Preparticipation Physical Examination

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.
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.
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.

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
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.
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
  • Athletes who have had recent surgery will need appropriate review of results and status of any rehabilitation if indicated.
  • 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.
  • 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.
  • 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


      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.
  • 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
  • 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.
  • 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.
  • 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.
  • 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


    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.
  • 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.
  • 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.
  • 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.
  • P.24
  • 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
  • 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
A variety of PPE forms are available on the Internet, or use of an institutional or statewide form may be required.
  • 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.
  • 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,
  • 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
    • 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.
  • 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.
  • 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.

  • 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.
  • 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.
  • 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.
  • 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.
  • P.26
  • 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.
  • 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 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.
  • 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

    • 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
    • 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.
  • 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


      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
    • 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,


      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
  • 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
    • 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
    • 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.
Academy of Pediatrics, American Academy of Ophthalmology. Protective
eyewear for young athletes. Pediatrics 1996;98: 311-313.
Academy of Pediatrics, Committee on Sports Medicine and Fitness.
Medical conditions affecting sports participation. Pediatrics
Bethesda conference: recommendations for determining eligibility for
competition in athletes with cardiovascular abnormalities. January 6-7,
1994. Med Sci Sports Exerc 1994;26(suppl): S223-S283.
DJ, Broekhoff J. Maturity assessment: a viable preventive measure
against physical and psychological insult to the young athlete? Phys
Sportsmed 1987;15:67-80.
Calabrese LH, LaPerriere A. Human immunodeficiency virus infection, exercise and athletics. Sports Med 1993;15:6-13.
Cantu RC. Guidelines for return to contact sports after a cerebral concussion. Phys Sportsmed 1986;14:75-83.

Cantu RC, Voy R. Second impact syndrome: a risk in any contact sport. Phys Sportsmed 1995;23:27-34.
DiFiori JP. Overuse injuries in children and adolescents. Phys Sportsmed 1999;27:75-89.
Dorsen PJ. Should athletes with one eye, kidney or testicle play contact sports? Phys Sportsmed 1986;14:130-138.
SE, Glover ED, Schroeder KL. The effects of smokeless tobacco on heart
rate and neuromuscular reactivity in athletes and nonathletes. Phys
Sportsmed 1987;15:141-147.
RA, Colvin E, Oh MK. Echocardiographic screening as part of a
preparticipation examination. Clin J Sport Med 1993;3: 149-152.
RA, La Russa J, Wang-Dohlman A, et al. Screening adolescent athletes
for exercise-induced asthma. Clin J Sport Med 1996; 6:119-123.
GS, Adelman S. Myocardial infarction associated with anabolic steroid
use in a previously healthy 37-year-old weight lifter. Am Heart J
Gallup EM. Law and the Team Physician. Champaign, IL: Human Kinetics Books, 1995:76-77, 80-81.
JE, Landry GL, Bernhardt DT. Critical evaluation of the 2-minute
orthopedic screening examination. Am J Dis Child 1993; 147:1109-1113.
DL. Professional considerations related to the conduct of
preparticipation examinations. Sports Med Stand Malpract Rep 1994;
6:33, 35-36, 49, 51-52.
S, Hayashi J, Ikematsu H, et al. An outbreak of hepatitis B in members
of a high school sumo-wrestling club. JAMA 1982;248: 213-214.
JP, Nichols JS, Filley CM, et al. Concussion in sports: guidelines for
the prevention of catastrophic outcome. JAMA 1991;266: 2867-2869.
CW, DuRant RH, Seklecki RM, et al. Preparticipation health screening of
young athletes: results of 1268 examinations. Am J Sports Med
SA, Henderson JM, Hunter SC. What conditions limit sports
participation? Experience with 10,540 athletes. Phys Sportsmed
BJ, Bodison SA, Wesley YE, et al. Results of screening a large group of
intercollegiate competitive athletes for cardiovascular disease. J Am
Coll Cardiol 1987;10:1214-1221.
McKeag DB. Preseason physical examination for the prevention of sports injuries. Sports Med 1985;2:413-431.
Peggs JF, Reinhardt RW, O’Brien JM. Proteinuria in adolescent sports physical examinations. J Fam Pract 1986;22:80-81.
NT, Guill MF, Brudno DS. Unrecognized exercise-induced bronchospasm in
adolescent athletes. Am J Dis Child 1992;146: 941-944.
Sallis RE, Jones K, Knopp W. Burners: offensive strategy for an underreported injury. Phys Sportsmed 1992;20:47-55.
Smith DM, Kovan JR, Rich BSE, et al. Preparticipation Physical Evaluation, ed. 2. Minneapolis: McGraw-Hill, 1997.
Squire DL. Eating disorders. In: Mellion MB, ed. Sports Medicine Secrets. Philadelphia: Hanley and Belfus, Inc, 1993:136-141.
Tanner SM. Preparticipation examination targeted for the female athlete. Clin Sports Med 1994;13:337-353.
WC III, Lombardo JA. Preparticipation screening of college athletes:
value of the complete blood cell count. Phys Sportsmed 1990;18:106-118.
Torg JS, Glasgow SG. Criteria for return to contact activities following cervical spine injury. Clin J Sport Med 1991;1:12-26.
Camp SP. Sudden death in athletes. In: Grana WA, Lombardo JA, eds.
Advances in Sports Medicine and Fitness. Chicago: Year Book Medical
Publishers, 1988:121-142.

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