Each year millions of children, youth, and young adults participate in organized sports and are required by state and local school districts to have a preparticipation physical evaluation (PPE). Rare high-profile cases of death and serious injury on the playing field, usually among college and professional athletes, keep concerns about the risks of sports participation in the public eye.
The overall goal of the PPE is to ensure safe participation in an appropriate physical activity and not to restrict participation unnecessarily. Whether athletes receive the PPE in the context of an ongoing primary care relationship or as a focused preseason checkup, the following goals of the evaluation are universal:
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To identify conditions that may interfere with a person’s ability to participate in a sport
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To identify health problems that increase the risk of injury or death during sports participation
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To help select an appropriate sport for a person’s particular abilities and physical status
Sports and disciplined physical effort enhance fitness and coordination, increase self-esteem, and provide positive social experiences for participants, including individuals with physical and intellectual disabilities ( Box 24.1 ). Few children and youth have conditions that might limit participation, and most of these conditions are known before the PPE takes place (see Clinical Pearls, “Atlantoaxial Instability” and “Hypertension in the Pediatric and Adolescent Athlete” ).
The Special Olympics offers an opportunity for year-round sports training and athletic competition to approximately 2.5 million individuals with intellectual disabilities ( www.specialolympics.org ). The official sports include aquatics, track and field, basketball, golf, gymnastics, softball, tennis, and volleyball, among others. Participants must be at least 8 years old. A preparticipation physical evaluation (PPE) is required for admission to the program.
The healthcare provider should not restrict participation based on a patient’s intellectual disability alone. The thorough PPE outlined in this chapter should guide decisions about sports participation clearance, as it does for nondisabled patients. Past experience indicates there is some risk of eye injury in badminton, basketball, floor hockey, handball, soccer, softball, and tennis. An increased risk for those with atlantoaxial instability is associated with alpine skiing, diving, equestrian sports, gymnastics, high jump, soccer, and swimming.
The same care is due for persons seeking to join in the Paralympic Games, an opportunity offered by a different organizing group for athletes with a physical disability of a serious nature, such as amputation, cerebral palsy, spinal cord impairment, or visual impairment. These athletes, however, need not have intellectual disability.
Compared with nonparticipants, Special Olympics participants have demonstrated higher self-esteem and greater perceived physical competence and peer acceptance. Parents of child participants perceive better socialization skills and life satisfaction. Considering the physical, emotional, and social benefits of sports participation and physical activity, the American Academy of Pediatrics Council on Children with Disabilities urges pediatric healthcare providers to promote participation of children with disabilities. Clinicians should help individuals and families overcome barriers to participation and become aware of resources like Special Olympics and the National Center on Physical Activity and Disability ( Murphy et al, 2008 ).
Ideally the PPE occurs in the office of a healthcare provider with whom the individual has a longitudinal relationship and knows the patient’s medical, social, and family history. The PPE is individualized and tailored to the specific needs of the particular patient. The PPE may be the only opportunity to assess an athlete’s health and safety concerns including issues unrelated to sports participation.
Another approach to the PPE is the group examination station method, in which a large number of patients are evaluated in a single session by multiple providers. Each provider takes responsibility for a specific aspect of the evaluation at a station dedicated to that purpose. The station method can involve providers from a variety of disciplines such as medicine, nursing, athletic training, and physical therapy. Athletes move from one station to the next, with historical and objective information documented throughout on a standard form. A checkout station is critical to the success of this approach. The person in charge of this station reviews the data collected during the evaluation and coordinates any necessary follow-up testing or referrals, communicating directly with the athlete (and parents, if appropriate) and generating a written report. The PPE station format is not a comprehensive service for addressing issues unrelated to sports participation. The report should be sent to the patient’s primary care provider, and the need for patients to concurrently receive routine health maintenance care should be emphasized at the checkout station.
The PPE should be completed 6 weeks or well enough in advance of the planned sports activity so that any needed specialist evaluations, rehabilitation, or therapy can be completed before participation begins. Primary care providers are often asked to complete a sports participation form based on a recent visit. Because the overall goal of the PPE is to ensure safe participation in a specific sport, providers should emphasize the importance of scheduling a complete PPE visit to patients and parents. Once an initial, thorough PPE has been completed, subsequent PPEs can be shorter and should focus on interim problems and concerns. Collegiate athletes should have a PPE and a comprehensive health assessment upon entry into the athletic program with annual follow-up examinations based on injury or illness since the initial evaluation. For younger athletes (middle school and high school), a comprehensive PPE should occur every 2 to 3 years followed by annual questionnaire assessments and examinations for problem areas ( Sanders et al, 2013 ).
Individuals with Down syndrome are at increased risk of atlantoaxial subluxation. Because cervical spine radiographs do not accurately predict risk in asymptomatic children and adolescents, the American Academy of Pediatrics (AAP) no longer supports routine radiologic screening (AAP et al, 2011). However, it is important to discuss spinal cord injury risk with parents of children with Down syndrome who will be participating in sports (especially football, soccer, and gymnastics). Inquire about neck or radicular pain, weakness, change in gait, and bowel or bladder function, and perform a careful neurologic examination. If you find symptoms and examination findings of increased deep tendon reflexes, a positive Babinski sign, and ankle clonus or a change in tone, strength, or gait, immediately refer this child to a neurosurgeon with expertise in atlantoaxial instability.
Hypertension is the most common cardiovascular condition seen in competitive athletes. Blood pressure measurement is particularly important during the PPE for young athletes. In the pediatric population, the diagnosis of hypertension is made when blood pressure measurements on three or more occasions are above cutoffs based on the child’s gender, age, and height percentile. Stage 1 hypertension is defined as blood pressure measurements in the 95th to 99th percentile plus 5 mm Hg (or higher than 120/80 mm Hg). Stage 2 hypertension is defined as blood pressure measurements greater than the 99th percentile. If the child is asymptomatic, two additional measurements should be taken in the subsequent weeks for confirmation. If the blood pressure is persistently elevated, evaluation for an etiology, comorbid conditions, and end organ damage is warranted. Lifestyle modification and pharmacotherapy may be indicated. For patients 18 years and older, prehypertension is defined as blood pressure measurements of 120 to 139 systolic and/or 80 to 89 diastolic. Stage 1 hypertension is defined as 140 to 159 systolic and/or 90 to 99 diastolic and stage 2 hypertension is defined as 160 or higher systolic and/or 100 or higher diastolic. For patients with stage 2 hypertension, temporary restriction from sports participation is based on the cardiovascular demands of a particular sporting activity and the demands of practice and/or preparation. In addition to the preceding evaluation, a referral to a pediatric cardiologist is recommended. Patients with hypertension should also be counseled to avoid substances known to increase blood pressure (e.g., over-the-counter supplements, alcohol, tobacco, and highly caffeinated beverages) ( AAP et al, 2010 ).
The only proven benefit of the preparticipation physical evaluation (PPE) is recognition of athletes at risk for later orthopedic injury. With a careful history, recent or poorly rehabilitated injuries that can become worse with sports participation can be detected. The history provides the most information for the PPE. Asthma is a good example. Unless a patient is in respiratory distress when evaluated, asthma will not be detected during the physical examination. Sudden cardiac death on the playing field is a source of great concern, accounting for 56% to 95% of cases of sudden deaths in young athletes ( Barrett et al, 2012 ). Patients should be assessed for personal history of exertional symptoms (e.g., chest pain, dyspnea), prior detection of a heart murmur, unexplained syncope or near-syncope, symptoms of Marfan syndrome and family history of premature heart conditions or sudden death ( Mirabelli et al, 2015 ). Other potential causes of sudden death during sports include blunt chest and head trauma, drug abuse, asthma, heat stroke, and drowning.
A review of 1827 pediatric deaths from the U.S. National Registry of Sudden Death in Young Athletes (1980–2009), found that 14% were secondary to traumatic injuries of the head and/or neck ( Thomas et al, 2011 ). Conditions leading to these uncommon events are rarely associated with detectable physical findings. They may, however, be associated with symptoms revealed by a careful medical and family history during the PPE. For adolescent-age patients, it is important to obtain the health history from both the adolescent and the parents. A history and symptom questionnaire is often used and can be very helpful in practice. This is especially important when the PPE is conducted using a station-based screening format ( Womack, 2010 ).
The physical examination component of the PPE should center on high-yield areas, particularly those related to sports participation and issues identified by the history. Items such as auscultation of the lung fields and otoscopy are low-yield—unless the patient is symptomatic at the time of the evaluation. Such findings can distract providers from the more important PPE cardiac and orthopedic examinations.
Recommended components of the PPE are shown in Box 24.2 and followed by the 2010 Physical Examination Form endorsed by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopedic Society for Sports Medicine, and the American Osteopathic Academy of Sports Medicine. Many primary care providers are less comfortable with the orthopedic component of the physical examination. Garrick developed a “2-minute” screening orthopedic examination to be used in conjunction with a thorough history. This 14-step musculoskeletal examination consists of observing the athlete in a variety of positions and postures that highlight asymmetries in range of motion, strength, and muscle bulk ( Fig. 24.1 ) ( Garrick, 2004 ). These asymmetries serve to identify acute or old, poorly rehabilitated injuries. The steps pictured in Fig. 24.1 help in assessing most of the following:
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Posture and general muscle contour bilaterally
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Patient’s duck walk, four steps with knees completely bent
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Spine for curvature and lumbar extension, fingers touching toes with knees straight
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Shoulder and clavicle for dislocation
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Neck, shoulders, elbows, forearms, hands, fingers, and hips for range of motion
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Knee ligaments for drawer sign
History
General Medical History
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Illnesses or injuries since the last health visit or PPE
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History of having been denied or restricted from participation in sporting activities and reason for restriction
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History of heat illness or muscle cramps
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Current viral illness (patients with mononucleosis may return to play after 3 weeks if no longer symptomatic and no splenomegaly; fever at the time of the examination is an absolute contraindication due to the association with viral myocarditis)
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Sickle cell trait or disease (adequate hydration is necessary and caution should be taken to avoid extreme conditions due to risk of rhabdomyolysis)
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Hospitalizations or surgeries
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All medications used by the athlete (including steroids and nutritional supplements or medications taken to enhance performance)
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Use of any special equipment or protective devices during sports participation
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Allergies (including food-, insect bite–, and exercise-provoked allergies), particularly those associated with anaphylaxis or respiratory compromise
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Absence of paired organs (single-organ athletes may participate if the single organ can be protected and the patient/caregivers understand the risks involved)
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Immunization status, including hepatitis B, varicella, meningococcal, human papillomavirus, and pertussis
Cardiac
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Symptoms of exertional chest pain/discomfort
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Unexplained syncope or near-syncope
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Excessive exertional and unexplained dyspnea/fatigue, associated with exercise
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Prior recognition of a heart murmur
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Family history of premature death (sudden and unexpected, or otherwise) before age 50 years due to heart disease in one or more relatives
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Family history of disability from heart disease in a close relative younger than 50 years
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Specific knowledge of certain cardiac conditions in family members: hypertrophic or dilated cardiomyopathy, long-QT syndrome or other ion channelopathies, Marfan syndrome, or clinically important arrhythmias
Respiratory
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Coughing, wheezing, or dyspnea with exercise
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Previous use of asthma medications
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Family history of asthma
Neurologic
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History of a head injury with or without symptoms of a concussion (confusion, prolonged headache, memory problems)
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Numbness or tingling in the extremities
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Headaches
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History of seizure
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History of inability to move an extremity after a collision
Vision
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Visual problems
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Glasses or contact lenses
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Previous eye injuries
Orthopedic
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Previous injuries that have limited sports practice or participation
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Injuries that have been associated with pain, swelling, or the need for medical intervention
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Previous fractures or dislocated joints
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Previous or current use of a brace, orthotic, or other assistive device
Psychosocial
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Weight control and body image
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Dietary habits, calcium intake
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Stresses in personal life, at home, or in school
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Feelings of sadness, hopelessness, depression or anxiety
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Use or abuse of recreational drugs, alcohol, tobacco, dietary or performance supplements
Genitourinary and Abdominal
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Age at menarche, last menstrual period, regularity of menstrual periods, number of periods in the last year, and longest interval between periods (athletic girls tend to experience menarche at a later age than nonathletic girls)
Dermatologic
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History of rashes, pressure sores, or other skin conditions
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History of boils or methicillin-resistant Staphylococcus aureus skin infections
Physical Examination
General
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Height, weight, and body mass index (BMI)
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Palpation of lymph nodes
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Attention to signs of eating disorders, including oral ulcerations, decreased tooth enamel, edema
Cardiac and Pulses
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Elevated systemic blood pressure
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Heart murmur (auscultation should be performed in both supine and standing positions, or with Valsalva maneuver, to identify murmurs of dynamic left ventricular outflow obstruction); heart rate and rhythm to assess for arrhythmias
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Femoral pulses to exclude coarctation of the aorta
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Brachial artery blood pressure (sitting position with appropriate size cuff, preferably taken in both arms)
Respiratory
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Lung auscultation
Neurologic
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Comprehensive neurologic examination
Vision
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Visual acuity
Orthopedic
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Screening orthopedic examination (see Fig. 24.1 )
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Physical stigmata of Marfan syndrome (e.g., arm span greater than height and hyperextensible joints)
Genitourinary and Abdominal
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Palpation of the abdomen for organomegaly
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Palpation of the testicles for masses
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Examination for inguinal hernias
Dermatologic
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Skin lesions suggestive of herpes simplex virus, methicillin-resistant Staphylococcus aureus, or tinea corporis
