The Preparticipation Physical

Evaluation

Clark Madsen MD MS CAQSM

Intermountain Healthcare
Is it really necessary or
just liability shifting
bureaucracy?
 1990 Hank Gathers
Loyola Marymount

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The Competing Pressures of the
PPE

Athlete

• “I want to be safe but I just want to play”

Coach

• “We have to get these forms signed so we can begin practice”

Athletic Director

• “If it happened before coming here it isn’t our liability.”

Physician

• “This seems routine but am I liable if I miss something?”

2019 PreParticipation Physical
Evaluation
Who can perform a PPE?

• State dependent
– Most states allow APCs
– Some allow chiropractors

• Should be trained in proper assessment

How often should you get a PPE?

• High School
– Again, varies by state
– Most require yearly
– Check with high school athletic association.

• College
– Performed at discretion of the school with
NCAA guidance
• Others
– Varies
In what setting?

Office Station
•More intimate •Fast
•Usually better pt •Well trained team
relationship •Can be used to raise
•More resources to funds for school
follow-up on ed •Standardized quality
nd
concerns me
m
of PPE
ec o
R
Areas of Elevated
Interest
Cardiovascular Evaluation
 Causes of Death in NCAA Athletes

(Harmon et al., 2011)

Sports - (Harmon et al., 2011)
Harmon et al. Circulation, 2014
2004-2008, deaths in 43 deaths identified
voluntary NCAA •1:43,770 for all NCAA
database athletes
•Compared with •Cause of death determined
in 80% of cases
insurance claims

Cardiac
Autopsy Autopsies not
confirmed standardized
Harmon et al. Circulation, 2014
History/Physical – Is it Harmon et al.
Journal of
good enough? Electrocardiology,
2015

Varying ages
Metanalysis
and study
(15 studies) designs

Echocardiogram used
in only 2 studies
•No gold standard
(grouped outcomes)
History
Physical Exam
ECG
Argument for ECG Screening

• SCD is the leading cause

of death in athletic
competition

• History and Physical exam

are inadequate to identify
those at risk

• ECG criteria are improving

and can identify those
most at risk
EKG International Criteria
(Drezner et al., 2017)
Sheikh et al. Circulation, 2014

• Evaluation of ECG criteria. Retrospective

– European Society of Cardiology
– Seattle Criteria
– International (Refined) Criteria

• Comparison to Echocardiogram
– 1208 Black Athletes
– 4297 White Athletes
– 103 with confirmed HCM
Argument against Screening

• High cost
– could be used for proven
interventions

• High number of false positives

• Inter-rater reliability issues

• Time loss from workup

• False security with testing

• Highest cause of SCD is autopsy

negative

• Lack of evidence showing harm

reduction
AMSSM Position Statement on
Cardiovascular Screening
Don’t Forget Coronary
Artery Disease
Frank Hayes - 1924
Musculoskeletal
Evaluation
Key Points for Healthcare Team

• Full evaluation and plan needed for any

ongoing musculoskeletal injury
• Past or present overuse injuries should be of
extra concern
• Know the general MSK screening exam
– More in-depth evaluation needed for some
athletes
• Specific sport/position
• Previous injury
Overuse Injuries

Recovery
Durationinadequate
too Improper
high too fast equipment
Intensity too Improper
high too fast technique

Overuse
Injury
MSK
Screening Exam
1. Inspection
2. Neck ROM
3. Shoulder Shrug
4. Shoulder Abduction
5. Shoulder IR / ER
6. Elbow Flex / Ext
7. Elbow Pron / Sup
8. Clench Fist / Spread
9. Duck Walk
10. Back Inspection
11. Back Ext
12. Back Flex
13. Lower Ext Inspection
14. Heel Raise & Heel Walk
Exam Goals

Inspection

• Deformity
• Atrophy

ROM

• Untreated injury
• Potential for future injury

Strength

• Untreated injury
• Potential for future injury
Mental Health Evaluation
Key Points for the Healthcare Team

• Mental health issues are a rapidly rising

problem in youth
• PPE may be your first and only chance to
identify the problem
• Positive screening should have followup
testing (ex: PHQ-9 , GAD-7)
 Depression and Suicide

• Suicide is 2nd leading cause of death in

college students.

National Vitals Statistics Report, June 2019

 Causes of Death in NCAA Athletes

(Harmon et al., 2011)

Data from the National Health and
Nutrition Examination Survey

• Approximately 6.0% of U.S. adolescents aged 12–19 reported

psychotropic drug use in the past month.

• The use of antidepressants (3.2%) and attention deficit hyperactive

disorder (ADHD) drugs (3.2%) was highest
– Males (4.2%) were more likely than females (2.2%) to use ADHD drugs.
– Females (4.5%) were more likely than males (2.0%) to use
antidepressants.

• Psychotropic drug use was higher among non-Hispanic white (8.2%)

adolescents than non-Hispanic black (3.1%) and Mexican-American
(2.9%) adolescents.
 Legal
Implications
General Recommendations

• HIPPA
– When possible separate clearance form from
H&P to protect privacy. Schools just need
clearance info.
• The PPE is a screening tool and not
comprehensive
• Athletes have the right to restrict who sees
their medical records
General Recommendations

• Always have the ability to have a chaperone

– Most invasive exams have been removed
(hernia, breast)
• Restriction on Activity
– Usually to allow time for further evaluation
– Complete denial is usually made as a team
• Certain conditions have blanket denials
Gathers vs. Loyola Marymount

• $32 Million lawsuit against school and

medical staff
– Settled out of court for $2.4M
– Only managing cardiologist paid anything

Hank could have been a comedian, and actor or did speaking engagements.
It's not worth the risk. I would just say absolutely not, don't do it. If Hank had the
ability to do it again he wouldn't have paid the ultimate price.

- Bo Kimble, teammate, encouraging Chris Bosch to retire

Ivey vs. Providence Hospital
Knapp vs Northwestern Univ
Waiver vs. Informed Consent

Have athlete or parents write Exculpatory waiver

down their understanding of enforceability varies by state
the risks in their own words and are frequently struck down

“If I continue X could happen. I “The medical team has

chose to do so anyway.” discussed the risks and will not
be held liable.”
Take Aways for the Healthcare Team

Develop standardized approach to the PPE

Focus on ruling out life and limb conditions

Most athletes will be cleared but do not be afraid to delay clearance for further
tests
 Have you found
something on a PPE to
disqualify an
Athlete?