carcinoma, and decision
  making is similar to that of the athlete with a single testicle.
Commonly, athletes may present with a medical history significant for concussions or burners/stingers.
- Athletes with burners/stingers may be
  cleared if they are currently asymptomatic and there are no
  abnormalities on physical examination.
- Consider cervical spine radiographs to
  evaluate for instability or an MRI to evaluate for spinal stenosis if
  the burners/stingers are recurrent.
- Use of protective padding may be instituted.
- If the athlete has a history of
  neurapraxia with transient quadriplegia, consider referral to a
  specialist to rule out structural abnormalities. If there are
  structural abnormalities, the athlete should not participate in contact
  sports. Cases should be individually assessed.
Concussions occur an estimated 250,000 times per year in football alone.
- A generally accepted and clinically useful definition is a traumatically induced alteration in mental status.
- Classification and severity of concussion
  are rated by various systems, but there is no universally accepted
  system on concussion grading, as well as return to play.
- The concern in allowing a player with a
  concussion to return to play is termed “second impact syndrome.” This
  syndrome refers to the catastrophic results,
  
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  including
  elevated intracranial pressure and brain swelling, that may occur when
  a player with a concussion injuries his brain again.
- Players may return to play once their
  neurologic symptoms have subjectively resolved, there are no deficits
  on physical or neurological examination, and physical exertion does not
  cause a relapse in symptoms.
- In an athlete with a history of multiple concussions, one may consider a referral to a neurologist prior to clearance.
There is very little literature regarding risk of participation for athletes with convulsive disorders.
- In those with poorly controlled seizure
  disorders, clearance should be withheld for contact sports or any
  sports that are potentially hazardous to the athlete (e.g., scuba
  diving and motor racing) until appropriate medications are administered.
Referral to a neurologist for further testing and treatment of uncontrolled seizures should be considered.
Athletes may compete in athletics that pose no risk to themselves or others.
- In athletes who have well-controlled convulsive disorders, clearance may be granted for participation in all types of athletics.
  - If there are any concerns, or the athlete competes in a high-risk sport, consider referral to a specialist for further testing.
  - Determination of clearance for those with
    musculoskeletal injuries requires evaluating multiple factors but is
    often dependent on determining that the joint has full range of motion,
    is stable, and has near full strength (>85% to 90%).
- Clearance also hinges on the type of injury, as well as the sport that the athlete is involved in.
- Protective padding or taping may protect the athlete while allowing him or her to compete.
- If the athlete has an injury that does
  not allow him or her to compete safely, clearance should not be granted
  until appropriate measures are taken.
- Important factors to assess for on
  examination when dealing with sprains, strains, subluxations, and
  overuse injuries include the presence of an effusion, decreased range
  of motion, decreased strength (<85% when compared with the
  unaffected side), ligamentous instability, and inability to complete
  functional testing. If these are present, one should consider further
  testing or a referral to a specialist prior to clearance for athletic
  activity.

BOX 2-1 CLASSIFICATION OF SPORTS BY CONTACT

Contact/Collision

Basketball
Boxing
Diving
Field hockey
Football (tackle, flag)
Ice hockey
Lacrosse
Martial arts
Rodeo
Rugby
Ski jumping
Soccer
Team handball
Water polo
Wrestling

Limited Contact

Baseball
Bicycling
Cheerleading
Canoeing/kayaking (white water)
Fencing
Field events (high jump, pole vault)
Floor hockey
Gymnastics
Handball
Horseback riding
Racquetball
Skating (ice, inline, roller)
Skiing (cross-country, downhill, water)
Softball
Squash
Ultimate Frisbee
Volleyball
Windsurfing/surfing

Noncontact

Archery
Badminton
Bodybuilding
Bowling
Canoeing/kayaking (flat water)
Crew/rowing
Curling
Dancing
Field events (discus, javelin, shot put)
Golf
Orienteering
Power lifting
Race walking
Riflery
Rope jumping
Sailing
Scuba diving
Strength training
Swimming
Table tennis
Tennis
Track
Weightlifting

Modified from the American Academy of Pediatrics. Medical conditions and sports. Pediatrics 1994;94:492-493.

BOX 2-2 CLASSIFICATION OF SPORTS BY STRENUOUSNESS

High-to-moderate Dynamic and Static Demands

Boxing
Crew/rowing
Cross-country skiing
Cycling
Downhill skiing
Fencing
Football
Ice hockey
Rugby
Running (sprinting)
Speed skating
Water polo
Wrestling

High-to-moderate Dynamic and Low Static Demands

Badminton
Baseball
Basketball
Field hockey
Lacrosse
Orienteering
Table tennis
Race walking
Racquetball
Soccer
Squash
Swimming
Tennis
Volleyball

Low Dynamic and High-to-moderate Static Demands

Archery
Auto racing
Diving
Equestrian events
Field events (jumping, throwing)
Gymnastics
Karate or judo
Motorcycling
Rodeo
Sailing
Ski jumping
Water skiing
Weight lifting

Low Dynamic and Static Demands

Bowling
Cricket
Curling
Golf
Riflery

Modified from the American Academy of Pediatrics. Medical conditions and sports. Pediatrics 1994;94:492-493.)

MEDICOLEGAL ISSUES

The issue of clearance for participation in athletics is not uncommon.
When an athlete is not cleared for
participation in a certain sport, he or she may seek a second opinion
in hopes of gaining clearance for their desired sport.
Under the Rehabilitation Act of 1973 and
the Americans with Disabilities Act of 1990, the athlete may have the
right to participate against medical advice.
If the physician is contemplating
disqualification of an athlete, it may be prudent to consider a
referral to a specialist to determine risk of injury.
- Such information should be passed along
  to the athlete and his or her parents/guardians. It is important to
  document clearly such discussions.
If, despite the risks, the athlete
decides to participate against medical advice, one may consider having
the athlete or guardian sign an exculpatory waiver to indicate clearly
that the risk has been explained and that the athlete still wishes to
compete.
- In such a document, the athlete promises not to sue the physician or school, thereby releasing them from liability.
- A concern with this course of action is
  that the validity of such a document may vary from state to state, and
  some wonder whether this will actually protect the physician or
  institution from lawsuits.
- Cases should be handled individually; consider legal counsel based on the circumstances of the case.
There have been allegations of sexual improprieties against providers while performing the PPE.
- The greatest risk of such claims appears to come from the mass station-based format.
- In addition, athletes may not expect a
  thorough examination during the PPE. The physician should explain the
  extent of the examination, supply an appropriate environment, and use
  discretion.
- Consider the use of chaperones in appropriate circumstances.
- Consistency in the exam is important, as well as in attire of the athletes.
- The use of common sense should protect the physician from such accusations.
The liability of providers performing the PPE on a volunteer basis has received increased scrutiny.
- Some states have taken measures to protect volunteer examiners under “Good Samaritan” statutes.
- Physicians need to be aware of their state’s laws and proceed accordingly.
- To be protected under such statutes, the physician may not receive money or services in exchange for their time.