Learning Objectives

ipation
Review the guidelines for pre-
pre-participation

p ar t ic sports physical
Pre- al
Physic
Understand the key things to identify in a

Sp o rts iatrics
medical history for a patient planning to
P FAA r of Ped participate in athletics
hil p a Pai, MDical Professodical School
S nt Clin on Me
Assista Wood Johns
Robert

History of the PPE Benefits of the PPE

Initially suggested by Teddy Roosevelt in 1905 >7.6 million athletes participated in high school
sports in 2010-
2010-2011 academic year
Created 30 years ago, primarily to look at
congenital heart disease medical home

American Heart Association first developed updating of immunizations

screening guidelines in 2007 identification and management of chronic health
conditions
Most recent guideline from 2010 PPE 4th edition
monograph provision of anticipatory guidance related to sports
Benefits
facilitate and encourage safe participation, not
to disqualify
• 310 studies of the PPE Æ “the evaluation likely does
<2% of 2700 athletes screened disqualified
12% athletes required follow up
Athletics are good for teens
less likely to be truant
less likely to get pregnant
Limitations of PPE
Not necessarily effective screening tool
little to prevent morbidity and mortality in screened
athletes; ineffective for identifying athletes at risk for
sudden cardiac death or orthopedic injuries and at
detecting exercise-
exercise-induced bronchospasm”
bronchospasm”
Inconsistencies between states (no standard)
AHA guidelines are often not followed

Preparticipation Physical
It’s the Law
Evaluation 4th Edition 2010
National Federation of State High School Approved by:
Associations (NHFS) regards PPE as
AAP
prerequisite to sports
AAFP
liability issue American College of Sports Medicine
American Medical Society for Sports Medicine
high-
high-school and middle-
middle-school athletes required
to obtain signed every 1 to 2 academic years American Orthopedic Society for Sports Medicine
American Osteopathic Academy of Sports Medicine
 Recommendations for the
PPE 4th Edition 2010
PPE
Primary objectives: Who does it?
Screen for conditions that may be life-
life-threatening or
disabling Preferably primary MD/DO with review of previous
Screen for conditions that may predispose to injury or medical records
illness (e.g. recurrent ankle/shoulder injury,
injury, obesity)
Some states allow non-
non-physician healthcare
Secondary objectives:
providers to perform PPE
Determine general health
entry point to health care system
opportunity to initiate discussion of health-
health-related topics

Recommendations for the Recommendations for the

PPE PPE – Where?
When should you do it? Individual exam/office setting
privacy and continuity of care
At least 6 weeks prior to preseason practice
costly
Allows for strengthening/conditioning and
Station approach
identification of injury patterns and rehabilitation
Periodicity is determined by state law Can be done for entire athletic team at once
Time efficient
AHA recommend q 2 years with annual updates to
include history, height, weight, BP and a problem-
problem- Utilizes primary care providers and specialists
focused exam Inexpensive
 History form for preparticipation evaluation.

How should you do it?

History alone detects >75% of problems

Should be conducted with both athlete and

parent
Only 19-
19-39% of athlete’
athlete’s response match info from
parent
Include confidential information (HEADSS)
Peterson A R , Bernhardt D T Pediatrics in Review
2011;32:e53-e65

©2011 by American Academy of Pediatrics

History - Cardiovascular History - Cardiovascular

Annual incidence of sudden cardiac death = PCP evaluation: Cardiology referral:
1/100,000 – 1/200,000 high school aged teens
• Syncope known congenital heart
previously asymptomatic disease
• Near-
Near-syncope
Structural cardiac problems Æ fatal arrhythmias: Cardiac channelopathies
• Chest pain
>90% sudden death in young athletes
History of myocarditis
• Palpitations
36% from hypertrophic cardiomyopathy Coronary anomalies
• Excessive shortness of
8% from idiopathic LVH breath
17% from coronary artery anomalies
AHA Recommendations –
History (8 points)
• Exertional chest
pain/discomfort
• Exertional syncope or
near-
near-syncope
• Excessive exertional and
unexplained fatigue
• Prior recognition of heart
murmur
History -Musculoskeletal
history is very sensitive for identifying
abnormalities – 92%
Ask about current injuries
History of injuries that needed further evaluation
• Elevated SBP
• Premature death
(sudden) <50 y.o.
• Disability from heart
disease in close relative
<50 y.o.
• Family cardiac history
AHA Recommendations –
Physical Exam (4 points)
1. Heart murmur
2. Femoral pulses
3. Physical stigmata of Marfan syndrome
4. Brachial artery BP
Screening EKG not recommended
1 or more positive responses may be enough to
trigger a cardiology referral
Medications
Current and past medications
Therapeutic use exemption (TUE)
Screen for illicit drugs
Banned substances – college level
World Anti-
Anti-Doping Agency
NCAA
History - Dermatologic History - Neurologic
Open wounds – cleaned and covered Personal history of concussion
Sunblock usage
Post-
Post-concussion symptoms
Infectious
Symptomatic athlete should NEVER be allowed to
MRSA infections return to play
Impetigo
Neurocognitive testing (NCT) – controversial
Molluscum contagiosum
Tinea corporis
Herpes simplex

History - Neurologic History – Heat Illness

Cervical cord neuralgia –> transient quadriplegia Kills 1000 people each year in the U.S.
transient compression of cervical spinal cord from Proper hydration
forced hyperextension, hyperflexion, or axial loading
Common in athletes with cervical spinal stenosis Avoid stimulants and antihistamines

Transient - <15 minutes

Controversial if should be allowed to play contact
sports
History - Ophthalmologic History - Pulmonary
20/40 best corrected vision – “functionally one-
one-eyed
History of exercise-
exercise-induced bronchospasm (EIB)
Eye protection recommended for all athletes by AAP
and AAO Asthma is the most chronic illness in adolescents
10-
10-79% of athletes (high school, college, Olympics)
Some sports do not allow eyewear, so need contact have EIB
lenses
Athletes should have active prescription for
Ultraviolet blocking eyewear for sun or snow sports bronchodilator

History – Infectious
History - Genitourinary
Diseases
Mononucleosis and mono-
mono-like infection Solitary/horseshoe kidney – individual assessment

Disqualified from participation any sport where Inguinal hernia – worsen with sports requiring high
risk for abdominal trauma static demand

3-4 week symptom free Menstrual history: female athlete triad

Universal precautions eating disorder
Menstrual dysfunction
Osteoporosis
 Physical Exam – Vital
Physical Exam
Signs
Height Blood pressure
Weight
90-
90-94% or 120/80 = pre-
pre-hypertension
BMI >95% measured on 3 occasions = mild/moderate
can be inaccurate hypertension
Heart rate >99% + 5mm Hg = severe hypertension
Bradycardia Higher risk for a catastrophic event, worse end organ
damage
Wide pulse pressure

Physical Exam - HEENT Physical Exam

Vision: better than 20/40 corrected Neurologic exam

Auricular cartilage damage Æear protection Cardiovascular:

Not benign Æ cardiology referral
Nasal septum damage
Genitourinary (males only)
Dental caries Undescended/absent testicle
Only one functional testicle
History of groin pain
Physical Exam Physical Exam
Dermatologic lesions Musculoskeletal exam
Low yield in asymptomatic athletes
History 92% sensitive in detecting significant
musculoskeletal injuries
Refer if recurrent injury, joint instability, locking of
joints, weakness, muscular atrophy

Classification of sports
Contact – based on potential for injury from
collision

Strenuous/dynamic – put a larger load on LV

Static exercise – dangerous for

those with htn, L. heart obstruction,

risk of aortic dissection

 CONTACT/COLLISION - LIMITED CONTACT - NON-CONTACT

Contact/Collision Limited contact Non-

Non-contact
Boxing Baseball Archery
Basketball Bicycling Badminton
Cheerleading Canoeing/kayak Body building & wt lifting
(whitewater)
Diving
Field Hockey
Fencing
Field Events
Bowling
Canoe/kayak (flat water)
Determining Clearance
Football Floor hockey Crew/Rowing
Ice Hockey Flag football Curling
Lacrosse Gymnastics Dancing Must maintain confidentiality
Martial Arts Horseback Riding Field events
Rodeo Raquetball Golf 1. Cleared without restrictions
Rugby Skating (in line, ice, roller) Orienteering
Skiing/jumping/snowboard Skateboarding Race walking 2. Cleared with recommendations
Soccer Softball Riflery
Handball Squash Rope jumping 3. Not cleared, reconsider after further eval or
Water polo Volleyball Running (track, x-
x-country) treatment
Wrestling Windsurfing/Surfing Sailing
Ultimate frisbee Scuba diving 4. Not cleared for certain or all sports
Swimming
Tennis, table tennis

Determining Clearance – Determining Clearance –

Special Situations Special Situations
Seizures Down Syndrome
Risk of seizure very low during competition
Cervical spine instability – 30%
Refer to state’
state’s legal seizure-
seizure-free interval to return to driving: 3-
3-6
months Special Olympics requires C-
C-spine films
Athletes with poorly controlled epilepsy benefit from exercise Prohibited from collision sports regardless
Avoid:
If instability, no “neck-
neck-stressing”
stressing” sports
Archery -weigh lifting
Diving
Power lifting -weight training
Riflery -sports involving heights Gymnastics
swimming soccer
Determining Clearance – When to Disqualify an Athlete
Special Situations from Sports Participation
Pulmonary vascular disease with Vascular Ehlers-
Ehlers-Danlos syndrome
Acute febrile illness cyanosis or a hemodynamically
significant right-
right-to-
to-left shunt Coronary anomalies (especially
anomalous coronary origins)
Fever puts them at risk for acute heat illness Severe pulmonary stenosis
(untreated) Catecholaminergic polymorphic
Reduces maximal exercise capacity ventricular tachycardia
Severe aortic stenosis or
Type 1 Diabetes Mellitus regurgitation (untreated) Acute pericarditis
Severe mitral stenosis or Acute myocarditis
Monitor glucose: q 30 min during continuous exercise, regurgitation (untreated)
15 min after completion of exercise and at bedtime Any cardiomyopathy Acute Kawasaki disease

Permitted to participate in any sport

Recommendations for
vitamins and hydration
Sports Injury Prevention
Vitamins Time off
1300 mg calcium
400-
400-600 IU Vitamin D
Strengthen muscles
Hydration Increase flexibility
Fluids 2-
2-4 hr prior to activity (until urine is clear)
Every 15-
15-20 minutes during activity
Use proper technique
16-
16-24 hours after activity
Take breaks
<1 hour of exercise: water only
>1 hour of exercise: sports drinks Stop activity if there is pain
 Sports injury
Sports injury prevention
prevention
Play safe Wear the right gear
Baseball/softball: avoid headfirst sliding Properly fit equipment
Football: no spearing Athletes should not assume they can do more
Hockey: no body checking dangerous activities

References
Peterson, A, “Pre-
Pre-participation Sports Physical,”
Physical,” Pediatrics in Review, May 2011

Loutit, Carrie, “Pre-

Pre-participation Sports Physical – Continuity Clinic Curriculum,”
Curriculum,” 2011

The Preparticipation Evaluation Monograph. Forth Edition, McGraw-

McGraw-Hill 2010

AAP History / Physical Exam / Clearance Forms: http://www.amssm.org/Content/pdf%20files/PPE2010RevisedForm.pdf

http://www.amssm.org/Content/pdf%20files/PPE2010RevisedForm.pdf

“Contact Sports for Young Athletes.”

Athletes.” Pediatric Annals May 2010 vol 39, no 5

Metzl JD “Sports Medicine in the Pediatric Office”

Office”. Multimedia Case-
Case-Based Text With Video AAP 2008

American Academy of Pediatrics. Medical Conditions Affecting Sports

Sports Participation. Pediatrics 2008;121:841-
2008;121:841-8

http://pediatrics.aappublications.org.laneproxy.stanford.edu/content/121/4/8
http://pediatrics.aappublications.org.laneproxy.stanford.edu/content/121/4/8 41.long

Metzl JD: Preparticipation examinations of the adolescent athlete:

athlete: part 1 Pediatric Rev June 2001;22 (6):199-
(6):199-204 http://pedsinreview.aappublications.org.laneproxy.stanford.edu/cgi/content/fu
http://pedsinreview.aappublications.org.laneproxy.stanford.edu/cgi/content/fu
ll/22/6/199

Metzl JD: Preparticipation examinations of the adolescent athlete:

athlete: part 2 Pediatric Rev July 2001;22 (7):227-
(7):227-235 http://pedsinreview.aappublications.org.laneproxy.stanford.edu/cgi/content/fu
http://pedsinreview.aappublications.org.laneproxy.stanford.edu/cgi/content/fu
/22/7/227

Peds in Review 2011 the Preparticipation Sports Evaluation

http://pedsinreview.aappublications.org.laneproxy.stanford.edu/cgi/content/fu
http://pedsinreview.aappublications.org.laneproxy.stanford.edu/cgi/content/fu ll/32/5/e53?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=sports+medici
ll/32/5/e53?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=sports+medici