Physical: Evaluation Preparticipation

PPE PPE
PREPARTICIPATION
PPE PREPARTICIPATION PHYSICAL EVALUATION

PHYSICAL
EVALUATION 5th Edition
American Academy of Family Physicians
American Academy of Pediatrics
American College of Sports Medicine
American Medical Society for Sports Medicine
American Orthopaedic Society for Sports Medicine
American Osteopathic Academy of Sports Medicine PREPARTICIPATION
THE AUTHORITATIVE RESOURCE FOR ATHLETIC SCREENING
The fifth edition of this best-selling resource provides Topics include PHYSICAL
EVALUATION
practical guidance for determining athletic medical • System-based examination: cardiovascular,
eligibility, optimizing sports participation safety, and nervous system, respiratory, gastrointestinal
promoting healthy lifestyles. and urogenital, dermatologic, musculoskeletal,
Developed by leading medical societies, PPE: mental health, and more
Preparticipation Physical Evaluation guides health care • Preparticipation physical evaluation timing,
professionals through the preparticipation physical setting, and structure
evaluation (PPE) process in the medical home for
young athletes from middle school through college.
• Medical history
questions ■ PREPARTICIPA
HISTORY FORM
TION PHYSICAL EVAL
UATION
5th Edition
This newly revised and expanded edition is adaptable • Medical eligibility
Note: Complete
and sign this form
Name: __________ (with your paren
_______________ ts if younger than
_______________ 18) before your
Date of exami _______________ appointment.
nation: _____
_______________ _________ Date
for a wide range of individual or institutional needs.

Sex assigned ___________ of birth: _____
considerations
at birth (F, M, Sport(s): _____ _______________
or intersex): ______ _______________ _________
___________ _______________
How do you identif _______________
List past and curren y your gender? ___
t medical condit (F, M, or other):
_______________ ions. __________ __________________
_______________ _______________ _
5th Edition
• Return to play
_______________ _______________
Have you ever _______________ _______________
had surger y? If _____ _______________
_______________
New in the Fifth Edition

_______________ yes, list all past
surgical proced _______________ __
_______________ ures. __________ _____ _______________
Medicines and _______________ _______________ _
supplements: List _______________ _______________
all current prescr _____ _______________ _____ __________
guidelines
_______________ iptions, over-th _______________
_______________ e-counter medic _______________
_______________ _______________ ines, and supple _
_______________ _______________ ments (herbal
_______________ _______________ and nutritional).
Do you have any
• New chapter on transgender athletes

allergies? If yes, _______________ _______________
please list all your _______________ _______________
_______________ allergies (ie, medic _______________ ______
• Medicolegal and
_______________ ines, pollens, _______________
_______________ _______________ food, stinging insects ______
_______________ _______________ ).
_______________ _______________
_______________ _____ _____
• New chapter on female athletes

_______________ _______________
_______________ ___________
Patient Health _______________
ethical concerns
Questionnaire ______
Over the last 2 Version 4 (PHQ-
weeks, how often 4)
have you been
bothered by any
• New section on mental health

of the following

Feeling nervou problems? (Circle
s, anxious, or Not at all respon se.)
• Future research
Not being able on edge Several days
to stop or contro 0 Over half the
l worrying days Nearly every
Little interest or 1 day
pleasure in doing 0 2
• Incorporating PPE into routine health

Feeling down, things 1 3
depressed, or 0 2
hopeless 1 3
needs
(A sum of ≥3 2
is considered 0
positive on either 1 3
subscale [quest 2
ions 1 and 2, 3
or questions 3 and
supervision care
GENERAL QUEST 4] for screening
IONS purposes.)
(Explain “Yes”
• Plus much more…

answers at the

Circle questio end of this form. HEART HEALTH
ns if you don’t QUESTIONS ABOUT
know the answe (CONTINUED YOU
1. Do you have r.) Yes )
any concerns No
• Updated content based on the most current

discuss with your that you would 9. Do you get
provider? like to light-headed or Yes No
than your friends feel shorter of
2. Has a provide during exercis breath
r ever denied e?
participation in or restricted your
sports for any 10. Have you
reason? ever had a seizure
3. Do you have
practice guidelines, consensus statements,

any ongoing medica ?
recent illness? l issues or HEART HEALTH
QUESTIONS ABOUT
HEART HEALTH YOUR FAMILY
QUESTIONS ABOUT 11. Has any Yes
family membe No

YOU r or relative died
4. Have you Yes problems or had of heart
ever passed out No an unexpected
and expert opinions

during or after or nearly passed sudden death or unexplained
exercise? out before age 35
drowning or unexpl years (including
5. Have you ained car crash)?
ever had discom
or pressure in fort, pain, tightne
your chest during ss,
exercise? 12. Does anyone
6. Does your in your family
have a genetic
• Developed to enhance the health and safety

heart ever race, problem such heart
or skip beats (irregu flutter in your as hypertrophic
chest, (HCM), Marfan cardiomyopath
lar beats) during syndrome, arrhyth y
7. Has a doctor exercise? ventricular cardiom mogenic right
ever told you that yopathy (ARVC
heart problem you have any syndrome (LQTS) ), long QT
s? , short QT syndro
me (SQTS),
of all athletes and establish a standardized

Brugada syndro

8. Has a doctor me, or catecho
ever requested morphic ventricu laminergic poly-
heart? For examp a test for your lar tachycardia
le, electrocardiog (CPVT)?
or echocardiogra raphy (ECG)
phy. 13. Has anyone
in your family
an implanted had a pacemaker
approach to PPE
defibrillator before or
age 35?
• English and Spanish versions of the History Form

EASY-TO-USE PREPARTICPATION PHYSICAL EVALUATION FORMS
• History Form (English and Spanish versions) • Athletes With Disabilities Form: Supplement to the American Osteopathic Academy of Sports Medicine
• Physical Examination Form Athlete History
• Medical Eligibility Form
For other pediatric resources, visit the American Academy of Pediatrics
at shop.aap.org.
AAP
PPE
PREPARTICIPATION
PHYSICAL
EVALUATION
5th Edition
Editors
David T. Bernhardt, MD, FAAP
William O. Roberts, MD, MS, FACSM, FAAFP
American Osteopathic Academy of Sports Medicine
00_FM_i-viii.indd 1 3/20/19 4:21 PM

Published By
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American Academy of Family Physicians as Preparticipation Physical Evaluation; second, © 1996 McGraw-Hill
Healthcare as Preparticipation Physical Evaluation; third, © 2004 McGraw Hill Healthcare Information as
Preparticipation Physical Evaluation; fourth, 2010; fifth, 2019.
Printed in the United States of America
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ISBN: 978-1-61002-301-6
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00_FM_i-viii.indd 2 3/20/19 4:21 PM

PREPARTICIPATION PHYSICAL EVALUATION WORKING GROUP
AND AUTHORS
AUTHOR SOCIETIES
Editors
David T. Bernhardt, MD, FAAP
William O. Roberts, MD, MS, FACSM, FAAFP
Organization Representatives
Irfan M. Asif, MD
Chad Asplund, MD, MPH, FACSM
William Dexter, MD, FACSM
R. Robert Franks, DO, FAOASM
Elizabeth A. Joy, MD, MPH, FACSM
Chris Koutures, MD, FAAP
Patrick F. Leary, DO, FAOASM, FACSM
Jason Matuszak, MD, FAAFP, CAQSM
Kody Moffatt, MD, MS, FAAP, FACSM
Joseph Perez, MD, MBA, FAAFP
Karen M. Sutton, MD
ADDITIONAL CONTRIBUTORS
Brittany J. Allen, MD
Cindy J. Chang, MD, FACSM
Joanna Harper, MS
Constance LeBrun, MD, FACSM
Keith J. Loud, MD, MSC, FAAP
Ashwin Rao, MD
00_FM_i-viii.indd 3 3/20/19 4:21 PM

ADDITIONAL CONTRIBUTORS (STAFF)
Kait Perry, MPH

Anjie Emanuel, MPH
Gretchen Niemann, MA

James R. Whitehead

Jim Griffith, MBA, CAE

Lisa Weisenberger

Susan M. Rees
NATIONAL ENDORSEMENTS
National Athletic Trainers’ Association
James Scifers, DScPT, PT, SCS, LAT, ATC
National Federation of State High School Associations

William M. Heinz, MD
00_FM_i-viii.indd 4 3/20/19 4:21 PM

v
Contents
PREFACE................................................................................................. vii
CHAPTER 1. INTRODUCTION....................................................................1
CHAPTER 2. GOALS...............................................................................11
CHAPTER 3. TIMING, SETTING, AND STRUCTURE.....................................15
CHAPTER 4. HEALTH PRIVACY, ETHICAL ISSUES, AND
LEGAL CONCERNS..................................................................................25
CHAPTER 5. GENERAL CONSIDERATIONS OF THE HISTORY,
PHYSICAL EXAMINATION, AND MEDICAL ELIGIBILITY...............................35
CHAPTER 6. SYSTEMS-BASED EXAMINATION..........................................43
Section 6A. Cardiovascular Problems................................................................................ 43
Section 6B. Nervous System............................................................................................... 71
Section 6C. General Medical Conditions.......................................................................... 89
Section 6D. Respiratory System......................................................................................... 111
Section 6E. Gastrointestinal and Urogenital Systems..................................................... 117
Section 6F. Dermatologic Conditions..............................................................................123
Section 6G. Musculoskeletal Concerns............................................................................ 131
Section 6H. Mental Health...............................................................................................149
CHAPTER 7. FEMALE ATHLETES.............................................................161

CHAPTER 8. ATHLETES WITH A DISABILITY............................................179
CHAPTER 9. TRANSGENDER ATHLETES..................................................193
CHAPTER 10. RESEARCH......................................................................199
CHAPTER 11. CONCLUSION.................................................................213
FORMS.................................................................................................215
History Form (English)..................................................................................................... 217
History Form (Spanish).................................................................................................... 219
Physical Examination Form.............................................................................................. 221
Athletes With Disabilities Form: Supplement to the Athlete History............................223
Medical Eligibility Form...................................................................................................225
RESOURCES..........................................................................................227
INDEX..................................................................................................231
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00_FM_i-viii.indd 6 3/20/19 4:21 PM
vii
Preface
The preparticipation physical evaluation (PPE) is used in a variety of settings to determine

medical eligibility for youth, high school, and college sports; however, there has not been
a systematic approach to its implementation or an evaluation of its short- and long-term
outcomes. Since publication of the first edition of PPE: Preparticipation Physical Evaluation
in 1992, debate continues to surround the effectiveness of the PPE as a screening tool for
athlete safety and medical eligibility for sport participation. The PPE has not been evalu-
ated with respect to long-term athlete outcomes, and it is difficult to know whether the
PPE is effective for improving safety and health for the athletes participating in sports.
Concerns have been raised regarding the utility of the PPE to affect outcomes of relatively
rare events such as sudden cardiac death and more common events such as anterior cruci-
ate ligament (ACL) tear, or concussions. In particular, the effectiveness in detecting athletes
at risk for sudden cardiac death has been questioned. Several “public health” issues are
embedded within the topic of sports participation screening. If electrocardiography or
other screening tests or procedures are valuable for the select few who participate in orga-
nized sports, should the same interventions be applied to all children, adolescents, and
adults, assuming that we are to promote exercise as a path to long-term health? The deci-
sions to screen should be based on outcomes that truly save lives and then offered across
the population, not just to athletes. It is our hope that the examination will be incorpo-
rated into the electronic health record to collect data regarding both the immediate out-
come of the PPE, with regard to medical eligibility, and the long-term outcomes of athletes
during and away from sports.
Despite these concerns, the author societies (American Academy of Family Physicians,
American Academy of Pediatrics, American College of Sports Medicine, American Medical
Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and
American Osteopathic Academy of Sports Medicine) recognize the important role the PPE
plays in the health care of athletes, particularly of the adolescent population. The author
societies feel the ideal sport screening evaluation is best done in an athlete’s health care
home as an individual encounter incorporated into routine health supervision care. The
PPE completed with the medical record present and by a provider who knows the athlete
has the greatest chance of integrating the medical eligibility determination with the full
past medical and family history.
The PPE: Preparticipation Physical Evaluation, 5th Edition, reflects a rigorous attempt by
the writing group to identify and outline evidence-based and expert opinion principles
and practices in the examination and medical eligibility decision. We have added content
00_FM_i-viii.indd 7 3/20/19 4:21 PM

viii Preface
on mental health issues (section) and female athletes and transgender athletes (chapters),
in addition to updating the information in the other chapters. The process included
• Definition of the issues surrounding the PPE
• An extensive review of the literature
• Use of position, policy, and consensus statements from major organizations
• Review of expert opinion
• Peer review by other experts from all the author societies (assisting in content revisions)
This edition of PPE: Preparticipation Physical Evaluation has been reviewed extensively,
and we greatly appreciate the excellent recommendations of the many professionals from
the societies who have reviewed the document. These individuals include experts in pri-
mary care and multiple specialties, both private practice settings and academic settings.
The author societies hope that this guide will serve to enhance the health and safety of
athletes and all active people. In addition to facilitating care of the athlete, a standardized
approach to the PPE will set the stage for data collection that may lead to future insights
and changes based on outcomes.
00_FM_i-viii.indd 8 3/20/19 4:21 PM

CHAPTER 1
Introduction
The preparticipation physical evaluation (PPE) is intended to promote the health and
safety of athletes during training and competition. The PPE has traditionally been con-
sidered a screening tool for injuries, illnesses, or factors that might place an athlete or
others at risk. The author societies (American Academy of Family Physicians, American
Academy of Pediatrics [AAP], American College of Sports Medicine [ACSM], American
Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine,
and American Osteopathic Academy of Sports Medicine) hope that this monograph will
serve to enhance the health and safety of athletes in organized sports or vigorous physical
activities and to make the PPE an informative and useful experience for both the examiner
and the athlete. A standardized approach to the PPE provides a tool to facilitate care of the
athlete and sets the stage for data collection to fuel changes in the current process that are
based on outcomes data. A digital format will likely be required to accomplish large-scale
data collection and track outcomes.
The PPE was not developed as an evidence-based process, and there is a lack of out-
comes data to demonstrate the overall effectiveness even after several decades of use
among athletes.1 Even though adults participating in recreational sport or fitness activities
are at greater risk than children for complications and consequences related to physi-
cal activity, there are no requirements for adults to have a preparticipation evaluation in
the United States. Israel, which previously required an evaluation through age 40 years,
removed the requirement because of low incidence of catastrophic events during exercise
and the low likelihood of detecting conditions in people who have no symptoms.2 The
ACSM recently eliminated the recommendation for preparticipation evaluation for most
adults, and in place of classifying people into low-, moderate-, or high-risk categories, it
created an algorithm to guide the need for a medical evaluation before initiating physical
activity.3 This algorithm is relevant in the approach to athletes and nonathletes who want
to exercise but who are not required to undergo a PPE.
The origins of the PPE date back to a movement in the 1890s to bring routine physical
education into schools in Britain. Prominent physicians recommended obtaining “a much
more detailed account of a child’s physical backgrounds and conditions at the time of
entering school . . . .” This information was intended to ensure appropriate physical activ-
ity (but was also used to separate the social classes),4 and it was considered important for
keeping the learning environment healthy.5
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2 Chapter 1. Introduction
During the mass screenings of World War II draftees, the US Selective Service deemed
1 in 4 young men unfit for military service,6 and an integrated effort to prepare young
men for military service was started in US high schools.7 This led to supplementing the
established school health examination for school entry with a standardized preparticipa-
tion evaluation. The examination included provisions for prevention and modification of
“correctable defects” patterned after the military evaluation to put more young men onto a
path to successful integration into the military.6–8 In the mid-1960s, the American Medical
Association called for youth athlete screening and the PPE process for young athletes was
initiated in the United States.9
For the PPE to be effective, it should identify diseases or processes that affect athlete
health and safety, and it should be sensitive, accurate, practical, and affordable. Currently,
data on the ability of the PPE to meet these criteria are lacking and research demonstrates
that the PPE has little effect on the overall morbidity or mortality of athletes.10 The lack of
supporting research leaves the effectiveness of the examination in question, especially for
the preadolescent age-group, and all adolescents may be better served by the addition of
questions addressing exercise-related cardiac symptoms and family history to health super-
vision care.1 Outside the cardiac and musculoskeletal areas, there has been no additional
data to support the process.1 Despite the lack of efficacy data, the examinations are widely
performed, with every state requiring some level of PPE for high school scholastic athletes.
Some argue that “the PPE as currently practiced is ineffective and illogical” and “a research
agenda that would provide data to more effectively promote adolescent health both on
and off the playing field” is sorely needed.11
The National Federation of State High School Associations (NFHS) recommends a PPE
for every student-athlete before participation; however, the NFHS has neither the authority
to mandate the PPE nor the ability to standardize the PPE format across its member state
associations. Adopting a standard format across all 50 states and the District of Columbia
would make the process uniform. However, the state-to-state variability may be an avenue
to judge the efficacy of the examination, if we can develop a database to evaluate the out-
comes of the examination at the high school level. At the collegiate level, the National
Collegiate Athletic Association (NCAA) recommends, and most institutions require, a PPE
at entrance to the program, but who performs or reviews the examinations, the content
of the examinations, and whether the examinations are repeated after matriculation is left
up to each institution.12,13 Outside of scholastic-based competition, some youth sports
programs and organizations, such as the Special Olympics, require a PPE for participating
athletes (see Chapter 8).
Youth sport governing bodies do not have uniform or consistent requirements for a
PPE. This large group of young athletes has little or no formal screening before sports
activity other than routine health supervision examinations. This leaves many young
athletes with no structured PPE until they begin scholastic-based sports activity; how-
ever, no data suggest that the outcomes are different from those of the athletes who are
screened. In addition, every child should be active for health reasons, and many children
and adolescents participate in vigorous exercise or activities that are not organized and
never have any formal PPE screening. With the large number of young athletes participat-
ing in physical activity outside the scholastic or organized sports arena, it would make
01_ch01_1-10.indd 2 3/20/19 3:59 PM

3
sense to incorporate the PPE into routine health supervision visits at some interval with
the implied public health message that all children and adolescents should be active.
The specific International Classification of Diseases, Tenth Revision, Clinical Modification code
for sport-related participation evaluation is Z02.5, which is a billable diagnosis code for
reimbursement purposes. If used by all providers as a primary or secondary code when
a PPE is performed alone or as part of a health supervision examination, the electronic
health record could become a powerful tool for learning more about the PPE.
Requirements for the high school scholastic sport PPE vary widely by state. The fourth
edition PPE form recommended by the NFHS is not required or used by many states.14
The interval between examinations is not standardized and varies from annual to every
3 years,14 and no data suggest there is a difference in athlete outcomes that is based on
the frequency of the examinations. Several studies demonstrate that most PPE forms used
in high schools, and often in colleges, do not follow American Heart Association (AHA)
recommendations regarding cardiac screening questions and physical examination.15–17
In a number of states, providers of varying levels of training and expertise are permitted
to administer the PPE for high school athletes.16 Equally wide variation exists in how
physicians conduct, and document, these examinations and in their knowledge and
understanding of the process.18 Physicians also perceive several difficulties with the PPE,
including lack of time, integration of non-PPE topics, lack of a standardized approach,
relative importance of the responses to the questions, and how to perform the physical
examination.18
For some adolescents, the PPE is their only contact with a medical provider and the
health care system in any given year.15,19 However, the health care landscape is changing
in the United States, and in 2012, 74% of insured and 46% of uninsured adolescents
(approximately 5% of the US population is uninsured) had an annual health supervi-
sion examination, suggesting that integrating pertinent PPE questions into health super-
vision care may reduce duplication within the system.20,21 This increased adolescent expo-
sure to the health care system emphasizes the need for the examination to be performed
by an athlete’s primary care provider in the medical (or health care) home, but it also
requires that providers at all levels understand the PPE process and rationale. Integrating
the PPE into an athletes’ regular health supervision examinations would provide the
opportunity to facilitate general health care and update immunizations, to emphasize
the importance of regular vigorous exercise beyond the confines of organized sport, and
to reduce duplication of services. Ideally, the PPE findings will be used by physicians and
ancillary health team members (athletic trainers, sports physical therapists, and others)
as part of an overall health care program that focuses on the prevention, assessment,
treatment, and rehabilitation of athletic injuries, in addition to the clear health benefits
of exercise.
The purpose of the PPE is to facilitate and encourage safe participation, not to exclude
athletes from participation. While a systematic review22 of the PPE (>20,000 examina-
tions) identified only 3 athletes that were excluded, most individual studies report that
0.3% to 1.3% of athletes are denied medical eligibility to participate because of the PPE,
with 3.2% to 13.9% requiring further evaluation before participation.17,20,21,23–27
01_ch01_1-10.indd 3 3/20/19 3:59 PM

■■ ROUTINE SCREENING TESTS

Routine laboratory, cardiac, and pulmonary screening tests for PPEs remain controversial.
However, evidenced-based studies indicate that the utility of adding screening tests is lack-
ing; the PPE working group concurs that no routine screening tests are required during
the PPE for determining medical eligibility of asymptomatic athletes. A good screening
test should influence a disease or health outcome that has a significant impact on public
health. On the basis of the current World Health Organization criteria, screening should
be applied only to a population with a justifiably high disease prevalence to make a dif-
ference in outcomes. Key to effective screening is detecting an asymptomatic problem
and demonstrating improved long-term outcomes. There is a difference between finding
a potentially hazardous condition and changing the outcome of the condition. This judg-
ment hinges on the difference between screening tests and “case finding” diagnostic tests.
The value of a screening test or procedure depends on 2 variables: (1) the predictive value
of the proposed screening test, which is in turn affected by the prevalence of the condition
in the population being screened, and (2) the ability to reduce morbidity and mortality
by identifying the condition with the screening method. The screening test must also be
acceptable in cost and potential side effects. The questions used in the PPE are based on
time-honored expert opinion that is intended to draw out red flag conditions and direct
a focused case finding evaluation. The AAP recognizes the tragic nature of sudden cardiac
death (SCD) in children and proposes that all children, not just athletes, undergo a ques-
tion set to focus on those who may be at risk.28 The value of a case finding diagnostic test,
as compared with a screening test, is the ability to confirm a condition for which suspicion
already exists because of history or physical examination findings.
When evaluating screening tests for the PPE, studies have not supported the use of uri-
nalysis, complete blood cell count, chemistry profile, lipid profile, ferritin level monitor-
ing, or screening for sickle cell trait.29–33 Since the institution of sickle cell trait screening at
the college level as required by a legal settlement with the NCAA, exercise-associated sickle
cell deaths have decreased in number, but it is difficult to tell whether that is a product of
the screening or the associated educational impact of the requirement. Similarly, cardio-
pulmonary screening with electrocardiography (ECG), echocardiography, exercise stress
testing, or spirometry lacks research to demonstrate that the tests clearly meet screening
criteria in asymptomatic athletes across the 12- to 18- and 19- to 24-year-old age-groups
generally assessed in the PPE process.34–40
Of particular concern to physicians, parents, guardians, and athletes is the issue of
cardiovascular screening. Adding ECG or echocardiographic screening to the PPE in an
attempt to reduce risk of SCD during physical activity is controversial and difficult. While
cardiovascular screening recommendations will continue to evolve, the low prevalence of
SCD among the target population does not lend to effective reduction of risk of SCD. It
will be important to keep abreast of the topic. Key to this decision is the specificity and
sensitivity of our current testing when applied to the universe of youth, high school, and
college athletes in the United States. Universal ECG screening is not recommended for
US athletes aged 12 to 24 years by the AHA and American College of Cardiology, in part
because of the large number of false-positive results from examinations.41,42 While the
state of ECG use in US athlete screening is evolving, there may be specific populations
01_ch01_1-10.indd 4 3/20/19 3:59 PM

Routine Screening Tests 5
among US athletes that warrant screening.43 Electrocardiographic screening is well

described in a 2008 article by Lawless and Best.44
Although the literature is lacking well-controlled prospective trials, the

sensitivity in detecting underlying cardiac disease in this population ranges
from 51% to 95%, depending on the type of underlying disease and the
population being studied. Since many of the conditions that cause SCD in
athletes demonstrate similar ECG findings as to what is seen in normal ath-
letic adaptation, clinicians need to follow some simple rules in ECG inter-
pretation in athletes, and they need to be prepared for the consequences of
both over- and under-interpretation of the ECG in this group.
The most current ECG interpretation guidelines should reduce the number of false-
positive ECG findings in athletes for both case finding interventions and screening inter-
ventions.43 The current literature and expert opinion recommendations are addressed in
Chapter 6, Section 6A.
Findings from the PPE medical history or physical examination may indicate a need to
arrange specific case finding diagnostic tests. The examining physician may elect to defer the
final medical eligibility decision for sports participation while awaiting completion of diagnos-
tic testing. Additional specific recommendations to test for targeted conditions are not part
of the standardized screening examination. For example, a complete hematologic profile may
be recommended to check for anemia or nutritional deficiency in an athlete who has fatigue,
pallor, performance decline, heavy menstrual bleeding, low caloric intake, or a diet lacking red
meat. A lipid profile to test for familial dyslipidemia is recommended for a student-athlete who
has a family history of premature atherosclerotic heart disease or dyslipidemia. Urinalysis may
be indicated for an athlete with dysuria, hematuria, or a family history of certain types of kid-
ney disease. Urine screening, not as a part of the PPE, but as part of a drug-testing program for
performance-enhancing drugs, is common among elite-level and professional athletes and is
becoming more common for intercollegiate athletes.
Mandatory HIV screening for sports participation is discouraged because of the low risk
of transmission, although certain boxing organizations require it.45,46 While mandatory
testing of athletes for HIV or hepatitis is not recommended,47,48 voluntary testing should be
encouraged for athletes at high risk, that is, who have exposure to blood products, symp-
toms suggestive of disease, or significant risk factors detected during the PPE. The current
literature and expert opinion regarding testing for certain blood-borne diseases will be
reviewed in Chapter 6, Section 6C.
This monograph is intended to provide a state-of-the-art, practical, and effective evalu-
ation tool for physicians who perform PPEs for athletes in middle school, high school,
and college. The PPE can be performed as a stand-alone evaluation or can be incorporated
into routine preventive examinations within the medical home. The process and forms are
designed to apply in most settings (eg, office, school, urban, rural) and are easily adaptable
to suit individual or institutional needs.
The fifth edition of the publication
• Includes descriptions of goals, objectives, timing, setting, and structure of the examination
• Details the history, physical examination, and medical eligibility considerations
• Lists medical eligibility and return to play guidelines
01_ch01_1-10.indd 5 3/20/19 3:59 PM

• Addresses medicolegal and ethical concerns

• Explores future research and the use of electronic formats
The text of the monograph reviews the rationale for the primary and secondary history
questions as well as the examination maneuvers. While most of the content is based on the
expert opinion level of evidence, whenever there is higher-level evidence for the content, it
is noted in the text (Table 1-1). Numerous references are provided, including Web sites, to
support the discussion, provide useful resources, and offer a basis for further inquiry. The
systems-based sections in Chapter 6 are configured to make them user-friendly using feed-
back from the previous editions and include system-based history, examination, and medi-
cal eligibility content, particulars for athletes with disabilities, administrative concerns, and
updated future directions. A new section on mental health and a chapter on transgender
athletes have been added to the monograph, and the chapter on female athletes has been
expanded. Succinct, comprehensive, easily used forms (pages 215–226) are supplied for
athletes, parents or guardians, and clinicians.
Table 1-1. Strength of Recommendation Taxonomy (SORT)

In general, only key recommendations for readers require a grade of the “Strength of Recommenda-
tion.” Recommendations should be based on the highest quality evidence available. For example,
Vitamin E was found in some cohort studies (Level 2 study quality) to have a benefit for cardiovas-
cular protection, but good quality randomized trials (Level 1) have not confirmed this effect. It is
therefore preferable to base clinical recommendations in a manuscript on the Level 1 studies.
Strength of
Recommendation Definition
A Recommendation based on consistent and good quality patient-oriented
evidencea
B Recommendation based on inconsistent or limited quality patient-oriented
evidencea
C Recommendation based on consensus, usual practice, opinion, disease-
oriented evidence,a and case series for studies of diagnosis, treatment,
prevention, or screening.
Use the table below to determine whether a study measuring patient-oriented outcomes is of good
or limited quality, and whether the results are consistent or inconsistent between studies.
Treatment/Prevention/
Study Quality Diagnosis Screening Prognosis
Level 1
Good quality patient- Validated clinical SR/meta-analysis of SR/meta-analysis of

oriented evidence decision rule randomized controlled good quality cohort
trials (RCTs) with consis- studies
Systematic review
tent findings
(SR)/meta-analysis of Prospective cohort
high quality studies High quality individual study with good
RCTc follow-up
High quality diagnos-
tic cohort studyb All-or-none studyd
01_ch01_1-10.indd 6 3/20/19 3:59 PM

Routine Screening Tests 7
Table 1-1. Strength of Recommendation Taxonomy (SORT) (continued )
Treatment/Prevention/
Study Quality Diagnosis Screening Prognosis
Level 2
Limited quality Unvalidated clinical SR/meta-analysis of SR/meta-analysis of

patient-oriented decision rule lower quality clinical lower quality cohort
evidence SR/meta-analysis of trials or of studies with studies or with incon-
lower quality studies inconsistent findings sistent results
or studies with incon- Lower quality clinical Retrospective cohort
sistent findings trialc study or prospective
Lower quality diag- Cohort study cohort study with
nostic cohort study Case-control study poor follow-up
or diagnostic case- Case-control study
control studyb Case series
Level 3
Other evidence Consensus guidelines, extrapolations from bench research, usual practice,
opinion, disease-oriented evidence (intermediate or physiologic outcomes
only), and case series for studies of diagnosis, treatment, prevention, or
screening.
Consistency Across Studies
Consistent Most studies found similar or at least coherent conclusions (coherence

means that differences are explainable)
or
If high quality and up-to-date systematic review or meta-analyses exist, they
support the recommendation.
Inconsistent Considerable variation among study findings and lack of coherence

or
If high quality and up-to-date systematic reviews or meta-analyses exist,
they do not find consistent evidence in favor of the recommendation.
a
Patient-oriented evidence measures outcomes that matter to patients: morbidity, mortality symptom improvement,
cost reduction, quality of life. Disease-oriented evidence measures intermediate, physiologic, or surrogate end
points that may or may not reflect improvements in patient outcomes (i.e. blood pressure, blood chemistry, physi-
ologic function, pathologic findings)
b
High quality diagnostic cohort study: cohort design, adequate size, adequate spectrum of patients, blinding, and a
consistent, well-defined reference standard
c
High quality RCT: allocation concealed, blinding if possible, intention-to-treat analysis, adequate statistical power,
adequate follow-up (>80%)
d
An all-or-none study is one where the treatment causes a dramatic change in outcomes, such as antibiotics for
meningitis or surgery for appendicitis, which precludes study in a controlled trial.
Reprinted with permission from Ebell MH, Siwek J, Weiss BD, et al. Strength of Recommendation Taxonomy
(SORT): a patient-centered approach to grading evidence in the medical literature. J Am Board Fam Pract.
2004;17(1):59–67.
01_ch01_1-10.indd 7 3/20/19 3:59 PM

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3. Riebe D, Franklin BA, Thompson PD, et al. Updating ACSM’s recommendations for exercise preparticipation
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4. Carter AH. A discussion on the claims and limitations of physical education in school. BMJ.
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5. Neve M, Turner T. What the doctor thought and did: Sir James Crichton-Browne (1840–1938). Med Hist.
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6. Gallagher J, Brouha L. Physical fitness: its evaluation and significance. JAMA. 1944;125(12):834–838
7. Kleinschmidt EE. The schools contribute to national defense. 1941. J Sch Health. 2001;71(8):378–382
8. Rowntree LG. A movement for improvement in health and physical fitness; what role should we play in
Pennsylvania? PA Med J. 1928;1945(49):31–33
9. American Medical Association Subcommittee on Classification of Sports Injuries and Committee on
the Medical Aspects of Sports. Standard Nomenclature of Athletic Injuries. Chicago, IL: American Medical
Association; 1966
10. Best TM. The preparticipation evaluation: an opportunity for change and consensus. Clin J Sport Med.
2004;14:107–108
11. Bundy DG, Feudtner C. Preparticipation physical evaluations for high school athletes: time for a new game
plan. Ambul Pediatr. 2004;4:260–263 PMID:15153048
12. Montalto NJ. Implementing the guidelines for adolescent preventive services. Am Fam Physician.
1998;57(9):2181–2190
13. MacAuley D. Does preseason screening for cardiac disease really work? The British perspective. Med Sci Sports
Exerc. 1998;30(10)(suppl):S345–S350 PMID:9789860
14. National Federation of State High School Associations. Update on 2017 NFHS Survey Results on
Preparticipation Physical Evaluation. Presented at: Sports Medicine Advisory Committee; April 2017;
Indianapolis, IN
15. Krowchuk DP, Krowchuk HV, Hunter M, et al. Parents’ knowledge of the purposes and content of prepartici-
pation physical examinations. Arch Pediatr Adolesc Med. 1995;149(6):653–657 PMID:7767421
16. Fuller CM. Cost effectiveness analysis of screening of high school athletes for risk of sudden cardiac death.
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17. Glover DW, Maron BJ. Profile of preparticipation cardiovascular screening for high school athletes. JAMA.
1998;279(22):1817–1819 PMID:9628714
18. Madsen NL, Drezner JA, Salerno JC. The preparticipation physical evaluation: an analysis of clinical practice.
Clin J Sport Med. 2014;24(2):142–149 PMID:24231928
19. Carek PJ, Futrell M. Athletes’ view of the preparticipation physical examination. Attitudes toward certain
health screening questions. Arch Fam Med. 1999;8(4):307–312 PMID:10418536
20. Park MJ, Brindis CD, Vaughn B, Barry M, Guzman L, Berger A; Child Trends, National Adolescent Health
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22. Stickler GB. Are yearly physical examinations in adolescents necessary? J Am Board Fam Pract.
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23. Klein JD, Slap GB, Elster AB, Schonberg SK. Access to health care for adolescents: position paper of the
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24. Rosen DS, Elster A, Hedberg V, Paperny D. Clinical preventive services for adolescents: position paper for the
Society for Adolescent Medicine. J Adolesc Health. 1997;21(3):203–214
25. Fuller CM, McNulty CM, Spring DA, et al. Prospective screening of 5,615 high school athletes for risk of sud-
den cardiac death. Med Sci Sports Exerc. 1997;29(9):1131–1138 PMID:9309622
26. Lyznicki JM, Nielsen NH, Schneider JF. Cardiovascular screening of student athletes. Am Fam Physician.
2000;62(4):765–774 PMID:10969856
27. Koester MC, Amundson CL. Preparticipation screening of high school athletes: are recommendations
enough? Phys Sportsmed. 2003;31(8):35–38 PMID:20086484
28. Erickson CC, Salerno J, Berger S, et al. Prevention of sudden death in the young: what the primary care physi-
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29. Lombardo JA, Robinson JB, Smith DM, et al; American Academy of Family Physicians, American Academy
of Pediatrics, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports
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35. Epstein SE, Maron BJ. Sudden death and the competitive athlete: perspectives on preparticipation screening
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39. Rupp NT, Brudno DS, Guill MF. The value of screening for risk of exercise-induced asthma in high school
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40. Rupp NT, Guill MF, Brudno DS. Unrecognized exercise-induced bronchospasm in adolescent athletes. Am J
Dis Child. 1992;146(8):941–944
41. Maron BJ, Friedman RA, Kligfield P, et al. Assessment of the 12-lead ECG as a screening test for detection
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46. Drotman DP. Professional boxing, bleeding, and HIV testing. JAMA. 1996;276(3):193 PMID:8667554
47. Mitten MJ. HIV-positive athletes: when medicine meets the law. Phys Sportsmed. 1994;22(10):63–68
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nodeficiency virus and other blood-borne pathogens in sports. Clin J Sport Med. 1995;5(3):199–204
PMID:7670977
01_ch01_1-10.indd 10 3/20/19 3:59 PM

CHAPTER 2
Goals
The preparticipation physical evaluation (PPE) is considered a best practice for the care of
athletes by many sports organizations and governing bodies around the world. However,
the content, conduct, and efficacy of these examinations is not standardized across orga-
nizations or countries.1 The main goal of the PPE is to promote athlete health and safety
(Box 2-1). Finally, the PPE provides the medical background for shared decision-making to
determine medical eligibility and potential physical activity limitations by an athlete, the
athlete’s family, and the athlete’s physician or team physician and associated medical staff.
It is well-known that 75% or more of medical and orthopedic conditions are detected by
the history,2–4 and this monograph focuses on the history as the most relevant aspect of the
PPE. Recommendations from consensus documents by other organizations, such as the
American Heart Association and the US Preventive Services Task Force, are included in the
rationale for this monograph.
Box 2-1. Goals of the Preparticipation Physical Evaluation

1. Determine general physical and psychological health.
2. Evaluate for conditions that may be life-threatening or disabling.
3. Evaluate for conditions that may predispose to injury or illness.
4. Provide an opportunity for discussion of health and lifestyle issues.
5. Serve as an entry point into the health care system for adolescents without a health care home
or medical home.
■■ GOALS
1. Determine general physical and psychological health. Adolescents benefit from
routine health care from a provider in a health care home. The Society for Adolescent
Health and Medicine (SAHM) estimates that 5% to 10% of adolescents have a chronic
condition that requires ongoing care, and up to half of adolescents will have less-severe
medical problems.5 This suggests that more than half of adolescents should be seen at
least annually for care and that the opportunity for determining eligibility for sports par-
ticipation could be integrated into routine care. Preventive services are better delivered
when associated with a periodic preventive (supervision) health visit, but the number
of adolescents receiving preventive care remains low.6 With the emphasis in preventive
care and the health care home, the PPE should be in the toolbox of every primary care
provider, and all the key components of the PPE should be directed at every child and
adolescent to encourage regular strenuous physical activity for long-term health.
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12 Chapter 2. Goals
2. Evaluate for conditions that may be life-threatening or disabling. The PPE uses the
personal and family history to search for red flags and as an opportunity to investigate
potentially life-threatening or disabling medical or musculoskeletal conditions. There
is no solid evidence that a screening PPE will reliably identify important, but clinically
silent, conditions (such as many of the cardiac conditions associated with sudden
cardiac death),7 yet the consensus panel feels that a comprehensive, uniformly applied
approach to the PPE offers the best opportunity to meet this objective. Controversy
exists related to augmenting the history and physical examination with electrocar-
diography for the general population versus selective use for higher-risk popula-
tions. Details related to this controversy are highlighted in Chapter 6, Section 6A, the
Incidence of Sudden Cardiac Death in Young Athletes content.
3. Evaluate for conditions that may predispose to injury or illness. The PPE may iden-
tify medical or musculoskeletal conditions that may predispose an athlete to injury or
illness during training or competition, although there are no outcomes-based data to
support the ability of the PPE to achieve this goal. The PPE encounter is most likely to
find
• Acute, recurrent, chronic, or untreated injuries or illnesses
• Inadequately rehabilitated prior injuries
• Inadequate neuromuscular control predisposing to injury
• Congenital or developmental problems
Prior injury or illness is a leading risk factor for many sports-related problems.
Identification and treatment of certain conditions prior to participation in sport may
minimize participation time loss and reduce the risk of persistent injury or reinjury.
4. Provide an opportunity for discussion of health and lifestyle issues. The oppor-
tunity to use the PPE as a way to engage adolescents in a discussion of health issues,
including mental health, should not be overlooked. There is little solid evidence that
supports brief counseling interventions with adolescent lifestyle decision choices (eg,
tobacco and alcohol consumption), but the AAP, the SAHM, the American Academy
of Family Physicians, the American Medical Association, and others recommend such
counseling for preventive health visits.8 The PPE provides an opportunity to begin this
dialogue and to screen for mental health conditions.
Seventy percent of adolescents express a desire for more health care information from
their personal physician. Despite this statistic, most adolescents also relate that they
are not comfortable with questions related to risk behaviors, substance use, sexuality,
or weight and diet in the context of a station-based examination,3,9 lending credence to
integrating the PPE into the health care home. The opportunity for counseling an ath-
lete and answering health-related questions requires patient comfort and confidentiality,
which is difficult to ensure during a group PPE, but it may be feasible when performed
in an office-based setting or perhaps a modified one-on-one coordinated medical team
examination (see Chapter 3, the Methods and Setting of the Evaluation content).
In addition to an explanation of any abnormal findings from the PPE, topics such as
proper training techniques, weight-control behaviors, nutrition, tobacco use, alcohol
02_ch02_11-14.indd 12 3/20/19 3:14 PM

References 13
or drug use, driving while impaired or distracted, seat belt use, prevention of sexually
transmitted infections, and birth control, along with immunization education, may
be discussed or introduced for discussion at a later visit. This objective may be difficult
to achieve, but it may be the most important portion of the encounter. The SAHM
has resources that address many of the risks faced by an adolescent athlete (www.
adolescenthealth.org/Resources/Clinical-Care-Resources.aspx). The information
obtained during the PPE can provide a means to initiate discussion with an athlete
or to make referrals for health-related and lifestyle issues.
5. Serve as an entry point into the health care system for adolescents without a health
care home or medical home. The SAHM recommends that health care for adolescents
be readily available, visible, confidential, affordable, and flexible.10 A thorough PPE
can and ideally should be integrated into a regular examination with an athlete’s per-
sonal physician. In the opinion of the writing group, performing a PPE in the context
of a patient’s health care home is best practice.
The Affordable Care Act (ACA) has increased the number of children with medical
benefits, particularly in low-income households. A comparison of preventive services
before and after implementation of the ACA shows a positive, but not large, increase
in the use of preventive care.11 The greatest impact has been on minority and low-
income adolescents.11 The SAHM estimates that 5% to 10% of adolescents have a
chronic condition that requires ongoing care, and up to half of adolescents will have
less-severe medical problems.5
The underserved population is likely to have higher risk for both medical problems and
at-risk behavior and is often in higher need of a health care home to address both their
medical needs and their psychosocial issues. The PPE offers an opportunity to do this
whether the examination is initially performed in the medical office or it is performed
in a group setting with a health care home and follow-up established at a later time.
It is in the health care home setting that all the PPE objectives can reasonably be
achieved and integrated into the medical record. When the PPE is viewed as a point of
entry to the health care system, there are clear benefits to the health care home as the
site for the PPE. When station-based group examinations are used, follow-up becomes
a critical component of the PPE process. A careful and deliberate process for follow-
up visits and referrals is essential for group model PPEs not done one-on-one in the
health care home.
■■ REFERENCES
1. Roberts WO, Löllgen H, Matheson GO, et al. Advancing the preparticipation physical evaluation (PPE):
an ACSM and FIMS joint consensus statement. Curr Sports Med Rep. 2014;13(6):395–401 PMID:25391096
https://doi.org/10.1249/JSR.0000000000000100
enough? Phys Sportsmed. 2003;31(8):35–38 PMID:20086484 https://doi.org/10.3810/psm.2003.08.460
health screening questions. Arch Fam Med. 1999;8(4):307–312 PMID:10418536 https://doi.org/10.1001/
archfami.8.4.307
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14 Chapter 2. Goals
4. Krowchuk DP, Krowchuk HV, Hunter DM, et al. Parents’ knowledge of the purposes and content of prepar-
ticipation physical examinations. Arch Pediatr Adolesc Med. 1995;149(6):653–657 PMID:7767421 https://doi.
org/10.1001/archpedi.1995.02170190063011
5. Hulkower S, Fagan B, Watts J, Ketterman E, Fox BA. Clinical inquiries: do preparticipation clinical exams
reduce morbidity and mortality for athletes? J Fam Pract. 2005;54(7):628–632, 628 PMID:16009094
6. Adams SH, Park MJ, Twietmeyer L, Brindis CD, Irwin CE Jr. Increasing delivery of preventive services
to adolescents and young adults: does the preventive visit help? J Adolesc Health. 2018;63(2):166–171
PMID:29929838 https://doi.org/10.1016/j.jadohealth.2018.03.013
7. Wingfield K, Matheson GO, Meeuwisse WH. Preparticipation evaluation: an evidence-based review. Clin J
Sport Med. 2004;14(3):109–122 PMID:15166898 https://doi.org/10.1097/00042752-200405000-00002
8. Moyer VA, Butler M. Gaps in the evidence for well-child care: a challenge to our profession. Pediatrics.
2004;114(6):1511–1521 PMID:15574609 https://doi.org/10.1542/peds.2004-1076
9. Access to health care for adolescents and young adults: position paper of the Society for Adolescent
Medicine. J Adolesc Health. 2004;35(4):342–344
10. Copperman S. GAPS (AMA Guidelines for Adolescent Preventive Services). Arch Pediatr Adolesc Med.
1997;151(9):957–958 PMID:9308879 https://doi.org/10.1001/archpedi.1997.02170460095019
11. Adams SH, Park MJ, Twietmeyer L, Brindis CD, Irwin CE Jr. Association between adolescent preventive
care and the role of the Affordable Care Act. JAMA Pediatr. 2018;172(1):43–48 PMID:29114725
https://doi.org/10.1001/jamapediatrics.2017.3140
02_ch02_11-14.indd 14 3/20/19 3:14 PM

CHAPTER 3
Timing, Setting,
and Structure
The timing, setting, and structure of the preparticipation physical evaluation (PPE)
depends on many factors, including the age of the participants; the presence of a team phy-
sician; the availability of qualified health care professionals, trained and willing to do the
examinations; and the health insurance available to the athletes. Ideally, the examination
of an athlete should be embedded into the health supervision care structure, as part of pre-
ventive health visits, around the athlete’s birth date to distribute the evaluations through-
out the calendar year.
■■ QUALIFICATIONS OF THE EXAMINERS

Physicians with a doctor of medicine (MD) or doctor of osteopathic medicine (DO) degree
and advanced practice providers (nurse practitioners [NPs] and physician assistants [PAs])
with the clinical training to address the broad range of problems that may be encountered
during the PPE are allowed to complete the evaluation on the basis of individual state
laws. The PPE writing group concurs that the responsibility for conducting and determin-
ing medical eligibility should be completed by a physician (MD or DO), an NP, or a PA.1–3
It is essential that whoever performs the PPE has the clinical training, knowledge, and
expertise to conduct the evaluation and determine medical eligibility. Providers perform-
ing PPEs must be able to fulfill the goals and objectives outlined in the previous chapter
and should seek consultation with an appropriate specialist to address problems beyond
their expertise.1
State regulations determine which providers are licensed to perform PPEs for public
schools. Many states allow health care professionals other than physicians (MDs or DOs)
to perform the evaluation at the high school level. As noted in a letter from W. Heinz
outlining a 2017 National Federation of State High School Associations (NFHS) sur-
vey for this publication, all but one state allows a PA or an NP to perform the evalua-
tion, and some state associations allow a doctor of chiropractic (DC) to perform the
evaluation (one state requires certification). Regardless of their training, providers
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16 Chapter 3. Timing, Setting, and Structure
performing PPEs should be competent to screen athletes for problems that would affect
participation or place an athlete at undue risk (greater than the inherent risk of the
sport). Implementing standardized history forms in paper or electronic format or more-
comprehensive electronic history forms may mitigate the differences in training among
providers permitted by law to complete the PPE. At the collegiate, professional, national,
and international competition levels, the respective athletic governing bodies determine
who may perform the PPE, and standardized formats would likewise benefit those pro-
viders and athletes.4
■■ TIMING OF THE EVALUATION

If not incorporated into health supervision care during the birthday month, the PPE
should be performed well in advance of preseason practice to allow time to evaluate, treat,
or rehabilitate any problem identified in the evaluation that limits medical eligibility for
sport participation. The PPE writing group feels that student-athletes should ideally sched-
ule this with their primary care provider (PCP), who has access to medical records, can
adjust treatment of chronic medical conditions, and can incorporate the examination into
routine health supervision examinations. Both the American Academy of Family Physicians
(AAFP) and the American Academy of Pediatrics (AAP) endorse the concept of the medi-
cal home as a patient-centered model to improve timely, well-organized, and regular care;
eliminate barriers to care; create greater access to preventive care services, including the
PPE; and more evenly distribute the evaluations across the calendar year. Whether the PPE
is completed by a PCP or, when necessary, it is completed in a group examination format,
athletes should schedule the examinations at least 6 weeks before the start of preseason
practice. This approach allows a student-athlete to complete any needed evaluations or
consultations with less impact on school attendance and sports practice. Athletes examined
at the end of the school year for the next fall sports season should report any unresolved
injuries or medical problems from summer activities to the PCP, team physician, athletic
trainer, or school nurse before fall practice to allow for reevaluation. Many collegiate
sports medicine programs do not have athletes on campus 6 weeks prior to the season and
coordinate the PPE screening process to complete these examinations before the student-
athletes begin practice in their respective sports.
Student-athletes, medical provider staff, and school personnel need a clearly informed
process for managing the PPE medical eligibility forms to ensure that the information sent
to the school is free of confidential information and properly stored at the school. The
history and physical examination forms are intended to remain a part of an athlete’s con-
fidential medical record at the PCP’s office or, if done in the school or in a group examina-
tion, in a secure area that can be accessed only by designated medical providers on a “need
to know” basis in accordance with the Health Insurance Portability and Accountability Act
and the Family Educational Rights and Privacy Act (see Chapter 4).
For a PCP to play a greater role in the PPE process, both student-athletes and parents or
guardians must assume responsibility for scheduling an appointment before the start of
the sport season (at least 6 weeks preferable) and for accurately completing the health
history section.
03_ch03_15-24.indd 16 3/20/19 4:21 PM

Frequency of the Evaluation 17
■■ FREQUENCY OF THE EVALUATION

There are no outcomes-based data to guide the recommendations for frequency of the PPE,
and following the initial PPE, one might consider the examination to be a periodic athlete
health evaluation (PAHE) rather than a PPE.5 The current PPE intervals for high school
athletes are arbitrary and based on state or organization requirements. The American Heart
Association recommends every 2 years for cardiac evaluation, but this is also an arbitrary
recommendation based on the assumption that cardiac changes are detectable at 2-year
intervals as the heart matures. There is little evidence to support any of the prescribed inter-
val recommendations between 1 year and 4 years for the PPE or for routine health care.4
The AAP recommends an annual comprehensive health supervision visit from age
6 years to age 21 years for healthy children, adolescents, and young adults.6 The AAFP
recommends a preventive health visit every 1 to 3 years as necessary for adolescents and
young adults. A frequent argument for performing a complete PPE annually is that many
athletes and their parents or guardians use the PPE as their only visit for health care.7
When student-athletes have no PCP, the PPE encounter is unlikely to address all health
and anticipatory guidance issues in a comprehensive manner, especially when done
in a group setting. In a group examination setting, the examining PPE provider should
encourage these student-athletes to establish a medical home to begin periodic health
screening. Conversely, when a PCP performs annual examinations in the medical home,
required elements of the PPE should be incorporated into the health supervision encoun-
ter to maintain continuity of care so that a separate visit for a PPE would not be needed.
Incorporating the PPE into the routine health supervision screening after age 6 may pro-
mote physical activity and sports safety of children and adolescents before they reach the
age of interscholastic competition and potentially reveal risk for activity-related sudden
cardiac death or other medical conditions affecting physical activity of all children, not just
those involved in organized sports. Performing a PPE outside the medical home is inef-
fective, of little value, and presents a barrier to both health supervision care and participa-
tion in sports and activities.8,9 Given the time constraints of a typical health supervision
visit, screening and counseling should focus on evidence-based interventions that have
an impact on long-term morbidity such as depression and obesity. The goal of integrating
the PPE into the health care home may be more easily achieved if the PPE portion of the
examination is addressed every 2 to 3 years, rather than annually, to allow a different focus
for evolving child and adolescent risk at each visit.
College athletic departments generally determine the PPE frequency policies for
their athletes using National Collegiate Athletic Association, National Association of
Intercollegiate Athletics, and National Junior College Athletic Association recommenda-
tions and regulations. College student-athletes are often away from their medical home.
Colleges also assume some financial risk for athletes during practice and competition;
hence, more-comprehensive health examinations at the entry into a collegiate athletic
program are often the norm. Once a comprehensive evaluation has occurred, college
student-athletes usually undergo abbreviated annual evaluations that focus on injuries or
medical problems that have occurred since the comprehensive entry examination and have
not been resolved. The team physician at the collegiate level needs to be familiar with the
03_ch03_15-24.indd 17 3/20/19 4:21 PM

health history of the student-athletes and will typically perform the examinations or review
the information from examinations and yearly updates completed by providers who are
not associated with the college program. This PPE writing group feels this frequency is
appropriate for the college age-group.
At the high school level, a 2017 survey of all 51 state associations (50 states plus the
District of Columbia), completed by the NFHS Sports Medicine Advisory Committee,
with the results sent by a letter from W. Heinz, shows the following PPE intervals currently
required before participation in interscholastic sports activities:
• Thirty-nine states require an evaluation every 12 to 13 months (yearly) with or without
a mandated form. The 13-month (395-day) interval is allowed in 4 states primarily
because of insurance requirements.
• One state requires a comprehensive evaluation every 18 months.
• Seven states require every-other-year evaluations, most with a questionnaire in the inter-
vening year.
• Two states require comprehensive examinations every 3 years and require a question-
naire in each of the intervening years.
• One state has no required interval for the evaluation, leaving the frequency up to the
individual school districts.
• One state requires an evaluation at entry to high school sports and an annual statement
of health thereafter.
Seventeen of 51 states use the PPE form from the Preparticipation Physical Evaluation,
4th Edition, that is also reproduced in the NFHS Sports Medicine Handbook (2011). Several
states use a modified version of this form. The implementation of a nationwide format
for PPEs and a data-based recommendation regarding frequency of examination has been
hampered by lack of research and other factors. Some issues that have influenced these
decisions include (1) the requirements set by each state governing body and by specific
schools; (2) the cost, especially out-of-pocket expenses for students; and (3) the availabil-
ity of qualified personnel.
No outcome-based research indicates that more-frequent PPEs lessen the risk of injury
or death in student-athletes, so an optimal frequency for the examination has not been
established.9–14 The consensus of the PPE writing group is
• A comprehensive PPE should be performed every 2 to 3 years for grade school, middle
school, and high school athletes integrated into health supervision examinations within
the health care home.
• Annual updates should include both a history questionnaire focused on heart, head,
heat injury, and mental health issues and, if needed, a problem-focused examination of
any concerns detected in the history.
The basis for this recommendation is that student-athletes pass through stages of devel-
opment that have both physiological changes and psychological changes that merit moni-
toring. Careful cardiac auscultation every other to every third year may help screen for
previously undetected cardiac conditions. The annual history review also allows an oppor-
tunity to address new concerns that may have developed since the last comprehensive PPE.
The student-athlete, and parents or guardian, should confirm with the school when the
next PPE for medical eligibility is due.
03_ch03_15-24.indd 18 3/20/19 4:21 PM

Methods and Setting of the Evaluation 19
■■ METHODS AND SETTING OF THE EVALUATION

The most common methods for performing PPEs are individual examinations or group-
based assessments. The PPE writing group considers gymnasium- or locker room–based
examinations inappropriate to accomplish the goals and objectives of the PPE process.
Likewise, examinations done in an urgent care or retail clinic lack access to an athlete’s
medical record and are considered inappropriate. Using the PPE to accrue market share in
a community or as a fundraiser for the school or athletic department is also inappropriate.
Athletes often arrive at these examinations with forms either partially completed or not
completed at all and without a parent, so the data are inadequate for physician assessment
and decision-making. Group-based examinations away from the medical home should be
a last resort for high school and younger athletes. In college settings with formal medical
teams, group examinations may be preferred when full access to past medical history is
available.
When a group of medical personnel work together to complete the PPE, the history
review, physical examination, and sports medical eligibility process should still be a
one-on-one examination with a single provider rather than split into body system sta-
tions where the athlete has the heart and lungs examined at one station, the head and
neck at another, and so on. A quiet examination room is required to auscultate the heart.
Adolescent athletes should be seen apart from their parents or guardians for at least part of
the examination so that the provider can inquire about risk-taking behaviors.
Ideally, the PPE is performed in the office of an athlete’s PCP, allowing for better
continuity of care. The athlete’s PCP has an established relationship, is likely to know the
personal history, and usually has a complete set of medical records, including family his-
tory, immunizations, and previous laboratory and imaging studies. Access to the complete
medical record during the PPE reduces the possibility that a previously detected abnor-
mality or family risk factor that would predispose the athlete to unnecessary risk will be
missed or omitted. The PCP may be less likely to overlook health issues inadvertently or
consciously omitted on the PPE History Form by the athlete. In addition, the PCP should
have a better appreciation of the student-athlete’s known medical problems, a sense of
the athlete’s current health status, and knowledge of potential changes in treatment that
would optimize participation. For example, an asymptomatic athlete with a heart murmur
and echocardiogram showing benign findings can be readily cleared for participation. If
needed, the PCP can coordinate care with consultants and ensure proper follow-up for
medical conditions considered a risk for sport participation before determining medical
eligibility.
The office setting typically offers privacy and a chance to discuss confidential issues.
Familiarity also provides an opportunity to counsel an athlete on sensitive issues such
as mental health, gender identity, birth control, and prevention of sexually transmitted
infections in addition to a variety of risk-taking behaviors such as tobacco use, alco-
hol and recreational drug use, appearance- and performance-enhancement drug and
supplement use, and unsafe nutritional practices. Young athletes are often more willing
to discuss these issues with someone they know and trust, rather than a stranger in a
group examination.
03_ch03_15-24.indd 19 3/20/19 4:21 PM

Understanding the risk of exercise in relation to each question or physical finding is

essential to improve the outcomes of the PPE encounter. One purpose of this monograph
is to advance the quality of the PPE by closing that knowledge gap for PCPs. For a sum-
mary of the PPE administration process, see Box 3-1.
Coordinated medical team examinations are common in college settings, where the
athletes are treated by a team of health care professionals, and may have a limited role for
high school student-athletes who do not have health insurance, a PCP, or a health care
home. Coordinated examinations for high school athletes are often done as a community
service and can reduce costs for student-athletes who have limited financial resources. At
both levels, the group examinations depend even more on athletes and their parents or
guardians accurately and honestly completing the health history section. Coordinated
medical teams are typically organized by the school team physician or a local clinic, and
they often involve both primary care specialists and other sports medicine specialists.
On-site medical specialists and professionals may allow consultation for a wide range of
problems. A process should be in place to help any student-athlete who does not have a
medical home.
Box 3-1. The Preparticipation Physical Evaluation Administration Summary

1. The preparticipation physical evaluation (PPE) should be performed as part of the periodic
health supervision examination every 2 to 3 years, with updated interval histories at intervening
health supervision checks yearly.
2. The PPE is best performed in the setting of the primary medical home, by a provider who knows
the athlete well or who has a comprehensive medical and injury history of the athlete.
3. The writing group does not recommend that these examinations be performed in a station-
based or group setting or by providers who do not have access to the athlete’s comprehensive
medical and injury history. It is clear from the literature that these examinations are not equiva-
lent to the examination performed by the primary medical home.
4. If a station-based or group examination is used, it is important that review of the history and
physical examination be performed by the provider assessing medical eligibility and participa-
tion status.
5. Athletes and their parents or guardians are responsible for timely scheduling of PPEs, as
problems that require additional testing may delay the completion of the examination in time
for the start of season practices.
6. The final responsibility for a PPE lies with the provider who signs the Medical Eligibility Form
and assumes the medical liability.
7. Athletes with problems discovered during the PPE that are beyond the scope and expertise of
the examining provider should be referred to an appropriate specialist for consultation regard-
ing medical eligibility.
8. The standardized PPE History Form is the preferred format for documentation in either paper
format or electronic format.
9. Adolescent athletes should be seen apart from their parents or guardians for at least part of the
examination so that the provider can inquire about risk-taking behaviors.
10. Defined sections of the PPE are personal (or protected) health information and require confi-
dential, secure handling and permission of the athlete, or parent, or guardian, to be shared
beyond the athlete’s health care personnel.
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Methods and Setting of the Evaluation 21
When PPEs are done in a group setting, the team or lead physician should coordinate
the process and supervise the team of health care professionals to ensure that all appropri-
ate components of the assessment take place as outlined in Table 3-1. Insufficient provider
recruitment and attendance can lead to more athletes being screened than the providers
can manage in the session. It is better to be overstaffed to allow providers to spend appro-
priate time with each athlete.
Table 3-1. Elements of a Coordinated Medical Evaluation
Stage Purpose
Waiting area Sign-in, registration, and review, including careful instruction about
completing required forms.
Vitals station (private Height, weight, body mass index,a blood pressure, heart rate, and
setting) visual acuity may be performed by qualified personnel such as medi-
cal assistants, student athletic trainers, and medical students.
General medical examina- History review and physical examination performed by a single
tion station physician for a given student-athlete. Medical eligibility status or
referral plan determined.
Specialty examination Orthopedic assessment, cardiological evaluation, pulmonary function

stations testing, or other systems-based examination.
Optional stations Education and immunization areas.
a
Body mass index can be calculated from height and weight (www.cdc.gov/growthcharts).
In the coordinated medical team approach with multiple providers (Box 3-2), the PPE
writing group recommends that a single provider review the history and perform the exam-
ination for a student-athlete. However, individuals with known ongoing medical issues
should be redirected to the appropriate medical consultant on the basis of the nature of
the condition. Colleges typically use a coordinated medical team and may institute special
evaluations uniquely useful for a given sport.
The team or lead sports physician is responsible for assembling an interdisciplinary
group with the combined expertise to examine and review each athlete. On-site specialists
in orthopedics and cardiology can help with difficult medical eligibility assessments and
can expedite the evaluation of athletes with medical eligibility concerns. Physical thera-
pists, athletic trainers, nutritionists, and exercise physiologists can be incorporated to help
with check-in, checkout, “traffic control,” vital sign measurements, patient education, mus-
culoskeletal screening, and rehabilitation exercise instruction. Coaches and school admin-
istrators can be enlisted to help maintain order and discipline in what can be a chaotic
group environment.
The team physician must choose a location that will allow adequate space for the sub-
stantial number of participants and ensure private and quiet space for each individual
examination. Many providers use their medical offices after hours to conduct these
03_ch03_15-24.indd 21 3/20/19 4:21 PM

Box 3-2. Tips to Improve the Coordinated Medical Team Approach to

Preparticipation Physical Evaluations
Preparation
• Provide the athletes information in advance about the detailed nature of the examination.a
Privacy
• Ensure separate and private areas for examining male, female, and transgender athletes.
—— Require appropriate examination attire.
—— Ensure a private counseling room for discussion of sensitive issues.
Referrals
• Establish a clear protocol for return to the health care home or referral to specialists for more-
extensive evaluation or rehabilitation for every student-athlete who is not medically eligible for
sport participation.
• Aid athletes who need help arranging follow-up evaluations (ie, low-income, uninsured, and
those without primary care providers).
Medically Ineligible or Limited Student-Athletes
• Keep a record of athletes who are not medically eligible or who require further evaluation before
final medical eligibility is determined (see the Medical Eligibility for Participation content in each
system section of Chapter 6 that has it). The team physician or PPE site coordinator should follow
up with the athletes to establish the final disposition.
• Counsel any athlete who is not medically eligible for the desired sport regarding possible alter-
nate activities.
a
Filling out the history, physical examination, and medical eligibility forms (pages 217 and 218, 221, and 225)
carefully and in advance of the examination can improve the entire process. Therefore, at the start of a coordi-
nated medical team evaluation, explaining to the student-athletes and their parents or guardians how to correctly
complete the forms will result in a more useful completed form. Appropriate privacy, storage, and handling of
forms can give an athlete greater confidence in the confidentiality of the process.
examinations so that individual examiners and athletes have privacy. The rooms can be
arranged to allow an orderly flow of athletes and specific consultations to take place.
When a student-athlete does not meet medical eligibility requirements, effective com-
munication among the evaluating provider, the student-athlete, and the athlete’s parents or
guardians is essential. Communicating the medical details of the activity restriction to team
athletic trainers and coaches requires permission of the athlete and parents (see Chapter 4,
the HIPPA, FERPA, and Athlete Privacy content). In a medical team setting, the team physi-
cian will often lead this discussion. The decision to restrict activity is often not finalized
on the day of the evaluation. Rather, it occurs after consulting with medical subspecialists,
reviewing risks of participation with the consultant, and then meeting with the athlete (and
family) in a private setting to discuss the specific issue limiting medical eligibility.
■■ INTERIM ANNUAL EVALUATIONS

An interim annual evaluation takes place between comprehensive examinations, either
face-to-face or by questionnaire, usually before the first competitive season of the academic
03_ch03_15-24.indd 22 3/20/19 4:21 PM

References 23
year. All student-athletes should complete a risk-focused (heart, head, heat injury, and
mental health issues) history questionnaire, either comprehensive or medical, and
undergo an evaluation for any area indicated by the history. The purpose of the interim
evaluation is to assess problems that have occurred since an athlete’s comprehensive PPE.
When done in the provider’s office, it also serves as a time to reinforce previously discussed
lifestyle issues and restate critical questions regarding conditions such as syncope and
concussion.
Ideally, the provider reviews the History Form and determines what parts of the physi-
cal examination should be performed. While this may be a very brief visit, a more detailed
examination would be performed when the provider identifies a potentially serious issue.
For example, for a student-athlete reporting syncope during exercise, a complete cardio-
vascular assessment would be required before medical eligibility is determined. In some
states, the interim questionnaire is reviewed by an administrator of the school (school
nurse, athletic trainer, or activity director) who sends athletes with positive responses to
the appropriate provider of record for reevaluation and medical eligibility determination.
This requires good communication between the schools and the providers.
■■ REFERENCES
1. Herring SA, Kibler WB, Putukian M. Team physician consensus statement: 2013 update. Med Sci Sports
Exerc. 2013;45(8):1618–1622. https://www.sportsmed.org/AOSSMIMIS/members/downloads/education/
ConsensusStatements/TeamPhysician.pdf. Accessed February 11, 2019
2. Pickham D, Chan G, Carey M. Pre-participation screening for athletes and the role of advanced
practice providers. J Electrocardiol. 2015;48(3):339–344 PMID:25791248 https://doi.org/10.1016/j.
jelectrocard.2015.03.003
3. Herring SA, Kibler W, Putukian M. Sideline preparedness for the team physician: a consensus statement—
2012 update. Med Sci Sports Exerc. 2012;44(12):2442–2445 PMID:23160347 https://doi.org/10.1249/
MSS.0b013e318275044f
4. Roberts WO, Löllgen H, Matheson GO, et al; American College of Sports Medicine (ACSM); Fédération
Internationale du Médicine du Sport (FIMS). Advancing the preparticipation physical evaluation: an ACSM
and FIMS joint consensus statement. Clin J Sport Med. 2014;24(6):442–447 PMID:25347259 https://doi.
org/10.1097/JSM.0000000000000168
5. Ljungqvist A, Jenoure PJ, Engebretsen L, et al. The International Olympic Committee (IOC) consensus
statement on periodic health evaluation of elite athletes, March 2009. Clin J Sport Med. 2009;19(5):347–365
PMID:19741306 https://doi.org/10.1097/JSM.0b013e3181b7332c
6. American Academy of Pediatrics Committee on Practice and Ambulatory Medicine and Bright Futures
Periodicity Schedule Workgroup. 2017 recommendations for preventive pediatric health care. Pediatrics.
2017;139(4):e20170254 PMID:28213605
7. Krowchuk DP, Krowchuk HV, Hunter DM, et al. Parents’ knowledge of the purposes and content of prepar-
ticipation physical examinations. Arch Pediatr Adolesc Med. 1995;149(6):653–657 PMID:7767421 https://doi.
org/10.1001/archpedi.1995.02170190063011
Br J Sports Med. 2017;51(3):151–152 PMID:27935485 https://doi.org/10.1136/bjsports-2016-096892
9. Maron BJ, Friedman RA, Kligfield P, et al; American Heart Association Council on Clinical Cardiology,
Advocacy Coordinating Committee, Council on Cardiovascular Disease in the Young, et al; American
College of Cardiology. Assessment of the 12-lead electrocardiogram as a screening test for detection of
cardiovascular disease in healthy general populations of young people (12–25 years of age): a scientific
statement from the American Heart Association and the American College of Cardiology. J Am Coll Cardiol.
2014;64(14):1479–1514 PMID:25234655 https://doi.org/10.1016/j.jacc.2014.05.006
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11. Brukner P, White S, Shawdon A, Holzer K. Screening of athletes: Australian experience. Clin J Sport Med.
2004;14(3):169–177 PMID:15166906 https://doi.org/10.1097/00042752-200405000-00010
12. Metzl JD. Preparticipation examination of the adolescent athlete: part 1. Pediatr Rev. 2001;22(6):199–204
PMID:11389307 https://doi.org/10.1542/pir.22-6-199
13. Stickler GB. Are yearly physical examinations in adolescents necessary? J Am Board Fam Pract.
2000;13(3):172–177 PMID:10826864 https://doi.org/10.3122/15572625-13-3-172
14. O’Connor FG, Kugler JP, Oriscello RG. Sudden death in young athletes: screening for the needle in a hay-
stack. Am Fam Physician. 1998;57(11):2763–2770 PMID:9636339
03_ch03_15-24.indd 24 3/20/19 4:21 PM

CHAPTER 4
Health Privacy,
Ethical Issues,
and Legal
Concerns
Physicians and other health care professionals face complex health privacy, ethical, and
legal issues when administering the preparticipation physical evaluation (PPE) and com-
municating athlete medical eligibility with schools, coaches, athletic trainers, and parents
or guardians. The Health Insurance Portability and Accountability Act (HIPAA) and the
Family Educational Rights and Privacy Act (FERPA) require confidentiality and protection
of personal health information (PHI) when providers inform schools and coaches of ath-
lete participation decisions. These laws apply in different situations depending on the con-
text of the interaction. Ethical issues may arise when real or perceived breaches of conduct
occur during the examination. Similar breaches of conduct may arise when participation
recommendations differ from athlete, parent, coach, or team administration expectation.
Liability is a concern for those conducting the medical evaluation, especially when con-
troversial medical eligibility decisions involve informed consent, and waivers, designed to
circumvent medical opinion and allow participation. Federal law typically defers the deter-
mination of who is considered an adult to state law. Although age 18 is by far the most
common age, some states use age 19 or 21 as the legal age of majority. Further, state laws
vary greatly regarding emancipation, mature minor determination, and consent and pri-
vacy for the treatment of certain medical conditions, such as pregnancy and mental health.
This chapter is intended as a general overview and should not be considered a legal
opinion. Many of these issues are complex, and outcomes of similar situations may differ
depending on the jurisdiction.
■■ HIPAA, FERPA, AND ATHLETE PRIVACY

HIPAA Privacy Rule. The HIPAA Privacy Rule establishes national standards to protect an
individual’s medical records and other PHI from discovery outside the medical care team.
It applies broadly to all health care interactions, and breaches are punishable. Personal
04_ch04_25-34.indd 25 3/20/19 3:15 PM

26 Chapter 4. Health Privacy, Ethical Issues, and Legal Concerns
health information is defined as any information that can potentially identify a patient
(eg, athlete) and relates to past, present, or future physical or mental health conditions,
such as name, medical diagnosis, address, phone number, or social security number.1
HIPAA requires safeguards to protect the privacy of PHI, and it sets limits on what can
be done with such information without patient authorization. HIPAA also gives patients
rights over their health information, including the ability to examine and obtain their own
health records.1
The HIPAA Privacy Rule expressly allows release of some medical information without
an individual’s authorization in certain circumstances. If the player’s medical eligibility,
that is, whether the player is “medically eligible” or “not medically eligible” to participate,
is communicated without other medical information, it can be given to coaches and school
administrators and falls within the exempt category.2 However, if the school or coach
wishes to know more details beyond the medical eligibility, a signed authorization for
release of patient information must be obtained. Some states may have regulations that are
more stringent than federal HIPAA rules, and these more stringent state laws supersede the
federal regulations. Authorizations for release of information can be rescinded at any time
by the athlete or by the parents or guardians of a minor athlete.
FERPA regulations. FERPA is a federal law with similar intent to the HIPAA Privacy
Rule. The law protects the privacy of student education records and applies when infor-
mation is considered part of an educational record. FERPA pertains only to schools that
receive funding from the US Department of Education.3 FERPA provides students older
than 18 and all postsecondary students, or parents of students younger than 18 years and
not yet in postsecondary education, certain rights regarding their educational record,
including the right to inspect and, if necessary, correct educational records. FERPA also
allows schools to disclose student records without consent under certain circumstances,
including organizations conducting certain studies for or on behalf of the school.3
FERPA documents are specifically excluded from HIPAA. FERPA potentially allows
medical information that is classified as a part of the educational administrative record
to be released to parents or guardians, or to school personnel, without special consent—
information that would otherwise be protected if these records were under the auspices
of HIPAA. Often, school-based athletic training facility records, such as PPEs and training
room medical encounters maintained by team physicians or athletic trainers employed by
the educational institution, are judged to fall under the purview of FERPA. If a person or an
entity acting on behalf of a school—such as a team physician who provides services to
student-athletes under contract with or otherwise under the direct control of the school—
maintains student health records, these records are education records under FERPA, just as
they would be if the school maintained the records directly. This applies to health care pro-
vided to athletes either on-site or off-site by individuals with direct institutional ties.
Whether HIPAA or FERPA regulations apply in a given situation is a complex legal ques-
tion and may vary by state and by specific situation. It is prudent to review HIPAA, FERPA,
and institutional privacy policies with the educational institution’s legal counsel or privacy
officer to ensure proper procedures are followed for the release of PHI. School person-
nel should receive education on privacy regulations that affect athlete care and transfer of
health-related information. Sports organizations need to develop educational programs for
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HIPAA, FERPA, and Athlete Privacy 27
privacy legislation and legal constraints so that all personnel working with athletes follow
proper protocol to comply with all state and federal laws.
Confidentiality and PPE forms. The PPE Medical Eligibility Form has a “Medically
eligible for certain sports” check box and a “Not medically eligible for any sports” check
box that allow the physician to communicate the medical eligibility of an athlete to the
school without breaking the confidentiality rules governing medical interactions or divulg-
ing PHI.2 When the evaluation is performed in an office practice setting that is not affili-
ated with the school or sport club, it is safest, from a privacy perspective, to separate the
Medical Eligibility Form from the confidential history and physical portions of the evalu-
ation. The alternative is to have a clear release of medical information form signed by the
athlete (and parent or guardian if the athlete is a minor) allowing the entire or specific
portions of the PPE record with PHI to go to the school or team. Copies of the history and
physical examination forms should stay with the athlete’s medical record. With or without
HIPAA and FERPA regulations, athletes have a right to privacy, and all medical interactions
should respect athlete confidentiality.
For examinations done in a group setting, a confidential storage system for the
completed PPE forms must be developed and implemented. The information pertaining
to activity restrictions beyond medical eligibility status should be shared only with those
in the school administration who need to know. With parent, or guardian, and athlete per-
mission, a copy of the form should be made available to the athlete’s primary care physi-
cian or health care team whenever possible. Giving the athlete or the parent or guardian (if
the athlete is a minor) a copy of the form to take to the health care professional will often
facilitate this process.
The forms in this monograph are designed to share essential information regarding
athlete evaluation, emergency care, and future sports participation with those who need to
know but without jeopardizing PHI. A transition to an electronic format may improve this
process.
Restricting participation. When an athlete is medically ineligible to participate in a
sport or all sports, the questions of who needs to know of the restriction and how this
should be communicated frequently arise. The only information the coach and team
administration need to know is the medical eligibility to participate and in which, if any,
sports. In many cases, the athlete or the parent or guardian will share the decision and
the facts of the case with the coach. A signed medical release form must be obtained for
a physician to discuss the case details with the coach or administrator.4 At schools where
there are team physicians, athletes may be required to sign a form that authorizes sharing
of essential medical information among the physician, the athletic trainer, coaches, and
school administrators as a condition of participation. In some team circumstances, the ath-
letic trainer is part of the medical team and may be privy to the essential medical details of
an athlete’s case on a “need to know” basis for on-site care.
Sharing emergency and public health information. For athlete safety and rapid
response to emergency situations in a locker room or on a field of play, the Medical
Eligibility Form may include (with permission of the athlete or parents) information
such as known allergies, pertinent medications and medical conditions (eg, asthma or
type 1 diabetes mellitus), and tetanus status so that team personnel can react
04_ch04_25-34.indd 27 3/20/19 3:15 PM

appropriately. The team physician or athletic trainer should have access to a listing of
chronic medical problems, allergies, medications, and preferred locations for emergency
care when parents or guardians are not available. When a team physician or an athletic
trainer is not available, one of the coaching staff should have this information.
In some situations, PHI should be shared with officials or coaches without the consent
of the athlete (eg, an infectious disease such as herpes gladiatorum or meningococcal
meningitis in an athlete may threaten the health and safety of others). The issue of obliga-
tion to inform others of potential transmission, from a public health perspective, must be
balanced with the right of the athlete to keep PHI confidential. The answer regarding duty
to disclose will vary depending on jurisdiction. When these situations arise, legal counsel
should be sought regarding responsibilities as a health care professional. In cases for which
legal consult is not available, every effort should be taken to relay the potential public
health risk without divulging the identity of the individual involved. This may involve
reporting to the local or state Department of Public Health.
Electronic transmission. When coaches, athletic trainers, and medical providers com-
municate by electronic means, the information should be encrypted and password pro-
tected. Electronic record systems that are used to store information obtained during the
PPE or other medical encounters should be in password-protected and secure sites that
can be accessed only by authorized medical personnel. This information may be needed
to treat athletes on a sideline or in an athletic training facility. E-mail and text communi-
cations to and from a coach or an athletic trainer may not be secure when sent through
the Internet and must be encrypted to prevent loss of confidentiality. Athlete permission
is required for physicians to communicate PHI with coaches and athletic trainers via
encrypted e-mail or text messaging.
Restricting information. Athletes have the right to request a restriction or limitation on
the health information the school uses or discloses.1 The request must be in writing to the
facility where the team records are maintained. The request must state (1) what informa-
tion is to be limited; (2) whether the limit pertains to use, disclosure, or both; and (3) to
whom the limits apply. An athlete may also request that all confidential communications
be conducted away from the practice sessions, games sites, and locker rooms. For those
seeking more details about HIPAA, the US Department of Health and Human Services
Office for Civil Rights maintains a Web site at www.hhs.gov/ocr/index.html that provides
helpful information, including forms and educational materials about the privacy rule.
Travel. Ideally, the information obtained during the PPE should be available to the
team physician, team athletic trainer, and emergency medical personnel, all of whom
may be called to render emergency care for an athlete on a sideline or in an athletic train-
ing facility. Many teams travel with a copy of the student's health information so that it is
available if an athlete is injured during an away game. The PPE record must be in a secure
storage area during travel. Electronic digital-based records that are housed in a password-
protected secure site and that can also be accessed via the Web and graduated with respect
to record access that is based on need to know can make health data more easily accessible
and more secure.
When high school athletes have examinations completed by their primary care physi-
cians, confidentiality of the record becomes more complicated if it is to be housed at the
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Ethical Issues 29
school or travel with the team. A history of diabetes, seizure disorder, asthma, or allergies
can be critical in certain instances. The Medical Eligibility Form in this monograph allows
an athlete and his or her parents or guardians to include allergies and other emergency
information for team medical and coaching personnel that may be critical to care when
the parents are not present or the athlete cannot respond to questions. However, it falls to
the athlete or the parents or guardians to complete that section of the form or be present
to inform the on-site physician, athletic trainer, or coach of medical conditions that might
result in an emergency for the athlete.
■■ ETHICAL ISSUES
Breach of conduct. The issue of improper professional conduct during the PPE has sur-
faced on several occasions with allegations of sexual improprieties on the part of the
physician.5 Although most of these concerns have involved male to female and male to
male interactions, any physician-patient interaction has potential for transgressions, either
perceived or real. A chaperone should always be available for examinations, and the use
of a chaperone should be a shared decision between the patient and the provider. There is
always risk of accusations in any patient encounter when the door is closed and the physi-
cian is alone with a patient; a chaperone in the room is recommended when this is a con-
cern. Furthermore, athletes may not expect to have a thorough examination, and portions
of the PPE, although proper, can be perceived as improper, particularly when the genitalia
are involved. A full explanation of the examination and reasons for the procedure should
reduce the perception of impropriety, and the examination should be tailored to the his-
tory. Many past practices (such as testicular cancer examinations and inguinal hernia
checks for males and breast, genital, and pelvic examinations for females) are no longer
recommended for the routine health screening examinations or the PPE. If a medical chap-
erone is indicated and the athlete refuses, the athlete or parent should be given alterna-
tives, including seeking care elsewhere.
In every case, the health care professional should inform the athlete of the extent and
purpose of physical examination procedures before performing the examination; provide
an appropriate and confidential setting, including chaperones; and use discretion with
comments or actions that could be misconstrued. Offering examination stations with
physicians of both sexes and allowing athletes to choose the examiner during a multiple-
physician examination can also decrease the risk of perceived impropriety. Consistency in
patient attire and examination routine will decrease the risk of an athlete comparing his or
her examination with those of other athletes and questioning why it might have been dif-
ferent. Attire for males might include shorts and T-shirts and for females shorts and tank
tops under a T-shirt.
Ethical decision-making and restriction from participation. When PPE findings
lead to a medical eligibility recommendation for “no participation” in an athlete’s cho-
sen sport, the adage “first, do no harm” conflicts with the athlete’s desire to compete.
Although conditions that preclude participation are rare and many are well described,
athletes will sometimes challenge activity restrictions, leaving the physician with an ethical
dilemma that pits the athlete’s perceived right to participate against the physician’s desire
to do no harm. The decision to restrict participation in selected or all physical activities is
04_ch04_25-34.indd 29 3/20/19 3:15 PM

seldom made by a single physician and usually requires a thorough educational effort by
all involved to explain the decision. The athlete and the parents or guardians should be
involved in the shared decision-making discussion regarding medical eligibility and the
potential consequences of both the activity restriction and the potential risks or harms of
continuing to participate in the activity. An athlete or the parents may seek another medi-
cal opinion or pursue legal intervention to allow participation, even when accepted medi-
cal eligibility recommendations, such as those of the American Heart Association (AHA),
suggest that the risk is too great for safe participation.6 The decision to restrict participation
is not always clearly defined or easy, and it is important to remember that restricting medi-
cal eligibility is life altering for an affected athlete.
Ideally, a physician who restricts medical eligibility should consult with appropriate
specialists in the field to develop a participation recommendation that reflects the relative
risk for the athlete’s safety during practice and competition. Following the consultations,
it is imperative that the physician fully inform the athlete (and parents or guardians) of
potential risks associated with participation that are based on the disqualifying condition.
This will allow the athlete and the parents or guardians to make an informed decision
regarding participation that is based on the medical eligibility evaluation. It is important
to remember that athletes older than 18 years must give permission to discuss the disquali-
fying condition with the athlete’s parents or guardians. Medical eligibility conversations
are complicated because it is not easy to quantify a long- or short-term risk from a medi-
cal condition, and there is some degree of inherent risk in sports participation. The degree
of acceptable risk may also vary depending on the situation. Such discussions should be
clearly documented in the athlete’s medical record.
The ethics of medical eligibility should not be confused with the issue of whether it is
legally prudent to have an athlete participate for an institution. An institution may wish to
allow an athlete to play, even though there is significant risk, because of a player’s ability.
An institution may be motivated to allow an athlete to participate specifically to avoid a
potential lawsuit, particularly if there is divergent medical opinion regarding the condition
and how it affects medical eligibility. An institution may also wish to restrict an athlete
from participation rather than accept any legal risk from an adverse outcome. Ultimately,
the physician, together with consultants, must make a decision that is in an athlete’s best
interest and independent of other factors.
A physician determining medical eligibility should try to allow the athlete to participate
with reasonable risk in chosen activities. As the potential consequences of participation
become more serious, the level of acceptable reasonable risk decreases. When medical
conditions arise after an athlete has been deemed medically eligible for participation, the
physician may rescind eligibility until the problem is resolved.
■■ LEGAL CONCERNS
Legal aspects of limiting medical eligibility. A team physician and an institution have
the legal right to restrict an individual from participating in athletics if the decision is indi-
vidualized, reasonably made, and based on competent medical evidence.7 All institutions
may not evaluate risk in the same way. In other words, one set of physicians and a given
institution may elect to allow participation for a specific set of medical circumstances,
04_ch04_25-34.indd 30 3/20/19 3:15 PM

Legal Concerns 31
while another may not; however, if the decision is based on sound medical judgment, it is
legally acceptable and the courts have historically supported decisions made by the team
physician. This view has been highlighted within 3 noteworthy cases.
Case No. 1 Knapp v Northwestern University8: As a high school senior,

Nicholas Knapp experienced cardiac arrest and was successfully resusci-
tated. He subsequently had an implantable cardiac defibrillator placed
and was granted by 3 cardiologists full medical eligibility to play basket-
ball. He participated without incident during the summer before matricu-
lation. At Northwestern University, he was denied medical eligibility for
practice and competition by the team physician on the basis of the opin-
ion of their consulting cardiologist and the 26th Bethesda Conference
guidelines (the most current at the time). Northwestern agreed to honor
its commitment for his scholarship. Knapp sued Northwestern, citing
the Rehabilitation Act of 1973, which compels institutions that receive
federal funds to provide people who have disabilities with an opportunity
to participate fully in activities in which they have the physical skills and
capabilities to perform. The courts deemed that playing an intercollegiate
sport was not a “major life activity”; therefore, the Rehabilitation Act did
not apply. They agreed that Northwestern’s institutional decision, based
on established medical guidelines, was reasonable.
Case No. 2 Pahulu v University of Kansas: Alani Pahulu was a football

player at the University of Kansas (KU). During a spring football scrim-
mage, he experienced a hit to the head during a tackle and briefly experi-
enced transient quadriplegia. The team physician later examined Pahulu
and discovered that he had a congenitally narrow cervical spinal canal. In
consultation with a neurosurgeon, the team physician concluded that the
stenotic cervical spinal canal, coupled with the transient quadriparesis,
placed Pahulu at extremely high risk for subsequent and potentially per-
manent severe neurological injury. Thus, the team physician disqualified
Pahulu from football. Pahulu filed a lawsuit, but while he offered the
opinions of 3 outside specialists, who examined him after his disqualifica-
tion and concluded that he was at no greater risk of permanent paralysis
than any other football player, the court found that the KU physician
acted reasonably and rationally.7
Case No. 3 Class v Towson University: During an August football practice,

Gavin Class collapsed and experienced heat stroke, with a body tem-
perature of 42°C (108°F). He subsequently experienced cardiac arrest
and liver failure, requiring 14 surgical procedures, including a liver
transplantation. Class recovered and trained to rejoin the team. He was
deemed medically eligible by physicians from the University of Maryland
Medical Center and the Korey Stringer Institute, which specializes in heat
stroke research and evaluation for return to activity. However, Towson
University physicians considered him to have a severe health risk that was
04_ch04_25-34.indd 31 3/20/19 3:15 PM

too onerous for care by the football team’s medical staff. Class sued the
university and won in district court, where the judge was sharply critical
of Towson’s arguments for keeping him from playing football. However, a
federal appeals court overturned this decision and upheld the decision by
the Towson University medical team.
In summary, the decision to allow an athlete to participate, or not, at a specific institu-

tion has thus far been left in the hands of the team physicians, their consultants, and the
institution. The level of reasonable perceived risk will vary from institution to institution,
but the decisions regarding medical eligibility remain individualized and under local con-
trol. The preceding case summaries affirm the adage that participation in college athletics
is generally considered “a privilege and not a right.”
Exculpatory waivers. If an athlete wishes to participate despite contrary medical recom-
mendations, the athlete and his or her parents or guardians may suggest an “exculpatory
waiver” or “risk release” to clearly indicate that they are fully informed of the inherent
risk of participation against medical advice and that they assume the responsibility for all
aspects of this risk. An exculpatory waiver or risk release is a written contract among an
athlete and his or her parents or guardians, the physician, and the school or activity spon-
sor. In it, the athlete promises not to sue the physician or activity sponsor and releases the
physician and activity sponsor from liability.9 However, these kinds of documents tend to
be interpreted narrowly, and courts have invalidated contracts to release physicians from
liability for negligent medical care of their patients.5 Moreover, a waiver of legal rights by
an athlete who is a minor is usually not enforceable, even if a waiver is also given by the
parents or guardians, because minors have only limited legal capacity to enter contracts.7
Physicians and institutions should exercise extreme caution when entering into exculpa-
tory waivers with athletes who are deemed at significant medical risk.
Informed consent. A physician may choose to allow an athlete to participate if the
athlete and the parents or guardians express a clear understanding of the possible risks for
a potentially catastrophic condition and, despite the risk, choose to participate anyway.
Some legal experts recommend that physicians, to protect themselves, have the parents or
guardians and the athlete write, in their own words and in their own handwriting, a signed
letter indicating their understanding of the risks of continued participation, and that they
understand the risks they are taking, instead of signing a waiver.10,11 The difference is that a
standard waiver is usually a form with blanks that are filled in by the physician and writ-
ten in language that the parents or guardians or the athlete would not normally use. With
the standard waiver form, it has been successfully argued in court that, despite having
signed a waiver, the parents or guardians and the athlete did not fully understand the risks
involved. However, with a letter written by the parents or guardians or the athlete, it would
be difficult to convince a jury that the parents or guardians or the athlete did not under-
stand the risks before an adverse event occurred from continued participation. A video of
the athlete and the parents or guardians stating that they clearly understand the condition
that limits the medical eligibility and detailing their understanding of both the medical
condition and the associated risks is an alternative to a letter that some institutions have
used to document informed decision-making.
04_ch04_25-34.indd 32 3/20/19 3:15 PM

Legal Concerns 33
Limiting legal risk. To limit legal risk, medical eligibility recommendations should be
individualized after appropriate studies and consultant opinions are obtained. National
guidelines, such as the AHA and American College of Cardiology document “Eligibility
and Disqualification Recommendations for Competitive Athletes With Cardiovascular
Abnormalities” (www.acc.org/~/media/fb92803045d249ae91b715650dd0ebe4.pdf),6 offer
helpful information in certain situations regarding medical eligibility but are necessarily
conservative. If one chooses to deviate from consensus guidelines, there should be clearly
articulated and documented medical reasons why continuing participation is reasonable
in a particular case. Consultant agreement and patient understanding and parent, or guard-
ian, understanding of the issues involved are essential to limit legal exposure for the pri-
mary or team physician, recognizing once again that a waiver of legal rights by an athlete
who is a minor is usually not enforceable.
Legal ramifications of the examination setting. The examination setting will have
some bearing on all aspects of the PPE. Physicians who evaluate and recommend sports
participation after completing a PPE in the office always face liability issues as they would
with any patient encounter. An examination and medical eligibility recommendation
completed by an athlete’s personal physician continues the physician-patient relation-
ship with access to an ongoing medical record. This method, therefore, leaves less room
for error and misunderstanding and less risk for missed or intentionally omitted medical
information compared with group examinations. Group examinations can be perceived as
quick and cursory, which may increase medical liability risk. Should the examination fail
to uncover a medical condition and injury ensue, the perception that the examination was
inadequate may support a concern of negligence. Appropriate documentation of the extent
of the examination can mitigate this risk. In addition, protecting an athlete’s privacy in
group settings may be more challenging than in private settings.
Mandatory reporting. As health care professionals conduct a PPE, the laws govern-
ing mandatory reporting of suspected abuse apply. Mandatory reporting laws require that
health care professionals report child abuse and neglect to a proper authority, such as a law
enforcement agency or child protective services. If an athlete discloses a previous history
of inappropriate examination by a medical professional, previous history of physical or
sexual abuse, or inappropriate sexual relationships during the PPE, mandatory reporting to
child protective services is required.
Good Samaritan statutes and charitable immunity. The legal liability of those who
perform PPEs as a volunteer is not easily understood. Good Samaritan statutes vary from
state to state and generally apply only to emergency situations and only regarding people
who render care without compensation or the expectation of compensation. Under a
Good Samaritan law, providers are typically protected from all liability except the types
associated with gross negligence or willful and wanton acts of malpractice. However, the
PPE is not considered emergency care and the examinations are planned in advance, so in
most states, providers should not depend on Good Samaritan statutes for liability or mal-
practice protection.
In many cases when physicians are doing PPEs as a volunteer, charitable immunity stat-
utes are more applicable. In general, these laws apply to licensed health care professionals
who are volunteering and acting within the scope of their practice. These laws typically
04_ch04_25-34.indd 33 3/20/19 3:15 PM

make it more difficult for a plaintiff to win a lawsuit and may cap damages or limit non-
economic claims. Historically, state laws control malpractice liability and every state has
different laws and different legal precedent. While it does not offer complete immunity,
the Volunteer Protection Act of 1997 was designed to encourage volunteerism by health
care professionals at nonprofit clinics and is a federal law that offers protection to those
volunteering at a nonprofit institution.12
It is essential for physicians to know their state’s statutes regarding PPEs in volunteer
settings. Physicians who do not carry personal malpractice insurance (eg, employed physi-
cians) may not be covered when providing volunteer medical examinations and medical
care. Those who do carry personal malpractice insurance may have limitations in scope,
particularly for non–primary care physicians. All physicians volunteering as a team physi-
cian or providing PPEs outside their normal office setting should verify professional liabil-
ity coverage. In some circumstances, individual liability could be purchased as appropriate.
Physicians who volunteer as examiners in mass screening PPE sessions that are not
covered under Good Samaritan or charitable immunity statutes must address the issue of
malpractice insurance coverage. It is prudent for physicians to check with their insurance
carrier before volunteering at PPE sessions.
■■ REFERENCES
1. Office for Civil Rights. Summary of the HIPAA Privacy Rule. US Department of Health and Human Services
Web site. https://www.hhs.gov/hipaa/for-professionals/privacy/index.html. Reviewed April 16, 2015.
Accessed February 12, 2019
2. Magee JT, Almekinders LC, Taft TN. HIPAA and the team physician. Sports Med Update. 2003;:4–7
3. Family Educational Rights and Privacy Act (FERPA). US Department of Education Web site. https://ed.gov/
policy/gen/guid/fpco/ferpa/index.html?src5rn. Updated March 1, 2018. Accessed February 12, 2019
4. Pearsall AW IV, Kovaleski JE, Madanagopal SG. Medicolegal issues affecting sports medicine prac-
titioners. Clin Orthop Relat Res. 2005;(433):50–57 PMID:15805936 https://doi.org/10.1097/01.
blo.0000159896.64076.72
5. Herbert DL. Prospective releases: will their use protect sports medicine physicians from suit? Sports Med
Stand Malpract Rep. 1994;6(3):35–36
6. Maron BJ, Levine BD, Washington RL, Baggish AL, Kovacs RJ, Maron MS. Eligibility and disqualification
recommendations for competitive athletes with cardiovascular abnormalities: task force 2; preparticipa-
tion screening for cardiovascular disease in competitive athletes: a scientific statement from the American
Heart Association and American College of Cardiology. J Am Coll Cardiol. 2015;66(21):2356–2361
PMID:26542659 https://doi.org/10.1016/j.jacc.2015.09.034
7. Mitten MJ. Emerging legal issues in sports medicine: a synthesis, summary, and analysis. St Johns Law Rev.
2002;76(1):100–182
8. Maron BJ, Mitten MJ, Quandt EF, Zipes DP. Competitive athletes with cardiovascular disease—the case
of Nicholas Knapp. N Engl J Med. 1998;339(22):1632–1635 PMID:9828254 https://doi.org/10.1056/
NEJM199811263392211
9. Gallup EM. Law and the Team Physician. Champaign, IL: Human Kinetics; 1995
10. Jones C. College athletes: illness or injury and the decision to return to play. Buffalo Law Rev.
1992;40:113–115
11. Mitten MJ. Team physicians and competitive athletes: allocating legal responsibility for athletic injuries. Univ
Pittsbg Law Rev. 1993;55(1):129–169
12. Hattis PA, Walton J. Understanding Charitable Immunity Legislation: A Volunteers in Health Care Guide.
Providence, RI: Volunteers in Health Care; 2003
04_ch04_25-34.indd 34 3/20/19 3:15 PM

CHAPTER 5
GENERAL
CONSIDERATIONS
OF THE HISTORY,
PHYSICAL
EXAMINATION,
AND MEDICAL
ELIGIBILITY
Key Points and Summary of Evidence

• The preparticipation physical evaluation should be integrated into the periodic health evalua-
tions of an athlete along with preventative care strategies by a provider from the medical home
health care team who has current and past medical records (strength of recommendation [SOR]:
Level C).
• Key findings during the musculoskeletal history will direct the focus of the musculoskeletal physi-
cal examination, as there are currently limited screening examinations that have been validated
to reduce injury risk (SOR: Level B).
• Medical eligibility and sports participation decisions should be clearly outlined and defensible
using evidence-based or expert opinion guidelines, and they should include specialty consultation
when needed (SOR: Level B).
• If an athlete does not qualify for a given sport, alternative activities should be discussed and
athletes should be monitored for physical and emotional repercussions of not being allowed to
participate in desired activities (SOR: Level C).
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36 Chapter 5. General Considerations of the History, Physical Examination, and Medical Eligibility
A systematic approach to the history, physical examination, and medical eligibility

decision-making process will enable an examiner to meet the goals and objectives of the
preparticipation physical evaluation (PPE) in an effective and efficient manner. As current
medical trends evolve, the PPE should be assimilated into the scope of preventive screen-
ing by primary care providers in the medical home1 or office-based periodic athlete health
evaluation by a team physician. The end result of the PPE requirement is often a substitu-
tion of the sports eligibility encounter for the athlete’s comprehensive health supervision
visit with his or her provider.
The challenge of the primary care workforce to routinely evaluate the approximately 46
million children2 in the United States who participate in some form of team or individual
sport is daunting, especially if required annually. For optimum accuracy, a premium must
be placed on a uniform process that is user-friendly and efficient. Obstacles to perform-
ing the PPE within the structure of health supervision care and periodic health evaluation
include time and scheduling limitations, inadequate training in the PPE process and its
implications, uncertainty regarding relative importance of each PPE component, length of
the PPE form, time spent covering non-PPE topics, and lack of a standard approach to the
examination.3,4
Integrating the standardized PPE questions and physical examination into routine
health supervision examinations will reduce the likelihood of missing key elements and
improve encounter efficiency.1 Adopting the standardized PPE form into the routine health
examination electronic medical record increases the potential to collect meaningful data
that can direct future guidelines with evidence-based and outcome-driven content.5
This chapter discusses general considerations of the preparticipation history, physical
examination, and medical eligibility determination, and it will serve as a prelude to con-
cerns covered in Chapter 6 that are more organ-system specific.
■■ HISTORY
The medical history may improve the accuracy of the PPE. In PPE evaluations of high
school and collegiate athletes, the medical history alone detects 88% of general medical
conditions and 67% to 75% of the musculoskeletal conditions.6 While medical history has
value, there are limitations to the question set, which has not been proven to improve or
change athlete outcomes. While the goal of the history questions is to detect all conditions
that confer unacceptable risks to participation, the questions have not been subjected to
scientific investigation7; thus, it is impossible to achieve a zero-risk competitive sport envi-
ronment that is based on the question responses.
For athletes younger than 18 years, both the athlete and the parent or guardian are
asked to respond to medical history questions. Involving parents in the history portion of
the examination is essential to improve the accuracy of the examination, as when studied,
the concordance between athlete responses and parent or guardian responses to the medi-
cal history questions was only 19% to 39%.8 Full access to an athlete’s medical records
during an examination completed within the health care home should improve the accu-
racy of the medical information available to the provider who is determining medical
eligibility.
Illiteracy and limited English proficiency are barriers to completing an accurate medical
history.9 The use of medical interpreters or forms translated into the native language of an
05_ch05_35-42.indd 36 3/20/19 4:21 PM

Physical Examination 37
athlete family’s will result in a more accurate history.10 Making the history forms available
in advance of the evaluation date, to be completed by the athlete and parents, can improve
the accuracy of the history data on the form and reduce the errors associated with a rushed
form completion immediately preceding the evaluation. Completing the form in advance
of the PPE visit allows the family to identify issues that the athlete is not aware of or has
forgotten, especially family and early childhood history.
The medical history should be reviewed in a private setting with both the athlete and
the parent or guardian (if present) and again with the athlete alone for more sensitive
questions when age and developmentally appropriate. Any available medical records
believed to be pertinent should be reviewed for past injuries or illnesses that may not have
been reported in the current medical history or to clarify responses on the History Form.
Positive responses to the medical history questions should serve as a platform to pursue
the secondary questions associated with the issue to determine whether further medical
evaluation is warranted. It is also prudent to verbally clarify negative answers to key ques-
tions involving the heart, head, and mental health issues to underscore the importance of
truthful responses.
Questions regarding mental health concerns or high-risk behaviors should be addressed
when the athlete is alone and away from parents to increase the chances of honest
answers. While the written history forms may address some of these issues, many young
athletes will not provide frank responses to questions that will be seen by parents or
guardians. Providing confidential access to validated supplemental questionnaires such
as the Patient Health Questionnaire versions 2, 9, or adolescent (PHQ-2, PHQ-9, or
PHQ-A [ages 11–17 years]); the Generalized Anxiety Disorder 7-item (GAD-7) scale; or the
PROMIS Depression instruments can assist in screening for depression and anxiety during
the examination and pave a path to appropriate evaluation and treatment resources.11–13
The CRAFFT Screening Tool for Adolescent Substance Abuse 2.014 is designed for use with
children and youths younger than 21 to address alcohol or other drug use disorders and
is endorsed by the American Academy of Pediatrics (AAP).15 The Brief Eating Disorder
in Athletes Questionnaire (BEDA-Q) is a validated screening tool to help distinguish
disordered eating patterns in elite-level female athletes16 and may be useful for suspected
energy balance issues.
■■ PHYSICAL EXAMINATION
The structured physical examination begins by measuring vital signs and visual acuity.
Elevated blood pressure (discussed in Chapter 6, Section 6A) and abnormal visual acuity
are 2 of the most common abnormalities found during a PPE.17
Review of growth curve measurements can identify atypical weight loss or gain that
may suggest disordered eating or insufficient energy availability, unhealthy weight-cutting
behaviors in sports with weight classes, or performance-enhancing supplement use that
may not be otherwise identified.16 Height curves should be reviewed for reduced growth
velocity, suggesting either insufficient caloric intake or delayed pubertal development, that
may place an athlete at higher risk for both overuse injury and contact or collision sport
injury.18 Decreased height velocity or delayed puberty may also indicate other medical
problems such as endocrine or nutritional problems and deserves further evaluation. Body
mass index curves should also be similarly reviewed but may be falsely skewed toward
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overweight status by muscle development in some athletes. (Body mass index can be calcu-
lated as the weight in kilograms divided by the height in meters squared.)
The physical examination builds on information elicited in the medical history. For
example, key musculoskeletal history findings should be followed by a careful physi-
cal examination of involved joints and musculoskeletal regions. Unfortunately, there is
currently no validated set of screening tests to predict injury risk in elite-level athletes,19
although in adolescents who are transitioning through puberty, poor neuromuscular con-
trol of the lower extremity may be a risk factor for anterior cruciate ligament disruption
and patellofemoral joint pain. The components of each segment of the physical examina-
tion are discussed in the system sections of Chapter 6.
If conditions discovered during the evaluation cannot be fully addressed because of
time constraints, the sport qualification decision should be postponed until a full evalua-
tion can be completed.
■■ DETERMINING MEDICAL ELIGIBILITY

Determining medical eligibility is an important and sometimes difficult decision-making
process, often pressured by time constraints associated with the start of team practice ses-
sions. When additional evaluation is needed, the medical eligibility decision should be
deferred until the necessary data are obtained. While up to 14% of athletes require further
evaluation before medical eligibility status can be determined, more than 98% of athletes
qualify to participate in their desired sport.20 For younger adolescents, temporary eligibility
restrictions are mainly in response to growth-dependent musculoskeletal findings.21
Reports of prior restricted medical eligibility are significant findings that require addi-
tional investigation. To establish current medical eligibility, records of past evaluations or
hospitalizations may be required to clarify past medical eligibility decisions and direct the
current evaluation.
When a condition limits medical eligibility, the practitioner and athlete should discuss
risks and benefits of participation in desired activities, potential use of assistive devices or
accommodations, risk to other participants, and selection of alternative activities that may
be a better fit for the athlete. Problems that limit medical eligibility usually require more
time than is allotted to a standard PPE appointment, and additional visits are often needed
to complete the investigation. Diligent review of old records, appropriate referrals to spe-
cialists, and scheduling of follow-up visits to determine medical eligibility take precedence
over sport schedule pressures or athlete desire to participate in a certain sport.
The initial medical eligibility for sports status of an athlete can be divided into the fol-
lowing 5 categories:
1. Medically eligible for all activities without restriction
2. Medically eligible for all activities with recommendations for further evaluation or
treatment (eg, “Check blood pressure in 1 month.”)
3. Not medically eligible for any activities until additional evaluation, treatment, or reha-
bilitation is completed
4. Not medically eligible to participate in specific activities
5. Not medically eligible to participate in any sports or physical activities
05_ch05_35-42.indd 38 3/20/19 4:21 PM

Medical Eligibility Considerations 39
A form for recording medical eligibility status is available on page 225.
■■ MEDICAL ELIGIBILITY CONSIDERATIONS

• The PPE may promote safe participation within the dynamic and static capabilities of
an athlete, rather than prevent all physical activity participation.
• Activity restrictions can be supplemented with alternative activities that fit within the
athlete’s medical eligibility.
• It is the opinion of the author societies that PPE sport qualification status is best deter-
mined using a single-examiner model in the medical home. If multiple providers con-
duct the PPE, one provider familiar with the demands of the activity and the current
medical literature should render the sport qualification decision after reviewing the
entire history and physical evaluation. It is often challenging to determine final medi-
cal eligibility in a station-based format if there are any questionable findings, if there
is a lack of medical records, or if there are time constraints. It may also be difficult to
arrange referrals in a timely manner in the station-based setting.
• In appropriate cases, consultation with a specialist in the area of concern should be
obtained.
• When considering any abnormality or condition found during the PPE that may influ-
ence participation, the practitioner should consider the following questions:
——Does participation put the athlete at risk for illness or injury above the inherent haz-
ards of the activity?
——Does participation increase the risk of injury or illness for other participants?
——Will treatment of the underlying condition allow safe participation (medication,
rehabilitation, bracing, and padding)?
——Can limited participation be allowed while treatment or evaluation is completed?
——If medical eligibility is denied for certain sports because of medical or safety con-
cerns, can the athlete safely participate in other activities or sports?
• Medical eligibility decisions should be based on pertinent clinical guidelines and
reviews, such as the AAP Council on Sports Medicine and Fitness guidelines on medi-
cal conditions affecting sports participation,22 or the American Heart Association and
American College of Cardiology guidelines on cardiovascular abnormalities.23
• Sport activities can be risk stratified by the degree of contact or collision (Box 5-1).22
Contact and collision sports have a higher risk of serious trauma-related injury and can
have high demands, both static and dynamic.
• Using a Medical Eligibility Form that is separate from the history and physical examina-
tion forms (such as on page 225) will help protect confidential medical information.
• When a school or an organization has a designated team physician or an athletic trainer,
permission to share important medical information must be obtained from athletes and
their parents or guardians (if a minor), even for personal data that might influence safe
participation or restrict sports participation.
• An athlete with restricted medical eligibility in a desired sport may experience the loss
of physical and emotional benefits of regular physical activity, and those with serious or
potentially lethal cardiac disease may be at risk for significant psychological distress. A
restricted athlete may experience a loss of perceived identity and self-esteem, and these
05_ch05_35-42.indd 39 3/20/19 4:21 PM

Box 5–1. Classification of Sports According to Contact

Contact Limited-Contact Noncontact
• Basketball • Adventure racinge • Badminton

• Boxinga • Baseball • Bodybuildingf
• Cheerleading • Bicycling • Bowling
• Diving • Canoeing or kayaking (white water) • Canoeing or kayaking (flat
• Extreme sportsb • Fencing water)
• Field hockey • Field events • Crew or rowing
• Football, tackle –– High jump • Curling
• Gymnastics –– Pole vault • Dance
• Ice hockeyc • Floor hockey • Field events
• Lacrosse • Football, flag or touch –– Discus
• Martial artsd • Handball –– Javelin
• Rodeo • Horseback riding –– Shot put
• Rugby • Martial artsd • Golf
• Skiing, downhill • Racquetball • Orienteeringg
racing • Skating • Powerliftingf
• Ski jumping –– Ice • Race walking
• Snowboarding –– In-line • Riflery
• Soccer –– Roller • Rope jumping
• Team handball • Skateboarding • Running
• Ultimate Frisbee • Skiing • Sailing
• Water polo –– Alpine • Scuba diving
• Wrestling –– Cross-country (Nordic) • Swimming
–– Slalom racing • Table tennis
–– Water • Tennis
• Softball • Track
• Squash
• Volleyball
• Weight lifting
• Windsurfing or surfing
Abbreviation: AAP, American Academy of Pediatrics.

a
The AAP opposes participation in boxing for children, adolescents, and young adults.
b
Extreme sports has been added since the previous statement was published.
c
The AAP recommends limiting the amount of body checking allowed for hockey players ≤15 y, to reduce injuries.
d
Martial arts can be subclassified as judo, jujitsu, karate, kung fu, and tae kwon do; some forms are contact sports
and others are limited-contact sports.
e
Adventure racing has been added since the previous statement was published and is defined as a combination
of ≥2 disciplines, including orienteering and navigation, cross-country running, mountain biking, paddling, and
climbing and rope skills.
f
The AAP recommends limiting bodybuilding and powerlifting until the adolescent achieves sexual maturity rating 5
(Tanner stage V).
g
Orienteering is a race (contest) in which competitors use a map and a compass to find their way through unfamil-
iar territory.
Adapted with permission from Rice SG; American Academy of Pediatrics Council on Sports Medicine and Fitness.
Medical conditions affecting sports participation. Pediatrics. 2008;121(4):841–848.
05_ch05_35-42.indd 40 3/20/19 4:21 PM

References 41
factors should be addressed as part of the sports qualification decision. Athletes who
do not qualify for their sport should be monitored for both psychological status and
physical status and provided consistent emotional support.22,24 Athletes with restricted
medical eligibility are often assessed by a team of physicians and other providers. The
medical home, parents, and medically related school personnel need to work together
to monitor any athlete with restricted medical eligibility. For athletes who are strongly
connected with a team, an alternative nonplaying role (such as manager, student-coach,
or a similar position) may allow them to continue their affiliation and identity as a
team member.
• Medical eligibility may change with time depending on new injuries, new illnesses,
new family medical issues, or newly disclosed personal or family history not previously
reported. In such cases, the change in participation status must be communicated to
team or institution officials, but the specifics of medical conditions resulting in the loss
of safe participation status should not be shared unless the patient and family grant
permission.
• Medical recommendations for participation surrounding a given condition may change
with time.
■■ REFERENCES
2. National Sporting Goods Association. Sports Participation Lifecycle Demographics. 2017 ed. Mt Prospect, IL:
National Sporting Goods Association; 2017
Clin J Sport Med. 2014;24(2):142–149 PMID:24231928 https://doi.org/10.1097/JSM.0000000000000008
5. Kriz PK, Clyne A, Ford SR. Preparticipation physical exams: the Rhode Island perspective, a call for standard-
ization. R I Med J (2013). 2016;99(10):18–22 PMID:27706273
enough? Phys Sportsmed. 2003;31(8):35–38 PMID:20086484 https://doi.org/10.3810/psm.2003.08.460
7. Best TM. The preparticipation evaluation: an opportunity for change and consensus. Clin J Sport Med.
8. Carek PJ, Futrell M, Hueston WJ. The preparticipation physical examination history: who
has the correct answers? Clin J Sport Med. 1999;9(3):124–128 PMID:10512339 https://doi.
org/10.1097/00042752-199907000-00002
9. Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health out-
comes: an updated systematic review. Ann Intern Med. 2011;155(2):97–107 PMID:21768583 https://doi.
org/10.7326/0003-4819-155-2-201107190-00005
10. Powers BJ, Trinh JV, Bosworth HB. Can this patient read and understand written health information? JAMA.
2010;304(1):76–84 PMID:20606152 https://doi.org/10.1001/jama.2010.896
11. Lewandowski RE, O’Connor B, Bertagnolli A, et al. Screening and diagnosis of depression in adolescents in a
large health maintenance organization. Psychiatr Serv. 2016;67(6):636–641 PMID:26876655
12. Maurer DM. Screening for depression. Am Fam Physician. 2012;85(2):139–144 PMID:22335214
13. Depression: a brief guide to PROMIS Depression instruments. Assessment Center Web site. https://www.
assessmentcenter.net/documents/PROMIS%20Depression%20Scoring%20Manual.pdf. Published
September 9, 2015. Accessed February 24, 2019
14. CRAFFT Web site. http://crafft.org. Accessed February 24, 2019
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15. Hagan JF Jr, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and
Adolescents. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017
16. Mountjoy M, Sundgot-Borgen J, Burke L, et al. The IOC consensus statement: beyond the female athlete
triad—relative energy deficiency in sport (RED-S). Br J Sports Med. 2014;48(7):491–497 PMID:24620037
https://doi.org/10.1136/bjsports-2014-093502
17. Dixit S, DiFiori J. Prevalence of hypertension and prehypertension in collegiate student athletes. Clin J Sport
Med. 2006;16(5):440
18. Kriz PK, Stein C, Kent J, et al. Physical maturity and concussion symptom duration among adolescent ice
hockey players. J Pediatr. 2016;171:234.e1–239.e2
19. Bahr R. Why screening tests to predict injury do not work—and probably never will…: a critical review. Br J
Sports Med. 2016;50(13):776–780 PMID:27095747 https://doi.org/10.1136/bjsports-2016-096256
20. Smith J, Laskowski ER. The preparticipation physical examination: Mayo Clinic experience with
2,739 examinations. Mayo Clin Proc. 1998;73(5):419–429 PMID:9581581 https://doi.org/10.1016/
S0025-6196(11)63723-3
21. Mayer F, Bonaventura K, Cassel M, et al. Medical results of preparticipation examination in adolescent ath-
letes. Br J Sports Med. 2012;46(7):524–530 PMID:22576783 https://doi.org/10.1136/bjsports-2011-090966
22. Rice SG; American Academy of Pediatrics Council on Sports Medicine and Fitness. Medical conditions
affecting sports participation. Pediatrics. 2008;121(4):841–848 PMID:18381550 https://doi.org/10.1542/
peds.2008-0080
23. Maron BJ, Zipes DP, Kovacs RJ; American Heart Association Electrocardiography and Arrhythmias
Committee of the Council on Clinical Cardiology, Council on Cardiovascular Disease in the Young, Council
on Cardiovascular and Stroke Nursing, et al; American College of Cardiology. Eligibility and disqualifica-
tion recommendations for competitive athletes with cardiovascular abnormalities: preamble, principles,
and general considerations; a scientific statement from the American Heart Association and American
College of Cardiology. Circulation. 2015;132(22):e256–e261 PMID:26621642 https://doi.org/10.1161/
CIR.0000000000000236
24. Sidelined USA Web site. https://www.sidelinedusa.org. Accessed February 24, 2019
05_ch05_35-42.indd 42 3/20/19 4:21 PM

CHAPTER 6
Systems-Based
Examination
A. Cardiovascular Problems
■■ HISTORY FORM QUESTIONS
Heart Health Questions About You

1. Have you ever passed out or nearly passed out during or after exercise?
2. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?
3. Does your heart ever race, flutter in your chest, or skip beats (irregular beats) during
exercise?
4. Has a doctor ever told you that you have any heart problems?
5. Has a doctor ever requested a test for your heart? For example, electrocardiography (ECG)
or echocardiography.
6. Do you get light-headed or feel shorter of breath than expected during exercise?
7. Have you ever had a seizure?
Heart Health Questions About Your Family

8. Has any family member or relative died of heart problems or had any unexpected or
unexplained sudden death before age 35 years (including drowning or unexplained car
crash)?
9. Does anyone in your family have a genetic heart problem such as hypertrophic cardiomy-
opathy (HCM), Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy
(ARVC), long QT syndrome (LQTS), short QT syndrome (SQTS), Brugada syndrome,
or catecholaminergic polymorphic ventricular tachycardia (CPVT)?
10. Has anyone in your family had a pacemaker or an implanted defibrillator before age 35?
06_ch06_43-160.indd 43 3/20/19 4:22 PM

44 Section 6A. Cardiovascular Problems
■■ KEY POINTS
• Sudden cardiac arrest (SCA) and sudden cardiac death (SCD) are rare events in
athletes.
• Sudden cardiac arrest in young athletes and children is caused by a diverse group of
structural, valvular, and electrical diseases of the heart.
• A detailed personal and family history may help identify athletes at risk for SCD.
• Sudden cardiac death may be the first manifestation of underlying cardiac disease;
warning symptoms that require cardiac workup include syncope and/or chest pain dur-
ing exercise, palpitations during exercise, unexplained breathlessness during exercise,
and unexplained seizures.
• A family history of sudden unexpected or unexplained death, sudden death before the
age of 50 years (especially younger than age 35) caused by cardiac problems, sudden
infant death, unexplained drowning, unexplained near drowning, car crashes caused by
unexplained driver loss of consciousness, or unexplained seizures may indicate the pres-
ence of a genetic cardiovascular disorder placing the athlete at increased risk for SCD.
• Physical examination should focus on detecting hypertension, pathological heart mur-
murs, and any physical findings suggestive of Marfan syndrome.
• Athletes with suspected or identified risk for SCD should be evaluated by a cardiologist,
preferably a cardiologist who has experience taking care of athletes.
Cardiovascular disorders, although rare, are the leading cause of sudden death in young
athletes during exertion.1–3 Identifying young athletes at risk for sudden death is difficult
because of their healthy appearance despite harboring unsuspected cardiovascular disease.4
The prevalence of SCA or death (SCA/D) in young athletes may not differ from the general
population.
Preparticipation cardiovascular evaluation attempts to identify athletes with abnormal-
ities that may provoke SCD on the basis of personal and family history.5,6 The American
Heart Association (AHA) and the American College of Cardiology (ACC) indicate that the
principal objective of preparticipation evaluation from a cardiovascular perspective is to
reduce the risk of sudden death related to a heart-related condition associated with physi-
cal activity and enhance the safety of athletes during exercise by using red flag symptoms
and family history to detect the potential for SCD.6 In 2015, the AHA and ACC updated
their consensus statement on preparticipation cardiovascular screening in athletes
with specific recommendations for a detailed personal and family history and physical
examination.7
This section
• Reviews the incidence and causes of SCD in young athletes
• Defines a comprehensive cardiovascular assessment of athletes using personal and fam-
ily history and appropriate physical examination
• Discusses the diagnostic investigation for concerning history or examination findings
• Examines the concept of differential risk for SCD in certain athletic populations
• Explores the role of electrocardiography (ECG) and other noninvasive cardiovascular
screening of athletes
• Provides guidelines and resources for the management and medical eligibility decisions
for athletes identified with cardiovascular disorders
06_ch06_43-160.indd 44 3/20/19 4:22 PM

Incidence of Sudden Cardiac Death in Young Athletes 45
■■ INCIDENCE OF SUDDEN CARDIAC DEATH IN YOUNG ATHLETES

The exact incidence of SCD in the United States among athletes and nonathletes is
unknown. Both the number of cardiac arrests and the number of athletes at risk are elusive
and often not uniformly defined in studies. Research to date has relied on survey or non-
mandatory reporting systems that may underestimate the true incidence.5,6,8 Some studies
include only deaths that meet the definition of exercise-associated sudden death (collapse
during or within 1 hour of activity), while others include all athletes who die independent
of activity. A study from the entire province of Ontario, Canada,9 showed an overall inci-
dence of 0.76 SCAs per 100,000 athlete-years in 12- to 45-year-olds and a rate of 1.167 per
100,000 athlete-years in 12- to 17-year-olds during or within 1 hour of participation in phys-
ical activity. Of the total 74 participants who had arrests in the overall cohort, 16 (3 were
12- to 17-year-olds) were engaged in competitive athletics for which a PPE may have been
required and 58 were in unorganized recreational participation. Comparable rates for the
general population in the same area of Canada were 4.84 SCAs per 100,000 person-years for
12- to 45-year-olds and 0.69 SCAs per 100,000 person-years in 12- to 17-year-olds.10
According to available studies, a generally accepted annual incidence of SCD in the
United States is 1.25 cases per 100,000 high school athletes per year and 2 per 100,000
college athletes per year with a range from 0.25 to 33 per 100,000 athletes per year.11–14
However, a recent study showed that the rate may be as high as 6.8 per 100,000 athletes
per year in elite-level English soccer players screened at ages 15 to 17 years with both
ECG and echocardiography.11 In this targeted screening of soccer players, 6 of the 8 deaths
occurred in players who had tested negative for cardiac risk, suggesting that screening is
not sensitive enough to detect all potential cases, in contrast to concerns about specificity
that dominate the discussion in the United States. Studies that include all athletes who
die indicate that roughly half of cardiac-related deaths occur during exertion and the
remainder occur at rest or during sleep.14–16 In contrast to that of athlete deaths, the SCD
rate in King County, WA, for the general population aged 14 to 24 years is approximately
1.5 per 100,000 persons per year.17
Athletes may have different SCA/D risk based on age, sex, race, sport, or level of play.13
Sudden cardiac death in athletes is more common in males, with male to female ratios
ranging from 5:1 to 9:1.1,18 Sudden cardiac arrest or death rates are also consistently higher
in African American collegiate athletes.12 The risk for SCD during and away from exercise
in male African American college athletes is 6.25 per 100,000 athletes per year, and among
National Collegiate Athlete Association Division I male college basketball players, the risk
rises to 19 per 100,000 athletes per year; about half the college deaths occurred during
exertion.12 Although SCD can occur in any sport, at the college level these deaths occur
most frequently in basketball and football players. In the United States, college basket-
ball and football have the highest levels of participation. It should be noted that 57% of
all Division I basketball players and 43% of all Division I football players are of African
American descent. More-intensive screening strategies may be warranted in this popula-
tion, but prospective outcomes-based studies are lacking. A large multicentered random-
ized trial to evaluate the usefulness of ECG in PPE screening would define the utility of
the intervention and provide an evidence-based solution to the controversy; however, the
numbers needed to reach a reasonable conclusion are daunting.
06_ch06_43-160.indd 45 3/20/19 4:22 PM

■■ CAUSES OF SUDDEN CARDIAC DEATH IN YOUNG ATHLETES

Sudden cardiac arrest or death may have a variety of congenital or acquired causes primarily
involving structural and electrical problems19–22 (Box 6A-1). Exercise is a known trigger for
SCD at all ages, especially in sedentary populations. The most commonly reported causes
of SCA/D in young athletes include hypertrophic cardiomyopathy (HCM), coronary artery
anomalies, arrhythmogenic right ventricular cardiomyopathy (ARVC), dilated cardiomyopa-
thy, myocarditis, long QT syndrome (LQTS), ventricular preexcitation or Wolff-Parkinson-
White syndrome, aortic dissection, and atherosclerotic coronary artery disease (CAD).12,13,20,23
However, in studies with autopsy data available, up to 44% of athletes and military recruits
with sudden death during exercise have no structural or anatomical abnormalities.24–26 These
cases, known as autopsy-negative sudden unexplained death (ANSUD), are likely caused
by arrhythmias. Some may be caused by genetic abnormalities, but the exact mechanism
remains unclear for many because of the lack of a genetic autopsy. Current studies of young
US athletes show that HCM represents 8% to 36% of cases, which is lower than some pre-
vious estimates.11,27,28 Atherosclerotic CAD as a cause of SCD increases with age, beginning
about age 20 years and progressively increasing in frequency through age 35 and beyond.24
The combined prevalence of all cardiovascular conditions known to cause SCD in the
young athletic population is estimated to be 300 per 100,000 athletes.6 However, identify-
ing conditions associated with SCD has not been shown to change the outcomes. Many
athletes with preexisting cardiovascular conditions must be competing without a problem
Box 6A-1. Causes of Sudden Cardiac Death in Young Athletes

Structural or Functional
• Hypertrophic cardiomyopathy
• Idiopathic left ventricular hypertrophy
• Coronary artery anomalies
• Myocarditis
• Arrhythmogenic right ventricular cardiomyopathy
• Dilated cardiomyopathy
• Aortic rupture (Marfan syndrome)
• Aortic stenosis
• Atherosclerotic coronary artery disease
• Postoperative congenital heart disease
Electrical
• Long QT syndromea
• Catecholaminergic polymorphic ventricular tachycardiaa
• Wolff-Parkinson-White syndrome
• Brugada syndromea
• Short QT syndromea
Other
• Drugs and stimulants

• Primary pulmonary hypertensiona
• Commotio cordis
• Autopsy-negative sudden unexplained death
a
Familial or genetic.
06_ch06_43-160.indd 46 3/20/19 4:22 PM

Causes of Sudden Cardiac Death in Young Athletes 47
given the roughly 100- to 150-fold difference in prevalence between cardiovascular condi-
tions and athlete deaths.
Autopsy-Negative Sudden Unexplained Death

ANSUD describes the entity of which an individual has died, but the autopsy fails to demon-
strate a structural cardiac abnormality. In these cases, electrical diseases (eg, Wolff-Parkinson-
White syndrome) or ion channel disorders (eg, LQTS) are thought to play a precipitating
role. While some of these conditions may be detectable on an ECG, there is little docu-
mented correlation between the detection and the outcomes. In Australia, ANSUD represents
approximately 30% of SCDs in individuals younger than 35 years.21,22 A prospective study of
SCD in Australia and New Zealand showed a rate that was 1.3 per 100,000 persons per year
for children, adolescents, and young adults with 40% categorized as ANSUD, but only 15%
of the SCDs and 13% of the ANSUDs were associated with exercise.29 In US military recruits,
ANSUD accounts for approximately 35% of nontraumatic sudden deaths.24 When postmor-
tem genetic testing or molecular autopsy has been completed in cases of ANSUD, more than
one-third of patients are found to have a pathogenic cardiac ion channel mutation.30,31
ANSUD was the initial event in more than 80% of mutation-positive patients30 and in
more than 90% of US military recruits.32 In 2004, Tester et al30 reported a family history
of either SCD or syncope documented by a medical examiner in 26 of 49 general popula-
tion cases (53%) of ANSUD (average [SD] age of 14.2 [10.9] years). A personal history of
syncope, seizure-like activity, cardiac arrest, or a combination of those before these sud-
den unexplained deaths (SUDs) was reported in 7 of the 49 cases.30 The high frequency of
familial SCD or syncope in people who have ANSUD emphasizes the need for a careful
evaluation of athletes with a family history of SUD.
Hypertrophic Cardiomyopathy
Hypertrophic cardiomyopathy accounts for 8% to 36% of SCDs in US athletes younger than
30 years.12,15 The characteristic morphological features of HCM include asymmetrical left
ventricular (LV) hypertrophy (usually involving the ventricular septum), LV wall thickness
of 16 mm or more (normal: <12 mm; borderline: 13–15 mm), a ratio between the septum
and the free wall thickness of more than 1.3, and a non-dilated LV with impaired diastolic
function.8 Histological analysis shows a disorganized cellular architecture with cardiac myo-
cyte disarray and intramural tunneling (myocardial bridging) in which a segment of coro-
nary artery is completely surrounded by myocardium in about one-third of cases.
The prevalence of HCM in the general population is 1:500 and approximately 1:800 to
1:2,600 in competitive athletes.12,33,34 It is an autosomal dominant disorder with variable
expression in more than half of cases.35 Although HCM may appear in childhood, the
morphological expression typically develops in early adolescence to young adulthood
and is characteristically present by the end of physical maturity in most individuals who
are genetically predisposed for the disorder.28 The phenotypic expression of HCM in
adolescence is the primary rationale supporting the recommendation that preparticipa-
tion cardiovascular evaluation be performed every other year while in high school and at
matriculation to college, although there are not data to support this interval.4,6,28
Most athletes with HCM are asymptomatic, and sudden death is often the sentinel event
of their disease. In one study from 1985 to 1995, only 21% (10 of 48) of athletes who died
of HCM had any signs or symptoms of cardiovascular disease in the 36 months before
06_ch06_43-160.indd 47 3/20/19 4:22 PM

their death.4 Symptoms may include exertional chest pain, dyspnea, light-headedness, or
syncope.36 During physical examination, the characteristic murmur of HCM with left out-
flow tract obstruction is a harsh systolic ejection murmur (best heard at the right upper
sternal border) that increases with maneuvers that decrease venous return (eg, Valsalva
maneuver or moving from squatting to standing) and diminishes with maneuvers that
increase venous return (ie, lying supine or moving from standing to a squatting position).
However, only 25% of people with known HCM have a murmur,37 so most athletes with
HCM will have normal findings from cardiac auscultation of the heart.
An ECG finding will be abnormal in more than 90% of patients with HCM,38 with
prominent Q waves in 2 or more leads (except III and aVR), deep negative T waves in 2 or
more leads from V2 to V6, or dramatic increases in QRS voltage associated with ST depres-
sion or T-wave inversion.39 Echocardiography confirms the diagnosis of HCM by identify-
ing pathological LV wall thickness (>16 mm) and a non-dilated LV without alternative
explanation. In cases when the diagnosis of HCM is uncertain (ie, borderline LV wall
thickness of 13–15 mm), magnetic resonance imaging (MRI) with gadolinium or repeated
echocardiography after 4 to 6 weeks of deconditioning may help in distinguishing HCM
from athletic heart syndrome. Cardiac MRI may also be necessary to confirm apical HCM,
as detection of this condition using standard echocardiography is technically difficult.
Coronary Artery Anomalies

A coronary artery anomaly is another common anatomical cause of SCD in athletes. The
most common coronary anomaly is an abnormal origin of the left coronary artery aris-
ing from the right sinus of Valsalva. Impingement of the anomalous artery as it traverses
between the expanding great vessels during exercise may lead to ischemia and a subsequent
arrhythmia. Other features that may contribute to ischemia during exercise include an acute
angled takeoff, a hypoplastic ostium, an intramyocardial course of the anomalous artery, or
downstream distal atresia of the coronary artery as it reaches its epicardial territory.
Prodromal symptoms are present in less than half of coronary artery anomaly–related
SCD cases.32,40 In one study, only 12 out of 27 athletes (44%) who died of an anomalous
coronary artery had prodromal symptoms such as exertional syncope, chest pain, or pal-
pitations in the 24 months before their death.40 In athletes with unexplained symptoms,
transthoracic echocardiography can identify the coronary artery origins in about 95% of
patients. Advanced cardiac imaging such as computed tomography (CT) angiography, car-
diac MRI, or coronary angiography may be needed to detect anomalous origins and can
also identify other coronary anomalies such as an acute angled takeoff, intramyocardial
course, and hypoplastic coronary arteries.
Myocarditis
Myocarditis accounts for 6% of SCDs in US athletes and military personnel.6,24 Acute
inflammation of the myocardium may lead to an arrhythmogenic focus and sudden death.
Coxsackievirus B is implicated in more than 50% of cases, but echovirus, adenovirus, influ-
enza virus, and Chlamydophila pneumoniae (formerly Chlamydia pneumoniae) have also been
associated with myocarditis. The acute phase of myocarditis appears with an influenza-like
illness that may lead to dilated cardiomyopathy with signs and symptoms of congestive
heart failure. Histological analysis shows a lymphocytic infiltrate of the myocardium with
06_ch06_43-160.indd 48 3/20/19 4:22 PM

necrosis or degeneration of adjacent myocytes. The myocardial tissue infection can result in
scarring or fibrosis, which can become an arrhythmogenic focus. Fibrosis can be detected
with cardiac MRI, and advanced fibrosis may limit medical eligibility for sports.41 An ECG
may show diffuse low voltage, ST-T wave changes, heart block, or ventricular arrhythmias.
Laboratory testing during the acute phase may show leukocytosis, eosinophilia, an elevated
erythrocyte sedimentation rate or C-reactive protein level, and increased levels of myocar-
dial enzymes. Echocardiography showing a dilated LV, global hypokinesis or segmental
wall abnormalities, and decreased LV ejection fraction will confirm the diagnosis. Return to
play may be considered when imaging abnormalities resolve. Cardiac consultation may be
needed to determine medical eligibility and assist with the return to play decision.
Arrhythmogenic Right Ventricular Cardiomyopathy

Arrhythmogenic right ventricular cardiomyopathy represents 4% of SCDs in the United
States,6 but it was reported as the leading cause of SCD (22%) in the Veneto region of
northeastern Italy.42 Arrhythmogenic right ventricular cardiomyopathy is characterized by
a progressive fibrofatty replacement of the right ventricular myocardium that causes wall
thinning and right ventricular dilatation. The estimated prevalence is 20 per 100,000 in the
general population and results from mutations in genes that are encoding for desmosomal
(cell adhesion) proteins.43
Arrhythmogenic right ventricular cardiomyopathy can appear with myocardial electrical
instability, leading to ventricular arrhythmias that precipitate cardiac arrest, especially during
physical activity. Some athletes may have prodromal symptoms such as syncope, chest pain,
or palpitations.44 Physical examination findings are typically normal. The ECG may show
right precordial T-wave inversion (beyond V1), an epsilon wave (small terminal notch seen
just beyond the QRS in V1 or V2), a prolonged QRS duration greater than 110 milliseconds, or
a right bundle branch block pattern. Echocardiography, cardiac MRI, or CT may demonstrate
right ventricular dilatation and wall thinning, reduced right ventricular ejection fraction, focal
right ventricular wall motion abnormalities, or right ventricular aneurysms. Fibrofatty infiltra-
tion of the right ventricle is best seen on a cardiac MRI or by histological analysis at autopsy.
Aortic Dissection and Marfan Syndrome

Marfan syndrome is the most common inherited disorder of connective tissue that affects
multiple organ systems, with a reported prevalence of 20 to 30 per 100,000 individu-
als.45 Marfan syndrome causes cystic medial necrosis, resulting in a progressive dilatation
and weakness of the proximal aorta that leads to dissection or rupture and sudden death.
Myxomatous degeneration of the mitral or aortic valves may also lead to valvular dysfunc-
tion. Marfan syndrome is caused by mutations in the fibrillin 1 gene, with 75% of cases
inherited through autosomal dominant transmission with variable expression and 25%
from de novo mutations.45
Cardiovascular complications are the major cause of morbidity and mortality in
patients with Marfan syndrome. The risk of aortic rupture or dissection increases during
adolescence, and 50% of patients with undiagnosed Marfan syndrome will die by 40 years
of age.45 Symptoms of aortic dissection typically include sudden, excruciating chest or tho-
racic pain, often described as “tearing” or “ripping.” Heart failure may occur secondary to
aortic valve incompetence.
06_ch06_43-160.indd 49 3/20/19 4:22 PM

Physical examination findings include highly variable clinical features, which typically
appear in adolescence and young adulthood. Diagnostic criteria of Marfan syndrome
primarily focus on cardinal manifestations of the disorder (aortic root aneurysm or dila-
tion) and ophthalmologic features (ectopic lens).45 In the absence of family history, aortic
root aneurysm or dilation and an ectopic lens are sufficient to make the diagnosis, or one
of these cardinal findings plus evidence of an FBN1 mutation or a systemic score of 7 or
higher can suggest the diagnosis (Table 6A-1). A systemic score of 7 or higher or presence
of 1 cardinal manifestation is sufficient for diagnosis of Marfan syndrome when an athlete
has a positive family history.
Physical examination should focus on hypermobility of wrist or thumb (or both), chest
wall deformities, murmur associated with mitral valve prolapse, hindfoot deformities,
and other features associated with a marfanoid appearance (Table 6A-1). While physical
Table 6A-1. Systemic Score Suggestive of Marfan Syndrome
Feature Score
Wrist AND thumb sign +3
Wrist OR thumb sign +1
Pectus Carinatum Deformity +2
Pectus Excavatum or Chest Asymmetry +1
Hindfoot Deformity +2
Plain Flat Foot +1
Spontaneous Pneumothorax +2
Dural Ectasia +2
Protucia Acetabulae +2
Scoliosis or Thoracolumbar Kyphosis +1
Reduced Elbow Extension +1
3 of 5 Facial Features +1
Skin Striae +1
Severe Myopia +1
Mitral Valve Prolapse +1
Reduced Upper Segment / Lower Segment & Increased Arm Span to Height Ratio +1
a
A score of ≥7 is considered a positive systemic score.
Used with permission from The Marfan Foundation. Calculation of systemic score. The Marfan Foundation Web site.
https://www.marfan.org/dx/score. Accessed February 22, 2019.
06_ch06_43-160.indd 50 4/1/19 10:24 AM

examination features alone are not sufficient for diagnosis, they may raise suspicion and
warrant more detailed family history and cardiovascular evaluation according to the rules
in Table 6A-2. More details about the diagnosis of Marfan syndrome may be found on the
Marfan Foundation Web site at www.marfan.org/dx/home.
Table 6A-2. Diagnostic Criteria for Marfan Syndrome

The diagnosis of Marfan syndrome relies on a set of defined clinical criteria (the 2010 Ghent
nosology) developed to facilitate accurate recognition of the syndrome and improve patient
treatment and counseling. The diagnostic criteria put more weight onto the cardiovascular mani-
festations of the disorder. Aortic root aneurysm and ectopia lentis (dislocated lenses) are now
cardinal features.
• In the absence of any family history, the presence of these 2 features is sufficient for the unequivo-
cal diagnosis of Marfan syndrome.
• In the absence of one of these 2 cardinal features, the presence of either an FBN1 mutation or a
positive systemic score is required.
• In some cases, genetic testing can be helpful.
Experts expect that while use of new diagnostic criteria makes a definitive diagnosis of Marfan
syndrome take longer, it decreases the risk of a premature or missed diagnosis.
In the Absence of Family History In the Presence of Family History
1. Aortic root dilatation z score ≥2 and ecto- 1. Ectopia lentis and family history of Marfan
pia lentis = Marfan syndrome. syndrome (as defined to the left) = Marfan
2. Aortic root dilatation z score ≥2 and an syndrome.
FBN1 mutation = Marfan syndrome. 2. A systemic score ≥7 points and family
3. Aortic root dilatation z score ≥2 and history of Marfan syndrome (as defined to
a systemic score ≥7 points = Marfan the left) = Marfan syndrome.
syndrome. 3. Aortic root dilatation z score ≥2 if patient
4. Ectopia lentis and an FBN1 mutation asso- age ≥20 y, or ≥3 if patient age <20 y,
ciated with aortic root dilatation = Marfan and family history of Marfan syndrome (as
syndrome. defined to the left) = Marfan syndrome.
Adapted with permission from The Marfan Foundation. Summary of diagnostic criteria. The Marfan Foundation
Web site. https://www.marfan.org/dx/rules. Accessed March 18, 2019.
06_ch06_43-160.indd 51 4/1/19 10:25 AM

Aortic Stenosis
Aortic stenosis is responsible for 3% of SCDs in US athletes. The most common cause of
aortic stenosis in youths is a bicuspid aortic valve, which occurs in 1% to 2% of the general
population and was found in 2.5% of competitive athletes whose conditions were inves-
tigated by echocardiography.46 Narrowing of the aortic valve causes elevation of LV end-
diastolic pressure and cardiac work, leading to LV hypertrophy without a compensatory
increase in coronary blood supply. Ischemia can develop secondary to increased LV cardiac
mass, coupled with poor coronary artery supply and decreased diastolic filling time that is
worsened with physical exertion.
Athletes with aortic stenosis are usually asymptomatic, and only about 5% will
develop chest pain, angina, or syncope. Physical examination reveals a systolic ejection
murmur at the right upper sternal border and an apical ejection click. The murmur of
aortic stenosis typically diminishes with maneuvers that decrease venous return (ie,
Valsalva maneuver or moving from squatting to standing) and thus has the opposite
characteristics of the murmur associated with HCM. Aortic stenosis is confirmed by
echocardiography, which shows narrowing of the aortic valve with an elevated pres-
sure gradient. Athletes with mild aortic stenosis (mean pressure gradient using Doppler
echocardiography: <25 mm Hg) may participate in all types of sports. Athletes with
moderate stenosis (mean pressure gradient: 25–40 mm Hg) will be limited to the sports
that are low intensity, and athletes with severe stenosis (mean pressure gradient:
>40 mm Hg) will be limited from all participation.47
■■ CORONARY ARTERY DISEASE

Newer research suggests that atherosclerotic CAD begins to increase around age 20 and
accounts for nearly 10% of SCDs in college-aged athletes and progressively increases to
age 35 years; CAD is the most frequent cause of SCD in athletes older than 35 years.6,12
Atherosclerotic plaque development is progressive and related to coronary risk factors such
as hypertension, diabetes, dyslipidemia, tobacco use, illicit drug or anabolic steroid use,
and a family history of premature atherosclerotic disease. Homozygous familial hypercho-
lesterolemia is a very rare autosomal dominant disease characterized by accelerated severe
atherosclerosis and coronary artery obstruction appearing at an early age (adolescence).48
Exercise may cause myocardial ischemia with symptoms of exertional chest pain (typical
angina), light-headedness, palpitations, or dyspnea, or it may be a stimulus for plaque dis-
ruption, arrhythmia, and SCA.
Ion Channel Disorders

Ion channel disorders are primary electrical diseases of the heart that predispose to poten-
tially lethal ventricular arrhythmias and are characterized by mutations in ion channels
that lead to dysfunctional sodium, potassium, calcium, and other ion transport across cell
membranes. Confirmed ion channelopathies account for approximately 3% of SCDs in US
athletes.6 In an additional 3% of SCDs in athletes, routine postmortem examination fails
to identify a structural cardiac cause of death1,6 that may be caused by inherited arrhythmia
06_ch06_43-160.indd 52 3/20/19 4:22 PM

Coronary Artery Disease 53
syndromes and ion channel disorders such as LQTS, short QT syndrome, Brugada syn-
drome, or familial catecholaminergic polymorphic ventricular tachycardia (CPVT).1
The prevalence of ion channel disorders as a cause of SCD in US athletes may be under-
estimated because ANSUD represents a substantially larger proportion of SCDs in the
younger study populations, and the accurate diagnosis of ion channelopathies postmor-
tem is limited.
Long QT syndrome is the most common ion channelopathy and characterized by
prolongation of ventricular repolarization as measured by correcting the QT interval for
heart rate. There are 10 recognized gene abnormalities for LQTS involving potassium and
sodium ion channels that are important in cardiac repolarization.49 Most arrhythmias
from LQTS are triggered by emotional or physical stress and appear with syncope or near
syncope, seizures, or sudden death (Table 6A-3). Syncope is usually caused by torsades de
pointes, a specific form of polymorphic ventricular tachycardia.
The diagnosis of LQTS involves measurement of the QT interval in lead II (alterna-
tive leads: V5 or V6) on an ECG and calculating the corrected QT interval (QTc) (using the
Bazett formula) to compensate for heart-rate–related changes. The upper limit of refer-
ence for the QTc is 0.47 seconds in males and 0.48 seconds in females; a QTc greater than
0.50 seconds is considered marked QT prolongation.39 Patients with LQTS may also have
bizarre, flat, or peaked T-wave morphological features; alternating T-wave polarity (T-wave
alternans); or prominent U waves or T-U wave complexes.50 Findings from ECG of patients
at rest may be normal in up to 30% of patients who are genetically positive for LQTS, and
a significant proportion of the normal population will have a QTc up to 0.47 seconds.51
Adolescents with a QTc greater than 0.53 seconds are twice as likely to experience SCD as
those with a lesser QTc.52
Relying on the computer-generated QTc is not appropriate because it is frequently inac-
curate. The QT interval should be confirmed by using the Bazett formula with heart rates
between 60/min and 90/min, preferably performed manually in lead II or V5 using the
Table 6A-3. Signs and Symptoms of Cardiac Ion Channel Disorders
Disorder Trigger Event

LQTS-1 Emotional stress, physical exercise, swim- Syncope, sudden death, seizure, drown-
ming, or diving into water ing or near drowning, or motor vehicle
crash
LQTS-2 Emotional stress, physical exercise, or Syncope, sudden death, seizure, or motor
auditory stimuli (loud noises) vehicle crash
LQTS-3 Rest or sleep Sudden death or sudden infant death
CPVT Emotional stress or vigorous physical Syncope, sudden death, seizure, or

exercise drowning or near drowning
Abbreviations: LQTS-, long QT syndrome type; CPVT, catecholaminergic polymorphic ventricular tachycardia.
06_ch06_43-160.indd 53 3/20/19 4:22 PM

teach-the-tangent method to avoid inclu-

sion of a U wave (see Figure 6A-1 for more
details). If the QTc value is borderline or
abnormal, consider repeating the ECG
after mild aerobic activity for a heart rate
less than 50/min or repeating the ECG
after a longer resting period for a heart rate
greater than 100/min. Within the “gray Tangent
zone” range of 0.44 to 0.50 seconds, there
will be both unaffected individuals and QT
potentially affected individuals, making

the determination of eligibility for sports
participation very difficult. Threshold
A QTc greater than 0.5 seconds, with or

without symptoms and regardless of fam-
ily history, distinguishes individuals most
at risk for a cardiac event, thus limiting
athletic participation. These individuals QT
should be fully evaluated by an electro-
physiologist or cardiologist who is expe-
Figure 6A-1. QT Interval Calculated by
rienced with LQTS and physical activity
before a determination of medical eligi- Tangent and Threshold Methods
bility for sport participation is made.
Catecholaminergic polymorphic ventricular tachycardia is a familial disorder charac-
terized by stress-induced ventricular arrhythmias that result in SCD in children and young
adults and most commonly involves a cardiac ryanodine receptor or calcium channel
release mutation. Catecholaminergic polymorphic ventricular tachycardia can appear with
syncope, drowning or near drowning, seizure, or sudden death triggered by vigorous physi-
cal exertion or acute emotion. Leenhardt et al53 reported that syncope was a symptom for
20 of 21 patients presenting with CPVT, with the first syncopal event occurring at 7.8 (±4)
years of age, and a family history of syncope or sudden death was present in 30%. Physical
effort or emotion usually triggered symptoms, and the diagnosis of CPVT was generally
delayed because of the misdiagnosis of epilepsy or vasovagal events.
Hypertension
Hypertension is the most common cardiovascular disease encountered in the athletic
population, and an elevated blood pressure (BP) was found in 6.4% of athletes presenting
for routine preparticipation physical evaluation (PPE).54 Athletes with persistently elevated
BP should be questioned about a family history of hypertension and the use of stimu-
lants (such as caffeine, nicotine, or ephedrine) or anabolic steroids. Athletes younger than
25 with upper extremity hypertension should also have a lower extremity BP checked to
exclude coarctation of the aorta.
The eighth report of the Joint National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure55 recommends for adults 18 to 60 years of age ini-
tiating pharmacological treatment of diastolic BP of 90 mm Hg or higher with the goal
06_ch06_43-160.indd 54 3/20/19 4:22 PM

Personal and Family History 55
of achieving 90 mm Hg or lower and systolic BP of 140 mm Hg or higher with a goal of

achieving 140 mm Hg or lower. The Fourth Report on the Diagnosis, Evaluation, and Treatment
of High Blood Pressure in Children and Adolescents55 established BP standards for pediatric and
adolescent patients based on sex, age, and height. The fourth report also classified hyperten-
sion in athletes younger than 18 years as prehypertension, stage 1 hypertension, and stage 2
hypertension and mirrored the taxonomy used for adults.55 The diagnosis of hypertension
in athletes younger than 18 years requires at least 3 BP measurements with values from
90% to 95% of age-, sex-, and height-based reference ranges defined as prehypertension;
values from 95% to 99% plus 5 mm Hg, defined as stage 1 hypertension; and values greater
than 99% plus 5 mm Hg, defined as stage 2 hypertension. A convenient pocket guide to
BP measurement in children is available at www.nhlbi.nih.gov/health/public/heart/hbp/
bp_child_pocket/bp_child_pocket.pdf, with tables based on sex, age, and height and with
systolic BP and diastolic BP values listed for prehypertension, stage 1 hypertension, and
stage 2 hypertension.
All children and adolescents diagnosed as having hypertension require a careful evalu-
ation for secondary causes of hypertension and target organ disease. This includes blood
chemistry analysis (glucose test, creatinine test, electrolyte tests, lipid profile, and thyroid
function test), hematocrit measurement, urinalysis, and echocardiography.56 Consider
evaluating for hyperaldosteronism with serum renin, aldosterone, and cortisol levels. Renal
ultrasonography is also recommended for all children with stage 1 or stage 2 hypertension.
Evaluation of target organ disease, including echocardiography and a retinal examination,
is recommended in all athletes with comorbid risk factors of diabetes mellitus or renal
disease associated with a BP between the 90th percentile and the 94th percentile and in
all patients with BP in the 95th percentile or higher and stage 2 hypertension.55 Athletes
found to have stage 2 hypertension or findings of end-organ damage should not be
allowed to participate in any competitive sport until their BP is further evaluated, treated,
and under control, at which time medical eligibility for participation can be reevaluated.
■■ PERSONAL AND FAMILY HISTORY

A comprehensive personal and family history is critical to identifying athletes with red flag
conditions that may result in SCD. The PPE cardiovascular questions were developed to
elicit responses that may indicate the presence of a serious cardiac condition and prompt
further investigation. Parent or guardian verification of personal and family history is rec-
ommended for high school and middle school athletes. Use of a standardized and detailed
questionnaire (such as the History Form on pages 217 and 218) is strongly recommended
to assist health care professionals in performing a comprehensive cardiovascular risk
assessment. For a detailed review of the approach to positive history or physical examina-
tion findings, the Special Communication series in Current Sports Medicine Reports (May/
June 2015 and July/August 2015) is a recommended resource.57,58
Personal History
The medical history should focus on exertional-related symptoms that suggest underlying
cardiovascular disease. The AHA recommends that the personal medical history include
specific questions on (1) exertional chest pain or discomfort, (2) unexplained syncope or
06_ch06_43-160.indd 55 3/20/19 4:22 PM

near syncope, (3) excessive exertional or unexplained dyspnea/fatigue associated with exer-
cise, (4) prior recognition of a heart murmur, and (5) a history of elevated systemic BP.6 A
history of palpitations or an irregular heartbeat related to exercise, which is not included in
the AHA recommendations, is also considered relevant to SCA risk.36
Other questions with the potential to affect cardiovascular risks may include current
or past illicit drug use (ie, cocaine, amphetamines, or ecstasy), ergogenic medication (ie,
anabolic steroids, human growth hormone, or stimulants), or supplement use, such as cal-
cium,59,60 or a recent acute viral syndrome (risk of myocarditis). Questions to ask in follow-
up to an abnormal history response can be found in Table 6A-4.
Exertional chest discomfort, pain, pressure, or tightness may indicate the presence of
myocardial ischemia with exercise, especially if associated with syncope, near syncope, or
palpitations. Chest pain associated with other symptoms is very concerning and warrants
a careful cardiac investigation. In young athletes, chest discomfort is most often caused
by exercise-induced asthma or gastroesophageal reflux, but exertional angina can occur.
Congenital coronary artery anomalies, such as anomalous origin of the left coronary artery
or myocardial bridging (intramyocardial course) and LV hypertrophy from aortic stenosis
Table 6A-4. Abnormal History Follow-up Questions
Follow-up Question Additional Follow-up Questions

Have you ever experienced • How would you describe your pain? What does it feel like?
chest pain or discomfort Where is it located?
with exercise? • Are there things other than exercise or how hard you exercise
that cause your chest discomfort?
• When does your chest discomfort occur during exercise? Begin-
ning, middle, end, or after?
• How long does your chest discomfort last after you stop
exercising?
• Have you ever passed out or felt like you were about to pass out
while you had your chest discomfort?
• Is there anything else associated with your exertional chest
discomfort?
• Does the discomfort in your chest make you slow down or stop
your exercise?
• Has anyone in your family (parents, sisters, brothers, grand-
parents, uncles, aunts, or cousins) died of heart attack or heart
problems?
• Has anyone in your family had an unexplained death?
• Was anyone in your family born with a heart condition?
• Has anyone in your family been told they cannot play sports?
• Does anyone in your family have an implantable cardiac
defibrillator?
• Do you take any medications or supplements?
• Do you use any street or recreational drugs?
• Do you use any nutritional supplements or drugs to improve your
performance?
• What do you use to improve your performance?
06_ch06_43-160.indd 56 3/20/19 4:22 PM

Table 6A-4. Abnormal History Follow-up Questions (continued )

Have you ever nearly lost or • Did the collapse occur during or immediately after exercise?
actually lost consciousness? • If the collapse occurred immediately after exercise, were you
already stopped or still moving?
• Did you feel anything that warned you or made you feel like
something was wrong, such as chest pain, palpitations (irregular
heartbeat), visual changes, wheezing/shortness of breath, nau-
sea, or itching?
• What happened after the collapse? Did you wake up quickly, or
were you out for a long time? How long? Did you have a seizure?
Did you wet your pants, pass stool, or bite your tongue? Did
anyone check your breathing, heart rate, or temperature at the
time of your collapse?
• What medications and supplements were you using before the
event?
• Were you ill in the few days before your collapse?
• Have you ever collapsed like this before?
• Is there a family history of collapse during exercise or of sudden
cardiac arrest or death?
Have you ever had exces- • Is the shortness of breath recent or new for you or has it been
sive shortness of breath or there for a long time (weeks or months)?
fatigue with exercise beyond • Does this occur every time you exercise or only when you exer-
what is expected for your cise hard?
level of fitness? • Do you get chest discomfort along with the shortness of breath?
• Do you get light-headed or dizzy?
• Have you passed out during exercise?
• Does anyone in your family have a serious heart condition or has
anyone died suddenly?
• Do you have a history of exercise asthma or allergies?
• Have you recently moved to a different home or recently moved
to the area?
• Are you not playing as well as you should or could because of
excessive fatigue? Are you getting tired during regular or usual
daily activities?
Have you ever been told • What can you tell me about your heart murmur?
that you have a heart • Were you born with the murmur? Is it still present?
murmur? • Have you been told it is an innocent murmur and not to worry
about it? Have you been told it should be fixed or watched
closely?
• Do you get chest pain, shortness of breath at rest or with exercise,
or racing, pounding, or skipped heartbeats that you can feel in
your chest?
• Does anyone else in your in your family have a heart murmur?
Do you experience the • Are the palpitations associated with passing out (syncope) or
skipped, irregular, or racing near passing out (pre-syncope)?
heartbeats (palpitations) • Do the palpitations have an abrupt onset and end (termination)?
with exercise? • Is there anything that stops or starts the palpitations consistently?
06_ch06_43-160.indd 57 3/20/19 4:22 PM

Table 6A-4. Abnormal History Follow-up Questions (continued )

Has anyone in your family • What is your relationship with the family member who died?
<35 years of age died • What age did the death occur, especially if <35?
suddenly or unexpectedly of • Do you know what caused the death? Was it a heart attack?
heart disease? • Do you know anything about the death (signs, symptoms, and
circumstances)?
Has anyone in your family • Can you name the heart disease that caused your family mem-
<35 years of age been ber’s disability?
disabled from heart disease • What treatments or surgical procedures has your family member
or had cardiac treatments had?
including surgery? • Can you describe the disability?
Are there any cardiac • What is the diagnosis, who has it, and at what age did the diag-
conditions in your extended nosis occur?
family members such as • How was the diagnosis made?
hypertrophic or dilated • Has anyone in your family had genetic testing for these heart
cardiomyopathy, long QT conditions?
syndrome or other ion • Have any of your family members had pacemakers or defibrilla-
channelopathies, Marfan tors implanted?
syndrome, or arrhythmias? • Has anyone in your family died unexpectedly or had surgery for
these conditions?
or HCM (LV wall thickness outgrows its blood supply) may produce ischemic chest pain
during exercise. CAD incidence increases after age 20 years and should be considered in
the differential diagnosis of angina in athletes with risk factors or clinical symptoms.
Exertional syncope or near syncope can occur during or immediately following exercise
and involves a transient loss of both consciousness and postural tone. Exertional syn-
cope that occurs during exercise is a red flag symptom and an ominous sign of potential
underlying cardiovascular disease, warranting a thorough investigation before allowing an
athlete to return to sport.61 Careful questioning of the athlete should be made to distin-
guish between syncope occurring during exercise (ie, the athlete collapses while running
toward the finish line or during play) and syncope occurring after exercise (ie, the athlete
collapses shortly after crossing the finish line). Collapse after the finish line does not guar-
antee a benign cause. The absence of prodromal symptoms before a syncopal event also
warrants a higher level of suspicion for a pathological cause, because a sudden, abrupt loss
of consciousness is more likely associated with the sudden onset of a ventricular arrhyth-
mia as seen in patients with arrhythmogenic conditions, including LQTS and CPVT. In a
review of 474 athletes with a history of syncope or near syncope found during the PPE,
33% with syncope occurring during exercise had structural cardiac disease known to cause
SCD.62 The diagnostic workup is usually performed in consultation with a cardiologist and
includes ECG, echocardiography, stress ECG, and possibly advanced cardiac imaging (such
as MRI or CT) to investigate for rare structural abnormalities such as ARVC or congenital
coronary artery anomalies. Tilt table testing is not indicated.
06_ch06_43-160.indd 58 3/20/19 4:22 PM

Syncope or near syncope (dizziness or light-headedness) occurring after exercise is

much more common and unlikely to represent underlying cardiovascular disease, espe-
cially if preceded by light-headedness, diaphoresis, nausea, or tunnel vision, all of which
suggest a neurally mediated event (so-called vasovagal syncope). Exercise-associated col-
lapse (EAC) is commonly observed at endurance events and involves athletes who are
unable to stand or walk unaided as a result of light-headedness, faintness, dizziness, or
syncope.63 During exercise, increases in heart rate and stroke volume result in a substantial
rise in cardiac output and offset diminished systemic vascular resistance from vasodila-
tation in exercising muscles. After exercise, without the muscle contraction in the legs
(muscle pump) to maintain venous return, cardiac filling may be dramatically reduced.
Forceful ventricular contractions against a diminished ventricular volume are postulated
to excessively stimulate ventricular mechanoreceptors, causing not only reflex vasodila-
tation and bradycardia but subsequent hypotension and syncope (exercise-associated
postural hypotension).64 Neurally mediated syncope, also known as neurocardiogenic syn-
cope, is generally regarded as the most common mechanism of syncope or near syncope
in young adults and can be triggered by situational stressors as well as exercise stressors.
Nonetheless, EAC, or any suspected neurocardiogenic syncope associated with a complete
loss of consciousness or near syncope, deserves a diagnostic workup to exclude an underly-
ing cardiac disorder. In addition, recurrent cases of apparently benign vasovagal syncope
should be investigated with ECG at minimum.
Excessive unexplained dyspnea or fatigue associated with exercise may also indicate a
cardiovascular condition such as myocarditis, and hypertrophic or dilated cardiomyopathy.
Palpitations or irregular heartbeats may signify arrhythmias or conduction abnormalities,
such as supraventricular tachyarrhythmias, ion channel disorders, or Wolff-Parkinson-
White syndrome. These symptoms warrant further investigation before determining medi-
cal eligibility for sports participation. A clear history of either an abrupt increase in heart
rate disproportional to activity or palpitations associated with syncope or near syncope
requires further investigation with ECG, echocardiography, exercise stress testing to exhaus-
tion, cardiac event monitoring, and potentially consultation with an electrophysiologist.
A history of previously performed cardiac testing such as ECG, echocardiography, or
exercise treadmill testing may indicate a previously suspected cardiac disorder, and a care-
ful review of past medical records may establish the outcomes of the evaluation. This
should preclude repeating the studies.
Family History
A detailed family history may help identify athletes with a predisposition to underlying
cardiac disease. The high frequency of familial SCD or syncope in exercise emphasizes the
need for a careful family history of SUD to identify athletes at risk for primary arrhythmia
syndromes. The AHA recommends that the family history include specific questions on
(1) premature death (sudden and unexpected, or otherwise) before age 50 years caused
by heart disease in one or more relatives, (2) disability from heart disease in a close rela-
tive younger than 50 years, and (3) specific knowledge of family members with cardiac
conditions known to cause SCD in athletes.7 A family history of nontraumatic sudden
death before age 50, particularly before 35 years old, is likely cardiac related and may be
familial, including HCM, Marfan syndrome, ARVC, LQTS, Brugada syndrome, CPVT, and
06_ch06_43-160.indd 59 3/20/19 4:22 PM

lipid abnormalities causing premature CAD. In addition, a family history of unexplained

syncope, unexplained near drowning or drowning, unexplained motor vehicle crash, unex-
plained seizure activity, or sudden infant death syndrome may indicate the presence of an
arrhythmia, including ion channel disorders such as LQTS or CPVT.
The AHA recommends that the PPE include (1) auscultation for heart murmurs, (2) palpa-
tion of femoral pulses to exclude coarctation of the aorta, (3) examination for the physical
stigmata of Marfan syndrome, and (4) a brachial artery BP taken in the sitting position.7
Auscultation of the heart should be performed in the supine and standing positions (or
with Valsalva maneuver), specifically to identify pathological murmurs. Particular attention
should be paid to the presence and character of any murmurs, the timing of murmurs in
relation to S1 and S2, extra heart sounds (S3 and S4), and clicks (Table 6A-5).
Table 6A-5. Significance of Abnormal Heart Murmurs
Auscultatory Finding Significance
• Harsh, loud (usually ≥ grade 3), systolic ejection murmur HCM-associated LV outflow tract
• Loudest right upper sternal border obstruction
• Increases with maneuvers that decrease venous return (ie,
Valsalva, or moving from squatting to standing)
• Systolic ejection murmur heard best at right upper sternal Aortic stenosis
border
• Radiation to neck
• Diminishes with maneuvers that decrease venous return
• (ie, Valsalva) and increases with maneuvers that increase
venous return (ie, squatting)
• Holosystolic murmur heard best at the apex Mitral valve regurgitation and pos-
• Radiation to axilla sible dilated cardiomyopathy or
HCM
• Diastolic murmur heard at right upper sternal border Aortic valve insufficiency and pos-
• Murmur accentuated with hand grip (increased systemic sible Marfan syndrome or bicuspid
vascular resistance) aortic valve
• High-frequency diastolic murmur heard best at left upper Pulmonary valve insufficiency from
sternal border primary pulmonary hypertension
(Graham Steele murmur)
• Soft early systolic murmur heard best at the upper sternal Physiological (hyperdynamic) flow
border while supine (increased venous return) murmur in a well-trained athlete
• Murmur often absent or diminished when standing or
sitting and with Valsalva maneuver
Abbreviations: HCM, hypertrophic cardiomyopathy; LV, left ventricular.
06_ch06_43-160.indd 60 3/20/19 4:22 PM

Limitations of the Preparticipation Cardiovascular Evaluation 61
The inability of physicians to distinguish pathological murmurs from physiological

murmurs by auscultation, regardless of experience or level of training, is well-known.64
Simplifying the physical examination allows better differentiation between benign mur-
murs and pathological murmurs. Characteristics of pathological murmurs that require
further evaluation or referral include loud (> grade 2/6) or harsh murmurs; radiation of
the murmur laterally, rather than upward; presence in middle to late systole, accompanied
by a click; or any murmur that gets louder (or changes quality) with dynamic maneuvers
(standing or squatting) or Valsalva maneuver. In addition, any holosystolic or diastolic
murmur requires further evaluation. In the absence of concerning symptoms or family
history, innocent murmurs require no further investigation. If doubt persists, either car-
diac imaging with echocardiography or consultation with a cardiovascular specialist is
recommended.
Simultaneous palpation of radial and femoral artery pulses is an important component
of the physical examination. In the presence of systemic arterial hypertension, delayed
femoral artery pulses when compared with radial artery pulses may indicate the presence
of coarctation of the aorta, which requires additional evaluation.
Brachial artery BP should be measured in the sitting position with the cuff on the bare
arm at heart level after the patient has been at rest for several minutes in a quiet area.
Measuring BP with an appropriately sized cuff will improve accuracy of the test. The cuff
size is critical for large athletes, who will require a large adult or even thigh cuffs, as an
undersized cuff will falsely elevate the BP measurement.65 The “ideal” cuff should have a
bladder length that encircles at least 80% of the arm circumference.65 If the BP is initially
elevated, the athlete should sit or lie quietly for 5 to 10 minutes before the measurement is
repeated. The full evaluation of elevated BP will require additional visits with the athlete’s
primary care providers to establish the diagnosis, treatment plan, and medical eligibility.
■■ INVESTIGATION OF ATHLETES WITH CARDIOVASCULAR SYMPTOMS

Athletes identified with cardiovascular symptoms or signs such as exertional syncope or
near syncope, chest pain, palpitations, or excessive exertional dyspnea require a thorough
cardiovascular evaluation to exclude underlying heart disease before they are allowed to
participate in vigorous physical activity. The diagnostic workup of athletes with red flag
symptoms or physical findings such as exertional syncope includes ECG, echocardiogra-
phy, stress ECG, ambulatory rhythm monitoring, or other advanced cardiac imaging (such
as MRI or CT) to evaluate for the presence of structural abnormalities such as ARVC or
congenital coronary artery anomalies, and it may require consultation with a cardiologist.
The investigation of rapid or irregular heartbeats associated with supraventricular tachyar-
rhythmias, ion channel disorders, or Wolff-Parkinson-White syndrome will include similar
studies and may require consultation with an electrophysiologist.
■■ LIMITATIONS OF THE PREPARTICIPATION CARDIOVASCULAR

EVALUATION
No outcomes-based studies demonstrate that the PPE is effective in preventing or detecting
the rare instance of an athlete at risk for SCD; however, many athlete abnormalities have
06_ch06_43-160.indd 61 3/20/19 4:22 PM

been found during the evaluations. Disease-specific presentations are important warn-
ing symptoms, and concerning family history requires investigation. Some athletes who
experience SCA/D have red flag conditions that are not recognized, and some have no red
flag conditions at the time of their PPE screening.25,65–67 To be effective medical evaluation
tools, the PPE questionnaires require an honest athlete or parent completing the forms.
Previous studies have demonstrated a lack of concordance between answers supplied by
parents compared with those of the student-athletes, so parental involvement is crucial to
the process for best outcomes.68 The ability of providers to distinguish physiological car-
diac murmurs from pathological cardiac murmurs with cardiac auscultation is limited64;
however, access to echocardiography allows those in doubt to easily determine the cause of
a heart murmur.
■■ NONINVASIVE CARDIOVASCULAR SCREENING OF ATHLETES

The value of adding ECG or echocardiography screening to determine the medical eligi-
bility of athletes is highly debated and is magnified by the very low prevalence and rate
of both SCA and SCD in athletes that may not differ from that of the general popula-
tion.69,70 The AHA and ACC continue to recommend against the routine use of ECG and
echocardiography for screening of young athletes in the United States. The American
Medical Society for Sports Medicine has published a position statement on PPE cardiac
screening to help primary care sports medicine physicians decide whether to use ECG
as a screening tool, rather than as a “case finding” study.10 The statement suggests a new
paradigm for determining medical eligibility using ECG as a screening tool on the basis of
the perceived risk of the athlete population, the individual physician ability to accurately
interpret findings from the screening and subsequent evaluation studies, and the available
cardiology infrastructure to complete the evaluations generated by positive testing in a
timely manner.
Outcomes From Cardiovascular Screening

The outcomes of any athletes who have had cardiovascular screening beyond history
and physical examination, and the natural course of those diseases screened for, are not
well-known for athletes or nonathletes. The PPEs that included ECG of 12-year-old boys
(n = 415) and girls (n = 318) at rest before entering competitive sports programs resulted
in restricted medical eligibility of 5.5% of athletes, with 0.5% held from any participation
because of examination findings.71 Recently, a longitudinal observational cohort study
of more than 11,000 elite-level, adolescent English Football (soccer) Association athletes
screened with a required ECG and echocardiography at age 16.4 (±1.2) years, from 1996
through 2006, showed that the prevalence of cardiovascular diseases that may be associ-
ated with sudden death is 0.38% (42 per 11,168 athletes or 376 per 100,000 athletes).11
There were 8 deaths attributed to cardiac disease among the screened athletes. The mean
time between screening and SCD was 6.8 years. Cardiomyopathy accounted for 7 of 8
SCDs. Six of the 8 athletes with SCD had normal preparticipation ECG and echocardio-
graphic (false-negative) screening results. This questions the efficacy of the single-time
screening model used in this process and suggests that perhaps the frequency of screening
06_ch06_43-160.indd 62 3/20/19 4:22 PM

Noninvasive Cardiovascular Screening of Athletes 63
over time needs to increase or the age of initial screening might be increased. However,
more-frequent ECG and echocardiographic screening will lead to increased cost of the
evaluation program. More research is needed on the natural course of diseases associated
with sudden death in elite-level athletes compared with both non–elite-level athletes and
nonathletes, as well as models and modalities used for cardiovascular screening.
The decision to add screening tests to the PPE requires careful consideration of
the actual differential risk of SCA/D in the targeted population compared with the
expected false-positive and false-negative aspects of the proposed screening test. Indi-
vidual providers performing the PPE or the institutions requiring the PPE may choose
to add a screening test to the medical eligibility evaluation when the benefit to the popu-
lation at risk is greater than potential harm (Figure 6A-2). Continual quality control and
improvement should be emphasized if a screening test, such as ECG, is added to the PPE.
In an era of “choosing wisely,” adhering to the principles of population screening and
considering additional cost to the health care system add to the complexity of this
decision.
If ECG is added to the PPE as a screening test, the most current athlete-specific criteria
for ECG interpretation should be used to decrease the number of false-positive test results
and minimize the additional testing, cost to the health care system, and undue stress for
the individual athlete and family. For individual practitioners interested in including the
ECG in the preparticipation evaluation or in offering ECG screening within the model
of informed decision-making with athletes and families, a summary of the ECG criteria
and next steps from the “International Criteria for Electrocardiographic Interpretation in
Athletes”37 is provided in Figure 6A-3.
Figure 6A-2. Strength of Rationale for ECG Screening

Abbreviations: ECG, electrocardiographic; SCA/D, sudden cardiac arrest or death.
When assessing the benefit of adding an ECG to athlete screening, the perceived location on each
of the above scales may help determine the answer for a specific population. The rationale to add
an ECG is not supported by answers that tend toward the weak end of each scale.
Reprinted with permission from Drezner JA, O’Connor FG, Harmon KG, et al. AMSSM position
statement on cardiovascular preparticipation screening in athletes: current evidence, knowledge
gaps, recommendations and future directions. Br J Sports Med. 2017;51(3):153–167.
06_ch06_43-160.indd 63 3/20/19 4:22 PM

Figure 6A-3. International Consensus Standards for ECG Interpretation in Athletes

Abbreviations: AV, atrioventricular; ECG, electrocardiographic; LBBB, left bundle branch block; LVH, left ventricular
hypertrophy; PVC, premature ventricular contraction; RBBB, right bundle branch block; RVH, right ventricular hyper-
trophy; SCD, sudden cardiac death.
Reprinted with permission from Drezner JA, Sharma S, Baggish A, et al. International criteria for electrocardio-
graphic interpretation in athletes: consensus statement. Br J Sports Med. 2017;51(9):704–731.
■■ MEDICAL ELIGIBILITY RECOMMENDATIONS FOR ATHLETES WITH

IDENTIFIED CARDIOVASCULAR DISEASE
Activity recommendations involving temporary or permanent sports disqualifica-
tion or restrictions for athletes with identified cardiovascular disease should be made
in consultation with a cardiologist. The AHA and ACC scientific statement “Eligibility
and Disqualification Recommendations for Competitive Athletes With Cardiovascular
Abnormalities” provides participation recommendations for competitive athletes with car-
diovascular abnormalities, and the most recent version of this document should be used
for decision-making.6 These expert consensus recommendations provide a framework for
determining medical eligibility for patients who have various cardiovascular abnormalities
by using the dynamic and static components of sport activities. The AHA and ACC scien-
tific statement recommendations take into account the severity of disease, the potential for
sudden death or disease progression, and the type and intensity of exercise involved in a
particular sport.7
The cardiopulmonary risk can be estimated by using the dynamic and static compo-
nents of an activity (Figure 6A-4). The cardiopulmonary demands of physical activity are
defined by the effects on the LV of the heart. Static exercises produce a pressure load on
06_ch06_43-160.indd 64 3/20/19 4:22 PM

Medical Eligibility Recommendations for Athletes With Identified Cardiovascular Disease 65
the LV, while dynamic exercises produce a volume load on the LV. The combination of
static loads and dynamic loads varies by sport.
Medical eligibility recommendations have become increasingly complex with the addi-
tion of newer technologies for the evaluation and treatment of cardiovascular conditions
Bobsledding/Luge Body buildinga,b Boxing

Field events (throwing) Downhill skiing Canoeing
III. High (>30%)
Gymnasticsa,b Skateboardinga,b Kayaking

Martial arts Snow boardinga,b Cyclinga,b
Rock climbing Wrestlinga Decathlon
Sailing Rowing
Water skiinga,b Speed skating
Weight liftinga,b Triathlona,b
Windsurfinga,b
Archery American footballa Basketballa

II. Moderate (10–20%)
Auto racinga,b Field events (jumping) Ice hockeya

Divinga,b Figure skating Cross-country skiing
Increasing Static Component
Equestriana,b Rodeoinga,b (skating technique)

Motorcyclinga,b Rugby Lacrossea
Running (sprint) Running (middle distance)
Surfing Swimming
Synchronized swimmingb Team handball
“Ultra” racing Tennis
Bowling Baseball/Softball Badminton

Cricket Fencing Cross-country skiing
I. Low (< 10%)
Curling Table tennis (classic technique)

Golf Volleyball Field hockeya
Riflery Orienteering
Yoga Race walking
Racquetball/Squash
Running (long distance)
Soccera
A. Low (<50%) B. Moderate (50–75%) C. High (>75%)

Increasing Dynamic Component
Figure 6A-4. Classification of Sports

This classification is based on peak static and dynamic components achieved during competition; however, higher
values may be reached during training. The increasing dynamic component is defined in terms of the estimated
·
percentage of maximal oxygen uptake (VO2max) achieved and results in an increasing cardiac output. The increasing
static component is related to the estimated percentage of maximal voluntary contraction reached and results in an
increasing blood pressure load. The lowest total cardiovascular demands (cardiac output and blood pressure) are
shown in the palest color, with increasing dynamic load depicted by increasing blue intensity and increasing static
load by increasing red intensity. Note the graded transition between categories, which should be individualized on
the basis of player position and style of plan.
a
Danger of bodily collision.
b
Increased risk if syncope occurs.
Reprinted with permission from Levine BD, Baggish AL, Kovacs RJ, Link MS, Maron MS, Mitchell JH; American Heart
Association Electrocardiography and Arrhythmias Committee on the Council on Clinical Cardiology, Council on
Cardiovascular Disease in the Young, Council on Cardiovascular and Stroke Nursing, et al; American College of
Cardiology. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormali-
ties: task force 1; classification of sports: dynamic, static, and impact. Circulation. 2015;132(22):e262–e266.
06_ch06_43-160.indd 65 4/1/19 10:21 AM

in children and young adults. From a best practice perspective, determining medical eli-
gibility may seem straightforward on the basis of the AHA and ACC scientific statement.
However, disqualification from sport is life altering from both a physical health perspective
and a psychological health perspective. A less active lifestyle, limited to low-intensity activi-
ties, may lead to weight gain, depression, and a paradoxical increase in other cardiovascu-
lar conditions. New medical advances combined with shared decision-making involving
the athlete, family members, physicians, and other members of the interdisciplinary health
care team may allow changes in medical eligibility.72–74 In the shared decision-making
model, all parties contribute information to the problem at hand, and the health care team
provides the risk and benefit analysis of the different approaches. Ultimately, in a shared-
decision making model, both parties (athlete and physician) share responsibility for the
resolution of the health-related issue with an acceptable level of potential risk and poten-
tial long-term benefit for the athlete.
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64. O’Connor FG, Johnson JD, Chapin M, Oriscello RG, Taylor DC. A pilot study of clinical agreement in cardio-
vascular preparticipation examinations: how good is the standard of care? Clin J Sport Med. 2005;15(3):
177–179 PMID: 15867562
65. Drezner JA, Fudge J, Harmon KG, Berger S, Campbell RM, Vetter VL. Warning symptoms and family history
in children and young adults with sudden cardiac arrest. J Am Board Fam Med. 2012;25(4):408–415 PMID:
22773708 https://doi.org/10.3122/jabfm.2012.04.110225
66. Alapati S, Strobel N, Hashmi S, Bricker JT, Gupta-Malhotra M. Sudden unexplained cardiac arrest in appar-
ently healthy children: a single-center experience. Pediatr Cardiol. 2013;34(3):639–645 PMID: 23052663
67. Sealy DP, Pekarek L, Russ D, Sealy C, Goforth G. Vital signs and demographics in the preparticipation
sports exam: do they help us find the elusive athlete at risk for sudden cardiac death? Curr Sports Med Rep.
2010;9(6):338–341 PMID: 21068565
68. Carek PJ, Futrell M, Hueston WJ. The preparticipation physical examination history: who has the correct
answers? Clin J Sport Med. 1999;9(3):124–128 PMID: 10512339
69. Asplund CA, O’Connor FG. The evidence against cardiac screening using electrocardiogram in athletes. Curr
Sports Med Rep. 2016;15(2):81–85 PMID: 26963014
70. Asif IM, Drezner JA. Cardiovascular screening in young athletes: evidence for the electrocardiogram. Curr
Sports Med Rep. 2016;15(2):76–80 PMID: 26963013
71. Mayer F, Bonaventura K, Cassel M, et al. Medical results of preparticipation examination in ado-
lescent athletes. Br J Sports Med. 2012;46(7):524–530 PMID: 22576783 https://doi.org/10.1136/
bjsports-2011-090966”10.1136/bjsports-2011-090966
72. Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: what does it mean? (or it
takes at least two to tango). Soc Sci Med. 1997;44(5):681–692 PMID: 9032835
73. Baggish AL, Ackerman MJ, Lampert R. Competitive sport participation among athletes with heart disease: a
call for paradigm shift in decision making. Circulation. 2017;136(17):1569–1571 PMID: 29061571 https://
doi.org/10.1161/CIRCULATIONAHA.117.029639
74. Levine BD, Baggish AL, Kovacs RJ, Link MS, Maron MS, Mitchell JH; American Heart Association
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2015;132(22):e262–e266 PMID: 26621643 https://doi.org/10.1161/CIR.0000000000000237
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06_ch06_43-160.indd 70 3/20/19 4:22 PM
B. Nervous System
Heart Health Question About You

Medical Questions
1. Have you had a concussion or head injury that caused confusion, a prolonged headache, or
memory problems?
2. Have you ever had numbness, had tingling, had weakness in your arms or legs, or been unable
to move your arms or legs after being hit or falling?
■■ SECONDARY QUESTIONS
• What can you tell me about your head injury or concussion?
• Have you ever had an unexplained seizure?
• Has anyone in your family had unexplained fainting, seizures, or near drowning?
• Do you have headaches with exercise?
• What can you tell me about the symptoms in your arms or legs?
• Have you had any tests or imaging for the problem?
■■ KEY POINTS
• Concussions are common across all sports (not just collision sports), under-recognized,
and underreported.
• No one should return to play (RTP) after sustaining a concussion until completely
asymptomatic and successfully completing a graduated return to sport process.
• Return to play after concussion decisions must be individualized.
• Athletes younger than 18 years may take longer to recover after concussion than older
athletes.
• Female athletes with sport-related concussion (SRC) may be more symptomatic and
may take longer to recover.
• Sequelae of concussion may include persistent symptoms (postconcussion syndrome
[PCS]) that can last from weeks to months.
• Cervical cord neurapraxia (CCN) appears with motor or sensory changes in more than
one extremity (bilateral arms or legs or 1 arm and 1 leg) and is a spinal cord injury.
• An athlete with CCN should be evaluated for cervical spinal stenosis and neurosurgical
consultation considered.
• Return to play with cervical spinal stenosis is controversial.
• “Stingers” or “burners” are unilateral.
• Athletes with brachial plexus injuries may RTP when asymptomatic.
• Seizures should not preclude athletes from physical activity.
• Headaches can be triggered or worsened by exercise and may prohibit physical activity.
• Primary exertional headache (effort headache) occurs with aerobic exercise.
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72 Section 6B. Nervous System
■■ INTRODUCTION
A goal of the neurological preparticipation physical evaluation (PPE) is to detect neuro-
logical conditions that may limit or preclude medical eligibility, may require modified
athletic participation, may place athletes at higher risk for injury, or may affect athletic
performance.
Neurological conditions that affect sports participation and physical activity include
SRC and its sequelae, CCN (transient paraparesis, quadriparesis, or tetraparesis), brachial
plexus injuries (stingers or burners), seizure disorders, and headache disorders. A history
of head trauma, cervical spine injury, or neurological symptoms at rest or during activity
should prompt a more detailed neurological examination, including assessment of cranial
nerves, motor and sensory functions, deep tendon reflexes, cognitive function, and cerebel-
lar function.1 This section will review the PPE questions that address current or previous
neurological issues, provide a brief framework of pertinent issues, and discuss appropriate
workup, management, and medical eligibility concerns for each condition.
■■ SPORT-RELATED CONCUSSION
Sport-related concussion is an injury to the brain. The term mild traumatic brain injury, or
mild TBI, is often used interchangeably with concussion, which may not be accurate. The
fifth international Concussion in Sport Group has recently modified its definition of SRC
as follows:
Sport related concussion is a traumatic brain injury induced by biome-

chanical forces. Several common features that may be utilized in clinically
defining the nature of a concussive head injury include:
• SRC may be caused either by a direct blow to the head, face, neck or
elsewhere on the body with an impulsive force transmitted to the head.
• SRC typically results in the rapid onset of short-lived impairment of
neurological function that resolves spontaneously. However, in some
cases, signs and symptoms evolve over a number of minutes to hours.
• SRC may result in neuropathological changes, but the acute clinical
signs and symptoms largely reflect a functional disturbance rather than
a structural injury and, as such, no abnormality is seen on standard
structural neuroimaging studies.
• SRC results in a range of clinical signs and symptoms that may or may
not involve loss of consciousness. Resolution of the clinical and cogni-
tive features typically follows a sequential course. However, in some
cases symptoms may be prolonged.
The clinical signs and symptoms cannot be explained by drug, alcohol, or
medication use, other injuries (such as cervical injuries, peripheral ves-
tibular dysfunction, etc.) or other comorbidities (e.g. psychological factors
or coexisting medical conditions).2
The neurological signs and symptoms of SRC that are caused by mechanical acceleration
or deceleration are not related to macroscopic neural damage, but they are believed to be
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Sport-Related Concussion 73
caused by a disturbance in the neurochemical pathways or microstructural injury.2–4 The

pathophysiology of concussion, as described in animal models and some recent human
studies, involves a neurometabolic cascade of events.4–6
Brain trauma causes potassium release from the neurons, an increase in extracellular
glutamate,6,7 and activation of N-methyl-d-aspartate receptors, leading to neuronal depo-
larization. Depolarization drives additional potassium from the cell and allows both cal-
cium and sodium into the cell, depressing neuronal activity.4,7 To restore cell homeostasis,
the energy-dependent sodium-potassium ion pumps are upregulated, which depletes cell
energy reserve.4,6 Coupled with reduced cerebral blood flow following SRC, the increased
cell energy demand leads to an “energy crisis” in the brain tissue.4,6,8,9 Calcium sequesters
into mitochondria to normalize the increased intracellular calcium levels, which inhib-
its mitochondrial oxidative metabolism, exacerbating the cell energy crisis.4 The ensuing
hypometabolic state may persist for up to 4 weeks.10,11
Because this injury occurs at the cellular level, most athletes with SRC show no changes
with computed tomography, or CT, or magnetic resonance imaging (MRI) and do not
require neuroimaging. Standard neuroimaging may be necessary to evaluate for more-
serious brain injury, such as a subdural hematoma.12,13
There are 2 primary considerations for medical eligibility when an athlete has a history of
SRC noted during the PPE. First, the most recent concussion must be completely resolved;
second, a prior concussion places an individual athlete at a higher risk for future SRC. A his-
tory of SRC should trigger secondary concussion–related questions, including the number
of, frequency of, severity of, treatment of, and recovery from past SRCs and the presence of
mood, learning, attention, sleep, or migraine disorders. Before allowing an athlete to partici-
pate in contact sports or other activities that might increase his or her risk of additional brain
injury, a synthesis of the clinical data to determine medical eligibility and a thorough discus-
sion of the potential risk to the brain with the athlete (and parents if a minor) is essential.
There are potential health risks of returning an athlete with persistent symptoms to play,
including increased susceptibility to an additional, possibly more severe concussion; pro-
longed duration of symptoms; and second impact syndrome (SIS). A second injury before
the brain has fully recovered results in worsening cellular metabolic changes and signifi-
cant decreased cognitive function in animal laboratory models, which accounts for wors-
ening symptoms with an additional brain insult.12,14–19 SIS (diffuse cerebral swelling) is a
controversial and rare condition described as occurring when an individual sustains a sec-
ond head injury before the symptoms of the initial SRC injury have fully cleared.20 SIS has
a mortality rate approaching 50% and a morbidity rate nearing 100%, which emphasizes
the importance of allowing the brain to heal before returning to the activity that caused
the initial injury.21 SIS is an exceedingly rare phenomenon, but most cases have involved
high school and younger athletes.22 The potential risk supports the recommendation to
immediately remove an athlete from play following a suspected SRC and to withhold med-
ical eligibility while the athlete is symptomatic.
Diagnosing concussion and then defining recovery is complicated by the fact that there
is no single diagnostic sign, symptom, or objective test that clearly defines the diagnosis.
An athlete is clinically recovered from SRC when asymptomatic at rest and able to partici-
pate in usual activities without symptoms, including school, work, and sport.2
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Return to sport recommendations for children have been extrapolated from adult
consensus guidelines, and further research is required to refine a child-specific program.
Studies demonstrate a longer recovery period for younger athletes compared with college
and older athletes, so a more conservative approach to the return of younger athletes to
full participation is reasonable for contact and collision sports.23–29
The baseline comparison method, in which an athlete’s postconcussion performance
is compared with a healthy baseline evaluation from preseason, is still being investigated.
It has been described as the “gold standard” in concussion management by some,30,31
while other expert groups have not advocated for baseline testing.2 Several tools have been
suggested as adjuncts to the PPE, including baseline computerized neurocognitive test-
ing (CNT); the Child Sport Concussion Assessment Tool, 5th Edition, or Child SCAT5;
graded symptom checklists; the Balance Error Scoring System (BESS); the tandem gait; the
King-Devick test; and the Vestibular Ocular Motor Screening (VOMS).32–36 The routine use
of baseline CNT is not currently recommended.37 Obtaining baseline Sport Concussion
Assessment Tool (SCAT) or BESS measures for large numbers of athletes is time intensive
and likely cost prohibitive.31,33,38 The utility of the SCAT decreases 3 to 5 days after injury,
and when used serially to evaluate SRC, it should be done under the same conditions
as the baseline assessment.33,39–41 Impaired tandem gait performance has been noted in
pediatric patients with prolonged concussion recovery; however, normative data are not
available.35,42 Tools such as the King-Devick test and VOMS have demonstrated some use-
fulness in the evaluation of SRC.34,43–45 At this time, there are not enough studies of ade-
quate quality to recommend their inclusion in the SCAT or the PPE.23,37,46
The National Collegiate Athletic Association (NCAA) recommends a onetime prepartici-
pation baseline concussion assessment for all college varsity student-athletes that should
include, but not necessarily be limited to,
• Brain injury or brain concussion history
• Symptom evaluation
• Cognitive assessment
• Balance evaluation47
There is no consensus agreement on the definition of PCS. The fifth international
Concussion in Sport Group suggests the term persistent symptoms for failure of normal clini-
cal recovery beyond the expected time frame of more than 14 days in adults and more than
4 weeks in children.2 In athletes with persistent symptoms, it is important to evaluate for
cervical strains, vestibular injuries, oculomotor disorders, sleep-wake cycle disturbances,
and depression or anxiety that may confound the diagnosis and benefit from other inter-
ventions. The symptoms of these coexisting conditions can mimic symptoms of a concus-
sion and may unnecessarily prolong recovery and return to participation. Young athletes
with prolonged symptoms are more likely to have high pre-injury somatization.48,49
Athletes with persistent symptoms may benefit from additional evaluation by a concussion
specialist23 and should not return to participation until all symptoms have resolved.
The absolute number of concussions an individual can sustain and continue to par-
ticipate in contact sports has not been defined.12 High school athletes with a history of
concussions who have no physical, medical, or cognitive difficulties are generally allowed
to participate in all sports. Sustained attention and cognitive function deficits following a
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Cervical Cord Neurapraxia 75
mild concussion may persist long after the injury, limiting medical eligibility.50 The evidence
available regarding concussion recovery in children is sparse.51 Providers treating young ath-
letes with a history of multiple concussions may adopt a more conservative medical eligibil-
ity or RTP strategy. When repeated concussions occur with lesser force, are more severe, take
longer to fully recover, or show changes in baseline brain function, withholding medical
eligibility for contact or collision sports or “sports with high risk” should be considered.
Female athletes with SRC may be more symptomatic and may take longer to recover.
In addition, adult female athletes who have concussions are at increased risk for postcon-
cussion symptoms compared with males, but this has not been shown in female athletes
younger than 18 years.52
Clinicians should be aware of the potential for long-term consequences from multiple
sub-concussive impacts.51 There is increasing concern that head-impact exposure and recur-
rent concussions contribute to long-term neurological sequelae, including chronic trau-
matic encephalopathy and chronic neurocognitive impairment.12 Two studies showed no
increased risk of dementia, Parkinson disease, amyotrophic lateral sclerosis, or cognitive
or depressive problems in former high school football players compared to non-football–
playing classmates.53,54
There are no evidence-based guidelines for disqualifying or retiring an athlete from his
or her sport after concussion,12,23,55 although there are expert opinion publications that
provide some considerations for limiting medical eligibility.56,57 It may be prudent to refer
an athlete to a specialist with expertise in SRC when contemplating retiring an athlete from
a specific sport.
The fifth international Concussion in Sport Group examined neuropsychological assess-
ment (NP) and its role in screening and assessment. Mandatory baseline or preseason NP
testing is not required or recommended; however, it may be helpful in some situations and
may add useful information to the postconcussion interpretation of these tests. Preseason
testing provides an opportunity for a health care professional to discuss the significance
of SRC injury with an athlete. Post-injury NP testing is not required for evaluation of SRC
in all athletes; however, when necessary, the assessment should be performed by a trained
and accredited neuropsychologist.2
Several biomarkers are being investigated for concussion evaluation.58,59 None of these
biomarkers have been advanced to clinical use.60 Nutritional supplements are also being
investigated for potential preventive or therapeutic roles in cases of concussion.61,62 There is
no evidence that supplements can prevent or treat concussions.62
■■ CERVICAL CORD NEURAPRAXIA

Cervical cord neurapraxia, also called transient quadriplegia/tetraplegia or transient paraplegia, is
characterized by an acute transient impairment of sensory or motor function in more than
one extremity. The pathology is named for the number of extremities affected. Symptoms
can include burning pain, numbness, tingling, or loss of sensation with or without motor
weakness or paralysis. Symptoms usually resolve within 10 to 15 minutes but may last up
to 48 hours.63 The most common cause of CCN is cervical spinal stenosis caused by nar-
rowing of the spinal canal that can be congenital or acquired (degenerative changes, cervi-
cal instability, or intervertebral disk protrusion).64
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Findings from the physical examination, unless a player is examined at the time of
injury, are normal. An MRI of the cervical spine should be obtained to evaluate for an
underlying spinal abnormality such as cervical spinal stenosis.65 Cervical spinal steno-
sis can be defined by a cervical spinal canal measurement of less than 14 mm at C4.66
However, the concept of functional spinal stenosis or a canal so small as to obliterate the
protective cerebral spinal fluid cushion is more frequently used.66
There is debate as to whether players who have had an episode of CCN should be
allowed to RTP in subsequent athletic events.67 A review of 110 MRIs of adolescent and
adult athletes with CCN followed for 3 years showed a 56% risk of a recurrent episode
that strongly correlated with the degree of stenosis and led to the conclusion that cervical
spinal stenosis was a risk factor for CCN.68 A single uncomplicated episode of CCN did
not increase the risk of incurring permanent neurological sequele.68 Other experts strongly
disagree and contend that functional spinal stenosis is an absolute contraindication to par-
ticipate in contact or collision sports after an episode of CCN.65,66
Prepubertal athletes with CCN do not have congenital cervical spinal stenosis as mea-
sured by the sagittal spinal canal diameter or the Torg ratio. Cervical cord neurapraxia in
these athletes is attributed to the mobility of the pediatric spine rather than the presence
of cervical spinal stenosis.67,69 Long-term follow-up of a small pediatric cohort with CCN
showed full return to previous activities, including sports, and none of the children experi-
enced a subsequent permanent neurological injury.69
Given the medicolegal risk and controversy associated with CCN, following an episode
of CCN with documented cervical spinal stenosis, it is advised to seek neurosurgical con-
sultation before allowing RTP, particularly for players of collision sports.
■■ BRACHIAL PLEXUS INJURIES

Transient brachial plexus injuries, commonly referred to as “stingers” or “burners” or as
transient brachial plexopathy, involve unilateral upper extremity pain and paresthesia
following a blow to the neck or shoulder that resolve rapidly. Athletes typically report
burning dysesthesias beginning in the shoulder region and radiating down the arm
and hand.
These injuries are most common in players of contact and collision sports, such as
football, rugby, and wrestling. Injury rates in football players are reported as high as 26%
in a single season70 and 50% across a career.71 Career brachial plexus injuries are reported
by 50% to 65% of college and 30% of high school football players.72,73
There are 2 typical injury mechanisms for stingers: tensile stretch and compressive force.
Tensile injuries occur when the neck is forcibly stretched away from the ipsilateral shoul-
der as the shoulder is simultaneously depressed, stretching a portion of the nerve. Tensile
injuries are more common in high school or younger athletes. Stingers from compression
forces occur when the neck is forcibly flexed in a posterolateral direction on the affected
side, “pinching” the nerve tissues.74 Compression stingers are more common in athletes
20 years and older who have more-degenerative disk changes and foraminal narrowing.
Stingers are more likely an injury to the proximal cervical nerve root of the spinal nerve
complex compared with an injury to the brachial plexus. The cervical nerve roots do not
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Brachial Plexus Injuries 77
have a protective epineurium or perineurium to help absorb either compressive forces or

tensile forces. Recurrent stingers occur more frequently when degenerative disk disease is
present74 and when degenerative changes in the spine that occur with aging place the nerve
root at greater risk.75 The brachial plexus can be involved in a stinger, but its plexiform
nature is relatively resistant to stretch injury.
When there is a history of stingers, secondary questions should clarify the frequency
of previous episodes, the location of symptoms (unilateral or bilateral), and the current
reduction strategies (eg, neck collars, strengthening). An athlete may, at separate times,
have stingers in different arms; however, concurrent bilateral symptoms are, by definition,
caused by CCN pathology and should be evaluated as outlined previously in this section.
Physical examination to assess the involved and contralateral upper extremities includes
assessment of muscle strength (myotomes at C4–C8), sensation in C3–T1 dermatomes,
reflexes (biceps, triceps, and brachioradialis), and muscle-mass symmetry (ruling out
muscle atrophy); assessment of neck range
of motion; and provocative tests to repro-
duce symptoms (brachial plexus traction
test, cervical compression test, Spurling test,
and upper limb tension tests). A Spurling
test for “ruling in” radiculopathy is per-
formed by extending the head in a lateral
direction and then rotating it while apply-
ing axial pressure (Figure 6B-1), and it is
the most commonly used clinical examina-
tion technique for confirming the presence
of radiculopathy. During cervical extension,
the potential space in the posterior foram-
ina is decreased by 30%, which increases
cervical nerve root impingement (often
by a herniated cervical disk), producing a
positive test result. A Spurling test result Figure 6B-1. Spurling Test
is positive when the maneuver produces
radicular symptoms or pain radiation down
the involved arm.
Upper limb tension tests for ruling out radiculopathy, that is, the median and radial bias
maneuvers known as median and radial neurodynamic tests, are analogous to the straight
leg–raising test for the lower extremity. The tests put a stretch on the brachial plexus and
nerve, reproducing the symptoms when the result is positive. The tests are shown in Figures
6B-2 and 6B-3.
Either abnormal findings from a neurological examination or a history of recurrent
stingers should prompt cervical radiography, to evaluate for possible cervical spinal ste-
nosis, with or without adjuvant cervical MRI.1 When numbness, weakness, or both persist
for longer than 4 weeks, electromyography should be done to define the nature and loca-
tion of injury. Electromyography performed before 4 weeks has a high incidence of false-
negative results.76,77
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Figure 6B-2. Median Neurodynamic Test
Tilt of head to
contralateral side
Radioulnar joint
pronation
Volar flexion
of wrist Shoulder
abduction
Maximum stretch
of the radial nerve
Elbow
extension
Figure 6B-3. Radial Neurodynamic Test
Players with a history of stingers or burners may return to activity when free of any neck
or radicular pain and have full range of motion and strength.78 An athlete who recovers
from serial stingers quickly can be allowed to participate without restrictions. Long-term
significant nerve injury is a rare outcome, but it does occur.
Neck strengthening may benefit athletes with a history of stingers. In addition, pro-
tective equipment that limits lateral neck flexion and hyperextension may be helpful.79
Tackling technique should be reviewed by the coaching staff to prevent dangerous prac-
tices, in particular, spearing or “leading with the head.”80
Sports participation with other spine conditions is outlined in Table 6B-1.
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Brachial Plexus Injuries 79
Table 6B-1. Spine Condition Participation Recommendations
No Contraindication Relative Contraindication Absolute Contraindication

Klippel-Feil anomaly type II Developmental narrowing of the Odontoid anomalies: odontoid
lesion involving fusion of 1 cervical canal with 1 episode of agenesis, odontoid hypoplasia,
or 2 interspaces at C3 and cervical cord neurapraxia os odontoideum
below in an individual with
full range of motion and the
absence of occipitocervical
anomalies, instability, disc
disease, or degenerative
changes
Developmental stenosis with Episodes of cervical cord Atlanto-occipital fusion

a Torg ratio <0.8, with no neurapraxia with intervertebral
instability disc disease or developmental
changes (or both)
Spina bifida occulta Episode of cervical cord neura- Klippel-Feil anomaly, type I
praxia associated with MRI lesion involving mass fusion
evidence of cord defect or cord
edema
An episode of cervical cord Spear tackler’s spine as defined

neurapraxia associated with by Torg et al
ligamentous instability, symptoms
of neurologic findings lasting
longer than 36 h and/or mul-
tiple episodes
Healed nondisplaced Jefferson Atlantoaxial instability

fractures: athlete must have full,
pain-free ROM with no neuro-
logic findings
Type I and II odontoid fractures: Atlantoaxial rotatory fixation

athlete must have full, pain-free
ROM with no neurologic findings
Lateral mass fractures of C2: Acute fractures

athlete must have full, pain-free
ROM with no neurologic findings
Stable displaced vertebral body Vertebral body fracture with

compression fracture without a sagittal component
sagittal component: athlete must
be asymptomatic, be neuro-
logically normal, and have full,
pain-free ROM
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Table 6B-1. Spine Condition Participation Recommendations (continued )
No Contraindication Relative Contraindication Absolute Contraindication

Stable fractures involving the Vertebral body fracture with
posterior neural ring: athlete or without displacement but
must be asymptomatic, be with associated posterior arch
neurologically normal, and have fractures or ligamentous laxity
full, pain-free ROM (or both)
Ligamentous injuries: instability Comminuted fractures of the

<3.5 mm of displacement of 1 vertebral body with displacement
vertebra in relation to another into the canal
or <11° of rotation as demon-
strated on lateral radiographs
Healed disc herniation treated Any fracture with associated

conservatively or with discec- pain, neurologic findings, and
tomy and fusion as long as limited ROM
fusion is solid, there are no
symptoms or neurologic findings,
and ROM is full
Treated disc disease with Healed displaced fractures

residual instability is a relative involving the lateral masses with
contraindication resulting facet incongruity
C1-C2 fusion
Ligamentous injuries: instabil-

ity as demonstrated by more
than 3.5 mm displacement of 1
vertebra in relation to another
or greater than 11° of rotation
as demonstrated on lateral
radiographs
Acute disc herniation
Abbreviations: MRI indicates magnetic resonance imaging; ROM, range of motion.
Reprinted with permission from Conley KM, Bolin DJ, Carek PJ, Konin JG, Neal TL, Violette D. National Athletic
Trainers’ Association position statement: preparticipation physical examinations and disqualifying conditions. J Athl
Train. 2014;49(1):102–120.
■■ SEIZURES
Seizures are not very common among athletes, in part because patients with seizure disor-
ders may be discouraged from participating in strenuous exercise and team sports for fear
of exacerbating the disorder.81,82 Athletes with well-controlled seizure disorders can partici-
pate in collision and contact sports without affecting seizure frequency.81 However, concus-
sion may exacerbate seizure disorders in athletes.83
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Headaches 81
New-onset seizures or seizures occurring after head injury require a thorough medical
evaluation and seizure control before resuming sport participation. Syncope with myo-
clonic activity can easily be confused with seizure, and potential cardiac causes of syn-
cope should be ruled out before assuming a diagnosis of seizure disorder (see Chapter 6,
Section 6A). Some antiepileptic medications have side effects that may affect performance,
including rash, hirsutism, weight gain, nausea, behavioral changes, or cognitive impair-
ment.84 The World Anti-Doping Agency (WADA) and the NCAA do not ban most antiepi-
leptic drugs, but athletes and providers should keep current with the banned medication
lists.47,81
Water sports, archery, riflery, strength training, weight lifting, powerlifting, and sports
involving heights can present unique challenges for athletes with seizures, and limitations
may be indicated for some athletes.85,86 Water sports carry the risk of drowning and aerial
sports carry the risk of falls; these risks must be discussed with the athlete and the parents
or guardians. The athlete must never swim, dive, or train in the water alone.81 Coaches
should be informed so that they are aware of the risks. Athletes should inform their physi-
cian about any seizure activity so that control can be improved.
■■ HEADACHES
In a survey including male and female athletes, 35% reported headaches during activ-
ity.87,88 Frequent headaches can be caused or worsened by intense or prolonged physical
activity and can therefore interfere with sports participation. Providers should consider the
primary and secondary reasons for headache, including sport-specific causes, when evaluat-
ing an athlete as outlined in Box 6B-1.89,90 Physical examination should focus on ruling out
secondary causes of headache by assessing blood pressure, examining the retina for papill-
edema, and evaluating cranial nerve and cerebellar function.
Migraine headaches occur more often in females and frequently develop during ado-
lescence,91 with a community prevalence of 12% to 18%.92 Migraines do not limit medi-
cal eligibility, but they may hamper performance and day-to-day participation. Migraines
may be triggered by the stress of competition, by head trauma or head impact (heading a
soccer ball), or by physical exertion alone. Athletes with a history of migraines may take
longer to recover following concussion, and concussion may exacerbate their migraine fre-
quency.93–95 Athletes should be asked about migraine headache triggers so that preventive
strategies can be implemented.
Neither WADA nor the NCAA ban ergot derivatives or triptans, but beta-adrenergic
blocking agents are banned.47 Some medications used in migraine treatment may impair
performance or slow reaction time, increasing the risk of injury in some sports. Most
athletes can compete effectively and safely after taking a triptan. Some athletes require
pre-competition prophylaxis. If treatment is needed during competition, an injectable,
rapid-onset triptan may facilitate more-rapid RTP.
Two categories of headache relate strictly to exercise: primary cough headache, also called
benign exertion headache, and primary exertion headache, also referred to as effort headache.89,92
Primary cough headache is brought on suddenly by coughing, straining, or the Valsalva
maneuver in the absence of other intracranial pathology, such as cerebral aneurysm or
Arnold-Chiari malformation.89,90 Imaging, particularly of the posterior fossa, is required
06_ch06_43-160.indd 81 3/20/19 4:22 PM

Box 6B-1. International Headache Society Classification of Headaches89,90

Primary Headaches
• Migrainea
• Tension-type headache
• Trigeminal autonomic cephalalgia
• Other primary headache disorders
—— Primary cough headache (benign exertion headache)
—— Primary exercise headache (effort headache)
—— Primary headache associated with sexual activity
—— Primary thunderclap headache
—— Cold-stimulus headache
—— External-pressure headache
—— Primary stabbing headache
—— Nummular headache
—— Hypnic headache
—— New daily persistent headache
Secondary Headaches
• Headache attributed to
—— Head or neck trauma or injury (post-concussive headache)
—— Cranial or cervical vascular disorder
—— Nonvascular intracranial disorder
—— Substance or its withdrawal
—— Infection
—— Disorders of homeostasis
—— Disorder of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cervi-
cal structures
—— Psychiatric disorder
Painful Cranial Neuropathies, Other Facial Pain, and Other Headaches
• Painful lesions of cranial nerves and other facial pain

• Other headache disorders
a
May be triggered by exercise.
to rule out secondary forms of cough headache. Treatment strategies include nonsteroidal
anti-inflammatory medications such as indomethacin and altering breathing patterns dur-
ing weight lifting.92
Primary exertion headache is triggered by aerobic exercise, is pulsating in quality, and
lasts anywhere from 5 minutes to 48 hours.89 Subarachnoid hemorrhage and arterial dis-
section must be ruled out for any new or different acute-onset exertion headache.89,90
Prophylactic treatment strategies for recurrent exertion headaches include indomethacin
and graduated exercise programs that stay slightly below the onset threshold.92 An athlete
with effort headaches must also be asked about prior or current concussion and head
injury. Following a concussion, an athlete may continue to have headaches with exer-
tion related to the head injury. Exertion headaches not present before a concussion may
indicate that the brain is not completely healed, and the athlete should be restricted from
activity until the symptoms have resolved.2
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org/10.1177/0363546513488751
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06_ch06_43-160.indd 88 3/20/19 4:22 PM
C. General Medical Conditions
■■ MEDICAL HISTORY
History Form Questions

General Questions
1. Has a provider ever denied or restricted your participation in sports for any reason?
2. Do you have any ongoing medical issues or recent illness?
Secondary Questions
• When and why were you restricted from participation?
• Have you seen a doctor for this?
• Are you receiving any treatments or taking any mediations for the condition that
resulted in your restrictions?
• Do you have any follow-up medical visits or scheduled appointments for the condition?
• What has changed since you were restricted from participation?
• Have you been restricted from participation for other problems?
• Have you ever had surgery?
• Have you stayed overnight in the hospital?
• Do you still have that problem?
Key Points
• Only 1% to 2% of screened athletes are completely restricted from sports participation.
• The preparticipation physical evaluation (PPE) may identify chronic medical conditions
and other measures of general health status that can require more in-depth investigation
and follow-up.
• Medical eligibility can be coordinated with colleagues to determine the most appropri-
ate participation status and to monitor safe participation.
Reports of chronic medical conditions such as asthma, seizures, or even skin disease
offer opportunities to assess both the general health of an athlete and the potential influ-
ences on performance and medical eligibility. Athletes with adequate control of chronic ill-
ness can usually participate in most sports without restrictions, but regular care is essential
to ensure safe participation. Medications should be evaluated both for potential adverse
effects on performance, judgment, and stamina and for medications banned by the World
Anti-Doping Agency (WADA).
■■ WEIGHT CONCERNS
Athletes who have conditions such as underweight, overweight, or obesity have long-term
health issues that may affect medical eligibility and risk for injury or illness during sport
participation. During the PPE, values for height, weight, and body mass index (BMI)
should be plotted on age-appropriate growth charts and compared, if possible, with past
measurements. (Body mass index can be calculated as the weight in kilograms divided by
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90 Section 6C. General Medical Conditions
the height in meters squared.) The classification of underweight, overweight, and obesity is
based on BMI1 (Table 6C-1). Body mass index does not measure body fat directly and may
overestimate adiposity in muscular athletes, leading to an inaccurate classification of over-
weight; however, BMI has acceptable clinical validity for most people.2
Table 6C-1. Terminology for Body Mass Index Categories for Children
Based on Percentile for Age
Body Mass Index Category for Age Percentile Range for Age
Underweight <5th percentile
Normal or healthy weight 5th–85th percentile
Overweight 85th–95th percentile
Obesity >95th percentile
Adapted from Barlow SE; American Academy of Pediatrics Expert Committee. Expert committee recommendations
regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary
report. Pediatrics. 2007;120(suppl 4):S164–S192.
With any patient who is overweight or obese, every effort should be made to encour-
age regular physical activity, and limiting medical eligibility may be counterproductive.
However, some medical and musculoskeletal concerns should be addressed in this popula-
tion during the evaluation and before determining medical eligibility.
• Children who are overweight or obese are at higher risk for slipped capital femoral
epiphysis2 and may report more history of fractures or musculoskeletal discomfort.3
• Athletes who are obese are at increased risk for heat illness and cardiovascular strain, so
careful acclimatization to the environment and to exercise intensity and duration will
improve the safety profile. The fat tissue can store metabolic heat, potentially extending
the time to collapse from heat stroke, but also increasing time to remove excess heat.
These athletes may need additional education to ensure sufficient hydration, as well as
potential activity and recovery modifications during competition and training to reduce
heat stroke risk and cardiovascular strain.4
• Modifications of meal portions and food choices can enhance athletic performance and
ultimately improve health status.
• For previously sedentary or relatively inactive athletes, setting reasonable and readily
attainable goals with a planned and monitored stepwise plan to increase the training
load may reduce the risk of acute overload and increase the chance for ongoing long-
term physical activity.5
■■ DIABETES MELLITUS
Athletes with either type 1 or type 2 diabetes mellitus require careful screening for disease-
related complications. Before participation, instruction in appropriate blood glucose
concentrations and blood glucose monitoring, diet modifications for food choices (par-
ticularly carbohydrate intake), hydration, and insulin therapy before, during, and after
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Diabetes Mellitus 91
activity will improve safety and performance. Each athlete should have an emergency
action plan for hypoglycemia during athletic activity. With individualized pre-activity
counseling, good metabolic control, and absence of organ-specific complications, athletes
can participate in all sports without restrictions.6,7
Organ-specific complications of diabetes, including cardiovascular disease (hyperten-
sion and coronary artery disease), peripheral vascular disease, retinopathy, nephropathy,
neuropathy (peripheral and autonomic), and gastroparesis, tend to occur more in adult
patients, and they can limit participation in some activities.8
• For patients with coronary artery or peripheral vascular disease, individualized activ-
ity recommendations should be determined by either the primary care physician or
the consultant.
• Athletes with moderate to severe non-proliferative retinopathy should avoid activities
that significantly elevate blood pressure, such as weight lifting, or have repetitive high
impact, such as jogging.8
• Diabetic nephropathy may limit highly strenuous exercise, but each patient should be
evaluated and given individualized guidelines.8
• Patients with autonomic neuropathy must be screened for coronary artery disease and
may have thermoregulatory dysfunction that affects exercise in hotter or colder environ-
ments or results in greater risk for postural hypotension during activity.
• Significant peripheral neuropathy is an indication to limit weight-bearing exercise, given
the risk for fractures and ulcer formation.8
• Diabetic gastroparesis may affect fluid and electrolyte absorption, limiting safe partici-
pation in strenuous or prolonged activities in warm environments.
Because of the potentially serious or even fatal implications of hypoglycemia during
exercise, certain sports such as rock climbing, skydiving, and scuba diving are considered
high-risk for individuals who have diabetes. The process of training for and participating
in solo endurance or ultra-endurance events, such as ultramarathons, triathlons, or open-
water swimming, requires proper support during training and competition. Training and
competition partners (buddy system) will improve response time for hypoglycemic inci-
dents and promote safer participation.
Exercise can affect individual insulin needs, and each athlete must determine personal
response to exercise and appropriate insulin modifications. Consistent training regimens
that mimic competition can help establish appropriate adjustments to the insulin regimen.8
Many diabetic patients use insulin pumps, and reductions in basal rates or bolus dosing
before exercise may be necessary. If the device is suspended or disconnected during exer-
cise lasting longer than 60 minutes, supplemental insulin should be used.9 Insulin pumps
can be used during contact sports providing that the device is properly padded and secured
and a backup pump or insulin supply is available if the device is damaged.9
Athletes should routinely check blood glucose level before exercise, with optimal pre-
activity levels in the range of 150 to 250 mg/dL. If pre-exercise levels are under 100 mg/dL,
carbohydrates should be consumed and vigorous or prolonged exercise should be avoided.
Levels above 250 mg/dL require testing of urine or blood for ketone levels. If ketone levels
are present, exercise is contraindicated; if they are not, exercise should be performed with
close monitoring of blood glucose levels to avoid continued elevations that could trigger
ketoacidosis or other complications.9,10
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Every athlete with diabetes should have a written action care plan for games and prac-
tices that is prepared and agreed on by parents (if the athlete is a minor), school nurses,
athletic trainers, other medical providers, and key activity or sport supervisors.9 Elements
of the care plan must include
• Guidelines for monitoring and interpretation of blood glucose and urine ketone levels
• Guidelines for insulin therapy, including adjustments and correctional scales for
hyperglycemia
• Instructions for changes in duration or intensity of athletic participation
• Guidelines for recognizing hypoglycemia and hyperglycemia, including key signs and
symptoms, along with recommended response and treatment options9
• Medication list for the athlete
All athletes who have diabetes should wear a medication and disease alert tag at all
times, and all necessary testing equipment and supplies should be in a first aid pack that is
readily accessible.
■■ BLOOD-BORNE PATHOGENS: HIV AND HEPATITIS

HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) are the blood-borne patho-
gens of greatest concern for possible transmission during sport participation. While these
viruses can potentially spread through contact with body fluids and open wounds, the risk
of transmission in athletes has been associated with sexual contact, body piercing, tattoos,
and the sharing of needles to administer injected anabolic steroids and other drugs.10 These
viruses are present in many body fluids, but blood exposure is considered the threat to ath-
letes. There are no documented cases of HIV transmission during sport participation.
Hepatitis B virus is more concentrated in blood than HIV is and more easily transmit-
ted.11 Research publications from Japan and the United States report HBV transmission in a
high school sumo wrestling club and a college American-rules football team, respectively,
and transmission probably occurred because of contact with open wounds of the carrier
during sporting activity.11 Hepatitis B virus immunization reduces this risk. Hepatitis C
virus blood concentrations are thought to fall between those of HIV and those of HBV, and
transmission of HCV during sports participation has not been documented.
Even in sports during which there is sustained close body contact, the transmission of
HIV, HBV, and HCV is exceedingly low and has not been quantified.11 Since the risk of
transmission is minimal, the National Collegiate Athletic Association (NCAA), National
Federation of State High School Associations, American Academy of Pediatrics (AAP), and
American Medical Society for Sports Medicine (AMSSM) do not view these infections as
a reason to exclude athletes from participation. Mandatory HIV screening is not recom-
mended by any major sport governing bodies for participation,10 and participation for ath-
letes whose blood is known to test positive for HIV has not been limited.6 Confidentiality
must be maintained at all times, and the decision to disclose HIV, HBV, or HCV status is
up to an athlete and family (if the athlete is a minor).
Universal precautions are recommended to limit pathogen transmission when handling
blood or other body fluids. Athlete education should address both universal precautions
and high-risk behaviors such as sharing needles, body piercing or tattoo placement with
potentially contaminated equipment, and unprotected sexual activity.
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Allergies and Anaphylaxis 93
■■ MEDICATIONS AND SUPPLEMENTS
History Form Question

1. Medications and supplements: List all current prescriptions, over-the-counter medicines, and
supplements (herbal and nutritional).
Secondary Questions
• Do you take any herbals, minerals, or vitamins?
• Do you use anything to help with your exercise or workouts?
• Do you use anything for your skin?
• Are you currently taking any daily or as needed medications prescribed by your doctor?
Key Points
• Use of medications may reveal medical issues not revealed or recognized in the medical
history.
• Any prescription medication, over-the-counter medication, or supplement may affect
exercise performance or safety.
• Certain medications may be banned by a sport national governing body or require a
WADA therapeutic use exemption.
The PPE is an opportunity to review medications, supplements, and ergogenic aids;

counsel athletes on potential risks and benefits; and optimize the frequency and dosing
of prescription medications to better control underlying illnesses during exercise. In some
cases, participation in sports may require adjustments in the timing and dosing of certain
medications, such as using short-acting β-adrenergic agonists before exercise for asthma
or adjusting insulin doses depending on amount and intensity of exercise for players who
have diabetes.
Many athletes are hesitant to reveal the use of supplements or ergogenic aids, so an
open and inviting questioning style may help elicit an accurate history. It may take time to
investigate the components and potential risks/benefits of unfamiliar substances. Asking
athletes about motivation for taking supplements may allow insight into body image
issues, competitive pressures, and potential for future supplement or ergogenic aid use. Up
to 58% of supplements contain components not listed on product container labels that
have health risks or are on the banned substance list.12
■■ ALLERGIES AND ANAPHYLAXIS

1. Do you have any allergies? If yes, please list all your allergies (ie, medicines, pollens, food,
stinging insects).
Secondary Questions
• Have you ever had a severe allergic reaction? If so, to what and what was the reaction?
• Are there certain food or groups of foods you have been told to avoid because of
allergic reactions?
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• Did this reaction involve swelling of your lips or tongue, or did it make it difficult for
you to swallow, talk, or breathe?
• Have you ever needed medicine, included injected medicine, to treat an allergic reaction?
• Have you ever been taken to an emergency department, been put into the hospital, or
had a breathing tube placed because of an allergic reaction?
• Do you carry or have you been told to carry an EpiPen or another injected
epinephrine device?
Key Points
• Allergic reactions can range from minor rhinitis to life-threatening anaphylaxis.
• Athletes with a history of true anaphylaxis should have immediate on-site access to
injected epinephrine. A history of exercise-associated anaphylaxis requires thorough
evaluation and may require exercise modifications with restricted medical eligibility.
• An emergency action plan involving on-site medical staff, coaches, and other supervising
personnel should be created, discussed, and reviewed at the beginning of each season.
Allergies and associated reactions can range from minor rhinitis to life-threatening
anaphylaxis. Minor allergic reactions such as rhinitis may influence athletic performance
and can be associated with asthma and exercise bronchospasm. Improved baseline control
of environmental rhinitis or rhinosinusitis can improve the quality of exercise, though
adverse effects of some antihistamine medications may also compromise exercise.
True anaphylaxis involves more than one body system and starts with localized ery-
thema and edema before rapidly progressing to generalized urticaria, pruritus, airway
obstructions caused by lip or tongue swelling, laryngospasm and laryngeal edema, and
progressive hemodynamic instability with shock. Insect envenomation or food allergies
(often peanuts or shellfish) are common triggers. Many foods used by athletes, such as
energy bars, contain nuts or are cross-contaminated with nuts during production and are a
risk for athletes with peanut allergy. Past reactions to stinging insects such as Hymenoptera
(ie, bees, wasps, and yellow jackets) or fire ants can be a risk for outdoor sport athletes.
It is critical to differentiate between localized reactions and systemic urticaria, and life-
threatening anaphylaxis. Athletes with local reactions do not require exercise modification
or on-site injected epinephrine.
Any athlete with a past history of anaphylaxis should have immediate access to injected
epinephrine on-site (or on person for certain events such as distance running or cycling).
A school or another institution-based possession limitation to self-carry of injected epi-
nephrine devices may limit access and influence medical eligibility decisions. An emer-
gency action plan involving on-site medical staff, coaches, and other supervising personnel
should be created, discussed, and reviewed at the beginning of each season. Consultation
with an allergist for specific recommendations, potential allergen testing, and immuno-
therapy (especially with venom-associated anaphylaxis) is highly recommended.13
Exercise-induced anaphylaxis (EIAn) is a rare form of physical allergy induced by exer-
cise and is characterized by a spectrum of symptoms and signs ranging from sensation
of warmth, pruritus, cutaneous erythema, angioedema, and giant (>1 cm in diameter)
urticaria to hypotension, shock, and death. The exact role of exercise remains unknown.
Nonsteroidal anti-inflammatory (NSAID) medications, including aspirin, before exer-
cise may precipitate EIAn and should be avoided for at least 24 hours before activity by
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Surgical History 95
athletes with a history of EIAn triggered by NSAID or aspirin use. Foods may be a trigger to
food-dependent EIAn (FDEIAn), so allergy evaluation to determine foods that initiate the
reaction can be completed. Affected athletes need to avoid these foods for at least 3 hours
before or after exercise.13 The diagnosis of EIAn or of FDEIAn requires challenge testing
with physical exercise alone for EIAn or ingestion of the suspected food followed by physi-
cal exercise for FDEIAn. When results are equivocal, a double-blind, placebo-controlled,
food-exercise challenge should be performed.14
The management of EIAn and of FDEIAn is focused on avoiding triggers. Nonsedating
antihistamines can be used before activity, but this medication class does not appear to
be a reliable prevention strategy.3 Athletes allowed to exercise with this condition should
have immediate access to injected epinephrine and one or more trained exercise partners
who know the signs and symptoms of EIAn to administer epinephrine when needed.
Immunotherapy for FDEIAn has not yet been proven in consensus documents and is not
currently used in clinical practice.5
Cholinergic urticaria is an exaggerated response to body warming that is often seen
with exercise, especially in hot and humid environments. Cholinergic urticaria can also be
triggered by exposure to the heat of a hot tub or sauna. Urticarial papules initially appear
on the upper thorax and neck before spreading to the entire body and last from 15 min-
utes to several hours. There is limited risk for vascular collapse or systemic compromise.
Second-generation or long-acting antihistamines at double the usual recommended dose
are the first-line treatment recommendations.3
■■ SURGICAL HISTORY

1. Have you ever had surgery? If yes, list all past surgical procedures.
Secondary Questions
• What type of surgery did you have?
• When and where did you have it?
• Why was the surgery done, and was any treatment tried before the surgery?
• Are you still under the care of the surgeon?
• Are any future surgical procedures being planned?
• Did you gain or lose weight or muscle mass after the surgery?
• Have you been fully cleared by the surgeon to return to sports?
• Do you have any problems from the surgery itself that limit your participation in sports?
• Did you complete a rehabilitation program or see a physical therapist or an athletic
trainer after the surgery?
Key Points
• A surgical history may reveal past or current issues that affect medical eligibility for
sport participation.
• Complete recovery with no physical activity restrictions that is based on the final evalua-
tion by the surgical team is required for full medical eligibility.
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Following surgical procedures, the surgical team should determine athlete readiness for
return to physical activity and participation in specific sports. A progressive stepwise return
to sport based on the type of surgery, body parts involved, and general health of the athlete
before and after the procedure is recommended. An uncomplicated appendectomy or simi-
lar procedures, especially laparoscopic, usually result in a quick and full recovery in a pre-
dictable time frame and with limited impact on future athletic participation. Higher-risk
procedures involving the colon, major joints, paired organs, the heart, or the brain may
result in longer recovery times, may result in potential restrictions for future participation
in specific activities, or may require protective equipment to participate in some activities.
Athletes with persistent or easily induced fatigue, continued weight loss, or insufficient
rehabilitation (especially following orthopedic procedures) may be at higher risk for recur-
rent or new injury, and medical eligibility may be deferred until they are fully recovered.
Any ongoing use of postoperative medications, particularly opioid pain medication, which
risks dependence and impairs cognitive function, stamina, and reaction time, suggests that
an athlete is not ready for return to sport.
■■ SOLITARY ORGANS OR ORGAN ABSENCE

Medical Question
1. Are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?
Key Points
• Absence of a paired organ may not limit an athlete from contact or collision activities.
• Protective equipment may be advised for athletes with only one of usually paired organs.
The absence of one of a paired organ set is not a contraindication to sport participation,
but it does merit an informed-decision discussion of the risks associated with contact, col-
lision, or limited-contact sports with the athlete and family.6,15
Protective equipment may sufficiently reduce the risk of injury during collision and con-
tact sports for an athlete with a single eye or solitary kidney to participate safely.16 Contact
or collision sports may pose increased risk for athletes with a single kidney, especially if
the remaining kidney is compromised or located in an area at higher risk for injury.16 The
risk of injury leading to a loss of a kidney is very small, but not zero, and when counseling
patients with a solitary kidney on sports participation, level of participation, sport culture,
and relative degree of risk from other types of catastrophic injury, it should be consid-
ered.17 A risk classification system for patients with a solitary kidney was developed accord-
ing to overall risk of high-grade renal trauma or loss of a renal unit (Box 6C-1).18
Athletes with a single testicle must understand the higher risk of injury and loss of
fertility in contact, collision, and limited-contact sports. Use of a protective cup is recom-
mended for athletes with a solitary testicle.6 The injury risk to a single ovary is minimal,
and full participation is allowed.6
For consideration of an athlete who has a single eye or what constitutes a functional
single eye, please review the Eye Disorders and Vision content later in this section.
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Infectious Mononucleosis 97
Box 6C-1. Activity Classification System for Pediatric Patients With Solitary
Kidneys
High Risk Moderate Risk Low Risk

Highest Risk (>1.0%) (0.1%–1.0%) (<0.1%)
• Extreme skiing • Bicycle • Football • Baseball

• Extreme snowboarding • Horseback riding • Ice hockey • Basketball
• Horse racing • Skiing • Lacrosse
• Off-road biking • Sledding • Rollerblading
• Snowboarding • Running
• Soccer • Skateboarding
• Wrestling
Reprinted with permission from Papagiannopoulos D, Gong E. Revisiting sports precautions in children with solitary
kidneys and congenital anomalies of the kidney and urinary tract. Urology. 2017;101:9–14.
■■ INFECTIOUS MONONUCLEOSIS

1. List past and current medical conditions.
Secondary Question
• Have you had infectious mononucleosis (“mono”) within the past month?
Key Points
• The fatigue associated with mononucleosis may prohibit return to full activity for sev-
eral weeks to months.
• Splenomegaly is almost universally present with infectious mononucleosis (IM).
• Splenic rupture is rare beyond 28 days from the onset of IM symptoms.
Infectious mononucleosis is a common illness in adolescents and young adults caused

by the Epstein-Barr virus (EBV) through close-contact exposure with saliva or mucous of
an infected individual. Symptoms usually appear 4 to 7 weeks after exposure and usually
include the classic triad of fever, exudative pharyngitis, and posterior cervical lymphade-
nopathy,19 along with fatigue, headache, and left upper quadrant pain. The diagnosis can
be confirmed in an athlete who has the clinical picture with a combination of a complete
blood cell count with at least 50% lymphocytes and 10% atypical lymphocytes,20 a positive
result from a heterophile antibody test (specifically, the monospot test), and elevated EBV
IgM and IgG antibody titers. Diagnosis based on EBV antibody titers is preferred because
of decreased sensitivity and specificity of the monospot test in the pediatric population.
Supportive care is the foundation for management of IM.
The fatigue associated with IM may limit return to full sport participation for several
weeks in some athletes. Splenomegaly, and the potential for splenic rupture, is an under-
lying concern in the first 2 to 4 weeks of the illness while the spleen is enlarging. Splenic
rupture can occur during exertion and without trauma. Studies show a prevalence of
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splenic rupture in athletes with IM at 0.1% to 0.2%.19 The greatest risk for splenic rupture
is in the first 21 days after onset of IM symptoms, and the highest risk is in males younger
than 30 years within 4 weeks of symptom onset.20 Splenic rupture beyond 28 days of
symptoms can occur, but it is very rare.21,22
Return to activity and medical eligibility decisions have been traditionally based on res-
olution of clinical symptoms (mainly fatigue) and the absence of splenomegaly.20 Physical
examination is not reliable for assessing an enlarging or enlarged spleen, although clini-
cally palpable splenic enlargement can be used for serial monitoring.23 Serial ultrasonogra-
phy can be used to monitor spleen size in athletes with IM, and studies using this modality
have shown that spleen size tends to normalize within 28 days.23 Norms for spleen size are
not well-defined, especially for taller athletes.24 The use of ultrasonography is controversial
for individual cases because of the variation in normal spleen size and lack of accuracy in
predicting the risk of rupture.20,23 Serial laboratory testing is not helpful for return to play
decision-making.20
The AMSSM consensus statement recommends no return to sport for 3 to 4 weeks after the
onset of IM symptoms, mainly to reduce the risk of splenic rupture.20 Athletes may resume
light noncontact activities at 3 to 4 weeks if they are afebrile, they are well hydrated, and their
weight and energy levels have been regained. Return to contact or collision activity is more
controversial and is not advised for at least 4 weeks after symptom onset, with at least 1 week
of noncontact conditioning activities before contact.20 However, athletes who recover quickly
and feel well often return on a more accelerated schedule and seem to do well.
Highly trained athletes and any athletes with significant fatigue during the course of IM
may take several months to return to a higher level of fitness. A rapid return to sport may
increase the risk of splenic injury and may prolong overall recovery time.6,20
Individuals with chronic splenomegaly or hepatomegaly require individual and sport-
specific assessment that is based on degree of organ enlargement and underlying disease
states.6
■■ EXERTIONAL HEAT ILLNESS
Heat Illness
Medical Question
1. Have you ever become ill while exercising in the heat?
Secondary Questions
• Have you ever had exertional heat stroke?
• When did this occur?
• Did you go to the emergency department?
• How long were you in the hospital?
• Have you had an exercise-heat tolerance test?
• What medications or supplements do you take?
• Have you ever had heat exhaustion?
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Exertional Heat Illness 99
• Do you have muscle cramping during practice or games?

• What do you drink before, during, and after practices and games?
Key Points
• Exertional heat stroke (EHS) is the third leading cause of death among high school
athletes.
• Exertional heat stroke can be fatal and is most often seen during preseason football, but
it can occur during other sports and in cooler climates.
• Major EHS risk factors include hot, humid conditions; inadequate heat acclimatization;
poor aerobic fitness; and football and other protective equipment.
• Gradually acclimatizing athletes to hot conditions over 7 to 14 days and educating ath-
letes on adequate nutrition, sleep, and hydration are key to preventing heat illness.
• Maintaining hydration may slow the onset of EHS.
Heat illness adversely affects athletic performance and can be associated with severe
morbidity and death from EHS.25 From 1995 to 2009, there were 31 football player deaths
attributed to EHS.26 Heat illness is a particular concern for athletes practicing and compet-
ing in hot environments, especially with occlusive equipment such as football uniforms.
Prior heat illness increases the risk for subsequent heat intolerance or heat illness.27,28
The PPE should include specific questions regarding possible risk factors, including
prior heat illness, the associated environment, acclimatization status, equipment and
uniforms, fluid intake, weight changes during activity, and medication and supplement
use.29,30 The preparticipation evaluation is an opportunity for anticipatory guidance.
Educating athletes, parents or guardians, and coaches about risk factors and preventive
strategies is key to decreasing the incidence of heat illness.
Exertional heat stroke is defined as an elevated core body temperature (rectal tem-
perature: >40°C [104°F], usually >41°C [106°F]) with central nervous system (CNS)
changes. Risk factors for EHS are outlined in Box 6C-2. A history of previous EHS, a lack
Box 6C-2. Risk Factors for Exertional Heat Stroke

Extrinsic
• Environment
• Clothing and equipment
• Sport type
• Medications
• Supplements
Intrinsic
• Prior history of heat stroke

• Inadequate acclimatization
• Febrile condition or recent respiratory or gastrointestinal tract viral illness
• Overexertion
• Dehydration
• Poor aerobic fitness
• Excess body fat
• Large body size
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.
of acclimatization, a febrile illness, and high relative humidity in hot temperatures (wet
bulb globe temperature [WBGT] greater than usual for the setting) are the most significant
risk factors for athletes.31 Young age was considered a risk factor, but studies show that chil-
dren and adolescents are at similar, if not less, risk for heat stroke than adults.31 Children
can adapt to extremes of temperature as effectively as adults when exposed to high climatic
heat stress when hydration and other factors are similarly controlled.31 Children tend to
underestimate body water loss and need encouragement to replace their sweat losses. A
Centers for Disease Control and Prevention (CDC) report published in 2010 showed that
heat illness was most prominent in football players in the month of August who had over-
weight or obesity.26 Athletes should be informed of the increased heat intolerance caused
by some medications and supplements.32 The use of diuretics, caffeine, antihistamines, or
stimulants increases the risk of heat illness.29,30,32 Banned substances such as ephedra or
methamphetamines also increase the risk of heat injury.
Heat exhaustion usually occurs during high workloads, often in hot conditions, and is
a cause of collapse in athletes that is primarily cardiovascular in origin because of exten-
sive cutaneous vasodilation and is often associated with dehydration. Vasodilatation is a
response to rising core temperatures to increase skin blood flow for heat transfer. If the
combination of vasodilatation and reduced intravascular volume affects cardiac output,
athletes collapse, possibly as a protective mechanism to avoid heat stroke. Body tempera-
ture is not always elevated to dangerous levels and is usually less than 40°C (104°F) by
rectal measurement. Athletes generally improve with rest and fluid replacement within
24 to 48 hours and often return to play within a few days. Heat exhaustion may be on the
pathway to EHS for some athletes, but most collapse before their body temperature rises to
EHS levels.
Heat injury is a moderate to severe heat illness, which does not involve the CNS, char-
acterized by organ (eg, liver, kidney) and tissue (eg, gut, muscle) injury associated with
sustained high body temperature resulting from strenuous exercise in hot environments.
Exertional rhabdomyolysis is included in this group of heat injuries. The CNS is not
involved, distinguishing heat injury from EHS.
EHS and exercise-related collapse in the heat are best prevented by modifying activi-
ties in hot, humid conditions to adjust work to rest ratios on the basis of the heat load and
by gradually increasing the workload over several days in hot conditions to allow time for
heat acclimatization. Heat dissipation is compromised by vapor barrier uniforms and pro-
tective equipment such as shoulder pads and helmets, and equipment should be factored
into acclimatization.32 Adjusting physical activity by increasing rest breaks and decreasing
workload on the basis of the environment using WBGT is essential to reduce risk of EHS.
Rest breaks turn off heat production and allow heat loss. Free access to fluids is augmented
by increased rest. Poor physical conditioning and wearing dark, heavy clothing, or equip-
ment that inhibits heat dissipation, are also EHS risk factors.33 Although a history of EHS
should not disqualify an athlete from participation, some athletes are always heat intoler-
ant and a specific prevention strategy should be implemented. Some athletes may require
exercise testing in a heat chamber to determine heat tolerance. Some dietary supplements
can exacerbate hyperthermia and dehydration. Athletes with a documented history of heat
stroke or heat-related rhabdomyolysis merit further investigation. For more-detailed infor-
mation regarding the management of heat and heat illness in athletes, see Box 6C-3.
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Sickle Cell Trait 101
Box 6C-3. Resources for Management of Heat and Heat Illness in Athletes
• Armstrong LE, Casa DJ, Millard-Stafford M, Moran DS, Pyne SW, Roberts WO; American Col-
lege of Sports Medicine. External heat illness during training and competition. Med Sci Sports
Exerc. 2007;39(3):556–572. https://journals.lww.com/acsm-msse/Fulltext/2007/03000/
Exertional_Heat_Illness_during_Training_and.20.aspx. Published March 2007. Accessed
February 22, 2019
• Casa DJ, DeMartini JK, Bergeron MF, et al. National Athletic Trainers’ Association position state-
ment: exertional heat illnesses. J Athl Train. 2015;50(9):986–1000. http://natajournals.org/
doi/pdf/10.4085/1062-6050-50.9.07?code=nata-site. Published September 2015. Accessed
February 22, 2019
• McDermott BP, Anderson SA, Armstrong LE, et al. National Athletic Trainers’ Association position
statement: fluid replacement for the physically active. J Athl Train. 2017;59(9):877–895. http://
natajournals.org/doi/full/10.4085/1062-6050-52.9.02. Published September 2017. Accessed
February 22, 2019
• Sawka MN, Burke LM, Eichner ER, Maughan RJ, Montain SJ, Stachenfeld NS; American College
of Sports Medicine. Exercise and fluid replacement. Med Sci Sports Exerc. 2007;39(2):377–390.
https://journals.lww.com/acsm-msse/Fulltext/2007/02000/Exercise_and_Fluid_Replacement.
22.aspx. Published February 2007. Accessed February 22, 2019
Exercise-Associated Muscle Cramps

Exercise-associated muscle cramps (EAMCs) are common in athletes when the workloads
are higher than the level of muscle training. Cramping can occur in training or competi-
tion. Muscle cramps seem to occur more frequently in hot conditions, but they can hap-
pen in cool to cold conditions. The cause of EAMC is not well understood, even though it
occurs regularly in athletes. The 2 competing explanations are (1) altered neuromuscular
control and (2) a combination of electrolyte depletion and dehydration. Gradual increases
in training load and attention to fluid replacement during exercise may reduce EAMC in
athletes, especially those known to be prone to cramps. Cramping can be a presenting
concern or part of the clinical constellation of symptoms associated with EHS, exertional
rhabdomyolysis, exercise-associated hyponatremia, and exercise collapse associated with
sickle cell trait (ECAST).34
■■ SICKLE CELL TRAIT

Medical Question
1. Do you or does someone in your family have sickle cell trait or disease?
Key Points
• Athletes with sickle cell trait are at increased risk for sudden death during strenuous
exercise compared with the general population.
• Athletes with sickle cell trait are at risk for sickling during high-intensity physical activ-
ity, especially in hot, humid environments before acclimatization, at altitude, early in
conditioning, or with dehydration.
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• There is no clear evidence that athletes who have sickle cell trait should have additional
limitations or modifications in their exercise programs.
• Universal screening is not widely recommended for athletes, except for NCAA athletes
who are required as students to show proof of screening or decline screening.
Sickle cell disease involves 2 abnormal genes for hemoglobin, which causes a sickling
of the red blood cells that is associated with rhabdomyolysis, splenic rupture, and stroke.
Individual assessment must be made to determine medical eligibility, as some people who
are affected with sickle cell disease variants are not too anemic, but they can have splenomeg-
aly and require close monitoring. Overheating, dehydration, and chilling must be avoided.35
Sickle cell disease can become acute with catastrophic consequences if an athlete
becomes dehydrated or sustains an internal injury. Such athletes should avoid highly stren-
uous activities and all contact and collision sports.35
Sickle cell trait is an asymptomatic carrier condition with none of the manifestations of
sickle cell disease that is prominent in people who have descended from malaria-affected
countries. This condition is found in more than 2.5 million people in the United States
of African, Mediterranean, Middle Eastern, and Indian heritages, and approximately 7%
to 10% of African Americans have sickle cell trait.36 Sickle cell trait is not a disease, and
life expectancy is not reduced by the sickle cell mutation except when sickling occurs dur-
ing strenuous activity and is unrecognized.35 The US Armed Forces reported more than
a 20-fold increase in risk of death among recruits with sickle cell trait who are engaged
in strenuous activity compared with participants in the control group without sickle cell
trait.37,38 The threat seems greatest when intense exercise occurs in high heat and humid-
ity conditions for which the athlete is not acclimated, or at altitude greater than 1,500 m,
but can also occur in less stressful environments.39 The risk of heat illness, including heat
stroke, for athletes with sickle cell trait is similar to that for peer-group athletes.40–42 Death
occurs as a consequence of the complications of sickling, including rhabdomyolysis, pro-
found acidosis, acute renal failure, and multiple-organ system failure.40
Individuals with sickle cell trait may have episodes of hematuria, which requires evalu-
ation.43 Athletes with sickle cell trait may have higher rates of vaso-occlusive phenomena
(ie, splenic infarction at high altitudes, complications of traumatic hyphema) and venous
thromboembolism.
Sickle cell trait is associated with an increased risk of rhabdomyolysis and sudden
death.42 Sickling in athletes occurs more often in hot conditions and can be confused with
collapse from EHS. In a cohort study of nearly 48,000 black soldiers in the US Army, a
hazard ratio of 1.54 (95% CI, 1.12–2.12) was attributed to sickle cell trait, while the risk of
death was similar in soldiers with and without the trait.44 Other studies have confirmed the
significant increased risk of rhabdomyolysis in those with sickle cell trait.38,39
While sickle cell trait increases the risk for rhabdomyolysis and sudden death, manda-
tory screening is controversial. Division I, II, and III athletes of the NCAA are required to
have testing, show proof of previous testing, or decline testing with a signed waiver docu-
ment.45 Other sports conferences and many professional societies recommend voluntary
testing with universal preventive measures for gradual introduction of high-intensity con-
ditioning drills, especially at the onset of conditioning training.
Athletes with sickle cell trait should be counseled to stay well hydrated and to immedi-
ately report muscle pain or cramping during workouts to the coaching and medical staff. If
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Eye Disorders and Vision 103
an athlete with sickle cell trait has difficulty during training, the activity should be stopped
immediately. If rest, supplemental oxygen, and cooling does not immediately improve
the condition, the athlete should be transported to a hospital emergency department.
Fulminant rhabdomyolysis and its complications should be considered. The American
College of Sports Medicine, Civilian Health and Medical Program of the United States, and
NCAA provide useful recommendations for counseling.45,46 It is recommended that ath-
letes with sickle cell trait acclimatize gradually and engage in year-round training to main-
tain physical conditioning. Athletes and coaches, and medical staff, should be instructed
to recognized ECAST and to understand the importance prevention strategies, including
maintaining adequate fluid intake and avoiding all-out sprints early in training.41 Medical
eligibility for these athletes should be individualized.
■■ EYE DISORDERS AND VISION47

Medical Question
1. Have you ever had or do you have any problems with your eyes or vision?
Secondary Questions
• Have you had any eye injuries?
• Do you wear glasses or contact lenses?
• Do you wear protective eyewear, such as goggles or a face shield?
• Why don’t you wear eye protection (if applicable)?
• When was your last eye examination?
• Have you had eye surgery (eg, photorefractive keratectomy [PRK], laser-assisted in-situ
keratomileusis [LASIK])?
Key Points
• All athletes should have their visual acuity checked at the PPE.
• If corrected vision is worse than 20/20 at the time of examination, the athlete should be
referred for evaluation.
• If best corrected vision is worse than 20/40 in one eye, then eye protection of the eye
with normal vision should be strongly considered, since injury to the better eye could
cause significant disability.
• Eye protection is essential for certain high-risk sports.
• Eye injury and loss of vision are always a concern in sports.
• Eye protection should be used in moderate- to high-risk sports.
• Eye injuries increase risk of glaucoma later in life and need further monitoring.48
Abnormal visual acuity is among the most frequently reported findings during the
PPE.49 Athletes who are identified with abnormal visual acuity at the time of the PPE
should be evaluated and treated by an eye care professional. Visual acuity should be
assessed and documented at the time of the PPE.49 The AAP recommends vision screening
at all health supervision visits.50 Vision can slowly deteriorate over time without an athlete
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being aware of the changes. Poor vision can lead to poor sport performance and more
injuries.
Eye injury, and the potential for loss of vision, is always a concern in sports. Risk for
injury in a particular sport is categorized into high-risk, moderate-risk, low-risk, and “eye
safe.”51,52 Although it is difficult to quantify the relative risk of eye injury for a specific sport,
some sports such as basketball, baseball, softball, ice hockey, field hockey, and lacrosse
are classified as high-risk because of the number of eye injuries reported and the potential
for sufficient eye impact to cause injury.51 Sports with balls or a likely risk of being hit are
considered to be high-risk (eg, softball, martial arts). The sports with the highest risk of eye
injury are baseball and basketball. Track and gymnastics are considered eye safe sports.
Box 6C-4 provides the eye injury risk classification for a variety of sports.
In the United States, it is estimated that sports-related eye injuries account for more
than 100,000 physician visits per year, including more than 30,000 emergency department
visits.53 Although most injuries resulting from sports-related activities were superficial,
more than 20% of baseball-related injuries were blow-out fractures of the orbit.53 Most eye
injuries can be prevented with the correct safety gear.
Eye protection is key to reducing eye injuries. Protective devices can significantly reduce
the risk of eye injury, so it is important that all athletes and their parents or guardians are
made aware of the types of eye protection available and the risks of each sport. The AAP and
the American Academy of Ophthalmology (AAO) strongly recommend protective eyewear
for all participants in sports during which there is risk of eye injury.54 To review current ASTM
eye safety sports requirements, visit www.astm.org/COMMIT/SUBCOMMIT/F0857.htm. US
Lacrosse mandates the use of protective eyewear for girls’ lacrosse, and a full face shield is
required in boys’ lacrosse.55 USA Hockey requires Hockey Equipment Certification Council–
approved face masks for eye protection.56 The AAO reports that significant eye injury can be
reduced at least 90% when properly fitted, appropriate eye protectors are used.57,58
Lenses made of polycarbonate or CR-39 (allyl diglycol carbonate) are recommended for
eye protection. The AAP recommends that even in low–eye-risk sports, athletes use at least
approved street-wear frames that meet American National Standards Institute standard
Z87.1 with polycarbonate or CR-39 lenses. A strap must secure the frame to the head and
must be fitted by an experienced ophthalmologist, optometrist, or optician. For high–eye-
risk sports, the AAP recommends full sports goggles made of polycarbonate.50 A list of spe-
cific sports and recommendations for eyewear has been developed by the AAP Council on
Sports Medicine and Fitness. Athletes must be cautioned that contact lenses do not confer
any protection from injury and must not be considered eye protectors.
It is essential to consider eye protection for athletes whose vision is already impaired in
one eye, and the AAO and AAP recommend mandatory protective eyewear for all function-
ally one-eyed athletes, regardless of sport. A visual acuity of 20/40 or better in at least one
eye is considered to provide good vision. An individual is deemed functionally one-eyed
if the loss of the better eye would result in a significant change in lifestyle, and a best cor-
rected vision in one eye of less than 20/40 should be considered functionally one-eyed.59
Athletes who have had an eye injury or surgery may have a globe that is weakened and
therefore more susceptible to injury. Athletes with eye conditions, including a high degree
of myopia; surgical aphakia; retinal detachment; and a history of eye surgery, injury, or
infection, may be at increased risk for eye injury.60 Such individuals should be referred
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Eye Disorders and Vision 105
Box 6C-4. Categories of Sports-Related Eye Injury Risk for an Unprotected

Player
High-risk
• Small, fast projectiles

—— Air rifle use
—— BB gun use
—— Paintball
• Hard projectiles, “sticks,” and close contact
—— Baseball and softball
—— Basketball
—— Cricket
—— Fencing
—— Hockey (field and ice)
—— Lacrosse (men’s and women’s)
—— Racquetball
—— Squash
• Intentional injury
—— Boxing
—— Full-contact martial arts
Moderate-risk
• Badminton
• Fishing
• Football
• Golf
• Soccer
• Tennis
• Volleyball
• Water polo
Low-risk
• Bicycling
• Diving
• Noncontact martial arts
• Skiing (snow and water)
• Swimming
• Wrestling
“Eye Safe”
• Gymnastics
• Track and fielda
a
Javelin and discus have a small but definite potential for injury. However, good field supervision can reduce the
extremely low risk of injury to nearly negligible.
Adapted with permission from Vinger PF. A practical guide for sports eye protection. Phys Sportsmed.
2000;28(6):49–69.
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to an ophthalmologist for complete evaluation and medical eligibility determination.

Functionally one-eyed athletes should not participate in sports during which eye protec-
tion cannot be effectively worn. The AAO states that athletes with globe injury or who are
functionally one-eyed must not participate in boxing, wrestling, or full-contact martial arts.
An athlete, his or her parents or guardians, the coach, and school administrators, if nec-
essary, must understand
• The degree of risk of injury—with and without protection—to the better eye
• The level of protection available for the better eye
• The serious long-term consequences if injury to the better eye were to occur
If, after this discussion, a functionally one-eyed athlete still wishes to participate in
a given sport, appropriate protective eyewear should be used during participation; however,
some athletes choose not to use protective eyewear despite the risks and recommendations.
■■ IMMUNIZATIONS
1. Are your immunizations up-to-date?
2. Have you had your flu shot this year?
Key Points
• Athletes should receive all vaccinations recommended for the general population.
• In the United States, this vaccination schedule is published by the Advisory Committee
on Immunization Practices (ACIP) of the CDC.
• In the case of local epidemics or international competitions, additional vaccinations
may be needed.
Vaccines are effective in reducing, and, in some cases, even eliminating, serious infectious
diseases. Despite great education campaigns, vaccination rates among adolescents have
remained flat and in some cases have actually decreased. Vaccination rates for Tdap (tetanus
toxoid, reduced diphtheria toxoid, and acellular pertussis), varicella, and meningococcal
vaccines were reported to be 86.4%, 83.1%, and 81.3% in 2015.61 Rates of influenza vacci-
nation were reported to be 59.3% for children and adolescents and 41.7% for adults older
than 18 years. 61 Rates for human papillomavirus vaccine are low as well, with rates of 41.9%
in females and 28.1% in males. 61 Despite a long history of safety and effectiveness, vac-
cines have always had critics questioning whether vaccinating children is worth what they
perceive as the risks. In recent years, the anti-vaccination movement has become more vocal
and this has contributed to the lack of improvement in vaccination rates among children.
Athletes should receive all vaccinations recommended for the general population,
according to their age.62 In the case of international travels for competitions, the risk
of vaccine-preventable diseases endemic in the visited country must be considered.
Immunization guidelines for athletes include
1. Check the standard immunizations of childhood and adolescence and administer
missing immunizations for age.
2. Seasonal and age-related immunizations should be given (ie, seasonal influenza vac-
cine and suggested booster immunizations).
3. Immunize for special circumstances such as epidemics or intercontinental
tournaments.62
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References 107
The PPE should follow the CDC ACIP guidelines for age, which are updated annu-
ally. The schedule is found at www.cdc.gov/vaccines/schedules/hcp/index.html. Failure to
adhere to the recommended immunization schedules, including the timing of immuniza-
tions, can leave children susceptible to life-threatening vaccine-preventable diseases.
Despite the availability of immunizations, Neisseria meningitidis was responsible for
2 sports-related outbreaks of bacterial meningitis in Europe: one in soccer players dur-
ing an international soccer tournament and another in rugby players from a rugby club.63
Untreated bacterial meningitis can rapidly progress to a fatal outcome in healthy individu-
als. In 2007, a multistate measles (rubeola) outbreak was reported to be associated with
an international sporting event in Michigan, Pennsylvania, and Texas.64 Measles can be
fatal. This disease is still endemic in the United States, with more than 3.5 million cases
annually, 9,000 hospitalizations, and about 100 deaths. Outbreaks can frequently lead to
canceled practices, matches, and tournaments because of the highly contagious nature of
the virus. The National Hockey League experienced a mumps outbreak in 2014 when more
than a dozen players and referees were diagnosed from several teams.63 Although many of
the players had been vaccinated, some had received only 1 measles, mumps, and rubella,
or MMR, vaccine in childhood. This recommendation was changed to 2 immunizations in
childhood by the CDC in 1991. Updated immunizations may have averted this outbreak.
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risks for warfighters and athletes. Med Sci Sports Exerc. 2012;44(1):2045–2056 PMID:22811029 https://doi.
org/10.1249/MSS.0b013e31826851c2
47. Pieramici DJ. Sports-related eye injuries. JAMA. 2017;318(24):2483–2484 PMID:29279910 https://doi.
org/10.1001/jama.2017.17560
48. Bojikian KD, Stein AL, Slabaugh MA, Chen PP. Incidence and risk factors for traumatic intraocular pres-
sure elevation and traumatic glaucoma after open-globe injury. Eye (Lond). 2015;29(12):1579–1584
PMID:26381097 https://doi.org/10.1038/eye.2015.173
49. American Optometric Association (AOA) Sports Vision Section. National Athletic Trainers’ Association
(NATA) vision screening protocols. AOA Web site. https://www.aoa.org/Documents/optometrists/sports-
vision-section-NATA-vision-screening-protocols-august-2011.pdf. Published August 2011. Accessed
February 22, 2019
50. American Academy of Pediatrics Committee on Practice and Ambulatory Medicine and Section on
Ophthalmology, American Association of Certified Orthoptists, American Association for Pediatric
Ophthalmology and Strabismus, American Academy of Ophthalmology. Eye examination in infants, chil-
dren, and young adults by pediatricians. Pediatrics. 2003;111(4, pt 1):902–907 PMID:12671132
51. American Academy of Pediatrics Committee on Sports Medicine and Fitness. Protective eyewear for young
athletes. Pediatrics. 2004;113(3, pt 1):619–622 PMID:14993558
52. Strahlman E, Sommer A. The epidemiology of sports-related ocular trauma. Int Ophthalmol Clin.
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53. Haring RS, Sheffield ID, Canner JK, Schneider EB. Epidemiology of sports-related eye injuries in the United
States. JAMA Ophthalmol. 2016;134(12):1382–1390 PMID:27812702
54. American Academy of Pediatrics and American Academy of Ophthalmology (AAO) Communications
Advisory Board. Protective eyewear for young athletes - 2013. AAO Web site. https://www.aao.org/clinical-
statement/protective-eyewear-young-athletes. Published April 2013. Accessed February 22, 2019
55. US Lacrosse. Approved eyewear list. US Lacrosse Web site. https://www.uslacrosse.org/safety/equipment/
approved-eyewear-list. Updated January 7, 2019. Accessed February 22, 2019
56. USA Hockey. 2017-21 Official Rules and Casebook of Ice Hockey. Colorado Springs, CO: USA Hockey Inc; 2017.
https://www.usahockey.com/rulesandresources. Accessed February 22, 2019
57. Jeffers JB. An on going tragedy: pediatric sports-related eye injuries. Semin Ophthalmol. 1990;5(4):216–223
https://doi.org/10.3109/08820539009060173
58. Larrison WI, Hersh PS, Kunzweiler T, Shingleton BJ. Sports-related ocular trauma. Ophthalmology.
1990;97(10):1265–1269 PMID:2243676 https://doi.org/10.1016/S0161-6420(90)32421-1
59. Napier SM, Baker RS, Sanford DG, Easterbrook M. Eye injuries in athletics and recreation. Surv Ophthalmol.
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Physician. 2003;67(7):1481–1488 PMID:12722848
61. National Center for Health Statistics (US). Health, United States, 2016: With Chartbook on Long-term Trends in
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practices in professional athletes]. Ig Sanita Pubbl. 2011;67(3):387–400 PMID:22033165
63. Turbeville SD, Cowan LD, Greenfield RA. Infectious disease outbreaks in competitive sports: a review of the
literature. Am J Sports Med. 2006;34(11):1860–1865
64. Chen TH, Kutty P, Lowe LE, et al. Measles outbreak associated with an international youth sporting event in
the United States, 2007. Pediatr Infect Dis J. 2010;29(9):794–800 PMID:20400927
06_ch06_43-160.indd 110 3/20/19 4:22 PM

D. Respiratory System
■■ PULMONARY FUNCTION QUESTIONS

General Question
1. Do you have any ongoing medical issues or recent illness? (This question applies to “Yes,
asthma.”)
Medical Question
2. Do you cough, wheeze, or have difficulty breathing during or after exercise?
Secondary Questions
• Do you have asthma, environmental allergies, or both?
• Are these symptoms only during exercise or do they occur at rest?
• Do you wheeze or have noisy breathing, and if so, is it with breathing in or breathing
out?
• Have you ever used an inhaler or taken asthma medication, and if so, what kind?
• Are the medications effective in preventing or treating your symptoms?
• Is there anyone in your family who has asthma, eczema, or environmental allergies?
• Have you ever been hospitalized because of asthma? Have you required assisted ventila-
tion or intubation (a machine to breathe for you)?
• Have you ever missed a gym class, a practice, or a game because of problems with
breathing?
• Do you have any triggers such as allergies to pollen, exercising in cold or warm air,
heartburn, or other factors that make your symptoms worse, such as anxiety?
■■ KEY POINTS
• Most people with asthma will develop symptoms with an appropriate exercise
challenge test.
• Most athletes with exercise-induced bronchospasm (EIB) have other symptoms of
asthma, even if not diagnosed, but respiratory symptoms can also be functional.1
• Athletes with environmental allergies (atopy) are at increased risk for EIB.
• When exercise-induced dyspnea (EID) is not associated with EIB, cardiopulmonary
exercise testing is indicated to identify the cause of the EID.
• Exercise-induced laryngeal obstruction (EILO) (including the various types of exercise-
induced vocal cord dysfunction [VCD], laryngomalacia, and paradoxical vocal fold
motion) should be considered when suspected EIB does not respond to therapy or the
result from EIB testing is negative.2
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112 Section 6D. Respiratory System
■■ BACKGROUND INFORMATION
The most common pulmonary issues for athletes are intermittent and persistent asthma,
exercise-induced asthma (EIA) or EIB, EILO, traumatic or spontaneous pneumothorax, and
infections of the respiratory tract, such as upper respiratory tract infections or pneumonia.
EILO has replaced VCD to describe all conditions that cause inspiratory obstruction of the
larynx during exercise, but VCD is still in common use. Pneumothorax and respiratory tract
infections are acute issues that do not limit long-term medical eligibility. Confounding
problems, such as gastroesophageal reflux, anxiety, and panic attacks, can cause pulmonary
symptoms in athletes, but they are addressed in other sections of this chapter.
Asthma includes several phenotypical disorders that share a common end-organ path-
way characterized by airway inflammation, trachea and bronchial hyperreactivity, and
reversible bronchoconstriction (airflow obstruction) that may result in airway remodel-
ing.3 The terms EIA and EIB should not be used interchangeably. A consensus among the
American Academy of Allergy, Asthma & Immunology; the American College of Allergy,
Asthma, and Immunology; and the Joint Council of Allergy, Asthma and Immunology
defines the terms EIB with asthma for exercise-induced bronchoconstriction with clinical
symptoms of asthma and EIB without asthma for acute airflow obstruction without asthma
changes to the airway.4
In athletes with underlying asthma, the prevalence of EIB ranges from 50% to 90%.4 In
all athletes, the prevalence of EIB ranges from 11% to 50% depending on the sport type
evaluated and testing method used for diagnosis.3,5–7
Exercise alone or in combination with other triggers such as environmental allergens,
air pollution (smog, chlorine vapors, or nitrogen dioxide from propane-fueled ice-
resurfacer fumes) can cause airway obstruction symptoms.8–10 Athletes with environmental
allergies are more likely to have EIB and may experience symptom exacerbations during
their allergy seasons.6,11 In theory, exercise may trigger EIB because of an increased ventila-
tory rate, which overloads the ability of the airways to heat and moisturize the inhaled air
before it reaches the alveoli. Cold, dry air can cause dehydration of the airway, leading to
increased osmolarity of the airway surface and the release of inflammatory mediators by
mast and epithelial cells.4,12,13 These inflammatory mediators cause bronchoconstriction
and bronchial edema.
Because of the role of airway cooling and drying, winter sport athletes, especially those
in endurance events, may also have increased risk for EIB symptoms.7,12 Other diagnoses
must be considered in an athlete with respiratory concerns during exertion, especially
when the athlete does not respond as expected to treatment or provocative testing is not
consistent with asthma. Other diagnoses to consider in an athlete with difficulty breathing
during exercise include EILO, laryngeal prolapse, hyperventilation syndrome, cardiovascu-
lar causes, and anxiety.
EILO causes breathing difficulties in athletes and can be mistaken for asthma.14
EILO occurs in approximately 5% of the athletic population,5,13 and it may coexist with
asthma.14 EILO is often misdiagnosed in athletes because it often mimics EIB or asthma;
however, no bronchoconstriction or airway inflammation is associated with EILO. EILO is
characterized by abnormal closure at the supraglottic or glottis level of the larynx, usually
during inspiration,11 causing acute onset and resolution of resistive airflow associated with
06_ch06_43-160.indd 112 3/20/19 4:22 PM

shortness of breath, dyspnea, or stridor.9 An athlete with EILO will report no symptoms at
rest. EILO occurs more often in adolescents and females and in outdoor sport participants.
Triggers for EILO include stress, anxiety, allergic rhinitis, gastroesophageal reflux, and
poorly controlled asthma, making this a challenging diagnosis.15 Studies show that one-
third to one-half of athletes with EILO also have EIB.5
■■ HISTORY
Athletes with EIB often report cough, wheeze, dyspnea, chest tightness, or shortness of
breath with exercise. Less specific concerns can include feeling fatigued, exercise intoler-
ance, chest pain, abdominal pain, or headache. Symptoms are worse 5 to 30 minutes after
starting exercise, with resolution of symptoms 30 to 60 minutes after stopping exercise.
There is often an associated history of allergy or a family history of asthma. An athlete with
environmental allergies will often have EIB.
In athletes with a history of asthma, it is important to determine the severity of asthma
and the current level of control. Well-controlled asthma should not interfere with sports
training or competition. Asthma control in the past year can be assessed via history by
examining hospitalization with or without intubation; clinic, urgent care facility, or emer-
gency department interventions; frequency and need for oral corticosteroid bursts for
exacerbations; and how often practices or games have been missed because of asthma
symptoms. Use of β-adrenergic agonist medication more than twice a week and nighttime
cough with difficulty sleeping more than one time per month are indicators of subopti-
mal asthma control.10 An athlete with asthma should have an asthma action plan defining
treatment measures for symptoms that worsen.10 The medications currently used by the
athlete should be obtained, along with the name and phone number of the treating physi-
cian and the athlete’s asthma action plan, which can be shared with the school medical
personnel and athletic trainer.
For athletes with no prior history of asthma who report respiratory symptoms dur-
ing exercise, it is helpful to determine at what point during exercise the symptoms occur,
whether they are more common during one season or sport, and if the athlete can distin-
guish whether symptoms occur during inspiration or expiration. Difficulty with inspiration
or inspiratory stridor is more likely a laryngeal disorder, such as EILO, rather than EIB. An
athlete may describe “trouble getting air in” during exercise. It is important to ask about
other environmental factors that may exacerbate respiratory symptoms, such as tobacco
use, marijuana use, and secondhand smoke exposure.
Pulmonary evaluation of the anterior and posterior chest should be done in a quiet
room with the patient in the seated position using breaths that are deeper than those
of normal breathing. Breath sounds should be clear and equal bilaterally. Wheezing,
rubs, rales, prolonged expiratory phase, and cough with forced expiration require evalu-
ation for a cause and a treatment plan. Allergy signs such as allergic shiners, nasal pol-
yps, pharyngeal “cobblestoning,” or watery or bloodshot eyes may be noted during the
physical examination.
06_ch06_43-160.indd 113 3/20/19 4:22 PM

■■ TESTING
The preferred method to diagnose EIB with or without asthma is spirometry obtained at
rest followed by a challenge test known to elicit bronchoconstriction. Self-reported athlete
symptoms alone often result in an incorrect diagnosis.10 Baseline pulmonary function test-
ing alone will not determine the presence of EIB with or without asthma.12 The frequently
used β-adrenergic agonist trial for improvement in athlete symptoms during exercise is
not acceptable for diagnosis of EIB with or without asthma for a therapeutic use exemp-
tion (TUE) in national and international competitions. The 3 preferred methods to induce
bronchospasm for the diagnosis of EIB are
1. Dry-air exercise challenge test
2. Inhaled respiratory desiccant (eg, mannitol)
3. Eucapnic voluntary hyperpnoea
Dry-air exercise challenge testing and eucapnic voluntary hyperpnoea should be of suffi-
cient duration and intensity to reproduce the exercise respiratory demand that would elicit
the EIB response. Accepted protocols to effectively reproduce the EIB response in athletes
should be followed carefully to ensure an accurate diagnosis.14 If an athlete tests negative
for EIB and clinical suspicion is high, an alternative or second test should be performed,
such as cardiopulmonary exercise testing.16,17 Seasonal allergies may affect testing, so evalu-
ation should be performed when an athlete is symptomatic18 and is off all related medica-
tions to obtain an accurate test result.19 A drop of forced expiratory volume in 1 second, or
FEV1, of 10% during testing with associated dyspnea is considered diagnostic for EIB.
EILO may be confirmed with inspiratory-expiratory flow loop testing or direct visualiza-
tion of the vocal cords during an attack, which may be stimulated with exercise broncho-
provocation testing. EILO is best diagnosed with direct visualization of the larynx,15 both
at rest and during exercise, using continuous laryngeal endoscopy. Symptoms should be
correlated with the decrease in the cross-sectional area of the larynx. It is important to note
location, expiratory or inspiratory obstruction, and timing of the obstruction.9 Many ath-
letes will have EILO symptoms only during the stress of competition, and the diagnosis is
sometimes made clinically.
■■ TREATMENT
Some athletes are able to warm up before an event using sprint-interval exercise to cause
bronchoconstriction that is followed by a refractory period of 1 to 3 hours of normal breath-
ing.20 When warm-up is not effective, EIB is generally treated with an inhaled short-acting
β-adrenergic agonist taken 20 to 30 minutes before exercise.21 The physician must remem-
ber that elite-level athletes may need a TUE to use these medications. The athlete will need
instruction to use the inhaler properly and deliver the medication to the lungs with a spacer.
When possible, mitigating environmental factors may improve control. If β-adrenergic ago-
nist use extends beyond pre-exercise, persistent asthma is likely the cause and leukotriene
receptor antagonists, inhaled corticosteroids, or both should be considered as adjunct con-
trol medications.21 Athletes with chronic asthma who need to use bronchodilators more than
2 times per week independent of exercise should also use a controller medication.
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References 115
EILO is most commonly treated by diaphragmatic breathing control, laryngeal exer-

cise, or both performed under the guidance of a speech-language pathologist.22 A speech-
language pathologist trained in the area of EILO can often “cure” the problem with several
sessions of therapy. Other interventions include supraglottic surgical intervention, psycho-
therapy, hypnosis, biofeedback, and respiratory muscle training.
Key practice clinical recommendations with evidence rating can be found in Table 6D-1.
Table 6D-1. Key Recommendations for Practice
Clinical Recommendation Evidence Rating

Studies have shown that self-reporting of athlete symptoms often results in false- C
positive or false-negative diagnoses.10
Baseline pulmonary function testing is not appropriate for diagnosing EIB with C
or without asthma.12
Spirometry at rest followed by a challenge test to elicit bronchoconstriction is A

the preferred method to diagnose EIB with or without asthma.14,17
EIB is generally treated with an inhaled short-acting β-adrenergic agonist taken A

20–30 min before exercise.21
If β-adrenergic agonist use becomes more chronic—that is, >2–4 times per A
week as a result of exercise—leukotriene receptor antagonists, inhaled cortico-
steroids, or both should be considered as adjunct control medications.21
Many athletes are able to warm up before an event using sprint-interval B

exercise to induce bronchoconstriction that is followed by a refractory period of
1–3 h of normal breathing.20
EILO is most commonly treated by diaphragmatic breathing control, laryn- A

geal exercise, or both performed under the guidance of a speech-language
pathologist.22
Abbreviations: EIB, exercise-induced bronchospasm; EILO, exercise-induced laryngeal obstruction.

Athletes with EIB with or without asthma can be allowed to participate if their symp-
toms are controlled. An athlete’s rescue inhaler and asthma action plan should be on-site
either with the athlete or the athlete care network for travel, competition, and training.
Significant acute exacerbation of EIB with or without asthma should be evaluated and
resolved before resuming participation.
Athletes with acute respiratory illnesses associated with fever regardless of EIB status
should be restricted from activity until the fever and muscle aches resolve.
■■ REFERENCES
1. Weinberger M, Abu-Hasan M. Asthma in the preschool-age child. In: Wilmott RW, Boat TF, Bush A, Chernick
V, Deterding RR, Ratjen F, eds. Kendig’s Disorders of the Respiratory Tract in Children. 8th ed. Philadelphia, PA:
Elsevier; 2012:686–698 https://doi.org/10.1016/B978-1-4377-1984-0.00046-2
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2. Weinberger M, Abu-Hasan M. Is exercise-induced bronchoconstriction exercise-induced asthma? Respir Care.

2016;61(5):713
3. Bush A, Kleinert S, Pavord ID. The asthmas in 2015 and beyond: a Lancet commission. Lancet.
4. Del Giacco SR, Firinu D, Bjermer L, Carlsen KH. Exercise and asthma: an overview. Eur Clin Respir J.
2015;2:27984
5. Johansson H, Norlander K, Berglund L, et al. Prevalence of exercise-induced bronchoconstriction and
exercise-induced laryngeal obstruction in a general adolescent population. Thorax. 2015;70(1):57–63
PMID:25380758 https://doi.org/10.1136/thoraxjnl-2014-205738
6. Parsons JP, Mastronarde JG. Exercise-induced bronchoconstriction in athletes. Chest. 2005;128(6):3966–
3974 PMID:16354868 https://doi.org/10.1016/S0012-3692(15)49641-2
7. Ritz T, Bobb C, Griffiths C. Predicting asthma control: the role of psychological triggers. Allergy Asthma Proc.
2014;35(5):390–397 PMID:25295806 https://doi.org/10.2500/aap.2014.35.3779
8. See KC, Phua J, Lim TK. Trigger factors in asthma and chronic obstructive pulmonary disease: a single-centre
cross-sectional survey. Singapore Med J. 2016;57(10):561–565 PMID:26768322 https://doi.org/10.11622/
smedj.2015178
9. Maat RC, Røksund OD, Halvorsen T, et al. Audiovisual assessment of exercise-induced laryngeal obstruction:
reliability and validity of observations. Eur Arch Otorhinolaryngol. 2009;266(12):1929–1936 PMID:19585139
https://doi.org/10.1007/s00405-009-1030-8
10. Smoliga JM, Mohseni ZS, Berwager JD, Hegedus EJ. Common causes of dyspnoea in athletes: a practical
approach for diagnosis and management. Breathe (Sheff). 2016;12(2):e22–e37 PMID:27408644 https://doi.
org/10.1183/20734735.006416
11. Christensen PM, Heimdal JH, Christopher KL, et al; ERS/ELS/ACCP Task Force on Inducible Laryngeal
Obstructions. 2013 international consensus conference nomenclature on inducible laryngeal obstructions.
Eur Respir Rev. 2015;24(137):445–450 PMID:26324806 https://doi.org/10.1183/16000617.00006513
12. Berhardt DT, Roberts WO, eds. PPE: Preparticipation Physical Examination. 4th ed. Elk Grove Village, IL:
American Academy of Pediatrics; 2010
13. Rundell KW, Spiering BA. Inspiratory stridor in elite athletes. Chest. 2003;123(2):468–474 PMID:12576368
https://doi.org/10.1378/chest.123.2.468
14. Weiler JM, Brannan JD, Randolph CC, et al. Exercise-induced bronchoconstriction update—2016. J Allergy
Clin Immunol. 2016;138(5):1292–1295 PMID:27665489 https://www.ncbi.nlm.nih.gov/pubmed/27665489
15. Heimdal JH, Roksund OD, Halvorsen T, Skadberg BT, Olofsson J. Continuous laryngoscopy exercise
test: a method for visualizing laryngeal dysfunction during exercise. Laryngoscope. 2006;116(1):52–57
PMID:16481809 https://doi.org/10.1097/01.mlg.0000184528.16229.ba
16. Weinberger M, Abu-Hasan M. Perceptions and pathophysiology of dyspnea and exercise intolerance. Pediatr
Clin North Am. 2009;56(1):33–48 PMID:19135580
17. Anderson SD, Pearlman DS, Rundell KW, et al. Reproducibility of the airway response to an exercise protocol
standardized for intensity, duration, and inspired air conditions, in subjects with symptoms suggestive of
asthma. Respir Res. 2010;11:120 PMID:20807446 https://doi.org/10.1186/1465-9921-11-120
18. Goldberg S, Mimouni F, Joseph L, Izbicki G, Picard E. Seasonal effect on exercise challenge tests for the diag-
nosis of exercise-induced bronchoconstriction. Allergy Asthma Proc. 2012;33(5):416–420 PMID:23026183
https://doi.org/10.2500/aap.2012.33.3586
19. Smoliga JM, Weiss P, Rundell KW. Exercise induced bronchoconstriction in adults: evidence based diagnosis
and management. BMJ. 2016;352:h6951 PMID:26762594 https://doi.org/10.1136/bmj.h6951
20. Stickland MK, Rowe BH, Spooner CH, Vandermeer B, Dryden DM. Effect of warm-up exercise on exercise-
induced bronchoconstriction. Med Sci Sports Exerc. 2012;44(3):383–391 PMID:21811185 https://doi.
org/10.1249/MSS.0b013e31822fb73a
21. Dryden DM, Spooner CH, Stickland MK, et al. Exercise-induced bronchoconstriction and asthma. Evid Rep
Technol Assess (Full Rep). 2010;(189):1–154 PMID:20726625
22. Marcinow AM, Thompson J, Chiang T, Forrest LA, deSilva BW. Paradoxical vocal fold motion disorder
in the elite athlete: experience at a large division I university. Laryngoscope. 2014;124(6):1425–1430
PMID:24166723 https://doi.org/10.1002/lary.24486
06_ch06_43-160.indd 116 3/20/19 4:22 PM

E. Gastrointestinal and Urogenital Systems
Medical Questions
1. Are you missing a kidney, a testicle (males), your spleen, or any other organ?
2. Do you have groin or testicle pain or a painful bulge or hernia in the groin area?
• Does it limit your activity?
• Does it become red, swollen, or tender to touch?
• Is it a solid or hard lump?
■■ KEY POINTS
• Palpate the abdomen for masses or enlarged organs (enlarged spleen or liver, enlarged
kidney, or gravid uterus).
• A solitary kidney may not limit participation in contact or collision sports, and each
athlete should be counseled individually.1,2
• A solitary testicle may not limit participation in contact or collision sports and each ath-
lete should be counseled individually, but a protective cup should be worn for high-risk
sports.1
• The preparticipation physical evaluation (PPE) is an opportunity allowing the athlete a
chance to ask questions regarding the urogenital system.
• The presence of a hernia in the abdomen or groin is not a reason to limit participation.
Symptomatic hernias should be repaired.
Problems identified in the gastrointestinal (GI) and urogenital systems seldom limit
medical eligibility in athletes, and acute life-threatening problems are rarely uncovered
during the PPE. However, blunt trauma to the abdomen and fixed organs can be cata-
strophic, and organ loss may influence future participation. Chronic nausea, vomiting, or
diarrhea can interfere with hydration and reduce heat tolerance, alter electrolyte balance,
and reduce performance.
In children and young adults, 10% of abdominal injuries are sports related.3 Combining
injuries to the abdomen and those to the thorax, there are approximately 5 sports-related
injuries per 100,000 athlete exposures at the high school level.4 Injury surveillance at the
high school and college levels shows that the highest rates of internal organ injury were
among male players of contact sports, with incidence rates of 12 per 1,000,000 athlete
exposures for high school football, 10 for high school lacrosse, 8 for college football, and
8 for college ice hockey.5 The residual findings in the history or physical examination are
important from a health supervision or return to play perspective (Table 6E-1). Blunt
abdominal trauma can result in organ contusion, bleeding, and hematoma, especially for
those with organomegaly from acute and chronic diseases. The spleen and liver are both
fixed organs and vulnerable to high-speed contact injury in collision sports. More than
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118 Section 6E. Gastrointestinal and Urogenital Systems
Table 6E-1. Summary of Potential Health Issues of Gastrointestinal and

Urogenital Systems
Anatomy Function Health Issues

Teeth, tongue, Mastication, deglutition, Trauma, laceration, dental caries
lips, jaw initiating digestion
Esophagus, Digestion, absorption GI upset, GERD, trauma

stomach
Liver, spleen, Digestion, detoxification Hepatitis, infection, mononucleosis, hematoma,

gallbladder drug toxicity
Small and large Digestion, absorption Irritable bowel syndrome, including Crohn dis-
intestines ease and ulcerative colitis; absorptive deficiency
Kidney Fluid excretion, detoxification Solitary kidney; kidney stone, pyelonephritis;

drug toxicity
Ureter, bladder, Fluid excretion UTI, kidney stone

urethra
Groin pain Stabilizing core Inguinal disruption or sports hernia; adductor

muscle strain; osteitis pubis
Testicle, penis Hormonal, reproduction Traumatic orchitis; contusion; infection; solitary

organ; dermatitis
Ovary, uterus, Hormonal, reproduction Primary and secondary amenorrhea; infection;

vagina, vulva solitary organ; dermatitis
Abbreviations: GERD, gastrointestinal esophageal reflux disease; GI, gastrointestinal; UTI, urinary tract infection.
half of spleens are acutely enlarged during the course of infectious mononucleosis. Among
college students, mononucleosis is present in up to 4% of the population and is also com-
mon in young athletes.6,7 However, physical examination of an enlarged spleen is difficult,
and sensitivity in detecting enlargement is poor. The increased use of point-of-care ultraso-
nography may improve our ability to detect splenic enlargement.
Hematuria can be painless or painful and indicate disease of the kidney or collecting
systems, either acute or chronic. Evaluation is warranted. Athletes should be held from par-
ticipation until the cause is determined and treated before a final medical eligibility deci-
sion is made.
A history of organ loss in the GI or urogenital system (eg, kidney, testicle) does not
always limit medical eligibility, but it does require a discussion of risk to the remaining
paired organ and appropriate protective equipment. Primary amenorrhea and secondary
amenorrhea, including pregnancy, are issues that affect female athletes (see Chapter 7).
Reproductive and sexual concerns can be addressed during the examinations, and athletes
should be given the opportunity to ask questions about the urogenital system that they
have not addressed in the past. When possible, discussion of sexually transmitted infec-
tions and safe-sex practices should be included.
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Medical Eligibility for Participation 119
Abdomen
The abdominal examination should be performed with the athlete supine. The anterior
superior iliac spine should be exposed to ensure adequate inspection and palpation of all
4 quadrants. Abdominal masses, tenderness, rigidity, or enlargement of the liver, spleen,
or kidneys requires further evaluation before determining medical eligibility. Detection of
a palpable (gravid) uterus in a female athlete will require a more detailed examination,
which should be performed by the athlete’s primary care provider.
Genitalia
The indication to perform a male genitourinary (GU) examination is based on the history
of a possible undescended testicle, testicular lump, or inguinal bulge, or groin pain. A male
GU examination should always be performed in a private setting and should begin with a
brief description and reason for the examination. Athletes should be asked if they would
prefer to have a chaperone present, and some providers may choose to always have a chap-
erone present for this part of the examination. The testicular examination is commonly
done with the patient standing. Testicular irregularities or masses suggestive of cancer,
testicular size abnormalities (sign of steroid use if smaller), and inguinal canal hernias, or
pubic pain (possible core-muscle injury, previously called sports hernia) may be detected.
If a hernia is detected, the athlete (and parents or guardians if minor) should be educated
regarding symptoms and conditions requiring surgical repair.
A GU examination of female athletes is not part of the PPE (see Chapter 7).
Assessing physical maturity with Tanner staging has not been useful in determining
medical eligibility and is not recommended as a routine part of the PPE.8 However, Tanner
staging may be used as a guide to counseling on growth and development, sport safety,
and anabolic steroid use. It is easy to do as part of the physical examination, and a discrep-
ancy between an athlete’s age and his or her Tanner staging may lead to an investigation of
endocrine issues or discussion of physically immature athletes competing against more–
physically mature opponents in contact or collision sports.
■■ MEDICAL ELIGIBILITY FOR PARTICIPATION
Organomegaly
An enlarged liver or spleen is at risk for rupture, and the underlying cause must be deter-
mined. The spleen is discussed in detail in Chapter 6, Section 6C, in relation to infectious
mononucleosis. Hepatomegaly may signal the presence of infection (eg, hepatitis, infec-
tious mononucleosis) or malignant disease (eg, hepatocellular carcinoma, lymphoma).
Even though the incidence of hepatic rupture among patients with acute hepatomegaly is
low, participation in all sports should be avoided until the hepatomegaly is resolved. For
individuals with chronic hepatomegaly, participation in sports should be assessed individ-
ually and decisions based on the degree of enlargement, the associated disease state, and
the risk of the sport.
06_ch06_43-160.indd 119 3/20/19 4:22 PM

120 Section 6E. Gastrointestinal and Urogenital Systems
Inguinal Hernia
An athlete with an asymptomatic inguinal canal hernia may participate in all sports. The
athlete should be counseled regarding red flag symptoms for strangulated hernia—sudden
pain, nausea, and vomiting—or change in symptoms, such as heaviness, swelling, and
tugging, or burning sensation in the hernia area. Males may have a mass within the scro-
tum and females may have a bulge in their labia. Symptomatic inguinal hernias may
limit an athlete’s ability to participate and should be evaluated individually for surgical
intervention.
Kidney Abnormalities
An athlete who has a single functioning kidney should be counseled regarding the poten-
tial for kidney injuries ranging from contusion to complete rupture and should participate
in shared decision-making to determine medical eligibility. Some experts believe that an
athlete with a pelvic, iliac, or polycystic kidney, or evidence of hydronephrosis or a ure-
teropelvic junction abnormality, should not participate in contact or collision sports.8–11
Although the risk is small, the consequences of the loss of a single functioning kidney
(eg, transplantation or dialysis) may warrant disqualification from collision sports.2,9–11
Restricting medical eligibility of athletes with a solitary kidney from participation in
contact/collision sports is not universally accepted by all experts.2,9–11 Evaluation by a urol-
ogist or nephrologist may be prudent before determining medical eligibility.
An athlete with a functional solitary kidney who chooses to play in a contact or colli-
sion sport should receive a complete explanation of the risks of kidney injury, the possible
need for dialysis or transplantation, the lack of protective equipment (eg, flak or shock-
absorbing jacket) proven to reduce the risk of injury, and the signs and symptoms of renal
injuries.12 Although wearing a protective shock-absorbing jacket may reduce the risk of
renal injury, it does not guarantee complete protection.
Testicular Disorders
The incidence of sport-related testicular injury is extremely low.13,14 Counseling concerning
participation in contact or collision sports is required with athletes for unpaired or unde-
scended testicles. An individual with a single testicle is usually medically eligible for partici-
pation, although the use of a protective cup is suggested for higher-risk sports.1 Athletes must
be informed of the risk for injury to or loss of the remaining testicle. Although wearing a pro-
tective cup may reduce the incidence of injury, it does not guarantee complete protection.15
If an athlete has an undescended testicle that has not been thoroughly evaluated, the
examining physician should refer him for evaluation and inform him of the increased risk
of testicular cancer associated with this condition. Medical eligibility determination for an
athlete who has an undescended testicle is like that for an athlete with a single testicle.
■■ REFERENCES
peds.2008-0080
06_ch06_43-160.indd 120 3/20/19 4:22 PM

References 121
2. Grinsell MM, Showalter S, Gordon KA, Norwood VF. Single kidney and sports participation: perception ver-
sus reality. Pediatrics. 2006;118(3):1019–1027 PMID:16950993 https://doi.org/10.1542/peds.2006-0663
3. Bergqvist D, Hedelin H, Karlsson G, Lindblad B, Mätzsch T. Abdominal trauma during thirty
years: analysis of a large case series. Injury. 1981;13(2):93–99 PMID:7327735 https://doi.
org/10.1016/0020-1383(81)90041-3
4. Johnson BK, Comstock RD. Epidemiology of chest, rib, thoracic spine, and abdomen injuries among United
States high school athletes, 2005/06 to 2013/14. Clin J Sport Med. 2017;27(4):388–393 PMID:27428676
https://doi.org/10.1097/JSM.0000000000000351
5. Kucera K, Currie D, Wasserman E, et al. Incidence of sport-related internal organ injuries due to direct con-
tact mechanisms among high school and collegiate athletic participants across three national surveillance
systems. Inj Prev. 2017;23(suppl 1):A20–A21
6. Van Cauwenberge PB, Vander Mijnsbrugge A. Pharyngitis: a survey of the microbiologic etiology. Pediatr
Infect Dis J. 1991;10(10)(suppl):S39–S42
7. Candy B, Chalder T, Cleare AJ, Wessely S, White PD, Hotopf M. Recovery from infectious mononucleosis.
British J Gen P. 2002;52(483):844–851
8. Carek PJ, Mainous A III. The preparticipation physical examination in athletics: a systematic review of cur-
rent recommendations. BMJ. 2003;327:E170
9. Sharp DS, Ross JH, Kay R. Attitudes of pediatric urologists regarding sports participation by children with a
solitary kidney. J Urol. 2002;168(4, pt 2):1811–1815 PMID:12352366
10. Johnson B, Christensen C, DiRusso S, Choudhury M, Franco I. A need for reevaluation of sports participa-
tion recommendations for children with a solitary kidney. J Urol. 2005;174(2):686–689 PMID:16006949
https://doi.org/10.1097/01.ju.0000164719.91332.42
11. Gerstenbluth RE, Spirnak JP, Elder JS. Sports participation and high grade renal injuries in children. J Urol.
2002;168(6):2575–2578 PMID:12441987 https://doi.org/10.1016/S0022-5347(05)64219-X
12. Psooy K. Sports and the solitary kidney: how to counsel parents. Can J Urol. 2006;13(3):3120–3126
PMID:16813703
13. McAleer IM, Kaplan GW, LoSasso BE. Renal and testis injuries in team sports. J Urol. 2002;168(4, pt 2):
1805–1807 PMID:12352364
14. Wan J, Corvino TF, Greenfield SP, DiScala C. Kidney and testicle injuries in team and individual sports: data
from the national pediatric trauma registry. J Urol. 2003;170(4, pt 2):1528–1532 https://doi.org/10.1097/01.
ju.0000083999.16060.ff
15. McAleer IM, Kaplan GW, LoSasso BE. Renal and testis injuries in team sports. J Urol. 2002;168(4, pt 2):
1805–1807
06_ch06_43-160.indd 121 3/20/19 4:22 PM

06_ch06_43-160.indd 122 3/20/19 4:22 PM
F. Dermatologic Conditions
■■ HISTORY FORM QUESTION
Medical Question
1. Do you have any recurring skin rashes or rashes that come and go, including herpes or
methicillin-resistant Staphylococcus aureus (MRSA) infection?
• Do you take medication for your skin problem?
• Have you ever missed practices or games because of your skin problem?
■■ KEY POINTS
• Skin infections are common reasons to temporarily restrict participation in sports with
skin-to-skin contact.
• Herpes simplex, staphylococcal infections (including community-acquired methicillin-
resistant Staphylococcus aureus [CA MRSA] infection), molluscum contagiosum, and
tinea (fungal) are common skin infections that require treatment before allowing
participation.
• Contact, collision, and shared-equipment sports are of most concern for transmission
of skin infections.
• Proper diagnosis, documentation, and treatment duration are critical in determining
return to play.
• A standard approach to skin infections used by the National Federation of State High
School Associations (NFHS) can be found in the NFHS Sports-Related Skin Infections
Position Statement and Guidelines.1 A return to play form can be found at www.nfhs.
org/media/882323/2018-19_nfhs_wrestling_skin_lesion_form_may_2018.pdf. Similar
guidelines by the National Collegiate Athletic Association (NCAA) for wrestling can
be found in the NCAA Sports Medicine Handbook and the NCAA Wrestling Rules and
Interpretations.2,3
The ability to safely compete with other athletes can be compromised by various com-
mon skin conditions that are important to correctly identify and are generally easy to
treat. Participation by athletes with active infections may lead to outbreaks among team-
mates and opponents. Participation must be restricted if the infections are communicable
(to reduce risk to other competitors) or if the conditions increase the risk of becoming
infected by blood-borne pathogens.
In a national survey of high school athletes, skin infections occurred at a reported
rate of 2.27 cases per 100,000 athlete exposures. Wrestling (73%) and football (18%)
accounted for the majority of the infections, and bacterial (60%) and fungal (28%) were
the most commonly reported types of infection.4 A 15-year surveillance study of NCAA
wrestling showed that skin infections accounted for almost 9% of reported practice
06_ch06_43-160.indd 123 3/20/19 4:22 PM

124 Section 6F. Dermatologic Conditions
injuries and the largest percentage of time loss injuries (17%).5 Skin infections are most
easily transmitted during sports by skin-to-skin contact, but they can also be spread by
using shared equipment, towels, or razors and are particularly common in players of
wrestling, martial arts, and rugby. Yard et al6 found the incidence of skin infections to be
8% and 20% among high school athletes and collegiate athletes, respectively, with more
than half of the infections involving the head, face, and neck. Researchers of one study
reported a 33% likelihood of contracting herpes simplex virus (HSV) when wrestling with
an infected opponent.7
Data analysis from the National High School Sports-Related Injury Surveillance Study
showed that more than 60% of skin infections were bacterial, with tinea and herpes rep-
resenting 28% and 5%, respectively.4 National Collegiate Athletic Association surveillance
found herpetic infections to represent more than 45% of skin infections, with fungal and
bacterial infections representing 22% and 14% respectively.5 These conditions and the tim-
ing of their treatment can affect whether athletes will be declared eligible by the rules of
their sport at the time of practice or competition.3 The examiner should be aware that both
the NCAA and the NFHS have very specific policies on the identification of, treatment of,
and return to play for players with skin infections.
The NCAA recommends “. . . that qualified personnel, including a knowledgeable, expe-
rienced physician examine the skin of all wrestlers before any participation.”2 Restriction
from participation because of dermatologic conditions ranges from 6% to 8%, making this
one of the more common reasons to restrict participation.8
A thorough skin survey should be performed with particular attention to exposed areas
and any areas that might potentially come into contact with another competitor or equip-
ment (eg, wrestling mats, batting helmets). The principle objective in the dermatologic
examination is to identify skin infections: bacterial, viral, fungal, and infestations. The
examining physician needs to be alert for the signs and symptoms of skin conditions
that might limit participation, including fungal rashes (tinea), viral conditions (herpes
simplex, molluscum contagiosum, and warts), infestations (scabies and lice), and bacte-
rial conditions (impetigo, CA MRSA, carbuncles, furuncles, and folliculitis). The examiner
should also look for signs of trauma, acne, sun damage, and dermatitis (contact dermatitis,
eczema, psoriasis, or urticarial dermatitis), as well as marks of illicit drug use or cutting.9–11
While a thorough search for abnormal nevi is not possible within the limits of the pre-
participation physical evaluation (PPE), suspicious nevi noted during the examination
should be referred for further evaluation or treatment. These lesions should not preclude
medical eligibility for participation.
Several specific common skin infections are directly related to sport and possible medi-
cal eligibility issues.
Herpes gladiatorum (herpes simplex infection) is widespread and has potential for
epidemic outbreaks among wrestlers. Herpes simplex also causes “cold sores” that are also
spread by contact. The problem can threaten individual wrestlers and even entire teams.
Athletes can be infectious before the actual skin outbreak is visible. Lesions are vesicu-
lar, generally clustered on an erythematous base, and can progress to shallow ulcers with
06_ch06_43-160.indd 124 3/20/19 4:22 PM

surrounding erythema. They are most commonly seen around the face, neck, and arms,
usually on the right side because most wrestlers “lock up” on their right side. During the
initial outbreak, systemic symptoms may be present, including fever and adenopathy, sore
throat, general malaise, and headache.
Tinea gladiatorum is a fungal infection of the skin (tinea corporis) or scalp (tinea capi-
tis) and has been reported to occur in up to 42% of wrestlers.12 Typically, these lesions will
be erythematous plaques with flaking, a raised border, and central clearing. Scalp lesions
may be accompanied by hair loss. Diagnosis can be confirmed with a potassium hydroxide
(KOH) microscopy, a fungal culture, or both. The skin change can last far longer than the
infectious period of the rash.
Impetigo is a bacterial infection caused by either Staphylococcus species or Streptococcus
species that is highly contagious. It can appear as classic “honey”-crusted vesicles and
pustules or as a bullous rash that may be accompanied by adenopathy; however, systemic
symptoms are unusual.13 The rash can be confused with herpes gladiatorum.
Molluscum contagiosum appears as flesh-colored, small (3- to 5-mm) papules with a
central core, giving the classic umbilicated appearance. It is reportedly more common in
swimmers, gymnasts, and wrestlers; although athletes who have these lesions are usually
asymptomatic, some lesions may develop erythema and pruritus.14
Warts appear as firm, skin-colored, hyperkeratotic papules and are not typically painful.
They may be present anywhere on the body, but they typically affect the fingers and hands.
Plantar warts may have a flat, skin-colored, hyperkeratotic appearance, and they may be
painful. Diagnosis is typically made by simple visual inspection.15
Community-acquired MRSA is an increasing problem that seems to have a dispro-
portionate prevalence in athletes.16 There is no consensus as to why MRSA infection is
being observed in the healthy athletic population. Community-acquired MRSA infections
may have a variety of appearances: cellulitis, abscess, or bulla. Skin infections that do not
respond to standard antibiotics and all abscesses should be cultured and treated empiri-
cally as CA MRSA (SOR C).16
Community-acquired MRSA infection appears most commonly as a cut or abrasion that
has become infected, which can be very painful and extend into adjacent soft tissue. There
is a predilection for a MRSA infection to develop into an abscess.16,17 Fever and chills may
be present if bacteremia complicates the infection.

The presence of any open wound or infectious skin condition that cannot be protected
warrants exclusion from competition that involves close contact with another player or
shared equipment until the wound is healed. Merely covering the rash without treatment
is not acceptable for return to close-contact sports. Examples include open wounds that
cannot be adequately covered and infections, including herpes simplex, scabies, louse
infestation, molluscum contagiosum, tinea corporis, cellulitis, impetigo, and furuncles or
carbuncles.
Denying participation is especially important for sports that involve close physical con-
tact, such as wrestling, rugby, and martial arts, and for sports during which equipment (eg,
mats, helmets) is shared. Recent studies suggest that prompt identification and treatment
06_ch06_43-160.indd 125 3/20/19 4:22 PM

of athletes who have been infected is essential to reduce the spread of the infection to
teammates and opponents.7 Participation may be resumed when the condition has been
adequately treated and is no longer contagious and NCAA guidelines, NFHS guidelines,
or both have been met. Prophylactic treatment during the entire season with a nucleoside
analogue (eg, acyclovir, famciclovir, or valacyclovir) is generally effective in preventing
recurrence and recommended for athletes with recurrent herpes gladiatorum.18 Similarly,
fluconazole has been demonstrated to be a reasonably effective prophylactic for tineal
infections.19
Outbreaks of CA MRSA skin infections have been described with increasing frequency
among competitive athletes.20,21 One statewide surveillance program showed the incidence
of MRSA among athletes who have skin infections, while declining from 2008 to 2012, to
be 16% among football players and 43% among wrestlers.22 Since any open skin lesion is
a potential site for the development of CA MRSA infection, skin wounds identified during
the PPE (or more likely during the season) should be promptly treated and covered. Given
its prevalence, MRSA infection should be the presumptive diagnosis for lesions draining
pus, and athletes with suspected CA MRSA infection should be cultured and treated with
appropriate antibiotics. Ideally, abscesses should be treated with incision and drainage,
without antibiotics. Athletes may return to play when the infection is clinically controlled
and return to play guidelines have been met.
The NFHS and NCAA wrestling regulations for skin disorders are similar, although
the specific requirements for return to participation for wrestlers with skin infections dif-
fer between high school and college. Both age-groups require treatment for a specific
period of time and the ability to cover the lesion adequately. The requirements are based
on case series, expert consensus, and disease-oriented evidence. The guidelines and rec-
ommended form for return to high school sports with skin infections can be obtained
through the NFHS Sports-Related Skin Infections Position Statement and Guidelines1 (www.
nfhs.org/media/882323/2018-19_nfhs_wrestling_skin_lesion_form_may_2018.pdf) and
in Appendix C of the NCAA 2017-18 and 2018-19 Wrestling Rules and Interpretations2 (www.
ncaa.org) (SOR C). For a first episode of herpes gladiatorum, wrestlers should be treated
and not allowed to practice or compete for a minimum of 10 days. If general body signs
and symptoms such as fever and swollen lymph nodes are present, that minimum period
of treatment should be extended to 14 days. If antivirals are not used, the infected partici-
pant may return to full contact wrestling only after all lesions are well healed with well-
adhered scabs, there has been no new vesicle formation in the preceding 72 hours, and
there are no swollen lymph nodes near the affected area. For a recurrent HSV infection,
athletes must be free of systemic symptoms, have had no new lesions for 72 hours, and
have been on oral antiviral treatment for 120 hours to return to competition. Questionable
cases should be laboratory confirmed with viral culture, serology, immunofluorescence,
or polymerase chain reaction testing.1,2 Tinea corporis requires treatment with a topical
fungicide for a minimum of 72 hours, while tinea capitis requires a minimum of 2 weeks
with an oral antifungal medication. Treatment failure is common for tinea capitis, with
one study showing only a 70% cure rate.23 Molluscum and warts require treatment (topi-
cal or surgical) and covering.15 Bacterial dermatoses, including CA MRSA infection (impe-
tigo, furuncle, carbuncle, cellulitis, folliculitis, and skin abscess), are grouped together and
06_ch06_43-160.indd 126 3/20/19 4:22 PM

require no new lesions for 48 hours, no moist or draining lesions (active lesions may not
be covered to participate), and completion of at least 72 hours of oral antibiotics.13
Restriction of athletes with infectious skin conditions from practice and competition
is recommended until appropriate intervention, including guideline-based treatment
with appropriate medications, and, when necessary and appropriate, barrier protec-
tion are feasible. Occlusive coverage of the lesion must be with a non-permeable mem-
brane and a securely attached bandage or patch. Most sports require that competitors
completely cover open wounds and infectious skin conditions to prevent exposure to
other competitors.3 The consequences of failure to diagnose and adequately cover skin
lesions can be devastating to an athlete, who may be declared ineligible for competition
after months of training, and may lead to a widespread outbreak. Standard precautions
are recommended by the Centers for Disease Control and Prevention for wounds that are
open or bleeding.
Early and accurate detection, along with quarantine from contact until the infection
is eradicated, is the most effective means of containing an outbreak and minimizing the
spread of the disease. The NCAA requires that wrestlers be checked by a qualified examiner
before and during each day of a meet or tournament and that written documentation be
provided regarding diagnosis, type, and time of treatment and communicability.2
Prevention strategies for skin infections are varied and not standardized.7
Recommended approaches include close surveillance of all athletes, sanitizing the mats
and equipment daily, cleaning practice clothing daily, immediate showering with soap
after practices, and implementing pharmacological intervention to reduce the risk of new
and recurrent skin infections.24
Although the primary mode of skin infection transmission is through skin-to-skin con-
tact, most support the recommendation that mats and equipment (headgear) be cleaned
by using a solution of 1 part bleach in 9 parts water made daily. Season-long prophylactic
treatment of HSV with antiviral agents for individuals, as well as for entire teams, has been
demonstrated to be effective and is increasingly being implemented to prevent widespread
infection.15,25
Community-acquired MRSA transmission occurs through skin-to-skin contact and
exposure to shared equipment. Athletes should be reminded to practice good hygiene
techniques. One study demonstrated a 75% reduction in MRSA cases after implementing
an athlete educational program on hygiene26 (SOR B). Controlling MRSA transmission
includes handwashing, showering with soap, covering cuts and abrasions, laundering per-
sonal items such as towels and supporters, and refraining from sharing razors and towels
(SOR C). Carriage rates have been reported in the range of 5% to 27% and are generally
higher among athletes than among the general population. Recent guidelines from the
Infectious Diseases Society of America suggest that efforts to eradicate carriers with recur-
rent infections can be considered, but this is controversial (SOR C).27
Other skin conditions such as acne and conditions that might be worsened by exer-
cise or possibly affect performance (eg, urticaria, angioedema, cold-induced conditions
such as Raynaud syndrome)28 should be noted. While not typical reasons to restrict athlete
medical eligibility, these conditions may, at times, limit participation.15,29 Atopic and aller-
gic skin ailments can often be managed effectively. Acne can be difficult to control, even
06_ch06_43-160.indd 127 3/20/19 4:22 PM

among the athletes being treated, because sweat and constrictive uniforms and equipment
may exacerbate the condition. While acne should not affect eligibility or performance, it
may have adverse social and emotional consequences for an athlete, may be confused with
other skin conditions, and may be a break in the protective skin barrier and a portal for
secondary infection.
The American Academy of Pediatrics also has a policy statement on infectious diseases
in athletes that includes skin infection identification and care.30
■■ REFERENCES
1. National Federation of State High School Associations Sports Medicine Advisory Committee. Sports-Related
Skin Infections Position Statement and Guidelines. Indianapolis, IN: National Federation of State High School
Associations; 2018. https://www.nfhs.org/media/1014740/sports_related_skin_infections_position_
statement_and_guidelines_-final-april-2018.pdf. Accessed February 22, 2019
2. National Collegiate Athletic Association. Appendix C: skin infections in wrestling. In: 2017-18 and 2018-19
NCAA Wrestling Rules and Interpretations. Indianapolis, IN: National Collegiate Athletic Association; 2017.
http://www.ncaapublications.com/productdownloads/WR19.pdf. Accessed February 22, 2019
3. National Collegiate Athletic Association. 2014-15 NCAA Sports Medicine Handbook. 25th ed. Indianapolis, IN:
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24. Adams BB. Tinea corporis gladiatorum. J Am Acad Dermatol. 2002;47(2):286–290 PMID:12140477 https://
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28. Tlougan BE, Mancini AJ, Mandell JA, Cohen DE, Sanchez MR. Skin conditions in figure skaters, ice-hockey
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30. Davies HD, Jackson MA, Rice SG; American Academy of Pediatrics Committee on Infectious Diseases and
Council on Sports Medicine and Fitness. Infectious diseases associated with organized sports and outbreak
control. Pediatrics. 2017;140(4):e20172477 PMID:28947608 https://doi.org/10.1542/peds.2017-2477
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G. Musculoskeletal Concerns
Bone and Joint Questions

1. Have you ever had a stress fracture or an injury to a bone, muscle, ligament, joint, or tendon
that caused you to miss a practice or game?
2. Do you have a bone, muscle, ligament, or joint injury that bothers you?
■■ KEY POINTS
• Athletes with unresolved musculoskeletal pain require additional evaluation and man-
agement before sports participation.
• Stress fractures, overuse injuries, and recurrent soft-tissue injuries can be associated with
nutritional deficiencies, training errors, poor neuromuscular control, and abnormal
biomechanics.
• A general screening examination is reasonable for athletes with no symptoms and no
previous injury.
Musculoskeletal injuries and concerns are the most common problems that team phy-
sicians and health care professionals see in the office, in the athletic training facility, and
during the preparticipation physical evaluation (PPE). A thorough review of the muscu-
loskeletal history and examination of previously injured areas may improve detection of
musculoskeletal conditions during the PPE. This section addresses the issues for medical
eligibility related to the musculoskeletal system.
The first and most important step in the evaluation of the musculoskeletal system to
determine medical eligibility is to take a focused musculoskeletal history. Missed prac-
tices or games suggest a potentially serious condition. The nature and duration of missed
practices or games should be discussed and documented. The evaluating provider should
understand the mechanism of injury and any subsequent treatment, rehabilitation, or sur-
gical intervention. It is essential to understand whether the athlete was fully rehabilitated
and able to return to the prior level of competition without disability. Athletes with unre-
solved musculoskeletal pain, weakness, or instability may need additional evaluation and
rehabilitation to optimize function and exclude other conditions.
Fractures, dislocations, and some ligamentous injuries are more serious injuries.
Detailed information about mechanism of injury, sport involved, treatment, and rehabili-
tation history should be obtained. Athletes with injuries that have not fully healed or who
have associated neurological deficits may benefit from a referral to a primary care sports
medicine physician, an orthopedic surgeon, a physiatrist, a neurologist, or another special-
ist for advice regarding management and medical eligibility.
Bone stress injuries (BSIs) are common in sports with repetitive impact loading (eg, run-
ning), sports specialization associated with overuse injuries (eg, figure skating, gymnastics,
dance, basketball, rowing, baseball), and sports for which judging is subjective and appear-
ance is important (eg, figure skating, gymnastics, cheerleading).1 Bone stress injuries range
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132 Section 6G. Musculoskeletal Concerns
on a continuum from a stress reaction to a cortical fracture and result from the failure of
the skeleton to withstand repetitive, submaximal torsion or tension forces. Early identifica-
tion and evaluation for recurrent BSI is important because delayed diagnosis may result in a
higher-grade injury that requires longer healing time or even surgical intervention.
Training errors usually involve either a rapid increase in the intensity and duration of
training or a prolonged high-level training without periodization (including short- and
long-term rest breaks) and adequate workout recovery time.2–5 The training schedule, the
mode at the time of the stress injury, and any modifications to the training process should
be determined at the PPE. The athlete should be examined for conditions that may affect
the normal lower extremity biomechanics or neuromuscular control, such as leg-length
discrepancy (true or functional), sacroiliac joint dysfunction, pelvic rotation, core weak-
ness, subtalar restrictions, pes planus (flatfoot), or pes cavus (high arch). A full evaluation
may require an encounter away from the screening examination.
Low energy availability can lead to decreased bone mineral density and stress fractures.
Any athlete (female or male) with a history of stress fractures should be queried about
dietary restriction behaviors that result in low energy availability, and inadequate calories,
macronutrient imbalances, calcium intake, and vitamin D intake. Low energy availability
may signify a disordered eating issue and increase the risk of amenorrhea and either osteo-
porosis or osteopenia.6 Female athletes should be asked about menstrual history, as amen-
orrhea can be caused by inadequate calorie intake and interfere with the hormonal effects
on bone health (see Chapter 7).
Understanding historical findings, such as from imaging, surgery, and rehabilita-
tion, gives the physician a better idea of the nature of a previous injury (eg, minor vs seri-
ous). This inquiry may prompt an athlete to remember a procedure or workup, even if the
athlete may have forgotten the injury when answering previous questions.
Once the History Form has been completed and reviewed, a screening and focused
examination of the musculoskeletal system should be performed.
The type and extent of the musculoskeletal examination appropriate for the PPE is a much-
debated topic, and few studies are available to guide the clinician. Examiners need to
determine which method best suits a given situation, depending on history of injury, mus-
culoskeletal signs or symptoms, resources and time available, and type of sport or activity
in which the athlete will participate.
The yield of musculoskeletal examination is low in asymptomatic athletes who have no
history of injury. In addition, history alone has been shown to be 92% sensitive in detect-
ing significant musculoskeletal injuries.7 A general screening examination (Figure 6G-1)
may be a reasonable approach for asymptomatic athletes who have no previous injury,
despite a sensitivity of 50%.7 General joint screenings test gross muscular asymmetry, focal
areas of tenderness, joint range of motion, and overall muscle strength to aid in identi-
fying significant injuries and neuromuscular impairments. The examination may show
previously undetected range of motion deficits or reveal scars from undisclosed surgery
in athletes trying to avoid restrictions in medical eligibility. Adding a screening for lower
extremity neuromuscular control may reduce anterior cruciate ligament (ACL) injury risk.8
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Figures 1 to 9 and 11 to 13: © 2005 Rebekah Dodson. Figure 10: © 2005 Terry Boles.
Figure 6G-1. General Musculoskeletal Screening Examination
The general musculoskeletal screening examination consists of (1) inspection, with athlete standing,
facing toward examiner (symmetry of trunk, upper extremities); (2) forward flexion, extension, rotation,
and lateral flexion of neck (range of motion, cervical spine); (3) resisted shoulder shrug (strength, tra-
pezius); (4) resisted shoulder abduction (strength, deltoid); (5) internal and external rotation of shoulder
(range of motion, glenohumeral joint); (6) extension and flexion of elbow (range of motion, elbow);
(7) pronation and supination of forearm or wrist (range of motion, elbow and wrist); (8) athlete clench-
ing fist, then spreading fingers (range of motion, hand and fingers); (9) inspection, with athlete facing
away from examiner (symmetry of trunk, upper extremities); (10) back extension, with knees straight
(spondylolysis or spondylolisthesis); (11) back flexion, with knees straight, facing toward and away
from examiner (range of motion, thoracic and lumbosacral spine; spine curvature; hamstring flexibility);
(12) inspection of lower extremities, with contraction of quadriceps muscles (alignment, symmetry);
(13) toe stand and heel walk.
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If the athlete has (1) a previous injury or (2) pain, ligamentous laxity or joint instability,
locking, weakness, atrophy, or other signs or symptoms detected by the general screening
examination or the history, the general screening should be supplemented with relevant
elements of the joint-specific examination, or more in-depth evaluation may be required at
an additional encounter.9
Joint-Specific Testing
Assessing individual joints by inspection, palpation, range of motion, and well-established
specific maneuvers is more definitive than the general screening examination. However,
joint-specific examinations are time-consuming and have a low yield in an asymptomatic
athlete without a previous injury. Although such precisely focused tests may reveal infor-
mation that can improve performance and possibly prevent injury, these examinations are
time-consuming and require more in-depth knowledge of individual sports than the gen-
eral screening musculoskeletal examination requires. When time, resources, and expertise
allow, however, such examinations can supplement the general screening examination. The
author societies do not consider it necessary to perform an entire joint-specific examina-
tion for every athlete but rather to focus the examination using the history or abnormal
findings from the general screening. If the joint-specific examination confirms a problem, a
more thorough and focused examination with relevant diagnostic testing may be indicated
before determining medical eligibility. If the setting, time available, and examiner expertise
allow, this examination may be completed during the PPE.
Spine. The cervical spine should be inspected for posture and alignment. The ear canal
should line up with the middle of the
© 2005 Terry Boyles

shoulder. Forward flexion of the neck
should allow the chin to touch the
manubrium, extension should allow
a nearly vertical gaze, rotation should
let the chin almost touch the clavicle
in both directions, and the ears
should approach the shoulders with
lateral flexion. Any asymmetrical or
deficient motion should be noted.
Examination of the thoracolumbar
spine and back focuses on posture,
range of motion, and potential defor-
mities. The scapulae should be level,
symmetrical, and flat against the tho-
racic cage. The presence of scoliosis,
kyphosis at the thoracic level, or lor-
dosis at the lumbar level should be
documented. Scoliosis causes a rota-
tory deformity as the athlete bends
forward at the waist (Figure 6G-2).
Pain or restriction of forward flexion Figure 6G-2. Thoracolumbar Examination
may indicate lumbar disk disease. for Scoliosis
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Pain from compression fractures is most often midline, is most often worse with flexion of
the spine, and may be related to neurological findings. Back extension may increase pain
from a facet injury, spondylolysis, spondylolisthesis, or a sprain or strain.
As part of the thoracolumbar examination, the athlete bends forward at the waist. The
rotary deformities of scoliosis, such as asymmetrical, prominent ribs; curvature of the
spine; or an asymmetrical waist, are accentuated in this position.
Upper extremity. The shoulder examination begins with inspection for symmetry
with the athlete standing. It is important to visualize the posterior and anterior aspects
of the shoulder boney and muscular anatomies (for bruising, scapular symmetry, wing-
ing, atrophy, acromioclavicular joint prominence, and sternoclavicular joint prominence).
Palpate the bilateral sternoclavicular joint, acromioclavicular joint, and proximal biceps
tendon and bicipital groove. Range of motion in abduction (Figure 6G-3A), flexion (Figure
6G-3B), and internal rotation (Figure 6G-3C) and external rotation (Figure 6G-3D) are
then assessed. Most overhead athletes exhibit an excessive amount of external rotation and
a decrease in internal rotation in their dominant arm.
Deltoid strength can be assessed with manual resistance to straight abduction assess-
ments. Shoulder rotator cuff strength can be assessed while the athlete is sitting. The
supraspinatus is tested when the shoulder is lifted into scapular plane abduction to at least
45 degrees and internal rotation (empty can test) (Figure 6G-4A) with resistance to abduc-
tion movement over the distal humerus. The infraspinatus is tested with the shoulder in
adduction, in neutral rotation, and the elbows flexed to 90 degrees with resistance against
external rotation applied to the distal forearm (Figure 6G-4B). The subscapularis is tested
with the belly-press test or the lift-off test (Figure 6G-4C). For the belly press, the patient’s
hand is placed flat onto his abdomen with the hand, wrist, and elbow in a straight line; the
Figure 6G-3. Shoulder Range of Motion

Shoulder range of motion is evaluated in 4 directions. In abduction (A) and forward flexion (B), the
athlete should be able to reach completely overhead without excessive or asymmetrical motion of the
scapula; in internal rotation (C), the fingertips should reach approximately to the bottom of the opposite
scapula; and in external rotation (D), the fingertips should approach the top of the opposite scapula.
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Empty can test for External rotation strength Lift-off test for
supraspinatus for infraspinatus and subscapularis
teres minor
Figure 6G-4. Shoulder Impingement Signs
patient is then instructed to

press down on his abdomen;

and a normal result is the abil-
ity to compress the abdomen
without flexing at the wrist.
The lift-off test is done with the
patient’s elbow flexed and arm
behind the back with his hand
at midline and at waist level;
the patient is instructed to raise
his hand off the back, and a
normal result is the ability to
raise the hand off the back.10
Figure 6G-5. Assessing Rotator Cuff Impingement Shoulder impingement
The Neer impingement test (A) involves fully abducting and for- signs should be tested with
ward flexing the shoulder and arm. An alternative examination Neer impingement test and
for shoulder impingement, the Hawkins test (B), involves forward
Hawkins test (Figure 6G-5).
flexion to 90° and the shoulder is internally rotated. With internal
shoulder rotation, the examiner notes whether there has been an A screening for multidi-
exacerbation of shoulder pain. Localizing the exact site of the rectional instability includes
pain can help distinguish biceps tendinopathy or acromioclavicu- subluxation tests in the ante-
lar pathology from rotator cuff pathology. If there is true outlet rior and posterior planes
impingement, pain should localize to the anterior acromion of of a supine athlete (Figures
the shoulder and radiate laterally down the arm.
6G-6A–6G-6C) and in the
inferior plane of a seated ath-
lete (Figure 6G-6D).
The elbow is observed for swelling, discoloration, and carrying angle (cubital valgus)
(Figure 6G-7A). The elbow should extend fully and then flex to allow the athlete to touch
the ipsilateral shoulder with the hand. Forearm motion is assessed by having the athlete
pronate and supinate the forearms with the elbows bent 90 degrees at his or her sides. The
athlete should be able to turn the hand completely palm up and completely palm down.
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Figure 6G-6. Multidirectional Instability
Multidirectional instability can be gauged by assessing glenohumeral motion in several planes. Posterior
instability of the shoulder is assessed with the athlete supine by positioning the arm perpendicular to
the table with the elbow bent, then applying pressure along the long axis of the arm (A). The hand
supporting the posterior shoulder palpates for excessive motion. When assessing shoulder internal rota-
tion, it is important to stabilize the scapula by placing a hand against the scapular spine in the upright
patient; for the supine patient, placing the shoulder firmly against the examination table can achieve the
same goal. With the athlete seated (B), inferior subluxation is confirmed by the presence of the sulcus
sign—appearance of an indentation beneath the acromion with traction along the axis of the adducted
arm. In a normal shoulder, there should be some inferior laxity with the arm at the side. However, as
the arm is eternally rotated with the arm maintained at the side, this laxity should correct as the rotator
interval is placed into tension. Inferior subluxation that persists or is asymmetrical to the opposite side
suggests a tear of the rotator interval. During the apprehension test (C), which is used to assess for
anterior instability, the examiner abducts the arm in the scapular plane and externally rotates the supine
athlete’s shoulder. It is important to look at the athlete’s face while performing the maneuver to assess
for visible signs of apprehension of a dislocation event. If apprehension is observed during the test, the
relocation test (D) may be performed in the same position by applying a posteriorly directed force to the
humeral head, reducing anterior translation of the humeral head. Relocation of the head will decrease
the feeling of apprehension if instability is present. It is important to distinguish whether there is frank
apprehension or pain with this test. If the athlete experiences increasing pain with progressive external
rotation of the humeral head, this suggests that the humeral head has anterior subluxation; secondary
(internal) impingement of the rotator cuff is occurring, causing pain.11
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Figures A and B: © 2005 Terry Boyles

70°
Figure 6G-7. Elbow Examination

Abbreviation: UCL, ulnar collateral ligament.
The normal carrying angle of the elbow is at least 15° valgus with the athlete standing and the palms
forward (A). An excessive valgus angle may indicate instability or a previous injury. In a throwing ath-
lete, UCL instability should be assessed. This is accomplished by applying a valgus force to the elbow
(with forearm supination) at 25°–30° of flexion while noting laxity and end point (B). The modified
milking maneuver is done with the elbow in flexion and UCL stress applied by the examiner grasping
the thumb and applying a stress as pictured to assess UCL instability (C).
In a throwing athlete, medial stability can be assessed by applying a valgus force to the
elbow (Figure 6G-7B). The modified milking maneuver (Figure 6G-7C) also assesses medial
instability. The test result is considered positive if pain is noted over the ulnar collateral liga-
ment or if the joint opens medially. Direct comparison with the opposite arm is critical.
The hand and wrist should be evaluated for symmetry. Wrists should palmar flex equally
to about 80 degrees and dorsiflex to 70 degrees or more. There should be more ulnar devi-
ation than radial deviation. The fingers should be able to close into a full fist, and each fin-
gernail should point at the scaphoid bone with the fingers flexed across the palm. Intrinsic
muscle function can be checked by having the athlete touch each fingertip with the thumb
and spread and close the extended fingers.
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Lower Extremity Examination

The hip examination begins with observation of the standing posture. The iliac crest and
posterior superior iliac spine heights should be level with the floor when the torso is
aligned symmetrically, and the athlete should be able to stand on each foot without any
translation or tilting of the pelvis.
The hip joint should be palpated for tenderness in the greater tuberosities, hip flexor,
adductor, and external rotator tendons (behind the greater trochanter). The hip joint itself
refers pain mainly to the groin region.
Hip range of motion can be assessed with the athlete lying supine. Landmarks should
be reviewed at this point. With the hip and the knee fully extended, the hip joint is
rotated internally and externally (a “log roll” movement), and any asymmetry is noted.
Symmetry of abduction and adduction should also be observed. Hip flexion should be
beyond 90 degrees, and the knees should come straight toward the chest; any external
rotation indicates an intrinsic hip deformity. With the hip and knee flexed to 90 degrees,
the hip joint should have 40 degrees of internal rotation and 45 degrees of external rota-
tion (Figure 6G-8). Keeping the athlete’s hip flexed 90 degrees and extending the knee
checks hamstring flexibility. The popliteal angle should be 0 degrees to 10 degrees in young
children and can vary depending on patient age and sex.12,13 The popliteal angle refers to
the flexion angle of the knee created by tension in the hamstrings as the knee is extended
while the hip is flexed.
Acetabular labral tears, dysplasia, femoral acetabular impingement (FAI), and femoral
neck stress fractures are recognized as sources of hip or groin pain and functional limita-
tion. Passive assessment of the hip in flexion, adduction and internal rotation (FADIR)
is conducted as part of the supine assessment of the hip (Figure 6G-9). The FADIR test is
the most sensitive physical examination test for FAI.14 The examiner holds the monitoring
External Internal
rotation 0° rotation
Internal External
rotation rotation 40°
45°
40° 45°
0°
Figure 6G-8. Hip Range of Motion

Hip range of motion is evaluated with the athlete supine. As part of the examination, the hip and knee
are flexed to 90° and the hip joint is rotated. A rotation arc of 60°–85° should be observed. Pain or
restriction of motion relative to the opposite side warrants further evaluation.
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hand about the superior aspect of the hip with the leg cradled on the forearm and the knee
upon the hand. The hip is then brought into flexion, adduction, and internal rotation. Any
reproduction of the patient’s concern and the degree of impingement are noted. Loss of
internal rotation is common with anterior superior labral tears and FAI.15
The FABER test (Figure 6G-10) involves combining the motion of hip flexion, abduc-
tion, and external rotation. Evaluation documents pain provocation and range of motion.
Posterior hip pain may be indicative of sacroiliac joint involvement, while anterior hip
pain or groin pain indicates intra-articular hip pathology.16, 17
With the athlete standing, inspection should reveal a normal leg-thigh valgus angula-
tion of 12 degrees or less in males and 18 degrees or less in females. The patella should be
observed for abnormal lateral subluxation or tilt or an excessively high position (patella
alta) with the athlete seated. A patella apprehension test evaluates for patella instability
and a positive test result is apprehension with lateral translation of the patella and the
knee in extension (Figure 6G-11).18
The remainder of the knee examination should be done with the athlete supine. Each
patella should be evaluated for hypermobility by translating the patella medially and later-
ally with the knee in approximately 20 degrees of flexion; comparison with the opposite
side should be made. Joint-line tenderness may indicate a meniscal tear. Any amount
of knee effusion should be noted. Knee range of motion should be from full extension
or hyperextension to approximately 140 degrees of flexion. Knee ligament stability tests
include the Lachman test for ACL deficiency (Figure 6G-12A), posterior drawer test for pos-
terior cruciate ligament insufficiency (Figures 6G-12B and 6G-12C), and varus and valgus
Figure 6G-9. F lexion, Ad duction, and Figure 6G-10. F lexion, Ab duction, and
I nternal R otation (FADIR) Test E xternal R otation (FABER) Test
Figure 6G-11. Medial Lateral Patella Translation

(Glide Test)
The medial lateral patella translation (glide test) is typically
done in full extension. The patella is divided into 4 quad-
rants; lateral translation or glide >3 quadrants (more than
half the patella width) represents restraint incompetency or
tissue laxity.18
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Figure 6G-12. Assessing Ligamentous Instability of the Knee
Abbreviations: ACL, anterior cruciate ligament; PCL, posterior cruciate ligament.
Several tests are used to assess ligamentous instability of the knee. For each test, the degree of ex-
cursion and the quality of the end point are noted and compared with the opposite side. The Lach-
man test (A) is the most sensitive means to assess ACL deficiencies.19 The patient’s knee is flexed
approximately 20°, and the muscles are relaxed. The examiner stabilizes the femur with one
hand while pulling the tibia anteriorly with the other hand. It is important to note how far the tibial
tubercle translates anteriorly and whether there is a soft or firm end point at terminal translation.
All findings should be compared with the opposite side. The anterior drawer test (B) is not sensitive
(negative test result does not mean intact ACL), but it does indicate ACL insufficiency when posi-
tive. The Lachman test is far superior for determining the integrity of the ACL. The posterior drawer
test (C) can reveal PCL insufficiency. With the supine patient’s knee bent 90°, the examiner sits on
the patient’s foot to stabilize it and grasps the proximal tibia. The hamstrings should be palpated
to ensure they are relaxed. The examiner pulls the tibia anteriorly (anterior drawer test, B) and
pushes it posteriorly (posterior drawer test, C) from the neutral position. With the anterior drawer
test, lack of a firm end point and presence of excessive anterior tibial excursion suggest ACL insuf-
ficiency. With the posterior drawer test, the presence of excessive posterior tibial sag suggests PCL
insufficiency. With an intact PCL, the tibia is positioned anterior to the femur with the knee in 90°
of flexion. During the posterior drawer test, the examiner should palpate and quantify the change
in anteromedial femoral-tibial step-off that occurs with and without a posteriorly directed force on
the tibia. Varus stress test (D) and valgus stress test (E) gauge instability of the medial and lateral
collateral ligaments of the knee. The athlete’s knee is extended over the edge of the examination
table and flexed to approximately 20°. One of the examiner’s hands stabilizes the knee at the
joint line, and varus and valgus stresses are applied to the tibia. Once again, comparison with the
opposite limb is essential for these tests, given the reference range of variation in joint stability.
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stress tests for collateral ligament laxities (Figures 6G-12D and 6G-12E). It is important to
remember that a negative anterior drawer test result does not rule out an ACL tear and the
Lachman test is the better test for ACL integrity.
Palpation of the tibial tubercle is important to assess for Osgood-Schlatter disease (tib-
ial tubercle apophysitis). Osgood-Schlatter disease is an apophysitis of the tibial tubercle.
It is one of the most frequent causes
of knee pain in young children and

growing adolescents.
The lower leg and tibia examina-
tion should include the shin edema
test (SET) and shin palpation test
(SPT) to test for medial tibial stress
syndrome (MTSS). SET is sustained
palpitation of the distal two-thirds
of the medial surface of the tibiae
bilaterally for at least 5 seconds to
evaluate for signs of pitting edema.
SPT is palpation of the distal two-
thirds of the posteromedial border
of the tibiae for focal bony tender-
ness that may indicate BSI.20
The ankles are evaluated with
the athlete standing and sitting for
normal appearance. In the seated
position, active dorsiflexion to
20 degrees and plantar flexion to
40 degrees should be present. With
the knee extended, tightness in the
Achilles tendon can be assessed by
passively dorsiflexing the seated ath-
lete’s ankle while observing the lat-
eral aspect of the leg and ankle. The
ankle should dorsiflex 15 degrees to
20 degrees past neutral. Stress testing
for ligament laxity includes the ante-
rior drawer test for anterior sublux-
ation (Figure 6G-13A) and the talar Figure 6G-13. Assessing Instability of the Ankle
tilt test for lateral ligament stability Ligaments
(Figure 6G-13B). Two stress tests are used to assess instability of the ankle
At inspection of the foot, pes ligaments. For the anterior drawer test (A), which demon-
cavus or rigid flatfoot deformities strates anterior subluxation, the examiner pulls the heel
anteriorly while pushing posteriorly on the distal tibia.
should be noted. A supple flat-
For the talar tilt test (B), the examiner inverts the ankle by
foot does not affect an athlete’s pushing laterally on the medial tibia and medially on the
performance, but it may be a risk calcaneus. Excessive motion relative to the opposite edge
factor for upstream problems in should trigger further evaluation.
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the kinetic chain, such as MTSS or patellofemoral joint pain. As the foot pronates, the
tibia internally rotates and may stress the posterior tibialis muscle along its origin or may
change patellar tracking, resulting in patellar pain. Short-term splinting with an arch sup-
port along with eccentric strengthening may resolve the issue, providing that the remainder
of the kinetic chain is functioning correctly. If the flatfoot is supple, the plantar arch will
increase when the athlete stands on his or her toes. Toe deformities, including bunions,
contractures, and pressure points indicated by calluses, may become painful in athletic
footwear. Abnormalities associated with subtalar, midfoot, and forefoot problems should
be further assessed through a formal gait study or a running study (or both) in an exercise
physiology laboratory or similar facility.
Functional Movement Tests

The data supporting functional movement testing and improved outcomes are not strong.
Testing should be considered in players of lateral, pivoting, cutting sports. Poor core strength
and inadequate neuromuscular control of the femur is linked to increased risk of patello-
femoral pain syndrome and ACL tears.8,21 A combination of muscle testing to point out indi-
vidual deficiencies and coaches’ education to promote team active warm-ups and focused
strengthening programs may
reduce injury risk.8,21 Athletes in
sports requiring lateral, pivot-
ing, and cutting motions might
be evaluated in greater detail
with the box drop test and core
strength evaluation to deter-
mine deficits in neuromuscular
control that increase risk of ACL
rupture.22
Single-Leg Squat Test

A simple screening for poten-
tial lower extremity injury risk
is the single-leg squat (SLS)
test. Barefoot athletes are asked
to place their hands onto their
hips and stand on one limb
and flex the opposing limb to
90 degrees, followed by an SLS
to 30 degrees of knee flexion
with return to a fully extended Figure 6G-14. Single-Leg Squat Test
knee position. Abnormal Patients should place their hands on their hips or in front, as
responses, which include arms pictured, and stand on one limb and flex the opposing limb to
90°. (A) They then should perform 3 single-leg squats to 30° of
flailing, Trendelenburg sign, or
knee flexion and return to a fully extended knee position. (B) The
collapse of the supporting knee examiner should note any abnormal responses, which consist of
into valgus, should be noted arms flailing, the Trendelenburg sign, or collapse of the support-
(Figure 6G-14).23 ing knee into valgus.23
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Box Drop Test

The box drop test addresses dynamic neuromuscular control. The athlete is asked to do
a drop vertical jump maneuver from a box height of 31 cm (other heights, such as an
examination table step, are acceptable for the purpose of a preparticipation examination).
Participants are instructed to drop off the box and immediately perform a maximal verti-
cal jump (Figure 6G-15). In one study, an increase in the knee valgus and abduction angle
(knock-knee appearance) at landing increased the risk for ACL injury with 73% specificity
and 78% sensitivity.8
Figure 6G-15. Vertical Jump Maneuver

This series of figures illustrates a normal landing pattern. An abnormal test result would include “kissing
knees,” flailing arms, or loss of balance. (A) Starting position on 31-cm box. (B) Mid-flight immediate
after dropping off the box. (C) Initial contact. (D) Landing phase. (E) Toe off. (F) Maximum vertical jump
height. (G) Second landing.21
Sport-specific examinations. Players of certain sports are at higher risk for injury
because of stresses placed onto specific joints and muscles. Detailed evaluation of strength,
endurance, range of motion, and flexibility may be warranted for these athletes. For
example, baseball pitchers develop problems with rotation, both internal and external,
from repeated throwing that may improve with rehabilitation and evaluation of total range
of motion of the shoulder.
Hockey players and ballet dancers24 are at higher risk for FAI. “Cam”-type impingement
affects 79% of ice hockey players.25,26 Flexion, adduction, and internal rotation provocative
tests for cam-type and “pincer”-type FAI would be recommended.
Hyperlaxity at joint examination, especially in an athlete engaged in overhead arm
motions, is also associated with increased risk of joint injury.27 For example, an adolescent
baseball pitcher, swimmer, or volleyball player with shoulder concerns and evidence of sys-
temic laxity, such as hyperextension at the elbow, may have more-serious conditions such
as Ehlers-Danlos or Marfan syndrome. In the case of Ehlers-Danlos syndrome, knowledge
of the Beighton scale (Carter-Wilkinson criteria) (Table 6G-1) can help to objectively make
the diagnosis.28 The Beighton scale provides an objective way to risk stratify potentially
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Table 6G-1. Beighton Hypermobility Criteriaa
Physical Finding Point Value

Passive dorsiflexion of the metacarpophalangeal joint beyond 90° 1 point for each hand
Passive apposition of the thumb to the flexor aspect of the forearm 1 point for each thumb
Hyperextension of the elbows beyond 10° 1 point for each elbow
Hyperextension of the knees beyond 10° 1 point for each knee
Forward flexion of the trunk with knees fully extended so that the palms of 1 point
the hands rest flat on the floor
a
A total score of ≥5/9 is generally regarded as indicating hypermobility.
Adapted with permission from Grahame R, Bird HA, Child A. The revised (Brighton 1998) criteria for the diagnosis
of benign joint hypermobility syndrome (BJHS). J Rheumatol. 2000;27(7):1777–1779.
hypermobile athletes who require further clinical assessment. Common physical find-
ings are hyperextension of the knees and elbows beyond 10 degrees, dorsiflexion of the
metacarpal-phalangeal joints beyond 90 degrees, and passive apposition of the thumb to
the forearm.

The examining provider must decide whether an athlete is ready to participate in her sport
by using information gathered during the history and physical examination. Determining
medical eligibility for athletes who have musculoskeletal injuries or disorders requires
assessing short- and long-term risks and benefits with respect to the PPE findings. Some
problems may exceed the capacity of the PPE venue and require additional evaluation with
a repeated visit or consultation with additional specialists.
Medical eligibility for participation must be based on the degree and type of injury,
the ability of the injured athlete to compete safely, and the requirements of a given sport.
Participation may be possible in activities that do not directly affect the injured site (eg, a
wrist sprain might prevent a gymnast from full training but not a runner). Therefore, the
provider should also determine which strength and conditioning activities are appropri-
ate during the recovery period so that the athlete is able to maintain some level of fitness.
Protective padding, taping, or bracing may allow an athlete to train and compete safely,
as long as the protective device does not increase risk for other competitors. The types of
protective splinting or bracing permitted in competition vary by the sport and the rules of
the sport organization or league. If the examining physician is not certain of the rules con-
cerning safe participation with protective devices, consultation with a sports medicine spe-
cialist is suggested. The final decision on what type of protective padding or bracing may
rest with the on-site officials. In such situations, a change in the original type of protection
recommended by the sports medicine staff could be deemed necessary by the official. Any
alteration required by the official should be evaluated to ensure that it provides the neces-
sary protection for the injury.
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Referral or consultation is warranted when the examiner is uncertain of the athlete’s

ability to participate because of the injury or musculoskeletal deficit. In any case, the
physician(s) who initiated the treatment of an injury that is present at the time of the PPE
should be included in the medical eligibility decision. Reevaluation for sports participation
is required after rehabilitation is completed. Review of every musculoskeletal problem is
beyond the scope of this monograph, but selected problems deserve mention.
Sprains, Strains, Subluxations, Dislocations, and Contusions

Before medical eligibility for sport participation is given for either acute injuries or overuse
injuries, the athlete should be examined and the following conditions ruled out:
• Effusion, swelling, or other signs of inflammation
• Decreased range of motion of the affected joint or joints controlled by the muscle
• Strength less than 85% to 90% of the uninjured side or insufficient for the desired
activity
• Ligamentous instability of the affected joint
• Loss or alteration of sport-specific functional ability (ie, inability to complete pain-free
functional activity at 80%–90% effort)
For example, a football defensive back who is rehabilitating a lateral ankle sprain could
be assessed with backpedaling and side-to-side movements. If any of these findings are
abnormal, further treatment will be needed to allow for return to play. Referral, if neces-
sary, to a provider familiar with the sport-specific requirements and injury assessment is
recommended. Ultimately, the decision for medical eligibility is based on the examiner’s
clinical judgment and may be withheld until further evaluation and completion of pre-
scribed treatment or rehabilitation.
Fractures
Medical eligibility of an athlete with a fracture should be determined in consultation with
the treating physician. The location and type of fracture, the risk of reinjury or complica-
tions, and the effect of treatment should be considered. The possibility of protecting the
fracture during participation with a cast or splint should be considered if the risk of wors-
ening the injury is felt to be negligible.
Developmental Conditions
Any history or physical finding of spinal deformity (eg, scoliosis, spondylolysis, or spondy-
lolisthesis) requires a more thorough evaluation than is generally provided in the PPE.
Follow-up with the athlete’s primary care physician, sports medicine specialist, or spine
specialist is recommended should questions arise. Spondylolysis and spondylolisthesis
should be evaluated individually on the basis of symptoms, physical limitations, and
imaging findings. Spondylolysis and spondylolisthesis may require follow-up imaging to
assess progression. Generally, athletes with spinal deformities need not be excluded from
play. However, activities may need to be modified according to clinical symptoms and the
extent of the abnormality.
Clearing athletes with apophysitis of the tibial tubercle (Osgood-Schlatter disease),
calcaneus (Sever disease), ileum, or ischium and pain at the infrapatellar insertion of the
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References 147
patellar tendon (Larsen-Johansson disease) follows similar criteria as for overuse injuries
and acute strains.
If there are any questions concerning medical eligibility, consultation with a sports medi-
cine specialist is warranted. A systematic approach to history, physical examination, and
medical eligibility decisions should set the foundation for a safe sport season for the athlete.
■■ REFERENCES
1. Snyder RA, Koester MC, Dunn WR. Epidemiology of stress fractures. Clin Sports Med. 2006;25(1):37–52
PMID:16324972 https://doi.org/10.1016/j.csm.2005.08.005
2. Kadel NJ, Teitz CC, Kronmal RA. Stress fractures in ballet dancers. Am J Sports Med. 1992;20(4):445–449
3. Brunet ME, Cook SD, Brinker MR, Dickinson JA. A survey of running injuries in 1505 competitive and recre-
ational runners. J Sports Med Phys Fitness. 1990;30(3):307–315 PMID:2266763
4. Korpelainen R, Orava S, Karpakka J, Siira P, Hulkko A. Risk factors for recurrent stress fractures in athletes.
5. The team physician and strength and conditioning of athletes for sports: a consensus statement. Med Sci
Sports Exerc. 2015;47(2):440–445 PMID:25594944
6. Tenforde AS, Kraus E, Fredericson M. Bone stress injuries in runners. Phys Med Rehabil Clin N Am. 2016;
27(1):139–149 PMID:26616181 https://doi.org/10.1016/j.pmr.2015.08.008
7. Gomez JE, Landry GL, Bernhardt DT. Critical evaluation of the 2-minute orthopedic screening
examination. Am J Dis Child. 1993;147(10):1109–1113 PMID:8213685 https://doi.org/10.1001/
archpedi.1993.02160340095022
8. Hewett TE, Myer GD, Ford KR, et al. Biomechanical measures of neuromuscular control and valgus loading
of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. Am J Sports
Med. 2005;33(4):492–501 PMID:15722287 https://doi.org/10.1177/0363546504269591
9. Garrick JG. Preparticipation orthopedic screening evaluation. Clin J Sport Med. 2004;14(3):123–126 PMID:
15166899 https://doi.org/10.1097/00042752-200405000-00003
10. Burkhart SS, Tehrany AM. Arthroscopic subscapularis tendon repair: technique and preliminary results.
Arthroscopy. 2002;18(5):454–463 PMID:11987054 https://doi.org/10.1053/jars.2002.30648
11. Speer KP, Hannafin JA, Altchek DW, Warren RF. An evaluation of the shoulder relocation test. Am J Sports
Med. 1994;22(2):177–183 PMID:8198184 https://doi.org/10.1177/036354659402200205
12. Katz K, Rosenthal A, Yosipovitch Z. Normal ranges of popliteal angle in children. J Pediatr Orthop.
13. Gajdosik R, Lusin G. Hamstring muscle tightness. Reliability of an active-knee-extension test. Phys Ther.
1983;63(7):1085–1088 PMID:6867117 https://doi.org/10.1093/ptj/63.7.1085
14. Byrd JW, ed. Operative Hip Arthroscopy. 3rd ed. New York, NY: Springer; 2013
15. Martin HD, Shears SA, Palmer IJ. Evaluation of the hip. Sports Med Arthrosc Rev. 2010;18(2):63–75 PMID:
20473124 https://doi.org/10.1097/JSA.0b013e3181dc578a
16. Martin RL, Enseki KR, Draovitch P, Trapuzzano T, Philippon MJ. Acetabular labral tears of the hip: examina-
tion and diagnostic challenges. J Orthop Sports Phys Ther. 2006;36(7):503–515 PMID:16881467 https://doi.
org/10.2519/jospt.2006.2135
17. Kuhlman GS, Domb BG. Hip impingement: identifying and treating a common cause of hip pain. Am Fam
Physician. 2009;80(12):1429–1434 PMID:20000305
18. Arendt EA, Donell ST, Sillanpää PJ, Feller JA. State of the art: the management of lateral patellar dislocation.
J ISAKOS. 2017;2(4):205–212
19. Kim SJ, Kim HK. Reliability of the anterior drawer test, the pivot shift test, and the Lachman test. Clin Orthop
Relat Res. 1995;(317):237–242 PMID:7671485
20. Newman P, Adams R, Waddington G. Two simple clinical tests for predicting onset of medial tibial stress
syndrome: shin palpation test and shin oedema test. Br J Sports Med. 2012;46(12):861–864 PMID:22966153
https://doi.org/10.1136/bjsports-2011-090409
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21. Hewett TE, Myer GD, Ford KR, Slauterbeck JR. Preparticipation physical examination using a box drop
vertical jump test in young athletes: the effects of puberty and sex. Clin J Sport Med. 2006;16(4):298–304
22. Zazulak BT, Hewett TE, Reeves NP, Goldberg B, Cholewicki J. Deficits in neuromuscular control of
the trunk predict knee injury risk: a prospective biomechanical-epidemiologic study. Am J Sports Med.
23. Ugalde V, Brockman C, Bailowitz Z, Pollard CD. Single leg squat test and its relationship to dynamic knee
valgus and injury risk screening. PM R. 2015;7(3):229–235 PMID:25111946 https://doi.org/10.1016/j.
pmrj.2014.08.361
24. Duthon VB, Charbonnier C, Kolo FC, et al. Correlation of clinical and magnetic resonance imaging find-
ings in hips of elite female ballet dancers. Arthroscopy. 2013;29(3):411–419 PMID:23332372 https://doi.
org/10.1016/j.arthro.2012.10.012
25. Brunner R, Maffiuletti NA, Casartelli NC, et al. Prevalence and functional consequences of femoroacetabular
impingement in young male ice hockey players. Am J Sports Med. 2016;44(1):46–53 PMID:26464494 https://
doi.org/10.1177/0363546515607000
26. Philippon MJ, Ho CP, Briggs KK, Stull J, LaPrade RF. Prevalence of increased alpha angles as a measure of
cam-type femoroacetabular impingement in youth ice hockey players. Am J Sports Med. 2013;41(6):1357–
1362 PMID:23562808 https://doi.org/10.1177/0363546513483448
27. Amir D, Frankl U, Pogrund H. Pulled elbow and hypermobility of joints. Clin Orthop Relat Res. 1990;(257):
94–99 PMID:2379380
28. Gedalia A, Brewer EJ Jr. Joint hypermobility in pediatric practice—a review. J Rheumatol. 1993;20(2):371–374
PMID:8474078
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H. Mental Health
Patient Health Questionnaire Version 4 (PHQ-4)1–3

Over the last 2 weeks, how often have you been bothered by any of the following problems?
1. Feeling nervous, anxious or on edge. Responses: Not at all (0), Several days (1), More than
half the days (2), Nearly every day (3).
2. Not being able to stop or control worrying. Responses: Not at all (0), Several days (1), More
than half the days (2), Nearly every day (3).
3. Little interest or pleasure in doing things. Responses: Not at all (0), Several days (1), More
than half the days (2), Nearly every day (3).
4. Feeling down, depressed, or hopeless. Responses: Not at all (0), Several days (1), More than
half the days (2), Nearly every day (3).
A sum of ≥3 is considered positive on either subscale (questions 1 and 2, or questions 3
and 4) for screening purposes.
■■ KEY POINTS
• Mental health is increasingly recognized as a major health issue for athletes in the ado-
lescent and young adult years.
• Screening for mental disorders is an important component of the preparticipation phys-
ical evaluation (PPE).
• Several screening and diagnostic tools are available to help providers identify mental
disorders.
• Developing a treatment plan that includes local mental health providers to care for ath-
letes who screen positive for psychological issues is essential to deliver comprehensive
mental health care.
■■ INTRODUCTION
Many athletes are affected by underlying mental health conditions. The social stigma asso-
ciated with a mental health condition may limit disclosure by the athlete to the health care
team.4 Illness or injury may produce a variety of psychological responses in athletes, some
of which negatively affect sports participation or performance. In addition, psychological
factors, especially high levels of stress on or off the field, may be an important antecedent
to injuries.4 These factors may play an important role in injury recovery and may interfere
with successful return to play. Several psychological issues, including stress, anxiety, depres-
sion, eating disorders, and substance use disorders, can have illness or injury as triggers or
have unique presentations in athletes.
Athletes are subject to numerous stressors. For example, collegiate athletes, who typi-
cally excelled in their respective high schools, must now contend with increased com-
petition level for positions on the roster with equally talented teammates, experience
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150 Section 6H. Mental Health
the physical and psychological burdens of competing for and maintaining a starting
position, and negotiate relationships with teammates and coaches.5 These stressors are
compounded by the complex interactions of injury, illness, scholarship, identity-related
pressures, team culture, financial motivators, and failure to successfully compete or live
up to self-expectations or the expectations of coaches, teammates, and family. The social
supports of the collegiate environment and the social networks and connections of ath-
letic teams can buffer against social isolation and can provide some protective effects
to balance the stressors.6,7 Clearly, mental health issues are not unique to athletes, but
athletes often have unique presentations or treatment needs.5,8 Screening during the
PPE and at every medical encounter or anytime for concerning behaviors observed dur-
ing athletic participation may promote early identification of athletes at risk for mental
disorders.7
■■ MOOD DISORDERS (DEPRESSION)

As part of the health history portion of the PPE, questions addressing the mental health
status of the athlete should be considered, along with a plan for referral and follow-up.9,10
Providers need to be familiar with the test characteristics of the screening questionnaire
used in the PPE. Positive answers to screening questions should trigger a private discus-
sion between the physician and the athlete that is based on the design and instructions
of the screening tool used. The Patient Health Questionnaire version 4 (PHQ-4) com-
bines depression and anxiety screenings into a short question format. The PHQ-4 asks
for how often symptoms are noted over the last 2 weeks. Choices include “Not at all,”
“Several days,” “More than half the days,” or “Nearly every day” scored with 0, 1, 2, or
3, respectively. The total scoring for PHQ-4 ranges from 0 to 12, with categories of psy-
chological distress ranging from none to severe. The Anxiety subscale is the sum of items
1 and 2, and the Depression subscale is the sum of items 3 and 4. A score of 3 or greater
is considered positive on each subscale for screening purposes.1 For the tools suggested
in this monograph, on the PHQ-2 or PHQ-4 subsets of questions 1 to 2 or 3 to 4, a score
of 3 or greater; on the PHQ-9 or the PHQ-A11 (ages 11–17 years), of 5 or greater; or on
the Generalized Anxiety Disorder 7-item (GAD-7) scale, of 10 or greater should prompt
the examiner to explore these conditions further.1,3,12,13 The physician can then determine
whether the athlete needs to be evaluated by a mental health professional.
One of the more common mental health concerns is depression or major depres-
sive disorder (MDD). The average age of onset for major depression and dysthymia
is between the ages of 11 years and 14 years.9,14 The 12-month prevalence for major
depression in 12- to 17-year-olds is 8% and for 18- to 25-year-olds is 8.9%.9,14,15 A
recent 3-year study of National Collegiate Athletic Association (NCAA) Division I ath-
letes showed that the prevalence of clinically relevant levels of depression symptoms
was 23.7% and moderate to severe levels to be 6.3%; female athletes exhibit 1.8 times
the risk of male athletes.16 It is important to understand and recognize the breadth of
depressive disorders in athletes to properly identify, diagnose, and treat the disorders.17
Athletes may underreport symptoms of depression and be less likely to discuss con-
cerns or seek treatment of depression. Depression is a risk factor for suicide in athletes,
and suicide is the fourth leading cause of death in college athletes and the second
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Mood Disorders (Depression) 151
leading cause of death in college students.7 With appropriate education on warning

signs and the increased contact with student-athletes, athletic trainers and team physi-
cians may recognize depression early and then prevent the associated tragedies.7 (The
NCAA has published 2 resources, Mind, Body and Sport: Understanding and Supporting
Student-Athlete Mental Wellness and Mental Health Best Practices—Inter-association
Consensus Document: Best Practices for Understanding and Supporting Student-Athlete Mental
Wellness, which are available to practitioners and coaches to learn about mental health
in this unique population.18,19
In addition to experiencing usual diagnostic symptoms of depressed mood and anhe-
donia, athletes may experience other symptoms of depression (eg, anger, guilt, hope-
lessness, low self-esteem, concentration or attention problems, feeling of helplessness,
irritability, sleep disturbance, risk-taking behavior, substance misuse or use, prolonged or
incomplete recovery, staleness, or decreased performance). The PHQ-2, the PHQ-9, the
PHQ-A (ages 11–17 years), the Beck Depression Inventory-Fast Screen (BDI-FS), and the
Center for Epidemiologic Studies-Depression (CES-D) are tools that can be used to screen
and assess the severity of depression.13,20 There are no screening tools specific to the ath-
letic population.
Among the depression screening tools, BDI-FS is the most sensitive and specific (91%
each), but it is also a proprietary product, making it less useful as a screening tool.13,21 The
PHQ-2, PHQ-9, PHQ-A (ages 11–17 years), and CES-D are used by the American Academy
of Pediatrics and NCAA for mental health screening and are all freely accessible.21,22 The
sensitivity and the specificity for MDD of the PHQ-2 are 83% and 87% and 78% and
92%12,14; the PHQ-9 (modified), 88%23; and the CES-D, 71% and 57%. The CES-D is cul-
turally tested for Mexican and French adolescents.21,24,25 The NCAA recommends the use of
the CES-D for college athletes.22
The PHQ-2 is a reasonable screening tool for reducing the number of items on the
questionnaire.26 The PHQ-2 is incorporated into health supervision examinations as a
valid and practical tool for depression screening in busy medical settings. The brevity
of the PHQ-2 increases the feasibility of including it in the question set. The PHQ-2 is
only a first step in a comprehensive diagnostic process. High scores identify patients
who need further evaluation, such as PHQ-9 screening or a more extensive clinical
evaluation. If a diagnosis of depression is established, treatment with counseling or
medications is recommended.14 If the PHQ-2 screening is positive and the athlete denies
present suicidal ideation or plan, provisional medical eligibility can be granted and
additional evaluation arranged. If there is suicide ideation, the suicide prevention action
plan should be implemented.
In addition to depression, suicide may also be associated with substance use disorder,
risk-taking behavior, bullying, and post-traumatic stress disorder. Sports participation
seems to have a protective effect against suicide in males and females.7,27 This may be in
response to any physical activity, social bonding or connectedness, or achieving success in
the sport.6,7,27 Anabolic-androgenic steroid use has been shown to increase the risk of both
suicide and outwardly directed violence, such as assault and murder.27
One campus suicide prevention strategy, suggested by Drum and Denmark,28 is a staged
approach to managing depression and suicidal ideation in a student population through
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campus environmental enhancement of health promotion, which can lead to a reduced

likelihood that the depression or suicide will advance through early intervention, treat-
ment and crisis intervention, and relapse intervention.28
■■ ANXIETY DISORDERS
Nearly one-third of adolescents (31.9%) in the United States meet criteria for an anxiety
disorder.28 Of those, half begin experiencing their anxiety disorder by age 6 (Box 6H-1).29
Box 6H-1. Signs and Symptoms of Anxiety Disorders

Signs and symptoms of an anxiety disorder include the following ones and may be associated with
other athletic injuries or illnesses, such as concussion:
• Feeling apprehensive
• Feeling powerless
• An impending sense of danger, panic, or doom
• Breathing rapidly
• Sweating
• Trembling
• Feeling weak or tired
Adapted with permission from Goldman S. Anxiety disorders. In: Mind, Body and Sport: Understanding and Sup-
porting Student-Athlete Mental Wellness. Indianapolis, IN: National Collegiate Athletic Association; 2014:29.
Generalized anxiety disorder (GAD) is characterized by excessive worry and anxiety for
at least 6 months that is associated with at least 3 of the following symptoms: restlessness,
feeling on edge, easily fatigued, difficulty concentrating, irritability, muscle tension, or
sleep disturbance. Suicidal ideation is also associated with GAD.20
Anxiety disorders may be initially diagnosed in athletes during the PPE when PHQ-4
screening tools1 are used. The GAD-7 scale, the PHQ anxiety module, and the Beck Anxiety
Inventory, or BAI, can be used as tools to screen student-athletes and assess the severity
of an anxiety disorder. The age-appropriate Sport Anxiety Scale-2, or SAS-2, can be used
to assess levels of cognitive and somatic anxiety among athletes in sport performance
settings.20,30
The GAD-7 scale is a validated tool for identifying and tracking GAD. The scale is also
an excellent measure of severity, and increasing GAD-7 scale scores are strongly associated
with multiple domains of functional impairment and disability days.3 Mild, moderate,
and severe levels of anxiety can be determined by the GAD-7 scale score, like the levels
of depression on the PHQ-9.3,4 The GAD-7 scale is a valid option for additional anxiety
screening for PHQ-4 anxiety subset (questions 1 and 2) scores 3 or greater; however, it is
appropriate to use other screening tools for anxiety.
Panic disorder or panic attack is a specific anxiety disorder that manifests with a sud-
den feeling of intense fear, a general sense of helplessness, and the sensation of impending
doom. Symptoms, which can occur several times a day, appear suddenly, peak rapidly, and
may include chest pain, dyspnea, palpitations (pounding heart), sweating, trembling, nau-
sea, dizziness, weakness, numbness, or tingling.20
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Substance Use and Use Disorders 153
■■ ATTENTION-DEFICIT/HYPERACTIVITY DISORDER
Attention-deficit/hyperactivity disorder (ADHD) is characterized by a pattern of inatten-
tion or hyperactivity-impulsivity that is more prominent than that of peers at a comparable
level of development for 6 or more months (see Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition, for a list of ADHD criteria). Although ADHD in and of itself is not
a disqualifier for athletic participation, its diagnosis and management may begin during
the process of the PPE, especially if done in the primary care setting. Some signs or symp-
toms are present in most, but not all, children. Impairments from hyperactive-impulsive
or inattentive symptoms should be present in more than one setting and should interfere
with social, academic, or vocational functions to establish this diagnosis.20 There are sev-
eral age-dependent screening tools for ADHD, which also aid in the diagnosis. Expertise in
the evaluation of children and adolescents is required to make this diagnosis and initiate
treatment.21 It is important to facilitate a diagnostic evaluation for an athlete with sus-
pected ADHD22 for reasons related to academic accommodations, possible treatment with
medication, and regulations related to medication use and drug testing for collegiate, regu-
lated amateur, and professional athletes. Any provider prescribing medications for ADHD
should remain aware of and adhere to current regulations of any relevant governing body
(eg, NCAA, International Olympic Committee).
■■ SUBSTANCE USE AND USE DISORDERS

Substance use and substance use disorders are prevalent among adolescents and young
adults, including athletes at all levels. Substance use disorders are often characterized by
a variety of physical and behavioral signs and symptoms, including change in overall atti-
tude or personality, decreased academic performance, or a change in social relationships.
Specific physical signs may include mood swings, agitation, withdrawal, appetite changes,
sleep pattern disturbances, or weight change.20,31
College students, including student-athletes, are susceptible to the “college effect,” when
heavy and frequent alcohol use increases as students arrive on campus, and students buy
into the cultural myth that campus life is about alcohol use and other drug use.32 Such
beliefs and actions negatively influence academic success and increase the incidence of
sexual assault, interpersonal violence, and other harmful behaviors.32
High school and younger adolescent athletes are also at risk for these harmful behav-
iors. Although historical trends point toward decreasing alcohol use and binge drink-
ing among adolescents, the percentage of adolescents, including athletes, continuing to
use alcohol remains a concern. Almost 25% of 12th graders report binge drinking (ie,
≥5 drinks in a row in the past 2 weeks), and almost 50% of 12th graders and 25% of
10th graders report being drunk at least once in the previous 12 months.33 Alcohol use
patterns are often associated with other problems, such as risky sexual behavior; physi-
cal trauma from falls, fights, or car crashes; drunk driving; illicit drug use; or poor school
performance.
Substances used by athletes may include mood modulators, such as alcohol, cocaine,
heroin, or marijuana; medications to treat the symptoms of illness or injury, such as
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opiates for pain; or legal or illegal medications to assist with healing and subsequent
performance, including anabolic-androgenic steroids and stimulants. Substance use may
reflect poor stress coping or maladaptive responses to internal and external pressures to
succeed. Substance use may be an attempt to “stay on the field” in the context of disabling
illness or injury, overtraining, under-recovery, or sleep deprivation.
Athletes are vulnerable to substance use during transition periods, such as graduation
from school or following a career-ending injury.20 Student-athletes report that alcohol and
marijuana are the 2 most frequently used recreational drugs. The illicit use of prescription
stimulants and opioids is an increasing problem among student-athletes and of particular
concern at the college level.22,32 The percentage of student-athletes prescribed narcotics for
pain medication is higher than that of the general student body, which is understandable
with injury and pain being a part of competitive athletics, but use without prescription is
of great concern, given the potential for addiction to these medications.32 Opioid analge-
sics should always be prescribed in small quantities and with great care and supervision.
The age of traditional college students, 18 to 24, coincides with peak years for onset of
common mental health problems (schizophrenia, depression, anxiety, and suicide), and
this may be exacerbated by the use of alcohol and other drugs.34 Marijuana use is impli-
cated in exacerbating symptoms of anxiety, depression, and schizophrenia, and those at
risk of developing schizophrenia will have worsening symptoms with marijuana use. Even
for those who do not use regularly, marijuana use can impede concentration and attention
and can interfere with academic and athletic performance and operation of motor vehicles.
Student-athletes who used marijuana in the previous 30 days reported failing grades at
3 times the rate of nonusers.32
The CRAFFT 2.0 screening test is a screening tool for assessing substance-related
problems in adolescents. CRAFFT is an acronym for the 6 key words in the second sec-
tion of the assessment—car, relax, alone, forget, family/friends, trouble.35 If indicated, the
CRAFFT 2.0 can be followed up with the 18-item Mental Health Screening Form-III, or
MHSF-III, which is a useful screening tool for identifying mental health problems in indi-
viduals who depend on alcohol or other drugs.36 Other useful tests include the Alcohol
Use Disorders Identification Test, or AUDIT-C, and Cannabis Use Disorder Identification
Test - Revised, or CUDIT-R.20,22
■■ BULLYING AND HAZING

Bullying generally is defined as a systematic abuse of power in which a stronger individual
exhibits a pattern of intimidating behavior against someone weaker or less powerful.36
Bullying behavior may be peer to peer or coach to athlete. The coach-athlete relationship
involves an inherent imbalance of power, as the coach holds authority over his or her play-
ers by nature of the role. Bullying may have dramatic and long-lasting effects on those who
are bullied, impairing social and emotional development and causing substantial harm to
mental health.37 “Closed practices” or a culture of “what happens in the locker room stays
in the locker room” are red flags for potential bullying or abusive behavior.38 Defensive
techniques often employed by those engaging in bullying or manipulative behavior, as
well as techniques to counter these behaviors, have been described.37
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Sexual Abuse 155
Hazing is a form of bullying that is seen as temporary. Hazing and bullying are differ-
ent from each other because bullies usually act alone to single out someone perceived as
weak. Bullies want to exclude a person from a group.39 Hazing is an activity defined as any
requirement that humiliates, degrades, abuses, or endangers individuals. The individuals’
willingness to participate does not eliminate the activity from being hazing.40 Participation
in some sports may increase the likelihood of hazing (especially of rookies).27 Hazing can
result in injury or death.
Hazing arises in 2 ways, lack of supervision and failure to address the issue.39 The preva-
lence of hazing in sport—despite harsher penalties and intensive prevention efforts—has
been attributed in part to groupthink and masculinity in sport. Athletic teams are like a
family and become extremely close, allowing for forgiveness or ignorance of negative situ-
ations.41 Student-athletes are especially vulnerable to groupthink when they are isolated
from outside opinions, when they are in homogenous groups, when they are expected
to be obedient to “superiors,” and when there are no clear rules for decision-making.41
Hazing and bullying, both in traditional forms and online, exist in the absence of strong
leadership and direction, when groups are allowed to operate in secrecy and without
supervision. These groups are more likely to deviate from social norms of conduct when
coaches and administrators take a hands-off position and when there are not clear policies
or they are not consistently enforced.41
Coaches need to set clear and explicit rules, supervise all team activities, and take a no-
tolerance approach toward hazing. A coach has a moral obligation to protect and look
after student-athletes in his or her charge in lieu of the parent being present. Parents place
a great deal of trust in their child’s coach. A coach who allows hazing to occur is violat-
ing the trust placed in him or her and is breaking the law.39 The second issue arises when
coaches fail to address and define hazing. Administration sets zero-tolerance policies, but
coaches must adhere to those policies and do so in good faith. Without a unified front
from both coaches and administration, more-serious incidents can arise and create nega-
tive cultures for entire communities.39
Most educators, coaches, and administrators agree that the best way to end hazing is
to begin by sending a clear anti-hazing message.42 Then, implement a strong anti-hazing
policy, clearly communicate the policy to all parties, and enforce the policy when incidents
occur. The PPE can serve as a platform to educate about and prevent bullying and hazing
in sports as well as begin to treat any sequelae uncovered as a result of such abuse.
■■ SEXUAL ABUSE
Data indicate that up to 10% of Olympic athletes endured bullying and sexual abuse as
children and adolescents, often as part of their sports participation.27 Individuals who self-
reported experiences of sexual assault were significantly more likely to struggle academi-
cally, find it hard to handle intimate relationships, and experience hopelessness, mental
exhaustion, sleep issues, depression, and suicidal thoughts.43 All health care professionals
are ethically bound to conduct their interactions with their patients in the best traditions
of their respective professions at all times and guard against interpersonal violence at
every opportunity.
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Signs and symptoms of sexual abuse include44

• Child or teenager
——Has difficulty walking or sitting
——Suddenly refuses to change for gym or participate in physical activities
——Experiences a sudden change in appetite
——Demonstrates bizarre, sophisticated, or unusual sexual knowledge or behavior
——Becomes pregnant or contracts a venereal disease, particularly if younger than 14
——Reports sexual abuse by a parent or another adult caregiver
——Behaves secretive or isolated
——Exhibits trouble in school with grades or behavioral issues
——Talks of death or suicide
——Shows little attachment to parent, guardian, or another significant adult in his or
her life
——Avoids being around or making eye contact with certain individuals
• Adult
——Post-traumatic stress disorder symptoms
——Loss of appetite
——Trouble sleeping
——Hypervigilance
——Easily agitated over minor issues
——Declining grades or withdrawal from school
——Substance or alcohol use
——Risk-taking behavior
——Loss of interest in activities that he or she used to enjoy, including sports
participation
——Self-harm such as cutting or burning oneself
——Talk of death or suicidal ideation
While being a student-athlete does not increase risk of experiencing sexual violence,
student-athletes who experience sexual violence or other forms of interpersonal violence
in any setting bring these experiences and the resultant mental health consequences back
with them to the sport environment.41,43 During a PPE, sexual violence and sexual abuse
will not be discovered if the question is not asked. If suspected child or adult sexual abuse
is documented or suspected during the PPE, immediate notification of the Department
of Children’s Services or a law enforcement agency of the suspected abuse is mandatory.
There is not a legal requirement for the reporting chain to go through any athletic depart-
ment or school supervisor or administrator.44 Individuals in the sport environment need
to be aware of the resources available to the student-athletes so that they can manage the
mental health consequences that often result from these forms of violence.43
■■ SLEEP DISORDERS
Sleep is not a passive state of rest but rather an active state of rebuilding, repair, reor-
ganization, and regeneration. Sleep plays an important role in memory consolidation,
emotional regulation, physical growth, and cell repair.45 Despite the importance of sleep,
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References 157
difficulties with sleep hygiene are common. Most adults need 7 to 8 hours of sleep to
maintain optimum functioning, while adolescents and younger adults need 8 to 10 hours.
However, many student-athletes do not get the amount of sleep they need for optimum
sport or academic performance because of overprogramming, insomnia, sleep apnea, or
other sleep disorders.45
Sleep is made up of 2 distinct states, rapid eye movement (REM) and non-REM sleep.
Eighty percent of sleep is spent in non-REM stages comprised of
• Stage 1 (very light, transitional sleep)
• Stage 2 (moderate sleep)
• Stage 3 (deep sleep)
• Stage 4 (very deep sleep)
Stages 3 and 4 of non-REM sleep are crucial for both growth and cell repair. Stage 2,
which accounts for more than 50% of sleep, is important for many cognitive and body
functions. For example, sleep is critically important for regulating hormones that control
stress, hunger and appetite, growth and healing, and biological rhythms.45
Insomnia is common and defined as a persistent difficulty falling or staying asleep,
accompanied by daytime impairment. Insomnia disorder is associated with increased risk
of depression, substance use, and medical problems. Obstructive sleep apnea is also com-
mon and if left untreated is a major health risk factor. Student-athletes with obesity and
thick necks, such as football linemen, are at higher risk for developing sleep apnea.45
Several screening questionnaires can detect sleep problems, including the Pittsburgh
Sleep Quality Index, the Insomnia Severity Index, the STOP-Bang questionnaire, and the
Berlin Questionnaire.22,45
■■ SUMMARY
While screening tools are not validated as stand-alone assessments for mental disorders,
they may be incorporated into the PPE as indicated.22 The recommendations in this section
are intended to be a resource and guide for providers screening for mental health issues
while performing the PPE. Most of the conditions will require more-detailed assessment to
determine the diagnosis, the severity of the disease symptoms, and the need for treatment
with counseling or medication. Identification of local mental health providers, ideally who
have experience in treating athletes, is key in the development of a treatment plan for ath-
letes who screen positive for psychological issues.
■■ REFERENCES
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PHQ-4. Psychosomatics. 2009;50(6):613–621 PMID:19996233
2. Kroenke K, Spitzer RL, Williams JBW. The Patient Health Questionnaire-2: validity of a two-item
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MLR.0000093487.78664.3C
3. Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disor-
der: the GAD-7. Arch Intern Med. 2006;166(10):1092–1097 PMID:16717171 https://doi.org/10.1001/
archinte.166.10.1092
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Student-Athlete Mental Wellness. Indianapolis, IN: National Collegiate Athletic Association; 2014:17–20
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to recognize and refer student-athletes with psychological concerns at the collegiate level: an execu-
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10. Conley KM, Bolin DJ, Carek PJ, Konin JG, Neal TL, Violette D. National Athletic Trainers’ Association
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nize and refer student-athletes with psychological concerns at the secondary school level: a consensus state-
ment. J Athl Train. 2015;50(3):231–249 PMID:25730175 https://doi.org/10.4085/1062-6050-50.3.03
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college athletes and differences by gender and sport. Br J Sports Med. 2016;50(3):167–171 PMID:26782764
https://bjsm.bmj.com/content/50/3/167.long
17. Bader C. Mood disorders and depression. In: Mind, Body and Sport: Understanding and Supporting
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21. American Academy of Pediatrics (AAP). Mental health screening and assessment tools for primary care. AAP
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24. Garrison CZ, Addy CL, Jackson KL, McKeown RE, Waller JL. The CES-D as a screen for depression and other
psychiatric disorders in adolescents. J Am Acad Child Adolesc Psychiatry. 1991;30(4):636–641 PMID:1890099
https://doi.org/10.1097/00004583-199107000-00017
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https://doi.org/10.1097/00005053-198012000-00005
26. Kroenke K, Spitzer RL, Williams JB, Löwe B. The Patient Health Questionnaire Somatic, Anxiety, and
Depressive Symptom Scales: a systematic review. Gen Hosp Psychiatry. 2010;32(4):345–359 PMID:20633738
https://doi.org/10.1016/j.genhosppsych.2010.03.006
27. Lester D. Suicidal tendencies. In: Mind, Body and Sport: Understanding and Supporting Student-Athlete Mental
Wellness. Indianapolis, IN: National Collegiate Athletic Association; 2014:54–56
28. Drum DJ, Denmark AB. Campus suicide prevention: bridging paradigms and forging partnerships. Harv Rev
Psychiatry. 2012;20(4):209–221 PMID:22894730 https://doi.org/10.3109/10673229.2012.712841
29. Goldman S. Anxiety disorders. In: Mind, Body and Sport: Understanding and Supporting Student-Athlete Mental
30. Smith RE, Smoll FL, Cumming SP, Grossbard JR. Measurement of multidimensional sport performance
anxiety in children and adults: the Sport Anxiety Scale-2. J Sport Exerc Psychol. 2006;28(4):479–501 https://
doi.org/10.1123/jsep.28.4.479
31. De Souza MJ, Nattiv A, Joy E, et al; Expert Panel. 2014 Female Athlete Triad Coalition consensus state-
ment on treatment and return to play of the female athlete triad. Br J Sports Med. 2014;48(4):289–309
PMID:24463911 https://doi.org/10.1136/bjsports-2013-093218
32. Hainline B, Bell L, Wilfert M. Substance use and abuse. In: Mind, Body and Sport: Understanding and Supporting
33. Johnston LD, O’Malley PM, Bachman JG, Schulenberg JE. Demographic Subgroup Trends Among Adolescents
for Fifty-One Classes of Licit and Illicit Drugs, 1975–2012. Ann Arbor, MI: Institute for Social Research,
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34. Weitzman ER. Poor mental health, depression, and associations with alcohol consumption, harm, and abuse
in a national sample of young adults in college. J Nerv Ment Dis. 2004;192(4):269–277 PMID:15060400
https://doi.org/10.1097/01.nmd.0000120885.17362.94
35. Harris SK, Knight JR Jr, Van Hook S, et al. Adolescent substance use screening in primary care: validity
of computer self-administered versus clinician-administered screening. Subst Abus. 2016;37(1):197–203
PMID:25774878 https://doi.org/10.1080/08897077.2015.1014615
36. Carroll JFX, McGinley JJ. A screening form for identifying mental health problems in alcohol/other drug
dependent persons. Alcohol Treat Q. 2001;19(4):33–47 https://doi.org/10.1300/J020v19n04_02
37. Swigonski NL, Enneking BA, Hendrix KS. Bullying behavior by athletic coaches. Pediatrics.
2014;133(2):e273–e275 PMID:24420807 https://doi.org/10.1542/peds.2013-3146
38. Moffatt K. When the bully is a coach: what pediatricians and parents can do. AAP News. 2014;35(3)
39. Jonas J; National Federation of State High School Associations (NFHS). Hazing in high school athletics.
NFHS Web site. http://www.nfhs.org/articles/hazing-in-high-school-athletics. Published September 6, 2017.
40. Tokar K, Stewart C. Defining high school hazing: control through clarity. Phys Educator. 2010;67(4):204–208
41. Bell L, Wilfert M. Interpersonal violence and the student-athlete population. In: Mind, Body and Sport:
Understanding and Supporting Student-Athlete Mental Wellness. Indianapolis, IN: National Collegiate Athletic
Association; 2014:86–95
42. Can hazing be stopped? In: Nuwer H. High School Hazing: When Rights Become Wrongs. New York, NY:
Franklin Watts; 2000:122–128
43. Kroshus E. Risk factors in the sports environment. In: Mind, Body and Sport: Understanding and Supporting
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44. Child Welfare Information Gateway. What Is Child Abuse and Neglect? Recognizing the Signs and Symptoms.
Washington, DC: Child Welfare Information Gateway; 2013. https://www.childwelfare.gov/pubpdfs/
whatiscan.pdf. Accessed November 30, 2018
45. Grandner M. Sleeping disorders. In: Mind, Body and Sport: Understanding and Supporting Student-Athlete Mental
06_ch06_43-160.indd 160 3/20/19 4:22 PM

CHAPTER 7
Female Athletes
The basics of the preparticipation physical evaluation (PPE) are the same for both sexes;
however, specific medical and musculoskeletal concerns should be considered when evalu-
ating a female athlete.
■■ MEDICAL HISTORY
Obtaining an accurate, detailed, and current medical history is the most crucial component
of the PPE when approaching health issues in female athletes.
Musculoskeletal Injury
Bone and Joint Questions

1. Have you ever had a stress fracture or an injury to a bone, muscle, ligament, joint, or tendon
that caused you to miss a practice or game?
2. Do you have a bone, muscle, ligament, or joint injury that bothers you?
Key Points
• Bone stress injuries are more likely to occur in athletes with low bone mineral density
(BMD).
• Low BMD is part of the female athlete triad, which also includes low energy availability
and menstrual dysfunction.
• The PPE is an opportunity to discuss and screen for risk factors and conditions that con-
tribute to the female athlete triad.
• Female athletes are at greater risk for noncontact anterior cruciate ligament (ACL) inju-
ries compared with male athletes participating in the same sport.
• Female athletes are at greater risk for patellofemoral joint knee pain compared with
male athletes.
• Neuromuscular screening for risk of ACL injury and promotion of neuromuscular train-
ing should be included as part of the PPE.
Many athletes will have musculoskeletal injuries caused by sport participation. Com-
mon among female athletes are bone stress injuries (stress reactions and stress fractures).
Although often considered a nuisance injury, stress fractures can be season or career ending,
and may result in lifelong disability. Bone stress injuries often occur in the setting of the
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162 Chapter 7. Female Athletes
female athlete triad, and an affirmative answer to a history of bone stress injuries should
trigger further evaluation for other components of the female athlete triad.1-4 Notably,
female athletes with menstrual dysfunction experience longer interruption of training
caused by musculoskeletal injuries than those with regular cycles.5 Recurrent or persistent
injuries, such as medial tibial stress syndrome, and bone stress injuries—ranging from stress
reaction to stress fracture—should prompt an evaluation for underlying low energy avail-
ability and menstrual dysfunction.2 In addition to being at risk for injuries related to the
female athlete triad, female athletes are also at higher risk for certain musculoskeletal condi-
tions, such as noncontact ACL injuries, patellofemoral pathology (recurrent dislocation of
the patella and patellofemoral joint knee pain), and adolescent idiopathic scoliosis.6
A significant increase in incidence of distal forearm fractures among children and
adolescents in the past 2 decades has been noted in several studies, with some showing
a greater increase among girls compared with boys.7 This increased incidence could be
caused by overall increased physical activity or sport participation of girls, but decreased
acquisition of bone mass during pubertal longitudinal bone growth, a time of greater cal-
cium demand, could be another reason. Low BMD is more common throughout the skel-
eton in girls with forearm fractures than in those who have never broken a bone, and girls
aged 11 to 15 years with fractures reported lower current calcium intakes than their control
peers.8 A recent study including more than 900 adolescent boys and girls showed an inter-
action among fracture risk, physical activity, and bone health (both BMD and bone min-
eral content). Specifically, low levels of physical activity were observed among those with
lower BMD and prior fractures.9 This study highlights the important role regular physical
activity has in achieving healthy BMD. In addition, adequate calcium intake during child-
hood and adolescence is necessary for developing peak bone mass. However, only 10% of
adolescent girls achieve the recommended dietary intake of calcium of 1,300 mg/d.10
Hence, as highlighted by the study cited, a history of acute fractures or previous bone
stress injuries should lead to further inquiry regarding menstrual history, nutritional status,
bone health, eating patterns, and body image concerns, in addition to assessing for train-
ing errors, as a cause. Evaluation of nutrition status should include total calorie, calcium,
and vitamin D intakes. The recommended intake for calcium for males and females aged
9 to 18 years of age is 1,300 mg/d11 and for vitamin D intake is 400 IU/d.12 Adult women
19 to 50 years of age should have 1,000 mg of calcium per day13 and 600 IU of vitamin D
intake per day.14
Fatigue, poor performance, and difficulty recovering from training can result from
energy balance deficits. In turn, the combination of low energy availability and functional
deficits resulting from it can lead to bone stress injury.15 Some athletes with eating disor-
ders use excessive exercise to control or lose weight. They may also use extreme training to
potentially improve performance or achieve a desired body size, shape, or weight. Many
compulsive (addicted) exercisers will experience frequent muscle strains and recurrent
tendinopathies, in addition to bone stress injuries, and occasionally develop overtraining
syndrome from energy balance deficits.16
Noncontact ACL injuries are up to 7 times more likely to occur in females than males
playing the same sport.17 More than a decade of science has identified both modifiable risk
factors and non-modifiable risk factors contributing to ACL injury in female athletes.18,19
Modifiable risk factors include environmental factors such as playing surface and footwear,
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Medical History 163
anatomical risk factors such as higher body mass index (BMI), and neuromuscular fac-
tors including muscle imbalances, core strength, neuromuscular control, physical fitness,
muscle fatigue, and sport-skill level. Non-modifiable risk factors include anatomical factors
such as generalized joint laxity or generalized hypermobility, ACL notch size and geometry,
and posterior tibial slope.20 Other non-modifiable risk factors include opponent behavior
and unanticipated events during play, hormonal factors or menstrual cycle phase, and
demographic factors such as past injury history, family history, and genetics.21
Some injury prevention programs have demonstrated significant reduction in noncon-
tact ACL injury rates.22 These programs specifically address risk factors associated with
neuromuscular control and sport-specific skills.22 Screening for biomechanical risk factors
associated with higher rates of ACL injury can be performed as part of the PPE, especially
for female athletes participating in pivoting and cutting sports such as soccer, basketball,
and team handball. Athletes who are at risk and identified through past history of ACL
injury or through the PPE screening process should start an ACL injury prevention pro-
gram. For primary prevention, coaches in higher-risk sports should be encouraged to incor-
porate an ACL injury prevention strategy into routine warm-ups for the team.
Several protocols for neuromuscular control in the peer-reviewed literature are used
in clinical practice. The Landing Error Scoring System (LESS) is one such system,23 devel-
oped by the military, during which athletes are asked to jump off a 30-cm box and the
landing posture is observed to determine a risk score. A recent field validation of the LESS
test among elite-level, youth soccer players showed a sensitivity of 86% and a specificity
of 64% in predicting ACL injury.23 Although the LESS test takes less than 10 minutes per
athlete to administer, it is likely still a barrier to performing neuromuscular screening as
part of the PPE in office settings. In addition, most primary care providers have not been
trained in this assessment. However, in a station-based PPE setting using providers adept
in this assessment, including physical therapists and athletic trainers, it may be feasible to
implement. From a systematic evaluation of field-based screening methods for the assess-
ment of ACL injury risk, LESS was found to show predictive validity in identifying ACL
injuries in a youth athlete population and to be practical for community-wide use.24
Neurological Conditions
Medical Question
1. Have you had a concussion or head injury that caused confusion, a prolonged headache, or
memory problems?
Key Point
• Female athletes have higher rates of concussion and postconcussion syndrome (persis-
tent concussion symptoms).
This topic is addressed in much greater detail in Chapter 6, Section 6B, but it is
important to note that recent studies of sports played by both sexes at the high school
and college levels have shown higher rates of concussion among female athletes.25,26 The
mechanism of concussion may vary between sexes playing the same sport, which should
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prompt further discussion of past head injury in an effort to prevent future injury.26 Female
athletes with sport-related concussion may be more symptomatic and may take longer to
recover. Likewise, adult female athletes, but not female minors, who have concussions are
at increased risk for postconcussion symptoms compared with men.27
Nutritional Concerns
Medical Questions
1. Do you worry about your weight?
2. Are you trying to or has anyone recommended that you gain or lose weight?
3. Are you on a special diet or do you avoid certain types of foods or food groups?
4. Have you ever had an eating disorder?
Secondary Questions
• How much would you like to weigh?
• In the past year, what was your highest weight? Lowest weight?
• Have you ever tried diet pills, sitting in a sauna, diuretics, laxatives, or vomiting to lose
weight?
• What exercises do you do in addition to training for your sport?
Key Points
• Disordered eating is more prevalent among athletes than nonathletes.
• Rates of eating disorder are higher among players of sports with weight classes, aesthetic
sports, and sports for which leanness confers a competitive advantage.
• Eating disorders and low energy availability may be associated with amenorrhea, persis-
tent or recurrent injury, or bone stress injuries.
• Hormonal contraceptive methods may mask low energy availability.
Adequate nutrition is essential to optimize performance for a female athlete. It is well-
known that some athletes limit their dietary energy intake and do not meet the levels
required for age and activity, especially those in sports with subjective judging, such as
gymnastics and diving; sports for which leanness confers a competitive advantage (eg,
long-distance running); or sports for which “making weight” is important (eg, crew, wres-
tling). Even 5- to 7-year-old girls participating in these appearance-oriented sports report
higher weight concerns than either girls who do not participate in sports or girls involved
in sports such as soccer and volleyball.28 An athlete who is underweight, is undernour-
ished, or has nutrition concerns deserves further evaluation, discussion, and education
pertaining to nutrition, energy availability, and weight, and the PPE is an ideal opportunity
for this type of intervention.29
A full history with accurate information can be difficult to obtain because athletes
may provide inaccurate information about eating behaviors and weight loss out of fear
of restricted athletic participation, loss of self-control, or uncovering underlying personal
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Medical History 165
stressors. Asking gender-neutral questions is important to identify both male athletes and
female athletes with body weight issues. It is also important to identify external pressures
that “force” athletes to alter their weight. A weight loss recommendation from a coach is
a known risk factor for developing maladaptive weight loss behaviors.30 Asking about spe-
cial diets or avoiding particular food groups (eg, fat, dairy, meat, gluten) is a subtle way to
discern whether a female athlete is at risk for disordered eating behaviors or she is at risk
for nutritional deficiencies.31 The extent of vegetarianism among young people with eating
disorders is higher than among any other age-group,32 and college-aged women who are
self-reported vegetarians are more likely to display disordered eating attitudes and behav-
iors than nonvegetarian peers.33
Identifying an athlete who is either a vegetarian or lactose intolerant provides the
opportunity to discuss iron intake, in addition to calcium and vitamin D intakes. Iron defi-
ciency anemia is considerably more common among female athletes, especially those who
are menstruating regularly. The recommended daily allowance (RDA) for elemental iron for
girls aged 9 to 13 years is 8 mg/d, for females aged 14 to 18 is 15 mg/d, and for females
aged 19 to 50 is 18 mg/d. The RDA for vegetarians is increased to 33 mg/d. According to
the National Institutes of Health Office of Dietary Supplements, the iron RDAs for vegetar-
ians are 1.8 times higher than for people who eat meat because heme iron from meat is
more bioavailable than nonheme iron from plant-based foods, and meat, poultry, and
seafood increase the absorption of nonheme iron.34 The average US diet provides only 5 to
7 mg of iron per 1,000 kcal,35 so girls and young women on restricted calorie diets rarely
get adequate iron without supplementation. Several symptoms pertaining to the cardiovas-
cular system, such as syncope or near syncope, chest pain, or tachycardia during exercise,
can also be symptoms of anemia.
Vitamin D is increasingly recognized for its critical role in bone health and the man-
agement of osteoporosis. Serum concentration of 25-hydroxyvitamin D (25[OH]D) is
the best indicator of vitamin D status. The National Academy of Medicine concluded that
people are at risk of vitamin D deficiency with serum 25(OH)D concentrations of less than
12 ng/mL. Some are potentially at risk with levels ranging from 12 ng/mL to 20 ng/mL.14
Recommended intake of vitamin D should be 400 IU/d in children and adolescents and
600 IU/d in adults (19–50 years of age).14
An affirmative response to a past or current eating disorder or disordered eating confers
a greater risk of bone stress injury, and those with a past history of anorexia nervosa are
more likely to retain some degree of dietary restriction and risk of insufficient nutritional
intake.36 Disordered eating in the adolescent and athletic population, both male and
female, is increasing.37,38 This includes a spectrum of unhealthy nutritional behaviors with
calorie restriction from inadvertent under-eating (ie, poor nutritional habits) to intentional
calorie deprivation and purging through self-induced vomiting, laxative use, diuretic use,
and excessive exercise. Disordered eating with calorie deprivation is most prevalent among
athletes participating in sports with weight classes (eg, wrestling, rowing [crew], judo),
sports in which judging may be influenced by appearance (eg, gymnastics, figure skating,
diving, dancing, cheerleading), and sports emphasizing leanness for optimal performance
(eg, track and field, long-distance running, Nordic skiing).1 However, the risk for disor-
dered eating is high for all sports participants, as the intensified pressure to achieve an
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ideal body weight or physique may not be inherent in the sport itself but rather in the ath-
lete’s perception of what is necessary for optimal performance.1
The prevalence of disordered eating and eating disorders among athletes is higher
than among the general population and higher among female than male athletes.39 Early
recognition and intervention with athletes engaging in disordered eating is essential to
prevent escalation to more-serious eating disorders. Body mass index is commonly used
to determine appropriate weight for height and screen for weight-related health concerns.
In children and teens, “BMI for age” is both sex specific and age specific and is plotted on
sex-specific growth charts for ages 2 to 20 years (www.cdc.gov/growthcharts). For adults
older than 20 years of age, BMI is determined without regard to sex or age. Underweight
is defined by the Centers for Disease Control and Prevention (CDC) and the World
Health Organization as BMI for age at less than the fifth percentile for children and ado-
lescents and less than 18.5 kg/m2 for people older than 20 years. Underweight athletes
should undergo a thorough medical evaluation, must be asked about emotions related
to food and body image, and must be counseled about proper weight and nutrition.
Similar concern should be raised for younger athletes who drop one percentage line on
their growth chart and even more so for those who drop 2 lines. All underweight athletes
should be referred to a registered dietitian, and consideration should be made for referral
to a mental health professional when there are concerns for an eating disorder or other
mental disorders.
A consequence of disordered eating and eating disorders is a state of low energy avail-
ability. Energy availability is the amount of body energy store remaining after subtracting
exercise energy expenditure and dividing by fat-free mass (FFM). Energy availability can be
calculated by the following formula40:
Typical daily dietary Typical daily exercise

Energy availability energy intake (kcal/d) − energy expenditure (kcal/d)
=
(kcal/kg FFM/d) FFM (kg)
Dietary energy intake should represent average 24-hour dietary intake. Online tools
can be used by an athlete to determine 24-hour dietary intake. Mean daily exercise energy
expenditure should be used in the formula. Exercise energy expenditure can be calculated
using the following formula, in which MET indicates metabolic equivalent task41:
Exercise energy expenditure (kcal) =
0.175 × MET value of activity × body weight (kg) × minutes of activity (min)
MET value of a given activity can be found on the Compendium of Physical Activities
Web site (https://sites.google.com/site/compendiumofphysicalactivities/Activity-
Categories).42 Fat-free mass can be determined by methods that assess body composition,
such as dual energy x-ray absorptiometry (DXA) testing, air displacement plethysmograph,
bioelectrical impedance scales, skinfold calipers, and underwater weighing. Energy avail-
ability of at least 30 kcal/kg FFM is considered sufficient to support normal reproductive
function.43 Energy availability less than 30 kcal/kg FFM is associated with disruption of
normal menstrual cycles.44
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Medical History 167
Menstrual History
Females Only
1. Have you ever had a menstrual period?
2. How old were you when you had your first menstrual period?
3. When was your most recent menstrual period?
4. How many periods have you had in the past 12 months?
Secondary Questions
• Are you presently taking any female hormones or do you have an internal or implantable
hormone device (estrogen-containing device, progesterone-containing device, or birth
control pills)?
• Do you frequently miss school or practices because of menstrual cramps?
——Menstrual cramping, or dysmenorrhea, is a common problem among adolescent girls
and can affect school attendance and sports performance. The PPE is an ideal oppor-
tunity to provide relevant information on treatment options.
Key Points
• Low energy availability, disordered eating, and eating disorders are associated with men-
strual dysfunction.
• Low energy availability, disordered eating, and eating disorders may be associated with
amenorrhea, persistent or recurrent injury, or bone stress injuries (stress reaction and
stress fracture).
• Use of hormonal contraception may mask menstrual dysfunction associated with low
energy availability.
• Anemia is associated with heavy or frequent menstrual cycles.
Menstrual history is important for female athletes, because menstrual cycle abnormali-
ties may be a sign of low energy availability, pregnancy, or other gynecologic or medical
conditions. A detailed menstrual history is important if answers to any of the primary eval-
uation questions indicate a possible menstrual problem. Amenorrhea, both primary and
secondary, should be evaluated with additional history. Primary amenorrhea is defined
as the absence of menarche at age 15.45 In addition, lack of physical changes associated
with the onset of puberty by age 13 or delay in the progression of pubertal development,
including menarche within 5 years of initial breast development, should prompt further
endocrine and gynecologic evaluations.45 Secondary amenorrhea refers to missing at least
3 consecutive menstrual periods in a previously menstruating female; among the most
common causes is pregnancy, and this should be considered as a possible cause early
in the evaluation. Oligomenorrhea is defined as menstrual cycles between 35 days and
90 days once regular menses have been established.
Menstrual dysfunction is 2 to 3 times more common in athletes than nonathletes, and
10% to 15% of female athletes have amenorrhea or oligomenorrhea.46 Amenorrhea occurs
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more frequently in players of sports that emphasize leanness, such as running, gymnastics,
cheerleading, dance, and figure skating.1 Athletes with amenorrhea or oligomenorrhea
should undergo a thorough evaluation for causes of menstrual disturbance (eg, pregnancy,
polycystic ovary syndrome, thyroid disease) before attributing amenorrhea to low energy
availability. Consequences of low energy availability–associated amenorrhea or of oligo-
menorrhea include inadequate bone mineralization, bone stress injuries, changes in lipid
profiles, and disturbances of vascular dilation. Amenorrheic and oligomenorrheic athletes
should have their nutritional status assessed.
Low energy availability is often responsible for the development of oligomenorrhea or
amenorrhea, and osteopenia or osteoporosis, in athletes.44,47 Low energy availability may
occur as a result of intentional dietary restriction (as is seen in athletes who practice disor-
dered eating or have eating disorders), unintentional under-fueling, excessive exercise, or
maintaining a body weight that is too low for height and age. Modifying diet, exercise, and
oftentimes body weight is necessary to increase energy availability, restore regular men-
struation, and optimize BMD.48–50
Further diagnostic testing can be requested following the initial evaluation at the PPE.
Laboratory testing may detect electrolyte disturbances and metabolic disruption that result
from eating disorders. Hypokalemia may be observed as a result of self-induced vomiting,
diuretic use, and laxative use. Excessive water intake may result in hyponatremia. Elevated
liver enzyme and low triiodothyronine (free) levels may be observed in athletes who have
malnutrition caused by dietary restriction. Functional hypothalamic amenorrhea is a diag-
nosis of exclusion, once excluding other causes of amenorrhea, but can result in laboratory
findings of low or normal levels of luteinizing hormone, follicle-stimulating hormone, and
serum estradiol.51 Additional testing should include checking prolactin level and thyroid-
stimulating hormone level as other causes of amenorrhea or oligomenorrhea.
Hypermenorrhea (menorrhagia) and polymenorrhea alone or together may lead to
iron deficiency from excessive blood loss, resulting in anemia, fatigue, and poor athletic
performance. Hypermenorrhea is excessive menstruation flow and duration at regular cycle
intervals. Polymenorrhea is menstrual cycles occurring at greater than normal frequency. If
either of these conditions is present, an evaluation for possible anemia and to determine
the underlying cause is warranted. The provider should inquire about any previous gyne-
cologic evaluations; examine for physical signs of anemia such as pale conjunctiva, rapid
pulse, high-output flow murmur, or signs of pregnancy; and advise the athlete to follow up
for further evaluation.
Oral contraceptives, and other forms of hormonal birth control (eg, injectable
medroxyprogesterone acetate, progestin-containing intrauterine devices [IUDs],
implantable progesterone), may be overlooked by athletes when answering the medica-
tion question on the medical History Form. Hormone-based medications are usually pre-
scribed for contraception, but they are also used for managing irregular menstrual cycles,
menorrhagia, or dysmenorrhea and for non-menstrual–related conditions such as acne.
However, the use of hormonal contraception can mask the loss of menstruation as a sign
of low energy availability. It is important to educate athletes that the bleeding that occurs
while on the week of placebo oral contraceptive pills is only withdrawal bleeding and is
not the same as a naturally occurring menstrual period. Females on oral contraceptives
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Medical History 169
may continue to have a “monthly” blood flow caused by hormone manipulation despite
low energy availability. Females using progesterone-only contraception such as injectable
medroxyprogesterone acetate injections, Implanon rods, or progesterone-containing IUDs
often have cessation of menstrual periods. In highly active females, it can be difficult to
discern whether the loss of menstruation is caused by hormonal contraception or it is
caused by low energy availability.
Some forms of hormone replacement therapy can have a positive impact on bone
health. Transdermal forms of estrogen have been shown to improve BMD in adolescents
with anorexia nervosa (especially when combined with improvements in dietary energy
intake).52 Combined oral contraceptive pills (containing both estrogen and progesterone)
have a mixed effect on BMD.52 Oral estrogen undergoes first-pass metabolism in the liver,
resulting in a downregulation of insulinlike growth factor 1, especially in the setting of low
energy availability. The consequence of this is a negative impact on BMD.52 Alternatively,
in energy-replete females desiring contraception, use of combined oral contraceptives is
not associated with a decrease in BMD. Contraception provides a unique challenge in sexu-
ally active female athletes desiring contraception who are also struggling with an eating
disorder. Contraceptive-induced blood flow may be seen by the athlete as negating the
need to alter dietary intake and exercise volume to appropriately treat underlying eating
and energy balance problems, and oral contraceptive use does not lead to normalized or
increased BMD.53 It is also important to note that progestin-only birth control is associated
with lower BMD in both teenagers and adults.54 Following cessation of progestin-only con-
traception, BMD typically increases back to baseline; however, for weight-bearing athletes,
even temporary decreases in BMD may increase the likelihood of bone stress injuries.
Low Iron and Anemia

Key Points
• Anemia is associated with heavy or frequent menstrual cycles and nutritional energy
deficit.
• Limited evidence supports iron supplementation for low serum ferritin levels without
an associated anemia.
An athlete with iron deficiency anemia may present clinically with symptoms of exer-
tional fatigue, tachycardia, dyspnea, and headache. Athletes with iron deficiency anemia
may have compromised performance in endurance and non-endurance exercise activi-
ties.55 Following 8 weeks of supplementation with oral iron, along with increases in dietary
energy intake following nutrition consultation, performance is found to improve.55 Activity
level and training should be adjusted as symptoms resolve and exercise tolerance improves.
However, even after the anemia is corrected, the iron stores often remain low and supple-
mentation may be continued, especially in a symptomatic athlete.56 The prevalence of iron
deficiency anemia in athletes and nonathletes is 3%.57
It is commonly believed by athletes and coaches, especially those involved in either
endurance sports and exercise or high-altitude activities, that a low ferritin level adversely
affects athletic performance. Screening all female athletes during the PPE with a complete
blood cell count and serum ferritin test is a source of ongoing debate. Ferritin levels
of 12 ng/mL or less correlate with low bone marrow iron stores, although upregulated
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iron absorption rates have been found even with ferritin values as high as 60 ng/mL.58
Infection, inflammation, and other disease processes can falsely elevate ferritin levels
and confound the assessment of iron status.59 Endurance athletes have a high prevalence
of non-anemic iron deficiency that is based on ferritin cutoff values of 12 to 20 ng/mL.
Limited evidence shows that iron supplementation in non-anemic women with iron-
depleted ferritin levels less than 16 to 20 ng/mL resulted in improved performance param-
eters independent of an increase in hemoglobin level.57 Questions remain regarding the
appropriate ferritin level to begin iron supplementation, but most reports advise a ferritin
level of less than 30 to 35 ng/mL with an aim to continue iron supplements empirically for
6 months or until the ferritin level reaches 50 ng/mL.60 Iron is best obtained through the
diet as heme iron found in meat or nonheme iron from vegetables and grains. Heme iron
is better absorbed than nonheme iron, but ascorbic acid and meat proteins can enhance
the absorption of the latter. Of note, tannins (from tea), calcium, antacids, and phytates
(legumes and whole grains) can decrease intestinal absorption of the nonheme iron.
Ferrous iron supplements are better absorbed than the ferric iron supplements, with fer-
rous fumarate, ferrous sulfate, and ferrous gluconate averaging an absorption of 33%, 20%,
and 12%, respectively. The amount absorbed is labeled as elemental iron, and supplemen-
tation above 45 mg/d of elemental iron increases the risk of gastrointestinal side effects.
A female athlete physical examination should emphasize the areas of greatest concern in
sports participation and focus on any areas of concern identified in the medical history.
Ideally, the female athlete should be dressed in shorts, T-shirt, and tank top or sports bra
to facilitate an adequate examination. Opposite-sex physicians should consider having a
chaperone present during the physical examination portion of the PPE.
General Assessment
Observation of body composition and clinical evidence for an eating disorder or other
medical conditions should be made as outlined herein. While complications of eating dis-
orders can affect every organ system, it is important to note that many female athletes who
have an eating disorder may have completely normal findings from physical examination,
especially in the early stages.
Height and Weight

Height and weight are measured and recorded in a private area. Body mass index should
be calculated and if less than 18.5 kg/m2, should be investigated. If weight loss is reported,
suspected, or observed, and historical growth charts are not available for review, efforts to
obtain them should be undertaken.
Head, Eyes, Ears, Nose, and Throat, or HEENT

Both parotid gland enlargement resulting in “chipmunk cheeks” and erosion of dental
enamel or excessive dental caries are signs of bingeing behavior and purging (self-induced
vomiting) behavior, respectively. Erythema of the posterior pharynx, and food particles
lodged inside the tonsillar crypts, can also be indicative of self-induced vomiting.
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Cardiovascular System
Individuals with significant or long-standing anorexia nervosa are often hypotensive and
bradycardic (suspect if heart rate <50/min during the day or <45/min at night). However,
dietary restriction of iron-containing foods and consequent anemia may result in an
elevated resting heart rate. With chronic anemia, the heart may become hyperdynamic and
auscultation may reveal a prominent point of maximal impulse, a systolic ejection flow
murmur, and occasionally an S3. An electrocardiogram may reveal a prolonged QT interval
or abnormal T waves (or both) related to electrolyte changes from purging or laxative use.
High vagal tone in both athletes and those with anorexia nervosa can make isolated inter-
pretation of heart rate data challenging. As such, clinical interpretation should take into
account other factors that point to the underlying diagnosis. Current recommendations
suggest that adolescents who have anorexia nervosa with severe sinus bradycardia, defined
as a heart rate less than 50/min during the day or less than 45/min at night, be admitted to
a hospital for cardiac monitoring and gradual weight gain.61
Lungs
Pulmonary examination should reveal clear breath sounds. Although far less commonly
observed during the PPE, stridorous breath sounds may indicate exercise-induced laryn-
geal obstruction (EILO), also known as paradoxical vocal cord motion disorder or vocal
cord dysfunction, which is more prevalent among female athletes than male athletes.62 For
more-detailed information on EILO, please refer to Chapter 6, Section 6D.
Abdomen
In addition to the general abdominal assessment, if there is a high index of suspicion for
an eating disorder, the gastrointestinal tract can be more closely evaluated. A scaphoid
abdomen is often observed in underweight individuals. Conversely, abdominal distention
can result from decreased bowel motility, and stool may also be palpated in the left lower
quadrant if constipated. Epigastric tenderness to palpation may result from self-induced
vomiting. Palpation of the lower abdomen may reveal markedly enlarged ovaries (eg, ovar-
ian cysts) or uterine enlargement (eg, pregnancy).
Genitalia
The genitourinary and breast examinations are usually not part of a female athlete PPE. If
a pelvic or breast examination is warranted on the basis of the athlete’s medical history or
physical examination, it should be scheduled for a separate time.
Skin
Abnormal skin findings associated with eating disorders may include sallow skin discolor-
ation, dry skin and mucous membranes, loss of subcutaneous fat, cold hands and feet, and
the presence of lanugo (fine body hair) on the face, arms, and back. Conversely, hair loss,
especially along the hairline, may result from dietary restriction and weight loss. Yellow or
orange discoloration on the palms of the hands may result from hypercarotenemia that
is associated with excessive dietary intake of carotene- and lycopene-containing foods.
Callus formation on the knuckles (proximal interphalangeal joints) of the dominant
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hand (Russell sign), from the induction of vomiting, is a physical sign associated with
purging behavior.
Musculoskeletal System
The musculoskeletal screening examination is designed to detect clinically significant
impairments in joints and muscles. Female athletes are at greater risk for a number of
musculoskeletal conditions, thus prompting closer evaluation. Examining the patellofemo-
ral joint for pain, along with a dynamic evaluation of the knee and pelvis, may identify
individuals at greater risk for patellar femoral joint pain and ACL injury. Neuromuscular
screening (eg, LESS testing) may identify athletes who would benefit from an ACL injury
prevention program.
Additional Assessment
Assessment of BMD by DXA is based on the severity and number of triad risk factors.2 The
“2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to
Play of the Female Athlete Triad”2 provides detailed recommendations for DXA testing,
summarized in Table 7–1.
Table 7-1. Indications for Dual Energy X-ray Absorptiometry Testing to

Detect Low Bone Mineral Density2
Risk Factors ≥1 High-risk Triad Risk Factors ≥2 Moderate-risk Triad Risk Factors
Eating disorders • History of a diagnosed eating • Currently experiencing or history of
disorder (See Diagnostic and disordered eating for ≥6 mo
Statistical Manual of Mental
Disorders, Fifth Edition.)
BMIa • BMI <17.5 kg/m2; <85% • BMI between 17.5 kg/m2 and
estimated weight; and recent 18.5 kg/m2, 85%–90% estimated
weight loss of >10% in 1 mo weight, or recent weight loss of
5%–10% in 1 mo
Menstruation • Menarche at >16 years of age • Menarche between 15 years of age and
• Currently experiencing or his- 16 years of age
tory of <6 menses over 12 mo • Currently experiencing or history
of 6–8 menses over 12 mo
Fractures • 2 prior stress reactions/ • One prior stress reaction/fracture.

fractures, 1 high-risk stress • History of ≥1 non-peripheral
reaction/fracture,b or a low- or ≥2 peripheral long-bone traumatic
energy, nontraumatic fracture fractures (nonstress) should be consid-
ered for DXA testing if there is ≥1 mod-
erate or high-risk triad risk factors.
Prior z value • Prior z value <−2.0 • Prior z value between −1.0 and −2.0
(after at least a 1-y interval from base-
line DXA)
Abbreviations: BMI, body mass index; DXA, dual energy x-ray absorptiometry.
a
BMI can be calculated as the weight in kilograms divided by the height in meters squared.
b
High-risk stress reaction/fracture = femoral neck, sacrum, or pelvis.
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Determining Medical Eligibility 173
Bone mineral density z values (and not t values) should be reported for all children,
adolescents, and premenopausal women. For those younger than 20 years, posteroanterior
spine and whole body except for the head are the preferred sites of measurement.2 For
adult women 20 years of age and older, weight-bearing sites (posteroanterior spine, total
hip, and femoral neck) should be evaluated. The frequency of follow-up BMD assessment
by DXA may be as frequent as every 1 to 2 years and is based on both the initial BMD and
the ongoing clinical status of the athlete.2
Energy Availability and the Female Athlete Triad

Athletes who have health problems related to energy availability should follow up with
the team physician or return to their primary care physician for further evaluation. When
disordered eating alone or the female athlete triad is suspected, evaluation and treatment
using a multidisciplinary approach is warranted.2 Athletes are often reluctant to undergo
treatment, but their cooperation is imperative for a successful outcome. The treatment goal
for athletes with low energy availability is to optimize overall nutritional status, normal-
ize eating behavior, attain and maintain a healthy weight, manage physical complications,
modify unhealthy thought processes that maintain the disorder, treat underlying emo-
tional issues contributing to the disorder, and prevent future relapse.
Once the athlete is medically eligible for her sport, it may become more difficult to
motivate and enforce treatment recommendations in a reluctant patient. Depending on
the individual situation, medical eligibility may be denied until the athlete has undergone
more-extensive medical, psychiatric, or nutritional assessment and has made progress
toward recovery. It must be stressed to athletes, parents or guardians, and coaches that
inadequate caloric intake, disordered eating behaviors and eating disorders, and subse-
quent menstrual dysfunction predispose the athlete to adverse health consequences, injury,
and loss of training and competition time, particularly bone stress injuries.2
Medical eligibility and return to play can be determined by combining the female ath-
lete triad cumulative risk assessment and the return to play guidelines.2 An athlete in treat-
ment of an eating disorder or disordered eating (or parents or guardian if a minor) may be
asked to sign a contract stipulating the requirements to resume or continue participating in
her sport.2 Examples would include adherence to treatment, regular visits with the health
care team, and modification of training. If the contract is broken or weight and eating
behaviors do not improve, the athlete could be restricted from athletic participation on the
basis of the language in the contract.
Gynecologic Disorders and Pregnancy

Because ovarian injury is so unlikely in sports participants, there are no restrictions for
female athletes with only one ovary. Athletes with menstrual disorders should undergo
evaluation by a physician and be screened for gynecologic disorders such as polycystic
ovary syndrome, disordered eating, and a history of stress fractures. Athletes with oligo-
menorrhea or amenorrhea may usually be allowed to participate while undergoing further
evaluation, but it should be emphasized to them that menstrual irregularities and low
07_ch07_161-178.indd 173 3/20/19 4:22 PM

BMD increase stress fracture risk,1 and they should report any symptoms that appear
during training.
Pregnancy is the most common cause of amenorrhea, and a pregnancy test should be
considered. If pregnancy is confirmed, medical eligibility should be determined by the cli-
nician who is following the pregnancy and when appropriate, in consultation with a team
physician. Most pregnant athletes with normal pregnancies can safely continue to partici-
pate, with progressive modifications, as the pregnancy develops.63
Team physicians should also be aware of athletes traveling to countries where the Zika
virus is endemic. Athletes traveling to those areas should be educated on prevention and
transmission of Zika virus infection (eg, reducing exposure to mosquitos). Table 7-2
includes recommendations from the CDC regarding Zika virus exposure and pregnancy.64
Table 7-2. Zika Virus Exposure and Pregnancy

Traveling Partner How Long to Wait
If only the male partner trav- The couple should use condoms or not have sex for at least
els to an area with risk of Zika 3 months
• After the male partner returns, even if he doesn’t have
symptoms, or
• From the start of the male partner’s symptoms or the date
he was diagnosed with Zika
If only the female partner The couple should use condoms or not have sex for at least
travels to an area with risk of Zika 2 months
• After the female partner returns, even if she doesn’t have
symptoms, or
• From the start of the female partner’s symptoms or the
date she was diagnosed with Zika
If both partners travel to an The couple should use condoms or not have sex for at least
area with risk of Zika 3 months
• After returning from an area with risk of Zika, even if they
don’t have symptoms, or
• From the start of the male partner’s symptoms or the date
he was diagnosed with Zika
Source: National Center on Birth Defects and Developmental Disabilities. Zika and pregnancy: women and their
partners trying to become pregnant. Centers for Disease Control and Prevention Web site. https://www.cdc.gov/
zika/pregnancy/women-and-their-partners.html. Reviewed February 26, 2019. Accessed March 15, 2019.
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19. Price MJ, Tuca M, Cordasco FA, Green DW. Nonmodifiable risk factors for anterior cruciate ligament injury.
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21. Cameron KL. Commentary: time for a paradigm shift in conceptualizing risk factors in sports injury research.
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23. Padua DA, DiStefano LJ, Beutler AI, de la Motte SJ, DiStefano MJ, Marshall SW. The Landing Error Scoring
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methods for the assessment of anterior cruciate ligament (ACL) injury risk. Sports Med. 2016;46(5):715–735
25. Gessel LM, Fields SK, Collins CL, Dick RW, Comstock RD. Concussions among United States high school
and collegiate athletes. J Athl Train. 2007;42(4):495–503 PMID:18174937
26. Schallmo MS, Weiner JA, Hsu WK. Sport and sex-specific reporting trends in the epidemiology of concus-
sions sustained by high school athletes. J Bone Joint Surg Am. 2017;99(15):1314–1320 PMID:28763417
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34. Iron fact sheet for health professionals. Office of Dietary Supplements Web site. https://ods.od.nih.gov/
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36. Windauer U, Beumont PJ, Lennerts W, Talbot P, Touyz SW. How well are “cured” anorexia nervosa
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detecting, and managing disordered eating in athletes. J Athl Train. 2008;43(1):80–108 PMID:18335017
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39. Sundgot-Borgen J, Torstveit MK. Prevalence of eating disorders in elite athletes is higher than
in the general population. Clin J Sport Med. 2004;14(1):25–32 PMID:14712163 https://doi.
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40. Energy availability calculator. Female Athlete Triad Coalition Web site. http://www.femaleathletetriad.org/
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41. Women’s Sports Medicine Center. Estimate how many calories you are burning with exercise. Hospital
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48. Dominguez J, Goodman L, Sen Gupta S, et al. Treatment of anorexia nervosa is associated with increases in
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53. Bergström I, Crisby M, Engström AM, et al. Women with anorexia nervosa should not be treated with
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2008;121(11):943–948 PMID:18954837 https://doi.org/10.1016/j.amjmed.2008.07.012
57. Fallon KE. Utility of hematological and iron-related screening in elite athletes. Clin J Sport Med.
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gov/zika/pregnancy/women-and-their-partners.html. Updated August 21, 2018. Accessed February 22, 2019
07_ch07_161-178.indd 178 3/20/19 4:22 PM

CHAPTER 8
Athletes With
a Disability
Athletes with a disability, either physical or cognitive, represent a growing population of
sports participants with unique needs that may require accommodations. Federal legisla-
tion mandating equal access and opportunity to physical education and sports for people
with disabilities, as well as the noteworthy physical accomplishments by these athletes, has
ignited the interest and growth in this area of sports participation.1
The Americans with Disabilities Act defines disability as an impairment that limits a
major life activity.2 Typical impairments include cerebral palsy, blindness, deafness, paraly-
sis, cognitive limitation, and amputation, as well as other conditions that affect multiple
organ systems, such as autoimmune-mediated arthritis, muscular dystrophy, and multiple
sclerosis. There is little research that specifically addresses the development of sport skills,
strength, and endurance in athletes with disabilities.3
According to the 2010 US Census, about 56.7 million people, 19% of the population,
had a physical disability in 2010 and more than half of them reported the disability was
severe; 51.4 million were older than 15.4 Disabilities affect 8% of children younger than
15, 21% of people aged 15 and older, and 17% of people aged 21 to 64.4,5 The actual num-
ber of potential athletes with physical and cognitive impairments in the high school and
college age-groups is not known. During the past 20 to 30 years, thousands of military
personnel have sustained serious disabling injuries, which has rapidly expanded the num-
ber of individuals who may need additional considerations, accommodations, or adaptive
equipment to participate in sport.
Everyone should have the opportunity to participate and compete in sports activities.
Interest in physical activity and competition among people with disabilities has increased
participation in a variety of regional, national, and international competitions in the
United States and worldwide, including, but not limited to, Paralympic sports, Special
Olympic sports, sports for people who have hearing impairments, Dwarfism Games of
America, World Dwarf Games, and others. Opportunities can be found at Move Forward
(www.moveforwardpt.com/resources/detail/adaptive-sports-people-with-disabilities).6
■■ BENEFITS OF SPORTS FOR ATHLETES WITH A DISABILITY

Athletes with disabilities derive the same benefits from sports participation as other ath-
letes: increased exercise endurance, cardiovascular function, muscle strength, flexibility,
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180 Chapter 8. Athletes With a Disability
balance, and motor skills, as well as improved self-esteem, reduced anxiety and depression,
and the satisfaction derived from participation and competition. In addition, sports offer
an opportunity for community involvement and integration, a chance for experiencing
support and encouragement from the general community, and the dignity and satisfaction
that comes from competition. There are also benefits from sports participation that are
unique to an athlete with disabilities (Box 8-1).7
Box 8-1. People With Disabilities and Benefit From Sports Participation
Compared With Their Inactive Peers
Athletes With Paraplegia
• Fewer pressure ulcers

• Fewer infections
• Lower likelihood of hospitalization
Athletes With Limb Deficiencies
• Improved proprioception
• Increased proficiency using prosthetic devices
■■ PREPARTICIPATION PHYSICAL EVALUATION FOR ATHLETES WITH A

DISABILITY
The preparticipation physical evaluation (PPE) for an athlete with a disability should be
similar to an athlete with no disabilities along with addressing the unique needs of the
specific disability. The health care professional should be aware of common problems
associated with different disabilities and be able to identify and help manage conditions
that may compromise athlete safety. Just as important, the health care professional should
encourage physical activity and provide support as needed.
Competitions if Physically or Cognitively Impaired

As of 2014, schools in 12 states offer programs for students with disabilities, includ-
ing Adapted Sports, Unified Sports, and Allied Sports.8 These programs target physically
impaired (PI) and cognitively impaired (CI) competition groupings at the high school
level. The criteria for inclusion in these groups are defined by each state and are reviewed
herein. The fairness of the competitions requires that the qualification criteria are strictly
defined and enforced, because individuals whose conditions are more qualifying than the
inclusion criteria allow can upset the balance of competition and may increase the risk of
injury to the other competitors.
Physically impaired. Physically impaired competition criteria require an actual physi-
cal functional limitation that interferes with participation in regular competition. This
includes loss of a limb, or any neuromuscular, postural, skeletal, traumatic, growth, or
neurological impairment, that significantly impairs physical functioning, modifies gait pat-
terns, or requires mobility devices. Conditions that do not qualify students for CI competi-
tion may not qualify them for PI competition without some form of physical limitation.
In Minnesota, high school PI competition specifically excludes students who have asthma,
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Preparticipation Physical Evaluation for Athletes With a Disability 181
diabetes mellitus, seizure disorder, or other conditions. Some conditions, such as Tourette
syndrome or autism spectrum disorder, may qualify students for PI competition if the
impairment can be demonstrated in sport settings.
Cognitively impaired. Cognitively impaired competition is for individuals with lower
IQ levels, commonly less than 70. A physical disability is not a prerequisite for CI compe-
tition, and participants with higher IQ levels than the defined limit could dominate the
events. These athletes enjoy the competition and social nature of the events and deserve to
compete on a “level playing field” with others of similar cognitive ability.
Special Olympics and Paralympics. The Special Olympics and the US Paralympics, a
division of the US Olympic Committee, have organized sports events and competitions for
athletes with cognitive impairments and physical impairments, respectively, ranging from
community settings to international settings. Each organization has its own set of govern-
ing rules and inclusion criteria for competition.
Special Olympics is an international organization currently serving nearly 5 million
people 8 years and older who have intellectual disabilities and come from more than
170 countries.9 The organization is dedicated to empowering individuals 8 years and older
with intellectual disabilities to become physically fit through sports training and competi-
tion.9 Special Olympics offers year-round training and competition in 30 summer and
winter sports.
Since 2000, Special Olympics has experienced tremendous growth and transformed
itself into a global organization. Consequently, providers are likely to encounter more
Special Olympians seeking PPEs for medical eligibility. Special Olympics competitions are
held at local, state, national, and international levels, and a PPE is required.10 Depending
on the host state regulations or the level of competition, the PPE is completed every
1 to 3 years to assess medical eligibility. Special Olympics World Games, for example,
requires a PPE to be performed within 12 months of a competition. The rules govern-
ing Special Olympics can be found at https://resources.specialolympics.org/Taxonomy/
Sports_Essentials/_List_Sports_Rules.aspx.11 The forms for the Special Olympics participa-
tion and medical eligibility can be found at https://resources.specialolympics.org/search.
aspx?s=Medical%20forms.12
International Paralympics focuses primarily on athletes with physical disabilities
in one of 10 eligible impairments and assigns numerical rank or grading to the level of
disability.13 These guidelines are intended to promote participation and fair competi-
tion. Teams need to stay within a defined sum of the grades at all times while compet-
ing. Providers encouraging athletes with unique impairments to participate should use
the Paralympic Web site as a guide to make sure the athlete’s impairment aligns with the
sport’s regulations.13,14 Accurate assessment of ability is critical to fair competition, and
there is an extensive structured learning and certification process for health care profes-
sionals who want to become Paralympic classifiers. The certification process is rigorous, as
there is potential for exploitation by Paralympic athletes who may try to fake a greater dis-
ability to participate in a different grade of competition. It is often necessary to observe the
athlete performing in sport activity to augment the findings from physical examination.
US Paralympics features competition in 29 sports, 23 summer and 6 winter, and pro-
vides funding and facilities for athletes with physical disabilities.14 The Paralympic Games
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are held every 4 years and immediately follow the Summer and Winter Olympic Games.
The Rio 2016 Summer Paralympic Games hosted approximately 4,350 athletes from more
than 160 countries competing in 22 different sports.15 New technology applied to pros-
thetic and assistive devices allows a wider range of athletes with physical impairments to
participate at higher levels of competition.
Methods of Evaluation
The PPE should ideally be performed by a health care professional involved in the longi-
tudinal care of the athlete. Specialty and subspecialty consultations are sometimes neces-
sary to determine medical eligibility for competition. The office-based PPE is preferred to
the station-based or mass screening examination. The decreased mobility of some athletes
makes the station method less practical, and access to the full medical record is often not
available during mass screening examinations.
Medical History
As in the general PPE guidelines, a thorough medical history is essential for the provider to
develop an informed participation recommendation (see sample PPE history form for ath-
letes with a disability on page 223). The history form should be completed by the athlete
(if possible) and the parents or guardians who are familiar with the athlete’s medical his-
tory. For a child or adolescent athlete and for athletes with cognitive impairments, a parent
or guardian should be present at the time of the PPE to provide the most accurate history.
The history should include a detailed summary of previous injuries and illnesses, risk
factors for injuries and illnesses, and current medications.
Questions. In addition to the questions asked of an athlete who does not have a cog-
nitive or physical disability (see Chapter 5 and the History Form on pages 217 and 218),
additional questions should specifically address the particular impairment. The questions
that follow emphasize areas of greatest concern for sports participation.
1. Does the athlete have a history of seizures? Are the seizures controlled? Seizures may be
seen in people intending to compete or already competing in Special Olympics or
Paralympics events.16 Athletes with uncontrolled seizures often require consulta-
tion with a neurologist to determine medical eligibility, and this may delay sports
participation.
2. Does the athlete have a history of hearing loss or impairment?
3. Does the athlete have a history of vision loss or impairment?
4. Does the athlete have a history of cardiopulmonary disease? Congenital cardiac disorders,
including heart murmurs, ventricular septal defects, and endocardial cushion defects,
are more common in people with Down syndrome and may limit the level and type
of participation. Consultation with a cardiologist may be necessary to determine med-
ical eligibility and may delay sports participation for the athlete.
5. Does the athlete have a history of renal disease or unilateral kidney? Renal anomalies,
such as hypoplasia, dysplasia, and obstruction, are common in people with Down
syndrome,17 and athletes with other medical conditions may also have congenital or
acquired renal abnormalities that may be structural or associated with a disease such
as diabetic nephropathy.
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6. Does the athlete have a history of symptomatic atlantoaxial instability (AAI)? Increased
movement or instability between the C1 (atlas) cervical vertebra joint articulation and
the C2 (axis, or axial) cervical vertebra joint articulation, that is, the atlantoaxial joint,
can lead to spontaneous or traumatic subluxation of the cervical spine. Atlantoaxial
instability is a potential risk in people with Down syndrome, and it may limit medi-
cal eligibility for certain events.18 In some events, the rules of the sport are modified
to accommodate risk (eg, swimming participants need to start in the water and not
with a dive from the starting blocks). Patients who have symptomatic AAI may report
or demonstrate fatigue, gait abnormalities, neck pain, limited neck range of motion,
changes in coordination, spasticity, hyperreflexia, clonus, or extensor-plantar reflex.
7. Has the athlete had heat stroke or heat exhaustion? Thermoregulation in people with spinal
cord injuries can be impaired because of skeletal muscle paralysis (impaired shivering
and reduced ability to produce heat) and a loss of autonomic nervous system control
(impaired sweating and vasodilation to dissipate heat).19 Medications used for pain
and bladder dysfunction can interfere with the normal sweating response. Also, athletes
who have a history of heat illness are more at risk to develop the condition again.
8. Has the athlete had any fractures or dislocations? Ligamentous laxity and joint hyper-
mobility are prominent features in people with Down syndrome and Ehlers-Danlos
syndrome that may affect medical eligibility for some activities. Athletes who predom-
inantly use wheelchairs can have reduced bone mineral density with increased fracture
risk during activity.20
9. What prosthetic devices or other assistive equipment does the athlete use during sports par-
ticipation? Health care professionals need to be aware of an athlete’s need for adaptive
equipment and any existing regulations concerning their use in different sports. Also,
athletes using wheelchairs for mobility or sport are more at risk for shoulder, elbow,
and wrist injuries, as well as upper extremity peripheral nerve entrapment syndromes.
10. Does the athlete use an indwelling urinary catheter or require intermittent catheterization
of the bladder? Athletes with spinal cord injuries or other neurological disorders often
have bladder dysfunction or neurogenic bladders and may experience frequent urinary
tract infections.
11. Does the athlete have a history of pressure sores or ulcers? People who use wheelchairs are
prone to pressure ulcers over the sacrum and ischial tuberosities, and people who use
prosthetic devices are prone to pressure ulcers at prosthesis contact sites.
12. At what levels of competition has the athlete previously participated?
13. What is the athlete’s level of independence for mobility and self-care?
14. What medications is the athlete taking?
15. Does the athlete have any dietary restrictions?
16. Does the athlete have a history of autonomic dysreflexia? Autonomic dysreflexia is an acute,
potentially life-threatening syndrome of excessive, unregulated sympathetic output that
can occur in people with spinal cord injuries at or above the sixth thoracic (T6) spinal
cord level.21 This condition may occur spontaneously or may be self-induced by an ath-
lete (“boosting”) in an attempt to improve performance.22,23 Spontaneous autonomic
dysreflexia can be triggered by any irritant below the level of cord injury, including
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irritation or distention of the bladder wall, urinary tract infection, and blocked catheter
or overfilled collection bag; distended or irritated bowel, constipation or impaction,
and hemorrhoids or anal infections; other infections; sunburn; pressure ulcers; ingrown
toenails; and even menstrual cramps. Signs and symptoms of autonomic dysreflexia
include excessively high blood pressure, bradycardia, pounding headache, blurred
vision, sweating and flushing of the skin above the level of spinal injury, and pale, cool
clammy skin and piloerection (goose bumps) below the level of spinal cord injury.
Boosting is a dangerous performance-enhancing technique that is deemed illegal by
all sport governing bodies. Athletes with spinal cord injuries at T6 or above sometimes
induce autonomic dysreflexia in an effort to improve cardiopulmonary performance,
oxygen use, and noradrenaline release.3,24 Methods of boosting include occluding the
urinary catheter, ingesting large amounts of fluids before an event to distend the blad-
der, overtightening leg straps, purposely wearing constrictive clothing, and sitting on
sharp objects.3,5
Physical Examination
The PPE physical examination for an athlete who is disabled should include all parts of the
examination for an athlete with no disability (see Chapter 5 and the Physical Examination
Form on page 221). Particular attention should be given to the ocular, cardiovascular, mus-
culoskeletal, neurological, and dermatologic systems (Box 8-2).
In addition to examining the athlete, a qualified health care professional or prosthetist
should thoroughly inspect all prosthetic devices, orthoses, and assistive or adaptive devices
to ensure all fit properly during exercise and are within the rules of competition.25
Ocular function. There is a high prevalence of vision abnormalities among Special
Olympics athletes. A study of Special Olympics athletes at the 1995 International Summer
Games revealed that almost one-third of the athletes had ocular problems.26 The most
common problems identified were poor visual acuity, refractive errors, astigmatism, and
strabismus.
Cardiovascular system. Congenital heart disease is present in as many as 50% of chil-
dren with Down syndrome who participate in sports.27 In a study of Paralympic athletes,
12% had structural cardiovascular abnormalities and 2% had abnormalities with high risk
for sudden cardiac death.28 These studies suggest that Special Olympics and Paralympic
athletes may require additional cardiovascular testing (eg, electrocardiography, echocar-
diography) as a part of their preparticipation evaluations to accurately assess medical eli-
gibility and reduce cardiac risk while participating in sports. Medical eligibility decisions
should follow the same guidelines used for an athlete who does not have a disability.
Neurological function. Since many athletes with physical impairments may also have
some form of neurological deficit, a complete neurological evaluation should be performed.
Peripheral nerve entrapment syndromes of the upper extremities are common in athletes
who use wheelchairs. Two of the most common entrapment syndromes are carpal tun-
nel syndrome and ulnar neuropathy at the wrist (Guyon canal syndrome). The examiner
should look for signs of muscle atrophy and weakness in the hand, test for sensory deficits
associated with a specific nerve distribution, and perform provocative tests for nerve impair-
ment, such as Tinel sign over the median nerve in the wrist or ulnar nerve in the elbow.
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Box 8-2. Findings to Screen for When Performing Physical Examinations

on Athletes With Disabilities
Ocular Function
• Poor visual acuity

• Refractive errors
• Astigmatism
• Strabismus
Cardiovascular System
• Congenital heart disease
Neurological Function
• Peripheral nerve entrapment

• Carpal tunnel syndrome
• Ulnar neuropathy (eg, cubital tunnel syndrome)
• Inadequate motor control
• Inadequate coordination and balance
• Impaired hand-eye coordination
• Ataxia
• Muscle weakness
• Spasticity
• Sensory dysfunction
• Atlantoaxial instability
• Hyperreflexia
• Clonus
• Upper motor neuron and posterior column signs and symptoms
Dermatologic Function
• Abrasions
• Lacerations
• Blisters
• Pressure ulcers
• Rashes
Musculoskeletal System
• Limited neck range of motion

• Torticollis
• Atlantoaxial instability
• Decreased flexibility, often with contractures, decreased strength, and muscle strength
imbalance
• Pelvic dysfunction caused by lower extremity prosthetic device that is creating unequal leg
lengths
• Rotator cuff tendinitis and impingement in athletes using wheelchairs
• Wrist and elbow extensor tendinitis in athletes using wheelchairs
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People with autism spectrum disorder often have motor clumsiness and apraxia, placing
them at increased risk for injuries when participating in sports.29
People with cerebral palsy frequently have motor control, hand-eye coordination, and
balance difficulties that can increase injury risk and affect their participation in certain
sports. Evaluating these functions will reveal whether sports requiring catching, throwing,
and controlling equipment such as floor hockey sticks, rackets, and bats may be difficult
for the athlete. Accommodations should be considered for athletes with functional deficits
that may pose risk to the athlete or other competitors.
Athletes with multiple sclerosis have varying degrees of disability. The examiner should
check for ataxia, muscle weakness, fatigue, spasticity, and sensory dysfunction.
Approximately 15% of children with Down syndrome have AAI, although the condi-
tions of most are asymptomatic.10 A very small number of these children develop signs
and symptoms of cervical myelopathy. The neurological manifestations of symptomatic
AAI include easy fatigue, abnormal gait, incoordination and clumsiness, sensory deficits,
spasticity, hyperreflexia, clonus, and other upper motor neuron and posterior column signs
and symptoms. Other people at increased risk for AAI include those who have rheuma-
toid arthritis, achondroplastic dwarfism (most common type of skeletal dysplasia), and
Klippel-Feil syndrome (abnormal fusion of ≥2 cervical vertebrae).30 Children with skeletal
dysplasias often have associated cervical spine instability with serious danger of spinal cord
compression.31 General screening must include a history and physical examination with a
focus on the neurological assessment. There are 3 key questions to address AAI32 and if the
answers are all no, further assessment and restrictions are generally not needed: (1) Does
the person show evidence of progressive myopathy? (2) Does the person have poor head/
neck muscular control? and (3) Does the person’s neck flexion allow the chin to rest on his
or her chest? Neurological signs and symptoms (Box 8-3)10 may be more predictive of risk
of injury progression than radiographic abnormalities in asymptomatic AAI patients.
Box 8-3. Common Signs and Symptoms of Symptomatic Atlantoaxial

Instability
Easy Fatigability
• Difficulty in walking
• Abnormal gait
• Neck pain
• Limited neck mobility
• Torticollis
• Incoordination
Sensory Deficits
• Spasticity
• Hyperreflexia
• Clonus
• Extensor plantar reflex (Babinski sign)
• Upper motor neuron signs and symptoms
• Posterior column signs and symptoms
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Dermatologic function. Athletes who use wheelchairs are especially prone to skin inju-
ries. The upper extremities should be examined for abrasions and blisters caused by fric-
tion, shear, or irritation from repeated contact with the wheelchair push rim. Skin wounds
can also result from contact with other chairs, wheelchair brakes, or sharp edges of the
wheelchair.
The skin over the sacrum and ischial tuberosities should be inspected for pressure
ulcers. Athletes using wheelchairs have elevated skin pressures in these regions for pro-
longed periods during training and competition and if using wheelchairs for mobility,
during normal daily activity. Sports wheelchairs are designed so that the athlete’s knees
are at a higher level than the buttocks, a position that leads to even more pressure over
the sacrum and ischial tuberosities.1 During sports participation, the combination of
skin pressure, shear, and moisture increases the risk for pressure ulcers. An athlete using a
wheelchair who has a pressure ulcer should be followed very closely to ensure healing of
the wound. If wound healing is delayed or worsened by participation, medical eligibility
should be rescinded until the skin is improving. The seat cushion should also be evaluated
and modified to decrease skin pressures, improve the skin healing, and reduce the risk of
further skin trauma.
Prosthetic devices can cause skin trauma; the prosthesis contact site should be inspected
for abrasions, blisters, rashes, or pressure ulcers. The prosthesis should be evaluated for
proper fit and reconditioned to decrease the risk of future problems. Pressure ulcers may
preclude full participation in sports until the condition is resolved or the prosthetic device
is properly reconditioned and fitted to the athlete. In a skeletally immature athlete, over-
growth of the stump can be a problem, leading to breakdown of the overlying skin and
soft tissues.25
Urogenital system. Examination should involve the same evaluation as for athletes
who are nondisabled. It is also important to examine any external devices used for bladder
drainage.
Musculoskeletal system. The musculoskeletal examination of an athlete who uses a
wheelchair should include evaluation of the stability, flexibility, and strength of commonly
injured sites (eg, shoulder, hand, and wrist) and the trunk.7
Athletes with lower-limb amputation and prostheses require a full assessment of
the lower back, pelvis, and lower extremities, and those with upper-limb amputation
and prosthetic devices require a full assessment of the upper back, shoulder girdle,
and upper extremities. Abnormal forces and motions placed onto the upper and lower
extremities by prosthetic devices during sports activities commonly result in injury to
these areas.
Athletes with musculoskeletal manifestations of AAI may develop either limited range
of motion of the neck or torticollis (head tilt). People with Down syndrome are often
hypermobile with ligamentous laxity, and participating in sports increases the incidence
of hip and knee injuries.27 Examination may reveal signs of instability, coordination
problems, or sensory deficits, or signs of upper motor neuron findings and weakness.
Exercise performance may be negatively affected by skeletal characteristics such as short
stature and short limbs.33
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As many as 78% of people with spinal cord injuries who use wheelchairs report hav-
ing shoulder pain at some time. Shoulder pain is more commonly reported in people
using wheelchairs who are not involved in sports compared with athletes who use
wheelchairs.34
Athletes with cerebral palsy have decreased strength, decreased musculotendinous flex-
ibility (often with contractures), and muscle strength imbalances, especially of the lower
extremities. These conditions vary in severity from mild and nearly imperceptible to very
severe and requiring wheelchair use.1 Overuse injuries, strains, and sprains are common,
especially at the hips, knees, ankles, and feet. The PPE should include a thorough examina-
tion of these regions.
Functional Assessment
An individualized functional assessment of all athletes with physical disabilities should be
part of the PPE. An athlete’s overall mobility while using prosthetic, orthotic, assistive, or
adaptive devices, including sport-specific tasks, should be evaluated by a provider with the
skills to perform this part of the evaluation. A physical therapist or physiatrist with exper-
tise in the area can do this portion of the assessment.
Diagnostic Imaging
Athletes with symptomatic AAI should have lateral cervical spine radiographic imaging
in flexion and extension to assess the changes in the atlanto-dens interval (ADI), which
is the distance between the posterior aspect of the anterior arch of the atlas and the ante-
rior aspect of the odontoid.35 Radiographic screening for asymptomatic AAI in athletes is
controversial, because there is little evidence to suggest it is a significant risk factor for pro-
gression to symptomatic AAI. Despite the lack of evidence confirming the value of these
radiographs in athletes with Down syndrome and asymptomatic AAI, the Special Olympics
requires that athletes with Down syndrome competing in certain sports and events have
a radiologic evaluation for AAI. The Special Olympics has chosen an ADI of greater than
5 mm for the diagnosis of atlantoaxial subluxation in children. An ADI greater than 3 mm
is consistent with atlantoaxial subluxation in adults.36 The sport activities with increased
risk for athletes with AAI are listed in Box 8-4.
Box 8-4. High-risk Sports for Athletes With Atlantoaxial Instability

• Alpine skiing
• Diving
• Equestrian sports
• Gymnastics
• High jump
• Judo
• Pentathlon
• Snowboarding
• Soccer
• Squat lift
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References 189
■■ DETERMINING MEDICAL ELIGIBILITY FOR ATHLETES WITH A DISABILITY

Medical eligibility for sports participation should follow the same principles used for
athletes with no disability (see Chapter 5). The emphasis in this population of athletes
is on inclusion and safe participation. Many of the conditions identified by history and
physical examination will not permanently preclude an athlete from participating in
sports, but they may require further evaluation, treatment, or rehabilitation before a
final medical eligibility status is determined. The PPE for a child with any impairment
will rarely be completed in a single office visit. A multidisciplinary approach involving
primary care providers, physiatrists and other subspecialists, physical and occupational
therapists, and adaptive physical education specialists may be needed to determine medi-
cal eligibility and safe participation in physical activities. The multidisciplinary team
needs to assess the safety of a given sport for an athlete with unique needs. The athlete’s
medical condition, his or her functional abilities, and the demands of the sport need to
be considered in the decision.
Athletes with symptomatic AAI should be restricted from sports that require excessive
neck flexion or extension or have risk for hard falls or landings.10 Special Olympics requires
a signed release (Special Release Concerning Spinal Cord Compression and/or symptom-
atic Atlanto-axial Instability) available on the Web site (www.specialolympicstn-area3.org/
AAI-Special-Release-for-Athlete-Completion.pdf).37
Pressure sores are a common reason for limiting physical activity of an athlete using a
prosthetic device or wheelchair.38 Pressure-induced skin ulcers may temporarily preclude
full participation in sports until the condition has resolved and the mechanical pressure
point can be modified.
Although CI and PI athletes may require accommodations, more subspecialty care, and
diagnostic tests, with anticipatory guidance and education, most are able to lead a very
active lifestyle, practice and compete, and enjoy all of the benefit of sport.
■■ REFERENCES
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8. Haddix J. State associations offer athletic opportunities for students with disabilities. National Federation
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opportunities-for-students-with-disabilities. Published November 21, 2014. Accessed February 22, 2019
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We_Do/What_We_Do.aspx. Accessed February 22, 2019
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2007;17(1):55–60 PMID:17304008 https://doi.org/10.1097/JSM.0b013e3180302587
11. Special Olympics. Rules and rule changes for all sports. Special Olympics Web site. https://resources.
specialolympics.org/Taxonomy/Sports_Essentials/_List_Sports_Rules.aspx. Accessed February 22, 2019
12. Special Olympics. Special Olympics forms. Special Olympics Web site. https://resources.specialolympics.org/
search.aspx?s=Medical%20forms. Accessed February 22, 2019
13. International Paralympic Committee. Paralympic Movement Web site. https://www.paralympic.org. Accessed
February 22, 2019
14. US Paralympics. Paralympic sports by impairment group. Team USA Web site. http://www.teamusa.org/us-
paralympics/sports. Accessed on February 22, 2019
15. Rio 2016 Paralympic Games: about Rio 2016. Paralympic Movement Web site. https://www.paralympic.org/
rio-2016/about-us. Accessed February 22, 2019
16. McCormick DP, Ivey FM Jr, Gold DM, Zimmerman DM, Gemma S, Owen MJ. The preparticipation sports
examination in Special Olympics athletes. Tex Med. 1988;84(4):39–43 PMID:2966449
17. Mercer ES, Broecker B, Smith EA, Kirsch AJ, Scherz HC, Massad CA. Urological manifestations of Down syn-
drome. J Urol. 2004;171(3):1250–1253 PMID:14767322 https://doi.org/10.1097/01.ju.0000112915.69436.91
18. American Academy of Pediatrics Committee on Sports Medicine and Fitness. Atlantoaxial instability in
Down syndrome: subject review. Pediatrics. 1995;96(1, pt 1):151–154 PMID:7596705
19. Price MJ, Campbell IG. Effects of spinal cord lesion level upon thermoregulation during exercise in
the heat. Med Sci Sports Exerc. 2003;35(7):1100–1107 PMID:12840629 https://doi.org/10.1249/01.
MSS.0000074655.76321.D7
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21. Blackmer J. Rehabilitation medicine: 1. autonomic dysreflexia. CMAJ. 2003;169(9):931–935 PMID:14581313
22. Position statement on autonomic dysreflexia and boosting. In: International Paralympic Committee Handbook.
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ing at the Paralympic games: policies, results and future directions. Br J Sports Med. 2013;47(13):832–837
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IOC Manual of Sports Cardiology. Ames, IA: John Wiley & Sons Ltd; 2017:475–485
25. Patel DR, Greydanus DE. The pediatric athlete with disabilities. Pediatr Clin North Am. 2002;49(4):803–827
PMID:12296534 https://doi.org/10.1016/S0031-3955(02)00020-2
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27. Winell J, Burke SW. Sports participation of children with Down syndrome. Orthop Clin North Am.
28. Pelliccia A, Quattrini FM, Squeo MR, et al. Cardiovascular diseases in Paralympic athletes. Br J Sports Med.
2016;50(17):1075–1080 PMID:27231335 https://doi.org/10.1136/bjsports-2015-095867
29. Ramirez M, Yang J, Bourque L, et al. Sports injuries to high school athletes with disabilities. Pediatrics.
30. McKay SD, Al-Omari A, Tomlinson LA, Dorman JP. Review of cervical spine anomalies in genetic syndromes.
Spine (Phila PA 1976). 2012;37(5):E269–E277
31. Svensson O, Aaro S. Cervical instability in skeletal dysplasia. Report of 6 surgically fused cases. Acta Orthop
Scand. 1988;59(1):66–70 PMID:3354325 https://doi.org/10.3109/17453678809149348
32. Faculty of Sport Exercise and Medicine. Sport pre-participation screening for asymptomatic atlanto-
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35. Tassone JC, Duey-Holtz A. Spine concerns in the Special Olympian with Down syndrome. Sports Med
Arthrosc Rev. 2008;16(1):55–60 PMID:18277263 https://doi.org/10.1097/JSA.0b013e3181629ac4
36. Special Olympics. Medical form instructions. Special Olympics Web site. https://media.
specialolympics.org/resources/leading-a-program/Medical-Form-Completion-Instructions_March2018.
pdf?_ga=2.81225175.1982788690.1529539804-2130909287.1529539804. Accessed February 22, 2019
37. Special Olympics. Authorization, consent and release. Special Olympics Web site. http://www.specialolym-
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38. Dec KL, Sparrow KJ, McKeag DB. The physically-challenged athlete: medical issues and assessment. Sports
Med. 2000;29(4):245–258 PMID:10783900 https://doi.org/10.2165/00007256-200029040-00003
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08_ch08_179-192.indd 192 3/20/19 4:23 PM
CHAPTER 9
Transgender
Athletes
A transgender person has a gender identity that is different than their sex designation
assigned at birth. Transgender athletes can be assessed for medical eligibility to partici-
pate in sports by using the standard preparticipation physical evaluation, or PPE, process.
The conundrum arises with the designation of sex and gender and the determination of
competition status that is based on either sex or gender. The terms gender and sex have
been defined by the World Health Organization (WHO)1 to standardize terms that are
often used interchangeably in many settings. The WHO definitions confine the words to
specific meanings for which sex refers to the biological and physiological characteristics
that define male and female and gender refers to the socially constructed roles, behaviors,
activities, and attributes that society considers culturally appropriate for men, women,
and people of other gender categories. The fundamental concepts of sex and gender
extend beyond the traditional male and female biological designations assigned at birth.
Although not universally accepted, there are likely several categories along a continuum
of biological sex in humans that include internal and external genitalia, chromosomes,
hormone levels, and secondary sex characteristics, in addition to a broad range of gender
identity categories. Determining when an individual is male, female, or another sex des-
ignation involves integrating all the elements of biological sex as well as self-described
gender identity.2 Sports competitions have traditionally been divided by sex, but as trans-
gender athletes move into the sports arena, participation across sex divisions can create
controversy. Questions surrounding transgender athletes in competition are just begin-
ning to be clarified.
The most common competition circumstances are transgender women athletes and
transgender men athletes with male sex assignments at birth and female sex assignments
at birth, respectively. The effect of the transmasculine and transfeminine transitions on the
ability to train and the potential for enhanced performance is unknown, and the issue of
fair competition is a common concern. As more individuals are identified at early ages and
treated for gender dysphoria with medications that block the onset of puberty, the effects
of innate sex hormone on muscle and bone development may be eliminated. Early medi-
cal intervention may reduce some of the controversial aspects of integrating male to female
(trans woman or trans female) and female to male (trans man or trans male) athletes
into competition. It is important to remember that not all transgender people have early
access to medications, and some do not ever use medications. The policies and decisions
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194 Chapter 9. Transgender Athletes
regarding transgender competition will more likely be decided by administrative bodies

than by individual physicians, but it will be important for physicians to understand the
controversies.
Policy regarding transgender competition is evolving at all levels of sport. The National
Collegiate Athletic Association (NCAA) and the International Olympic Committee (IOC)
are developing policies regarding transgender athletes. At the high school level, the
National Federation of State High School Associations (NFHS) considers this a matter to
be addressed on a state-by-state basis and policy is set at the state and community levels.
As of 2015, laws protecting students from discrimination based on their gender identity
have been ratified in 13 states and the District of Columbia. In an effort to encourage pro-
tection of students, the Federal Office of Civil Rights clarified that discrimination against
transgender students in schools is covered by Title IX and educators in schools across the
United States are accountable for ensuring the safety and inclusion of transgender students
in all school-sponsored activities. The NCAA document NCAA Inclusion of Transgender
Student-Athletes3 has more-specific language and is summarized (quoted) herein.
NCAA Policy on Transgender Student-Athlete Participation
The following policies clarify participation of transgender student-athletes

undergoing hormonal treatment for gender transition:
1. A trans male . . . student-athlete who has received a medical exception

for treatment with testosterone for diagnosed . . . gender dysphoria . . . ,
for purposes of NCAA competition may compete on a men’s team, but
is no longer eligible to compete on a women’s team without changing
that team status to a mixed team.
2. A trans female . . . student-athlete being treated with testosterone sup-

pression medication for . . . gender dysphoria . . . , for the purposes of
NCAA competition may continue to compete on a men’s team but may
not compete on a women’s team without changing it to a mixed team
status until completing one calendar year of testosterone suppression
treatment.3
An NCAA student-athlete not on gender transition hormone therapy may

compete based on sex assigned at birth; specifically:
• A trans male . . . student-athlete who is not taking testosterone related to
gender transition may participate on a men’s or women’s team.
• A trans female . . . transgender student-athlete who is not taking hor-
mone treatments related to gender transition may not compete on a
women’s team.3
The IOC consensus statement “Sex Reassignment and Hyperandrogenism”4 builds on
the 2003 Stockholm consensus on sex reassignment in sports. The IOC guidelines are
like the NCAA requirements, with added requirements for transgender female athletes.
The most recent change is that transgender athletes can compete with 1 full year of hor-
mone therapy for gender affirmation (cross-sex hormone therapy) and without gender
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195
affirmation surgery.4 The IOC Consensus Meeting group established the following guide-
lines to determine eligibility for competition:
1. Those who transition from female to male are eligible to compete in

the male category without restriction.
2. Those who transition from male to female are eligible to compete in

the female category under the following conditions:
2.1. The athlete has declared that her gender identity is female. The decla-
ration cannot be changed, for sporting purposes, for a minimum of
four years.
2.2. The athlete must demonstrate that her total testosterone level in

serum has been below 10 nmol/L for at least 12 months prior to her
first competition (with the requirement for any longer period to be
based on a confidential case-by-case evaluation, considering whether
or not 12 months is a sufficient length of time to minimize any
advantage in women’s competition).
2.3. The athlete’s total testosterone level in serum must remain below

10 nmol/L throughout the period of desired eligibility to compete in
the female category.
2.4. Compliance with these conditions may be monitored by testing. In

the event of non-compliance, the athlete’s eligibility for female com-
petition will be suspended for 12 months.4
These recommendations are not without controversy and will continue to evolve. In
particular, the eligibility of transgender female athletes to compete as females without
orchiectomy5 and the total testosterone level allowed in transgender female athletes are
issues that cause much of the concern regarding fair competition. There is perceived poten-
tial for unfair advantage in competitions for transgender female athletes who experienced
androgenization before a postpuberty or early adult hormonal transition. The outcomes
are far more complicated. For example, the previous body size for a transgender woman
no longer propelled by androgenized muscle may put the female transgender athlete at a
potential disadvantage in many sports.6 As is common with controversial challenges to the
social norms, the scientific data are limited and it is difficult to keep abreast of the evolving
social and legal standards. There are always concerns about the potential for “cheating” by
the transgender female group, and many of the restrictions reflect the same issues that the
World Anti-Doping Agency contends with for the full spectrum of sport.
The science behind the current policies is not clear regarding the effect of hormone
therapy for gender affirmation (cross-sex hormone therapy) and gender affirmation sur-
gery, especially regarding transgender female athletes. The concerns revolve around the
question of potential performance-enhancing benefits from previous exposure to male
hormones and muscle development for a transgender girl or woman competing against
biologically born girls or women. Some research implies that transgender female athletes
have testosterone and hemoglobin levels within the female reference range within a year of
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196 Chapter 9. Transgender Athletes
gonadectomy.7–10 Some “case study” data suggest that performance of transgender women
is reduced approximately 10% compared with age-grade performance measures within a
few weeks of testosterone suppression.6 However, there are no long-term or large-group
outcomes data quantifying performance in athletes who have made the transition.11 The
current opinion is to classify individuals for competition using testosterone levels mea-
sured for each athlete.
Regarding transgender female athletes who have not had surgery, but are suppressed,
there is a concern for “cheating the system” by manipulating suppression medications
to allow testosterone levels to rise during training so as to enhance performance. Most
transgender women athletes will reduce testosterone levels below the required limit for
psychosocial reasons. Conceivably, some transgender women may be willing to compete
in women’s sport with as much testosterone as permitted by the rules, and this group’s
behavior could be problematic. It is worth noting that individual responses to testosterone
vary from person to person. For example, there are intersex women with typical female per-
formance and musculature who do not respond to testosterone at all and have very high
levels of testosterone. In addition, there are other intersex athletes who would be excluded
from participating at all (in either binary category) if arbitrary standards are enforced.
A similar concern exists for transgender male athletes who may misuse the testosterone
supplementation required for maintaining the transition by increasing doses above the
therapeutic level during training.12 This controversy also exists for cisgender (person iden-
tifies with the gender associated with one’s sex assigned at birth) males who take testos-
terone replacement therapy post-orchiectomy for testicular cancer and other conditions.
Transgender and cisgender men doing well in men’s sport will likely be tested regularly for
performance-enhancing drugs if they truly reach elite-level athletic performance.
The process for approving transgender athletes for competition is rapidly changing
and will continue to evolve. Providing sport participation medical eligibility will be the
“simple” part of the process. Determining who fits into a specific competition class will
likely be under the purview of the administrative bodies governing the individual sport.
Like with all athletes, providers caring for transgender athletes need to be aware of the psy-
chosocial challenges associated with sport and their lives outside of sport, including men-
tal health screening and providing thorough anticipatory guidance for a variety of different
issues. In caring for the transgender population, primary care providers must be prepared
to address their health care needs and their competition status. Providers should be famil-
iar with local sport governing bodies’ regulations to help transgender athletes navigate
sports participation and advocate for themselves within these systems. As patient advo-
cates, providers should also be urging sports organizations to develop inclusive, affirming
policies that support access to sport participation for all.
For a detailed reference and thorough discussion related to transgender health care, the
authors suggest volume 7 of “Standards of Care for the Health of Transsexual, Transgender,
and Gender Nonconforming People” (www.wpath.org/publications/soc).13 Another help-
ful resource for care of transgender and gender diverse people designed to address issues
for children, adolescents, young adults, adults and older adults is the Gender Affirmative
Lifespan Approach with approaches to care aimed at countering the internalization of this
stigma and improving mental health outcomes (www.sexualhealth.umn.edu/ncgsh/gala).
09_ch09_193-198.indd 196 3/20/19 3:18 PM

References 197
■■ REFERENCES
1. World Health Organization (WHO). Gender, equity and human rights. WHO Web site. http://www.who.int/
gender/whatisgender/en. Accessed February 22, 2019
2. Harper J, Martinez-Patino MJ, Pigozzi F, Pitsiladis Y. Implications of a third gender for elite sports. Curr
Sports Med Rep. 2018;17(2):42–44 PMID:29420345 https://doi.org/10.1249/JSR.0000000000000455
February 22, 2019
3. Office of Inclusion. NCAA Inclusion of Transgender Student-Athletes. Indianapolis, IN: National Collegiate
Athletic Association; 2011. http://www.ncaa.org/sites/default/files/Transgender_Handbook_2011_Final.pdf.
4. International Olympic Committee. IOC Consensus Meeting on Sex Reassignment and Hyperandrogenism,
November 2015. Lausanne, Switzerland: International Olympic Committee; 2015. https://stillmed.olympic.
org/Documents/Commissions_PDFfiles/Medical_commission/2015-11_ioc_consensus_meeting_on_sex_
reassignment_and_hyperandrogenism-en.pdf. Accessed February 22, 2019
5. Newbould MJ. What do we do about women athletes with testes? J Med Ethics. 2016;42(4):256–259
PMID:26545708 https://doi.org/10.1136/medethics-2015-102948
6. Harper J. Race times for transgender athletes. J Sporting Cultures Identities. 2015;6(1). http://jrci.cgpublisher.
com/product/pub.301/prod.4/m.2. Accessed February 22, 2019
7. Gooren LJ, Bunck MC. Transsexuals and competitive sports. Eur J Endocrinol. 2004;151(4):425–429
PMID:15476439
8. Gooren LJ, Giltay EJ, Bunck MC. Long-term treatment of transsexuals with cross-sex hormones: extensive
personal experience. J Clin Endocrinol Metab. 2008;93(1):19–25 PMID:17986639 https://doi.org/10.1210/
jc.2007-1809
9. van Kesteren P, Lips P, Gooren LJ, Asscheman H, Megens J. Long-term follow-up of bone mineral density and
bone metabolism in transsexuals treated with cross-sex hormones. Clin Endocrinol (Oxf). 1998;48(3):347–
354 PMID:9578826 https://doi.org/10.1046/j.1365-2265.1998.00396.x
10. T’Sjoen G, Weyers S, Taes Y, et al. Prevalence of low bone mass in relation to estrogen treatment and body
composition in male-to-female transsexual persons. J Clin Densitom. 2008;12(3):306–313
11. Pitsiladis Y, Harper J, Betancurt JO, et al. Beyond fairness: the biology of inclusion for transgender and
intersex athletes. Curr Sports Med Rep. 2016;15(6):386–388 PMID:27841808 https://doi.org/10.1249/
JSR.0000000000000314
12. Genel M. Transgender athletes: how can they be accommodated? Curr Sports Med Rep. 2017;16(1):12–13
PMID:28067734 https://doi.org/10.1249/JSR.0000000000000321
13. Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of transsexual, transgender, and
gender nonconforming people. Int J Transgenderism. 2012;13(4):165–232 https://doi.org/10.1080/15532739
.2011.700873
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09_ch09_193-198.indd 198 3/20/19 3:18 PM
CHAPTER 10
Research
The evidence for the preparticipation physical evaluation (PPE) remains limited, and sub-
stantial work is needed to study the validity, content, and process. In an era of measuring
quality and cost, we must consider the scientific basis and economic impact of our recom-
mendations. The purpose of this chapter is to emphasize areas for which further investiga-
tion is needed and thoughtfully weigh alternatives to the present process.
■■ WHETHER TO PERFORM A PPE AT ALL

Important questions remain as to whether PPE should be required for sports participation,
and if required, should it be separated from or integrated into the standard heath super-
vision assessments or preventive health visits?1 Other overarching questions include the
following ones: Should a standardized assessment be required for some sports, all sports,
or even all children? When is the optimal timing of the PPE in a young person’s life, and
at what ages should the examinations be completed? What is the appropriate frequency
of examination? When should the examination be administrated, during the course of a
calendar year or in relation to the competitive season? Despite the long-standing nature
of the PPE monograph, there are variations in the format and frequency of the evaluation
across the multiple athlete cohorts (eg, state high school associations, college conferences,
sport governing bodies) that would lend to outcome studies and potentially lead toward
an optimum evaluation.
The PPE was not originally developed as an evidence-based process; on the contrary,
there is a lack of evidence to demonstrate the overall effectiveness even after several
decades of accepted use among athletes.1 Even though healthy adults participating in
recreational sport or fitness activities are at least at a 10-fold greater risk than children for
cardiovascular death2 related to physical activity, there are no requirements for adults to
have a preparticipation evaluation in the United States. Israel, which previously required
an evaluation through age 40 years to exercise in a gym or fitness center, removed the
requirement because of low incidence of catastrophic events during exercise and the low
likelihood of detecting conditions in people who have no symptoms.3 This follows suit
with the American College of Sports Medicine, which recently eliminated the recommen-
dation for preparticipation evaluation for most adults.4 Presumably, the college athletes
who have died during sports participation have also had multiple medical evaluations
before and at college entry, and some had additional testing, such as preparticipation
electrocardiography.
Any policy that limits physical activity for young people may be detrimental to lifelong
physical activity patterns.5 It is unclear whether the requirement to update the PPE may
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200 Chapter 10. Research
affect sport participation rates, as only 45% of uninsured children have a yearly physi-
cal examination.1 Abnormal results that require further evaluation and management may
increase the cost, and therefore barriers, to participation, even for non-worrisome findings.
Physical activity and sports participation rates are strongly linked with socioeconomic
status.6 So one must consider whether a PPE discriminates against the students in lower
socioeconomic classes. In addition, there is concern that a sports PPE may disrupt compre-
hensive and preventive continuity care for adolescents. This is particularly troubling, since
adolescence is a critical time for preventive care. While some argue that the sports physi-
cal examination ensures there is a point of contact with the medical community, there is
no evidence that the greater than 25% of adolescents getting a PPE somewhere other than
their primary care provider’s office are receiving either comprehensive care or preventive
care.7 More than 1 in 10 parents believe a sports physical examination is an adequate sub-
stitute for routine adolescent preventive care.7 On the contrary, teens and young adults,
particularly girls and women, have concerns about sexual activity and health, eating dis-
orders, smoking, personal and family use of alcohol, and other critical health issues being
included in the sports PPE.8 This represents a critical gap in the research and an area to
further explore.
There are no uniform standards governing youth sports participation, and it remains
unknown whether mortality and morbidity among nonschool-based sports participants
are significantly different than that among the interscholastic population, for whom
PPEs are commonplace. The overlap between youth sports and interscholastic sports is
unknown. In a nationwide survey of parents, nearly one-quarter reported that their chil-
dren did not have to undergo a PPE for sports participation.7 Further, most young people
do not have a separate PPE performed when participating in intramural sports, gym class,
or playground activities. Gym class activities mirror the static and dynamic demands of
their interscholastic sports counterparts. While playground and neighborhood activities are
not specifically included in the American Academy of Pediatrics Classification of Sports by
Physical Intensity,9 they would likely have greater dynamic and static demands than sports
such as billiards, golf, and riflery that presently require a PPE.
Implicit in the development of the PPE monograph is the belief that standardizing the
examination to provide a uniform assessment tool will be better for young athletes, prac-
titioners, the community, or a combination of those stakeholders. Several states mandate
a particular PPE form, with some based entirely, or in part, on the PPE monograph. There
are several other states without a mandated form.10 Data contrasting the difference in
outcomes for young athletes in states with different requirements have not been reported
and are an area for future research. Repeating the PPE at frequent intervals may lead to
reducing the clinical importance of the examination, especially when the yield of abnor-
mal results and the impact on outcomes is low.11 The perception is that PPE requirements
lead to an overwhelming volume demand, which, in turn, leads to less-knowledgeable
medical personnel who deliver substandard care and potentially allow inappropriate sport
participation. In addition, some believe that athletes “doctor shop” until they find a pro-
vider who will allow participation, which undercuts the already limited value of a PPE.
The standardized monograph may contribute to the perception held by 43% of parents,
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Whether to Perform a PPE at All 201
and possibly shared by many in the medical community, who believe “any qualified health
care provider” can perform a sports PPE.7
Valuable data may be obtained by analyzing the patterns or frequency of sport-related
morbidity and mortality in states before and after PPEs were mandated and comparing
those with participation rates, especially among medically underserved populations. This
may also be compared with data obtained from other countries or situations in which
PPEs are not routinely performed. According to a letter from W. Heinz on March 13, 2018,
a survey of National Federation of State High School Associations showed that PPEs were
mandated for high school sports participation in all states except Maine, Vermont, and
Rhode Island, where they were recommended as opposed to required. Debate continues
on whether to mandate PPE in states where it is not presently required.12 While not specific
to sport, data from the Centers for Disease Control and Prevention13 and the Kids Count
Data Center (Annie E. Casey Foundation)14 show that over the past 5 years and longer,
Maine, Vermont, and Rhode Island have maintained low adolescent death rates compared
with those of other states. For current policies and recommendations, it is imperative to
review the policies set forth by the sport administration.
Studies of the PPE consistently demonstrate the essential role of the history. Between
65% and 77% of medical and musculoskeletal conditions identified during the PPE14–18
(SOR: Level B) and 58% of disqualifying conditions were detected from history.19 This is
true despite limitations caused by recall bias and other issues that may affect the accuracy
of the history.16,20 For example, one study showed only 19.8% concordance between the
athlete and a parent completing the history portion of the PPE.20 Some barriers to an accu-
rate history may be avoided if the PPE is completed in a patient-centered medical home,
where the provider has full and ready access to the comprehensive medical, surgical, and
injury history of the athlete. Despite this, more than 1 in 4 athletes have their PPEs per-
formed by someone other than their primary care provider.7 Another strategy is a digital
record completed by the athlete and parents that follows the athlete from the initial exami-
nation though the end of the athlete’s career, with the option of continued tracking for
long-term outcomes.
The questionnaire in this monograph represents the expert opinion of the author societ-
ies to incorporate the available medical evidence into a standardized form. However, few
of the individual questions have been scientifically validated. There are no data comparing
the history obtained during a PPE that is completed outside the medical home with the
athlete’s actual medical history collated within the medical home which represents another
gap in our knowledge base.
Although the history in its current and previous forms is presumed valuable, there is a
need to refine the questionnaire. A systematic study of each question to elicit which ones
have useful positive or negative responses that influence athlete outcomes needs to be per-
formed. The sensitivity and specificity of the questions for evaluating each area of concern is
critical from a financial and outcomes-based perspective. Each question may not be clearly
written to elicit the desired information and may simply be misinterpreted by athletes and
parents; evaluation from this perspective is also needed. Findings will likely vary depending
on age of the group being examined (children, high school students, college students, or
professional athletes); research in one athlete population may not be applicable to other age-
groups and should not be extrapolated to older or younger athletes. In addition, developing
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PPE questions with acceptable sensitivity for concussion, cardiovascular conditions, exercise-
induced bronchospasm (EIB), disordered eating, musculoskeletal injuries, and other areas
of concern would be ideal. Finally, studying these issues among specific groups of athletes to
develop features that might be tailored to individual sports or populations, including child,
adolescent, and female athletes, would advance the utility of the PPE.21,22
The physical examination can reveal disqualifying conditions or problems that require
further evaluation and monitoring. Elevated blood pressure and abnormal visual acu-
ity are the most common abnormalities identified during the PPE according to current
research15,16,18,23–27 (SOR: Level B). However, hypertension is less common in physically
active people than in the general population.23 No data show that hypertension is detected
at a greater rate than from routine health supervision checks or that detection of these
abnormalities during the PPE improves outcomes for young athletes. The US Preventive
Services Task Force (USPSTF) recently cited a lack of evidence to support screening the
adolescent population for elevated blood pressure, so the importance of screening ado-
lescent athletes for elevated blood pressure is unclear.28 While there is a recommendation
to screen young children for abnormal vision, this is done routinely in health supervision
care, and the USPSTF has not evaluated vision screening of the adolescent population. The
yield of other components of the physical examination is even less well established. The
USPSTF recommends screening adolescents for obesity, as elevated body mass index (BMI)
increases risk for hypertension, diabetes mellitus type 2, and obstructive sleep apnea,
which all affect long-term health.29 Waist circumference and abdominal adiposity are
independent predictors of morbidity and mortality in the general population and may be
factors to consider during the PPE.30 Elevated BMI is also a risk factor for developing exer-
tional heat illness31,32 and has been reported to be associated with increased musculoskel-
etal injuries, although data are mixed.33–35 According to a letter from Sherry Barron, MD,
MPH, and Robert Rinsky to the National Football League Players Association in January
1994, data from a study by the National Institute of Occupational Safety and Health
showed that professional football players who were linemen were at a 3.7 times greater
risk of developing cardiovascular disease than the general population, and those in the
highest BMI subgroup were at a 6 times higher risk. There is no evidence that screening for
obesity or elevated BMI specifically in the athletic population changes outcomes, however.
Therefore, further research into the effects of BMI and waist circumference in this popula-
tion is warranted, and recording both during the PPE could be considered, if an associated
intervention to improve long-term health can be implemented.
The USPSTF has determined there is strong evidence to suggest more harm than benefit
for testicular cancer screening,36 and insufficient evidence of benefit with idiopathic scolio-
sis screening,37 for adolescents. While there may be state or local requirements to perform
these examinations, the corresponding sections have been removed from the PPE form
included in this publication.
The physical examination components of the PPE are much the same as a health super-
vision or adult health screening evaluation. The cardiovascular examination is the most
pertinent to the PPE. The American Heart Association (AHA) has published guidelines for
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Screening Studies 203
the screening of competitive athletes that lists recommended components of the cardiovas-
cular examination38 (see Chapter 6, Section 6A). Further research is needed to establish the
efficacy of the cardiovascular history, examination, and screening studies of the US popula-
tion relative to long-term public health.
The value of the musculoskeletal screening examination deserves further analysis. The
examination recommended in previous editions, originally described by Garrick and
Requa,39 was designed to identify asymmetries that may indicate an underlying injury or a
biomechanical imbalance that might predispose to injury. On the basis of current research,
most musculoskeletal conditions are identified in the history15–18,40 (SOR: Level B). In
addition, the overall sensitivity of the musculoskeletal examination is reported to be less
than 50%.40,41 The effectiveness of this aspect of the PPE may highly depend on age of the
participant, level of competition, and sport involved. More important, there is little evi-
dence that musculoskeletal examination findings identified in an asymptomatic individual
predict injury or affect outcomes.41 Attempts to screen for neuromuscular control have
been mixed but seem to be useful for reducing noncontact anterior cruciate ligament and
patellofemoral joint pain in athletes participating below the elite level of competition.
Ideally, research in this area will lead to physical examination findings that would predict
injury risk and suggest specific training programs to decrease the injury risk.
■■ SCREENING STUDIES
The US Commission on Chronic Illness (disbanded in 1956) defined screening as the
“presumptive identification of an unrecognized defect or disease by the application of
tests, examinations, or procedures which can be applied rapidly, to sort out apparently well
persons who probably have a disease, from those who probably do not.”42 It is typically a
secondary prevention measure since it attempts to “case find,” or detect individuals with
pathology that has not yet risen to the point at which the individual would spontaneously
seek medical care.11 The World Health Organization Wilson-Jungner criteria for appraising
a screening program is included in Box 10-1.
Box 10-1. Criteria for Appraising a Screening Program

1.The condition sought should be an important health problem.
2.There should be an accepted treatment for patients with recognized disease.
3.Facilities for diagnosis and treatment should be available.
4.There should be a recognizable latent or early symptomatic stage.
5.There should be a suitable test or examination.
6.The test should be acceptable to the population.
7.The natural history of the condition, including development from latent to declared disease,
should be adequately understood.
8. There should be an agreed policy on whom to treat as patients.
9. The cost of case-finding (including diagnosis and treatment of patients diagnosed) should be
economically balanced in relation to possible expenditure on medical care as a whole.
10. Case-finding should be a continuing process and not a “once and for all” project.
Reprinted with permission from World Health Organization. Andermann A, Blancquaert I, Beauchamp S, Déry V.
Revisiting Wilson and Junger in the genomic age: a review of screening criteria over the past 40 years. Bull World
Health Organ. 2008;86(4):317–319.
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The implementation of screening studies as part of the PPE remains controversial.

While proponents of screening studies will point to the number of cases of the tar-
get condition detected, there is substantial risk of bias when evaluating the efficacy of
screening tests, especially overdiagnosis bias in the case of PPE (ie, when people with
harmless abnormalities are counted as “lives saved” by the screening, rather than as
“healthy people needlessly harmed by overdiagnosis”) and because studies assessing
the validity of a screening test might not have excluded symptomatic patients from their
analysis, leading to a falsely elevated rate of detection compared with screening truly
asymptomatic populations.
Screening may be associated with lead-time bias and length bias, and there may be sub-
stantial costs of both time and resources (opportunity cost) that may be better applied to
other aspects of public health.43 There is a concern that recommendations for screening
tests are driven by secondary gain, especially when the cost of follow-up testing, examina-
tion, and treatment is high, or when equipment or methods are sold for profit, or even
when organizations depend on high visibility to maintain funding streams. There is sub-
stantial risk of discrimination in any screening program, especially when subpopulations
may be underrepresented in studies evaluating the screening tests, when there are differ-
ences in the false-positive and false-negative rates between subpopulations, and when indi-
viduals who are socioeconomically disadvantaged do not have the resources to complete
follow-up care for an abnormal screening test result.
The USPSTF makes evidence-based screening recommendations for the general popula-
tion and subsets of population. The USPSTF has not officially weighed in on the question
of the PPE for athletes, or any specific screening test performed or recommended to be
performed in the PPE; however, they have published several recommendations for, and
against, screening tests that may be germane to the PPE of the target population. Some of
the recommendations from the USPSTF may seem far afield from the screenings typically
considered for the PPE, but with the high rate of individuals who forgo routine preventive
care in the target population, even these may be considered (Table 10-1).44,45
Various measures, including laboratory tests (to assess for sickle cell trait, hemoglobin
level, lipid levels, blood chemistries, and others), pulmonary evaluation for EIB, cardiac
screening with electrocardiography or echocardiography, and musculoskeletal functional
movement evaluation have been proposed. While individual studies looking at each of
these strategies have shown promise, none are accepted as a screening test for the entire
population of individuals undergoing a PPE.46–51 While diagnostic tests provide value in
known or suspected disease, their role in screening is usually substantially dampened
by the prevalence of condition in the population being screened, the accuracy of the test
itself, and the ability to alter the outcomes across the universe of athletes for an identified
condition.
Exertional sickling has caused several deaths in competitive athletes,52 and it has led to
discussion regarding screening for sickle cell trait during the PPE. At this time, evidence
that screening for sickle cell trait prevents death from exertional sickling is not available.52
Nonetheless, when documented newborn screening results are not known, some institu-
tions and organizations have chosen to perform laboratory screening to confirm sickle cell
trait status despite the current lack of data regarding its effectiveness. As a result of a lawsuit
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Screening Studies 205
Table 10-1. US Preventive Services Task Force Recommendations for

Adolescents
Recommendation Gradea Year

Unhealthy Alcohol Use in Adolescents and Adults: Screening and Behavioral I 2018
Counseling Interventions
Blood Pressure in Children and Adolescents (Hypertension): Screeningb I 2013
Depression in Children and Adolescents: Screening (Age 12–18, only) B 2016
Drug Use, Illicit: Screeningb I 2008
Human Immunodeficiency Virus (HIV) Infection: Screeningb A 2013
Adolescent Idiopathic Scoliosis: Screening I 2018
Lipid Disorders in Children and Adolescents: Screening I 2016
Obesity in Children and Adolescents: Screeningb B 2017
Sexually Transmitted Infections: Behavioral Counselingb B 2014
Skin Cancer Prevention: Behavioral Counseling B 2018
Suicide Risk in Adolescents: Screening I 2014
Testicular Cancer: Screening D 2011
Tobacco Use in Children and Adolescents: Primary Care Interventionsb B 2013
a
Recommendation grades are as follows: A, high certainty of substantial net benefit; B, high certainty of moderate
benefit or moderate certainty of substantial net benefit; C, moderate certainty of small net benefit (may consider
targeted screening); D, moderate or high certainty of no net benefit or where harms outweigh benefits; I, insuf-
ficient evidence to determine balance between benefits and harms.45
b
Denotes a recommendation presently under update. These updates may result in a change in recommendation in
the near future.
Adapted from US Preventive Services Task Force (USPSTF). Published recommendations. USPSTF Web site. https://
www.uspreventiveservicestaskforce.org/BrowseRec/Index?age=Pediatric,Adolescent. Accessed February 22, 2019.
settlement, National Collegiate Athletic Association member institutions are required to

offer athletes screening for sickle cell trait, if sickle cell trait status is not already known.52,53
It is unclear whether being aware of an individual athlete’s sickle cell trait status improves
outcomes or is more cost-effective than following universal prevention techniques during
exercise and conditioning. While further research is needed, education for staff, coaches,
and athletes regarding exercise-related sickling during intense exercise is critical to reducing
deaths and complications of the condition.52
Another laboratory screening test of interest to some concerns iron deficiency and mon-
itoring serum ferritin levels. While iron deficiency with anemia may impair athletic perfor-
mance, the effects of iron deficiency in the absence of anemia are less clear.54,55 While iron
deficiency could indicate a “relative anemia” in some athletes, as evidenced by improve-
ments in performance parameters among those receiving iron supplementation,56–60 more
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research is needed to clarify this question. This is of particular interest when it comes to
female athletes, among whom the prevalence of iron deficiency is higher, with up to 1 in
5 elite-level female athletes found to have a serum ferritin level of less than 30 ng/mL.61,62
It remains unclear whether laboratory evaluation needs to be performed to identify these
athletes, however, because the same study showed that in most circumstances, iron defi-
ciency is accompanied by clinical findings that can be detected with a preparticipation his-
tory and examination.62 In summary, the value of ferritin level screening in the absence of
clinical symptoms or findings seems to be of low yield.
Cardiac screening demonstrates significant limitations in the screening of athletes.63
Some of these limitations involve the low prevalence of cardiac conditions that can result
in sudden death and genetic variations among populations at risk, as well as the number
and outcomes of false-positive test results, and perhaps even racial bias. The AHA rec-
ommends a 14-point evaluation, which has traditionally been a part of the PPE, but it
has poor sensitivity and specificity and its use is not supported by medical evidence as a
screening program.64 The USPSTF has not addressed the specific population of child or
adolescent athletes, but it has recommended against screening for cardiovascular disease
with electrocardiography in asymptomatic adults at low risk.65 These areas deserve further
attention, but evidence does not support wide implementation outside of research-related
programs.63,66
Airway hyperresponsiveness (ie, EIB/bronchoconstriction) has a variable penetration in
the community at large, and athletes in some sports may be disproportionately affected.
Evaluation of elite-level runners revealed that 10% of the men and 26% of the women had
EIB,67 whereas 50% of figure skaters68,69 and 79% of cross-country skiers70 tested positive
for the condition. The prevalence of EIB in Olympic athletes is estimated as high as 20%,
with a significant number of these athletes undiagnosed.71 Although the condition is preva-
lent, a screening method that is sensitive and specific is lacking. Exercise challenge testing
in the competition environment or eucapnic hyperventilation testing, both of which are
more sensitive than the history and physical examination alone, may be necessary to iden-
tify the disorder.72 Further, there is no literature to suggest that screening the whole popula-
tion of athletes, instead of treating symptomatic individuals, leads to improved morbidity
or mortality.
The Functional Movement Screen (FMS) is an increasingly popular evaluation tool
to include in the PPE, and there is a question of its utility for predicting and preventing
injury.73–75 A systematic review of the literature showed moderate evidence that raters
can achieve an “acceptable” level of inter-rater and intra-rater reliability for live ratings
but not for video rating.76 However, subsequent meta-analysis failed to demonstrate a
strong association between the FMS and subsequent injury; therefore, the FMS is not
supported by evidence at this time.77 Further, although there is considerable overlap
in test scores between injured athletes and uninjured athletes, even though individual
risk factors may be statistically significant, no screening test has demonstrated adequate
discrimination to separate 2 distinctly different populations.51 A critical review by Bahr
showed that it was unrealistic to expect screening tests, or a PPE in general, to predict
future injury risk.51
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Conclusion 207
■■ ELECTRONIC PPE
Web-based electronic versions of the PPE have been proposed not only as a means to
improve the efficiency of screening athletes but also as a method to provide a more exten-
sive branched-chain questionnaire that can be used to identify conditions that require
further evaluation and to share those results with the athlete’s medical home.78 It is likely
that widespread implementation of electronic medical records, interconnected through
regional or statewide health information exchanges, will improve the accuracy of the his-
tory elements of the PPE, with verifiable problem lists and musculoskeletal injury history
that is preserved across a community or region. Regional capture of PPEs may also aid in
the coordination of athlete care following injury or illness, improve the ability of the PPE
to predict future problems through data mining, and reduce fragmented medical docu-
mentation and therefore errors. In addition to helping athletes, these interventions may
help reduce legal risk.
■■ CODING AND PPE OUTCOMES

The specific International Classification of Diseases, Tenth Revision, Clinical Modification code
for sport-related participation evaluation is Z02.5, which is a billable diagnosis code
for payment purposes. Despite using this as a primary diagnosis, many insurance com-
panies do not reimburse for a sports physical examination, especially if the athlete has
undergone a routine health supervision visit within the last 12 months. When the PPE is
completed using preventive visit codes as the primary reason for the visit, it is helpful to
use the Z02.5 sports physical code in the secondary position so that the work of the PPE
is documented. If the PPE is the only reason for the visit, the Z02.5 code can be billed
in the primary position. In either case, coding the PPE encounter allows tracking of
sports physicals within the electronic medical record and has the potential to amass large
numbers of examinations within health systems. Diligent coding by all providers will
allow research into the PPE visit for short- and long-term outcomes. In large systems,
“big data” could be collected over a relatively short time that would help determine the
usefulness of the examination, predictive value of the examinations, and a reasonable
frequency for the examinations with respect to outcomes. Over longer periods of time,
the long-term outcomes of PPE encounters could help determine the utility of additions
to the current examination and help shape the future PPE.
■■ CONCLUSION
Research that substantiates the value, the content, and the format of the PPE remains
limited. To verify that we are doing more good than harm and to provide a standardized,
evidenced-based approach for the PPE, more research is needed. The electronic health
record and attention to coding the PPE encounters have the potential to shape the future
of the examination. The issues cited in this chapter are intended to identify knowledge
gaps and research areas to ultimately enhance the health of child, adolescent, and young
adult athletes in the United States. Box 10-2 identifies current research gaps.
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Box 10-2. Top Research Gaps

• Do PPEs change the mortality rate of the target population? That is, are individuals excluded from
sports participation necessarily “lives saved” by screening?
• Are abnormalities found at PPEs different than those found at routine health supervision visits,
are they clinically meaningful, and are outcomes modifiable for the target population?
• Do PPE requirements adversely affect sports participation rates, and are those participation rates
disproportionally affecting individuals at a socioeconomic or medical disadvantage?
• Do requirements for follow-up testing for abnormalities discovered at the PPE lead to harm,
reduce participation, or disproportionately affect individuals on the basis of race, socioeconomic
factors, or availability of medical resources?
• What is the relative importance of each of the questions in the questionnaire in preventing or
modifying morbidity or mortality from sports participation?
• Are the adolescents who have their PPE performed somewhere other than their primary medical
home otherwise receiving routine comprehensive or preventive care?
• What is the accuracy of a PPE, for detecting known or suspected conditions that may affect risk
or participation status, performed in another setting compared with that obtained in the indi-
vidual’s medical home?
• Is there any physical examination that has or are there any functional movement tests that have
adequate discernment to predict or prevent injury to warrant their inclusion in universal screening?
• What findings from screening tests performed as part of the PPE are discovered in truly asymp-
tomatic individuals at no apparent increased risk?
• Does regional capture and storage of electronic PPE findings reduce fragmentation of the medical
record, improve follow-up on abnormal results, reduce errors, or reduce legal risk?
Abbreviation: PPE, preparticipation physical evaluation.
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CHAPTER 11
Conclusion
The preparticipation physical evaluation (PPE) is ideally done as a part of routine health
screening examinations by an athlete’s primary care physician and should be considered
a part of the preventive health examination for all children and adolescents to encour-
age safe, regular physical activity of any kind. If integrating the examination into periodic
health screening is not possible, a PPE involving multiple examiners in private screening
areas can be used; however, this strategy has many flaws, including access to the medi-
cal record in most settings. The group examination format can be optimized by using
one physician to do the entire history review, examination, and medical eligibility state-
ment for each athlete. When the provider staffing mix does not allow a single-physician
approach, the station-based format can be tailored to use the available providers in an
efficient manner.
With one-third of young athletes discontinuing organized sports by age 13,1 and many
youth sports leagues not requiring a PPE for participation, young patients should be asked,
as a part of their health screening examinations, if they participate in or intend to partici-
pate in youth sports or any physical activity. Young patients who play a sport recreation-
ally (ie, not as part of a high school or club sport that requires a PPE) are not at any lower
risk for some of the conditions discussed. The PPE should become an integral part of the
health screening examinations for any active patient. If the patient does not intend to par-
ticipate in any regular physical activity, every child, adolescent, or adult preventive health
encounter should be used to encourage physical activity, and the same questions critical to
the PPE (especially as it pertains to the cardiovascular and central nervous systems) should
be addressed.
Although the PPE should ideally be completed 6 weeks before the onset of the season,
in reality, many of the examinations are done more urgently. This does not leave adequate
time for evaluation of suspicious or abnormal findings before the start of practices and
training. Physicians must be resolute in completing the full evaluation of any positive
findings from the screening before allowing an athlete to participate in either practices
or competitions. Athletes and their parents or guardians need to be educated to have the
examinations conducted in a timely manner so as to avoid loss of practice time in the early
season. State high school sports leagues and colleges vary in their preparticipation exami-
nation requirements from full physical examinations done yearly to those done every 2 to
3 years, most often with some form of health questionnaire in the off years.
The physician-athlete interaction associated with the PPE should serve as the founda-
tion for a trusting relationship and help optimize the athlete’s long-term health. For many
healthy adolescent athletes, the PPE may be their only contact with the health care system,
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214 Chapter 11. Conclusion
and integrating the PPE into health supervision encounters may reduce errors and redun-
dancy in the examination. It is important to emphasize the need for health supervision
examinations to ensure full immunization status and address other health supervision
issues for each athlete who is examined inside or outside the medical home. Young ath-
letes should know that the examination is in their best interest and will be conducted with
full confidentiality.
With a thorough evaluation and knowledgeable counseling, physicians and other health
care professionals can use the PPE as an opportunity to enhance safe sports participation
and promote healthy lifestyles. The PPE can provide a teachable moment that is not always
available to teenaged athletes who are often involved in high-risk activities away from the
playing field. As a whole, the examination should promote safe, cost-effective athletic par-
ticipation while guiding the athlete toward healthy behaviors during the risky adolescent
years and throughout life.
The PPE continues to evolve. The author societies of this fifth edition of the monograph
have updated the content of the body systems sections and tried to help you better under-
stand the complex issues of screening. The content for female athletes and athletes with
a disability has been enhanced, and a new section addressing mental health and a new
chapter on transgender athletes have been added. While the cardiovascular screening issue
has not been resolved, there is very little call for universal electrocardiography screening of
all athletes. There seem to be athlete groups at higher cardiac risk who may benefit from
screening, although when and how frequently to screen this subpopulation of athletes
remains unclear. It will be important for the users of this monograph to stay abreast of cur-
rent recommendations.
The issues pertaining to screening, the accuracy of the screening questions in predicting
who may be at risk for certain conditions (sudden death, concussions, and specific cardiac
questions), and the predictability of examination findings continue to be ripe for further
investigation. Further research in this area will help standardize this challenging process,
improve the identification of at-risk athletes (and nonathletes), and risk stratify those who
are detected with conditions that may affect continued sport participation. Research in
this area may or may not result in a costlier screening process. It is imperative that the PPE
screening not create unnecessary financial or logistical roadblocks to athlete participation.
As physicians and as a society, we must accept the imperfection of screening tools and that
participation in sports will always carry some risk.
Finally, the provider performing the PPE should not be a technician rushing through
the clinic appointment or group examination stations to determine the athlete’s medi-
cal eligibility to participate in a sport. Rather, the physician should be an educator and
advocate for the healthy active lifestyle of every patient participating in an organized sport,
recreational play, or fitness activity. We have the opportunity, with the expansion of the
electronic health record and diligent coding, to generate “big data” through large health
systems that may help shape the future PPE.
■■ REFERENCE
1. Wolff A. The American athlete, age 10. Sports Illustrated. October 6, 2003
11_ch11_213-214.indd 214 3/20/19 3:19 PM

Forms
HISTORY FORM (ENGLISH)....................................................................217
HISTORY FORM (SPANISH)....................................................................219
PHYSICAL EXAMINATION FORM��221
ATHLETES WITH DISABILITIES FORM: SUPPLEMENT TO THE ATHLETE
HISTORY��223
MEDICAL ELIGIBILITY FORM...................................................................225
Permission is granted to reprint the Preparticipation Physical Evaluation History Form (English and Spanish), Athletes
With Disabilities Form: Supplement to the Athlete History, Physical Examination Form, and Medical Eligibility Form
for noncommercial, educational purposes with acknowledgment. If the forms are to be used in books; periodicals;
newspapers; advertisements; premiums or promotional works; condensations, adaptations, or other derivative works;
filmstrips, slides, transparencies, microforms, or similar media; audio or video adaptations; software adaptations or
databases; or electronic information storage and retrieval systems or devices, the users must contact the publisher to
request permission.
12_Forms_215-226.indd 215 3/20/19 4:18 PM

12_Forms_215-226.indd 216 3/20/19 4:18 PM
217
■■ PREPARTICIPATION PHYSICAL EVALUATION
HISTORY FORM
Note: Complete and sign this form (with your parents if younger than 18) before your appointment.
Name: ________________________________________________________________ Date of birth: _____________________________
Date of examination: _______________________________ Sport(s): _____________________________________________________
Sex assigned at birth (F, M, or intersex): _________________ How do you identify your gender? (F, M, or other): ___________________
List past and current medical conditions. _____________________________________________________________________________

_______________________________________________________________________________________________________________
Have you ever had surgery? If yes, list all past surgical procedures. _______________________________________________________
_______________________________________________________________________________________________________________
Medicines and supplements: List all current prescriptions, over-the-counter medicines, and supplements (herbal and nutritional).
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Do you have any allergies? If yes, please list all your allergies (ie, medicines, pollens, food, stinging insects).
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Patient Health Questionnaire Version 4 (PHQ-4)

Over the last 2 weeks, how often have you been bothered by any of the following problems? (Circle response.)
Not at all Several days Over half the days Nearly every day
Feeling nervous, anxious, or on edge 0 1 2 3
Not being able to stop or control worrying 0 1 2 3
Little interest or pleasure in doing things 0 1 2 3
Feeling down, depressed, or hopeless 0 1 2 3
(A sum of ≥3 is considered positive on either subscale [questions 1 and 2, or questions 3 and 4] for screening purposes.)
GENERAL QUESTIONS HEART HEALTH QUESTIONS ABOUT YOU

(Explain “Yes” answers at the end of this form. (CONTINUED ) Yes No
Circle questions if you don’t know the answer.) Yes No 9. Do you get light-headed or feel shorter of breath
1. Do you have any concerns that you would like to than your friends during exercise?
discuss with your provider?
2. Has a provider ever denied or restricted your
participation in sports for any reason?
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY Yes No
3. Do you have any ongoing medical issues or
11. Has any family member or relative died of heart
recent illness?
problems or had an unexpected or unexplained
HEART HEALTH QUESTIONS ABOUT YOU Yes No sudden death before age 35 years (including
4. Have you ever passed out or nearly passed out drowning or unexplained car crash)?
during or after exercise?
5. Have you ever had discomfort, pain, tightness, 12. Does anyone in your family have a genetic heart
or pressure in your chest during exercise? problem such as hypertrophic cardiomyopathy
(HCM), Marfan syndrome, arrhythmogenic right
6. Does your heart ever race, flutter in your chest, ventricular cardiomyopathy (ARVC), long QT
or skip beats (irregular beats) during exercise? syndrome (LQTS), short QT syndrome (SQTS),
7. Has a doctor ever told you that you have any Brugada syndrome, or catecholaminergic poly-
heart problems? morphic ventricular tachycardia (CPVT)?
8. Has a doctor ever requested a test for your

13. Has anyone in your family had a pacemaker or
heart? For example, electrocardiography (ECG)
an implanted defibrillator before age 35?
or echocardiography.
12_Forms_215-226.indd 217 3/20/19 4:18 PM

218
BONE AND JOINT QUESTIONS Yes No MEDICAL QUESTIONS (CONTINUED ) Yes No

14. Have you ever had a stress fracture or an injury 25. Do you worry about your weight?
to a bone, muscle, ligament, joint, or tendon that 26. Are you trying to or has anyone recommended
caused you to miss a practice or game? that you gain or lose weight?
15. Do you have a bone, muscle, ligament, or joint 27. Are you on a special diet or do you avoid
injury that bothers you? certain types of foods or food groups?
MEDICAL QUESTIONS Yes No 28. Have you ever had an eating disorder?
16. Do you cough, wheeze, or have difficulty FEMALES ONLY Yes No
breathing during or after exercise?
29. Have you ever had a menstrual period?
17. Are you missing a kidney, an eye, a testicle
30. How old were you when you had your first
(males), your spleen, or any other organ?
menstrual period?
18. Do you have groin or testicle pain or a painful
31. When was your most recent menstrual period?
bulge or hernia in the groin area?
32. How many periods have you had in the past 12
19. Do you have any recurring skin rashes or
months?
rashes that come and go, including herpes or
methicillin-resistant Staphylococcus aureus
Explain “Yes” answers here.
(MRSA)?
______________________________________________________
20. Have you had a concussion or head injury that ______________________________________________________
caused confusion, a prolonged headache, or
______________________________________________________
memory problems?
______________________________________________________
21. Have you ever had numbness, had tingling, had
weakness in your arms or legs, or been unable ______________________________________________________
to move your arms or legs after being hit or ______________________________________________________
falling? ______________________________________________________
22. Have you ever become ill while exercising in the ______________________________________________________
heat? ______________________________________________________
23. Do you or does someone in your family have ______________________________________________________
sickle cell trait or disease? ______________________________________________________
24. Have you ever had or do you have any prob- ______________________________________________________
lems with your eyes or vision? ______________________________________________________
I hereby state that, to the best of my knowledge, my answers to the questions on this form are complete
and correct.
Signature of athlete: ______________________________________________________________________________________________________
Signature of parent or guardian: __________________________________________________________________________________________
Date: ________________________________________________________
© 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine,
American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educa-
tional purposes with acknowledgment.
12_Forms_215-226.indd 218 3/20/19 4:18 PM

219
■■ EVALUACIÓN FÍSICA PREVIA A LA PARTICIPACIÓN
FORMULARIO DE HISTORIAL CLÍNICO

Nota: Complete y firme este formulario (con la supervisión de sus padres si es menor de 18 años) antes de acudir a su cita.
Nombre: ________________________________________________________ Fecha de nacimiento: _____________________________
Fecha del examen médico: _______________________________________ Deporte(s): ________________________________________
Sexo que se le asignó al nacer (F, M o intersexual): _______________ ¿Con cuál género se identifica? (F, M u otro): _______________
Mencione los padecimientos médicos pasados y actuales que haya tenido. ________________________________________________
_______________________________________________________________________________________________________________
¿Alguna vez se le practicó una cirugía? Si la respuesta es afirmativa, haga una lista de todas sus cirugías
previas. _______________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Medicamentos y suplementos: Enumere todos los medicamentos recetados, medicamentos de venta libre y suplementos (herbolarios
y nutricionales) que consume. ______________________________________________________________________________________
_______________________________________________________________________________________________________________
¿Sufre de algún tipo de alergia? Si la respuesta es afirmativa, haga una lista de todas sus alergias (por ejemplo, a algún medica-
mento, al polen, a los alimentos, a las picaduras de insectos).
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Cuestionario sobre la salud del paciente versión 4 (PHQ-4)

Durante las últimas dos semanas, ¿con qué frecuencia experimentó alguno de los siguientes problemas de salud? (Encierre en un
círculo la respuesta)
Más de la Casi todos
Ningún día Varios días mitad de los días los días
Se siente nervioso, ansioso o inquieto 0 1 2 3
No es capaz de detener o controlar la preocupación 0 1 2 3
Siente poco interés o satisfacción por hacer cosas 0 1 2 3
Se siente triste, deprimido o desesperado 0 1 2 3
(Una suma ≥3 se considera positiva en cualquiera de las subescalas,
[preguntas 1 y 2 o preguntas 3 y 4] a fin de obtener un diagnóstico).
PREGUNTAS GENERALES PREGUNTAS SOBRE SU SALUD

(Dé una explicación para las preguntas en las que CARDIOVASCULAR (CONTINUACIÓN ) Sí No
contestó “Sí”, en la parte final de este formulario.
5. ¿Alguna vez sintió molestias, dolor, compresión
Encierre en un círculo las preguntas si no sabe la
o presión en el pecho mientras hacía ejercicio?
respuesta). Sí No
6. ¿Alguna vez sintió que su corazón se aceleraba,
1. ¿Tiene alguna preocupación que le gustaría
palpitaba en su pecho o latía intermitente-
discutir con su proveedor de servicios médicos?
mente (con latidos irregulares) mientras hacía
2. ¿Alguna vez un proveedor de servicios médicos ejercicio?
le prohibió o restringió practicar deportes por
7. ¿Alguna vez un médico le dijo que tiene prob-
algún motivo?
lemas cardíacos?
3. ¿Padece algún problema médico o enfermedad
8. ¿Alguna vez un médico le pidió que se hiciera
reciente?
un examen del corazón? Por ejemplo, electro-
PREGUNTAS SOBRE SU SALUD cardiografía (ECG) o ecocardiografía.
CARDIOVASCULAR Sí No
9. Cuando hace ejercicio, ¿se siente mareado o
4. ¿Alguna vez se desmayó o estuvo a punto de siente que le falta el aire más que a sus amigos?
desmayarse mientras hacía, o después de hacer,
ejercicio? 10. ¿Alguna vez tuvo convulsiones?
12_Forms_215-226.indd 219 3/20/19 4:18 PM

220
PREGUNTAS SOBRE LA SALUD PREGUNTAS SOBRE CONDICIONES MÉDICAS

CARDIOVASCULAR DE SU FAMILIA Sí No (CONTINUACIÓN ) Sí No
11. ¿Alguno de los miembros de su familia o pari- 20. ¿Alguna vez sufrió un traumatismo craneoence-
ente murió debido a problemas cardíacos o tuvo fálico o una lesión en la cabeza que le causó
una muerte súbita e inesperada o inexplicable confusión, un dolor de cabeza prolongado o
antes de los 35 años de edad (incluyendo problemas de memoria?
muerte por ahogamiento o un accidente auto- 21. ¿Alguna vez sintió adormecimiento, hormigueo,
movilístico inexplicables)? debilidad en los brazos o piernas, o fue incapaz
12. ¿Alguno de los miembros de su familia padece de mover los brazos o las piernas después de
un problema cardíaco genético como la mio- sufrir un golpe o una caída?
cardiopatía hipertrófica (HCM), el síndrome de 22. ¿Alguna vez se enfermó al realizar ejercicio
Marfan, la miocardiopatía arritmogénica del cuando hacía calor?
ventrículo derecho (ARVC), el síndrome del QT
largo (LQTS), el síndrome del QT corto (SQTS), 23. ¿Usted o algún miembro de su familia tiene el
el síndrome de Brugada o la taquicardia ven- rasgo drepanocítico o padece una enfermedad
tricular polimórfica catecolaminérgica (CPVT)? drepanocítica?
13. ¿Alguno de los miembros de su familia utilizó 24. ¿Alguna vez tuvo o tiene algún problema con
un marcapasos o se le implantó un desfibrilador sus ojos o su visión?
antes de los 35 años? 25. ¿Le preocupa su peso?
PREGUNTAS SOBRE LOS HUESOS Y LAS 26. ¿Está tratando de bajar o subir de peso, o
ARTICULACIONES Sí No alguien le recomendó que baje o suba de peso?
14. ¿Alguna vez sufrió una fractura por estrés o una 27. ¿Sigue alguna dieta especial o evita ciertos tipos
lesión en un hueso, músculo, ligamento, articu- o grupos de alimentos?
lación o tendón que le hizo faltar a una práctica 28. ¿Alguna vez sufrió un desorden alimenticio?
o juego? ÚNICAMENTE MUJERES Sí No
15. ¿Sufre alguna lesión ósea, muscular, de los 29. ¿Ha tenido al menos un periodo menstrual?
ligamentos o de las articulaciones que le causa
molestia? 30. ¿A los cuántos años tuvo su primer periodo
menstrual?
PREGUNTAS SOBRE CONDICIONES MÉDICAS Sí No
31. ¿Cuándo fue su periodo menstrual más reciente?
16. ¿Tose, sibila o experimenta alguna dificultad
para respirar durante o después de hacer 32. ¿Cuántos periodos menstruales ha tenido en los
ejercicio? últimos 12 meses?
17. ¿Le falta un riñón, un ojo, un testículo (en el

Proporcione una explicación aquí para las preguntas en
caso de los hombres), el bazo o cualquier otro
las que contestó “Sí”.
órgano?
______________________________________________________
18. ¿Sufre dolor en la ingle o en los testículos, o
tiene alguna protuberancia o hernia dolorosa en ______________________________________________________
la zona inguinal? ______________________________________________________
19. ¿Padece erupciones cutáneas recurrentes o que ______________________________________________________
aparecen y desaparecen, incluyendo el herpes o ______________________________________________________
Staphylococcus aureus resistente a la meticilina ______________________________________________________
(MRSA)? ______________________________________________________
Por la presente declaro que, según mis conocimientos, mis respuestas a las preguntas de este formulario
están completas y son correctas.
Firma del atleta: _______________________________________________________________________________________________________
Firma del padre o tutor: _________________________________________________________________________________________________
Fecha: _________________________________________________________
American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Se concede permiso para reimprimir este formulario para fines
educativos no comerciales, siempre que se otorgue reconocimiento a los autores.
12_Forms_215-226.indd 220 3/20/19 4:18 PM

221

PHYSICAL EXAMINATION FORM
Name: _________________________________________________________________ Date of birth: ____________________________
PHYSICIAN REMINDERS
1. Consider additional questions on more-sensitive issues.
• Do you feel stressed out or under a lot of pressure?
• Do you ever feel sad, hopeless, depressed, or anxious?
• Do you feel safe at your home or residence?
• Have you ever tried cigarettes, e-cigarettes, chewing tobacco, snuff, or dip?
• During the past 30 days, did you use chewing tobacco, snuff, or dip?
• Do you drink alcohol or use any other drugs?
• Have you ever taken anabolic steroids or used any other performance-enhancing supplement?
• Have you ever taken any supplements to help you gain or lose weight or improve your performance?
• Do you wear a seat belt, use a helmet, and use condoms?
2. Consider reviewing questions on cardiovascular symptoms (Q4–Q13 of History Form).
EXAMINATION
Height: Weight:
BP: / ( / ) Pulse: Vision: R 20/ L 20/ Corrected: □Y □N
MEDICAL NORMAL ABNORMAL FINDINGS
Appearance
• Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, hyperlaxity,
myopia, mitral valve prolapse [MVP], and aortic insufficiency)
Eyes, ears, nose, and throat
• Pupils equal
• Hearing
Lymph nodes
Hearta
• Murmurs (auscultation standing, auscultation supine, and ± Valsalva maneuver)
Lungs
Abdomen
Skin
• Herpes simplex virus (HSV), lesions suggestive of methicillin-resistant Staphylococcus aureus (MRSA), or
tinea corporis
Neurological
MUSCULOSKELETAL NORMAL ABNORMAL FINDINGS
Neck
Back
Shoulder and arm
Elbow and forearm
Wrist, hand, and fingers
Hip and thigh
Knee
Leg and ankle
Foot and toes
Functional
• Double-leg squat test, single-leg squat test, and box drop or step drop test
a
Consider electrocardiography (ECG), echocardiography, referral to a cardiologist for abnormal cardiac history or examination findings, or a combi-
nation of those.
Name of health care professional (print or type): ___________________________________________________ Date: ___________________
Address: ________________________________________________________________________ Phone: ___________________________
Signature of health care professional: _____________________________________________________________________, MD, DO, NP, or PA
12_Forms_215-226.indd 221 3/20/19 4:18 PM

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223

ATHLETES WITH DISABILITIES FORM: SUPPLEMENT TO THE ATHLETE HISTORY
Name: _________________________________________________________________ Date of birth: ____________________________
1. Type of disability:
2. Date of disability:
3. Classification (if available):
4. Cause of disability (birth, disease, injury, or other):
5. List the sports you are playing:
Yes No
6. Do you regularly use a brace, an assistive device, or a prosthetic device for daily activities?
7. Do you use any special brace or assistive device for sports?
8. Do you have any rashes, pressure sores, or other skin problems?
9. Do you have a hearing loss? Do you use a hearing aid?
10. Do you have a visual impairment?
11. Do you use any special devices for bowel or bladder function?
12. Do you have burning or discomfort when urinating?
13. Have you had autonomic dysreflexia?
14. Have you ever been diagnosed as having a heat-related (hyperthermia) or cold-related (hypothermia) illness?
15. Do you have muscle spasticity?
16. Do you have frequent seizures that cannot be controlled by medication?
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Please indicate whether you have ever had any of the following conditions:
Yes No
Atlantoaxial instability
Radiographic (x-ray) evaluation for atlantoaxial instability
Dislocated joints (more than one)
Easy bleeding
Enlarged spleen
Hepatitis
Osteopenia or osteoporosis
Difficulty controlling bowel
Difficulty controlling bladder
Numbness or tingling in arms or hands
Numbness or tingling in legs or feet
Weakness in arms or hands
Weakness in legs or feet
Recent change in coordination
Recent change in ability to walk
Spina bifida
Latex allergy
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
I hereby state that, to the best of my knowledge, my answers to the questions on this form are complete and correct.
Signature of athlete: ______________________________________________________________________________________________________
Signature of parent or guardian: ______________________________________________________________________________________________
Date: _________________________________________________________
© 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American
Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with
acknowledgment.
12_Forms_215-226.indd 223 3/20/19 4:18 PM

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225
MEDICAL ELIGIBILITY FORM

Name: _______________________________________________________ Date of birth: _________________________
□ Medically eligible for all sports without restriction
□ Medically eligible for all sports without restriction with recommendations for further evaluation or treatment of
__________________________________________________________________________________________________
__________________________________________________________________________________________________
□ Medically eligible for certain sports
__________________________________________________________________________________________________
__________________________________________________________________________________________________
□ Not medically eligible pending further evaluation
□ Not medically eligible for any sports
Recommendations: ___________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
I have examined the student named on this form and completed the preparticipation physical evaluation. The athlete does not have
apparent clinical contraindications to practice and can participate in the sport(s) as outlined on this form. A copy of the physical
examination findings are on record in my office and can be made available to the school at the request of the parents. If conditions
arise after the athlete has been cleared for participation, the physician may rescind the medical eligibility until the problem is resolved
and the potential consequences are completely explained to the athlete (and parents or guardians).
Name of health care professional (print or type): __________________________________________ Date: ____________________________
Address: _________________________________________________________________________ Phone: ___________________________
Signature of health care professional: _____________________________________________________________________, MD, DO, NP, or PA
SHARED EMERGENCY INFORMATION
Allergies: ____________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Medications: ________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Other information: ____________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Emergency contacts: ___________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
12_Forms_215-226.indd 225 3/20/19 4:18 PM

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Resources
• “Activity Categories” to determine metabolic equivalent task (MET) values (https://sites.
google.com/site/compendiumofphysicalactivities/Activity-Categories): Provides a MET
value of a given activity. From Compendium of Physical Activities.
• “Adaptive Sports: Staying Active While Living With a Disability” (www.moveforwardpt.
com/resources/detail/adaptive-sports-people-with-disabilities): Opportunities to partici-
pate and compete in sports activities for athletes with disabilities. From Move Forward.
• “Advancing the Preparticipation Physical Evaluation (PPE)” (www.ncbi.nlm.nih.gov/
pubmed/25391096): A consensus statement from the American College of Sports
Medicine and Fédération Internationale du Médicine du Sport.
• Authorization, Consent and Release (Special Release Concerning Spinal Cord Com-
pression and/or Symptomatic Atlanto-axial Instability) (www.specialolympicstn-area3.
org/AAI-Special-Release-for-Athlete-Completion.pdf): Special Olympics release form.
• “Clinical Practice Guideline for Screening and Management of High Blood Pressure
in Children and Adolescents” (https://pediatrics.aappublications.org/content/140/3/
e20171904). American Academy of Pediatrics guidelines on pediatric high blood pressure.
• Concussion assessment tools
——Child Sport Concussion Assessment Tool – 5th Edition (https://bjsm.bmj.com/
content/bjsports/51/11/862.full.pdf): A sport concussion evaluation tool for use by
health care professionals in the immediate evaluation of suspected concussion for
children aged 5 to 12
——Sport Concussion Assessment Tool – 5th Edition (www.sportphysio.ca/wp-content/
uploads/SCAT-5.pdf): A sport concussion evaluation tool for use by health care pro-
fessionals in the immediate evaluation of suspected concussion
• Concussion training (www.cdc.gov/headsup/providers/training/index.html): Free online
training developed by the Centers for Disease Control and Prevention and the American
Academy of Pediatrics.
• Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (www.psychiatry.org/
psychiatrists/practice/dsm): Defines and classifies mental disorders to improve diagno-
ses, treatments, and research. From the American Psychiatric Association.
• “Eligibility and Disqualification Recommendations for Competitive Athletes With
Cardiovascular Abnormalities: Preamble, Principles, and General Considerations”
(www.acc.org/∼/media/fb92803045d249ae91b715650dd0ebe4.pdf): American Heart
Association and American College of Cardiology consensus statement that offers helpful
information in certain situations regarding medical eligibility.
• “Exercise and Acute Cardiovascular Events: Placing the Risks Into Perspective” (https://
journals.lww.com/acsm-msse/Fulltext/2007/05000/Exercise_and_Acute_Cardiovascular_
Events__Placing.20.aspx): Discusses the potential cardiovascular complications of exer-
cise, their pathological substrate, and their incidence and suggests strategies to reduce
these complications. From the American College of Sports Medicine and American
Heart Association.
13_Resources_227-230.indd 227 3/20/19 3:19 PM

228 Resources
• “Exercise and Type 2 Diabetes” (https://journals.lww.com/acsm-msse/

Fulltext/2010/12000/Exercise_and_Type_2_Diabetes__American_College_of.18.aspx):
A consensus statement from the American College of Sports Medicine and American
Diabetes Association.
• “Family Educational Rights and Privacy Act (FERPA)” (www2.ed.gov/policy/gen/guid/
fpco/ferpa/index.html): Provides helpful information on FERPA, including FAQs and
parent and student information. From the US Department of Education.
• “The Female Athlete Triad” (https://journals.lww.com/acsm-msse/Fulltext/2007/10000/
The_Female_Athlete_Triad.26.aspx): Discusses the interrelationships among energy
availability, menstrual function, and bone mineral density that may have clinical mani-
festations including eating disorders, functional hypothalamic amenorrhea, and osteo-
porosis. From the American College of Sports Medicine.
• Gender Affirmative Lifespan Approach (GALA) (www.sexualhealth.umn.edu/ncgsh/
gala): A set of practices tailored to prevent stigmatization and discrimination, which
contribute to negative health outcomes for transgender and gender-diverse people.
From the National Center for Gender Spectrum Health.
• “Growth Charts” (www.cdc.gov/growthcharts): Charts for use by health care professionals
and parents to track the growth of babies, children, and adolescents. Body mass index can
be calculated from height and weight. From the National Center for Health Statistics.
• “HIPAA - Health Information Privacy” (www.hhs.gov/ocr/index.html): Provides helpful
information on HIPAA (Health Insurance Portability and Accountability Act), including
forms and educational materials. From the Office for Civil Rights.
• “Immunization Schedules” (www.cdc.gov/vaccines/schedules/hcp/index.html): The
preparticipation physical evaluation should follow the Centers for Disease Control and
Prevention Advisory Committee on Immunization Practices guidelines for age, which
are updated annually. Also, includes resources for health care professionals.
• “IOC Consensus Meeting on Sex Reassignment and Hyperandrogenism” (https://
stillmed.olympic.org/Documents/Commissions_PDFfiles/Medical_commission/
2015-11_ioc_consensus_meeting_on_sex_reassignment_and_hyperandrogenism-en.
pdf). An IOC (International Olympic Committee) consensus statement on sex reassign-
ment as it relates to sports.
• The Marfan Foundation (www.marfan.org/dx/home): More information about the diag-
nosis of Marfan syndrome.
• Mental Health Best Practices: Best Practices for Understanding and Supporting Student-Athlete
Mental Wellness (www.ncaa.org/sites/default/files/HS_Mental-Health-Best-
Practices_20160317.pdf): A National Collegiate Athletic Association resource for practi-
tioners and coaches addressing mental health issues in athletes.
• Mind, Body and Sport: Understanding and Supporting Student-Athlete Mental Wellness (www.
naspa.org/images/uploads/events/Mind_Body_and_Sport.pdf): A National Collegiate
Athletic Association resource for practitioners and coaches addressing mental health
issues in athletes.
• “Nutrition and Athletic Performance” (https://journals.lww.com/acsm-msse/
Fulltext/2016/03000/Nutrition_and_Athletic_Performance.25.aspx): A census state-
ment from the Academy of Nutrition and Dietetics, Dietitians of Canada, and American
College of Sports Medicine

Resources 229
• “Physical Activity, Fitness, Cognitive Function, and Academic Achievement in Children:

A Systematic Review” (https://journals.lww.com/acsm-msse/Fulltext/2016/06000/
Physical_Activity,_Fitness,_Cognitive_Function,.27.aspx): Explores the relationship
among physical activity, fitness, cognitive function, and academic achievement. From
the American College of Sports Medicine.
• A Pocket Guide to Blood Pressure Measurement in Children (www.nhlbi.nih.gov/health/
public/heart/hbp/bp_child_pocket/bp_child_pocket.pdf): Available with tables based
on sex, age, and height and with systolic blood pressure (BP) and diastolic BP values
listed for prehypertension, stage 1 hypertension, and stage 2 hypertension. From the
National High Blood Pressure Education Program Working Group on High Blood
Pressure in Children and Adolescents.
• Society for Adolescent Health and Medicine “Clinical Care Resources” (www.adolescen-
thealth.org/Resources/Clinical-Care-Resources.aspx): Resources that address many of the
risks faced by an adolescent athlete.
• “Sports-Related Skin Infections Position Statement and Guidelines” (www.nfhs.org/
media/1014740/sports_related_skin_infections_position_statement_and_guidelines_-
final-april-2018.pdf): A standard approach to skin infections used by the National
Federation of State High School Associations.
• Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming
People (www.wpath.org/publications/soc): A detailed reference and thorough discus-
sion related to transgender health care. From the World Professional Association for
Transgender Health.
• “The Team Physician and Strength and Conditioning of Athletes for Sports” (https://
journals.lww.com/acsm-msse/Fulltext/2015/02000/The_Team_Physician_and_
Strength_and_Conditioning.27.aspx): A consensus statement to optimize the per-
formance of athletes and minimize the risk of injury and illness. From the American
Academy of Family Physicians, American Academy of Orthopaedic Surgeons, American
College of Sports Medicine, American Medical Society for Sports Medicine, American
Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of
Sports Medicine.
• “Team Physician Consensus Statement” (www.aafp.org/dam/AAFP/documents/patient_
care/fitness/ACSMteamphysicianconsensus.pdf): A census statement from the American
Academy of Family Physicians, American Academy of Orthopaedic Surgeons, American
College of Sports Medicine, American Medical Society for Sports Medicine, American
Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports
Medicine.
• US Preventive Services Task Force “Recommendations for Primary Care Practice” (www.
uspreventiveservicestaskforce.org/BrowseRec/Index?age=Pediatric,Adolescent): Reviews
evidence of effectiveness and develops recommendations for clinical preventive service.
Policy and Position Statements

• American Academy of Family Physicians (www.aafp.org/about/policies/a-z.html)
• American Academy of Pediatrics (www.aappublications.org/search/policy/
numresults%3A10%20sort%3Apublication-date%20direction%3Adescending%20
format_result%3Astandard)

230 Resources
• American College of Sports Medicine (www.acsm.org/acsm-positions-policy/

official-positions/ACSM-position-stands)
• American Heart Association (www.heart.org/HEARTORG/General/American-Heart-
Association-Policies_UCM_303548_Article.jsp#.XIGS0P58A2w)
• American Medical Society for Sports Medicine (www.amssm.org/Publications.html)
• American Orthopaedic Society for Sports Medicine (www.sportsmed.org/aossmimis/
Members/Publications/Consensus_Statements.aspx)
• American Osteopathic Academy of Sports Medicine (www.aoasm.org/page/
Position_Papers)
• National Athletic Trainers’ Association (www.nata.org/news-publications/pressroom/
statements/position)
• National Federation of State High School Associations (www.nfhs.org)
• Society for Adolescent Medicine (www.adolescenthealth.org/Advocacy/Position-Papers-
Statements.aspx)

Index
Page numbers followed by an f, a t, or a b indicate a figure, a table, or a box, respectively.
■■ A Aortic stenosis, 46b, 52, 56, 60t

Arrhythmogenic right ventricular cardiomyopathy,
AAI. See Atlantoaxial instability 46, 49
Abdomen ARVC. See Arrhythmogenic right ventricular
distention of, 171 cardiomyopathy
in female athletes, 171 Asthma
injuries to, 117 exercise-induced bronchospasm and, 112
physical examination of, 119 exercise-induced laryngeal obstruction versus,
scaphoid, 171 112–113
Abnormal or anomalous origin of the left coronary history taking, 111, 113
artery, 48, 56 Atherosclerotic coronary artery disease, 46
Achondroplastic dwarfism, 186 Athletes
ACIP. See Advisory Committee on Immunization with disability. See Disability, athletes with
Practices female. See Female athletes
ACL injuries. See Anterior cruciate ligament injuries student-athletes. See College student-athletes
Acne, 127–128 transgender, 193–196
ADHD. See Attention-deficit/hyperactivity disorder Atlantoaxial instability, 183, 186b, 186–188, 188b
ADI. See Atlanto-dens interval Atlanto-dens interval, 188
Adolescents. See also Children Attention-deficit/hyperactivity disorder, 153
blood pressure in, 202 Autism spectrum disorder, 186
chronic conditions in, 13 Autonomic dysreflexia, 183–184
counseling of, 12 Autopsy-negative sudden unexplained death, 46–47
growth charts of, 166
health care information requests by, 12
hypertension in, 55 ■■ B
preparticipation physical evaluation of, 3
sleep of, 157 Bacterial dermatoses, 126
US Preventive Services Task Force recommenda- Bacterial meningitis, 107
tions for, 205t Balance Error Scoring System (BESS), 74
ß-Adrenergic agonist medications, 113–114 Baseline comparison method, 74
Advisory Committee on Immunization Practices, Bazett formula, 53
106–107 Beck Depression Inventory-Fast Screen, 151
Affordable Care Act (ACA), 13 Beighton scale, 144, 145t
AHA. See American Heart Association Belly-press test, 135, 136f
Airway hyperresponsiveness, 206 Benign exertion headache, 81
Allergies, 93–95 Berlin Questionnaire, 157
Amenorrhea, 118, 132, 167–168, 173–174 Binge drinking, 153
American Heart Association, 3, 17, 202 Biological sex, 193
Americans with Disabilities Act, 179 Blood pressure
Anaphylaxis, 93–95 brachial artery, 61
Anemia, 169–170, 205 and hypertension, 54–55, 202
Ankle ligaments, 142, 142f measurement of, 61
Anorexia nervosa, 165, 169, 171 Blood-borne pathogens, 92
ANSUD. See Autopsy-negative sudden unexplained Blunt abdominal trauma, 117
death BMD. See Bone mineral density
Anterior cruciate ligament injuries BMI. See Body mass index
in female athletes, 162–163 Body mass index, 89–90, 90t, 166, 172t, 202
noncontact, 162–163 Bone mineral density
risk factors for, 162–163 description of, 169
tests for, 140, 141f dual energy x-ray absorptiometry testing of, 172t,
Anterior drawer test, 141f, 142, 142f 172–173
Anterior superior iliac spine, 119 Bone stress injuries, 131–132, 161–162
Antiepileptics, 81 “Boosting,” 183–184
Anxiety disorders, 152, 152b Box drop test, 144
Aortic dissection, 49–50, 52 Brachial artery blood pressure, 61
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232 Index
Brachial plexus injuries, 76–79, 79t–80t Cisgender, 196

Brain trauma, 73 Class v Towson University, 31–32
Breach of conduct, 29 CNT. See Computerized neurocognitive testing
Brief Eating Disorder in Athletes Questionnaire Coding, 207
(BEDA-Q), 37 Cognitive impairment, 181
Bronchospasm, exercise-induced, 111–113 “Cold sores,” 124
Bullying, 154–155 College athletic departments, 17
“Burners.” See “Stingers” College student-athletes
alcohol use among, 153
bullying among, 154
■■ C preparticipation physical evaluation frequency for,
17
CA-MRSA. See Community-acquired methicillin- substance use and use disorders among, 153–154
resistant Staphylococcus aureus Community-acquired methicillin-resistant
Cardiac testing, 59 Staphylococcus aureus, 125–127
Cardiopulmonary risk, 64–65, 65f Compression fractures, 135
Cardiovascular disorders. See also specific disorder Compression “stingers,” 76
chest pain, 56 Computerized neurocognitive testing, 74
family history taking, 59–60 Concussion, sport-related, 72–75, 163–164
history-taking questions, 43, 56t–58t Confidentiality, 27
hypertension, 54–55 Congenital heart disease, 184
key points regarding, 44 Contact sports, 40b
medical eligibility recommendations for athletes Contusions, 146
with, 64–66 Coordinated medical evaluation, 21, 21t
noninvasive screening for Coordinated medical team, 20–21, 22b
electrocardiography, 63, 63f–64f Coronary artery anomalies, 48, 56
modalities for, 62 Coronary artery disease
outcomes from, 62–63, 63f–64f age-based incidence of, 58
personal history taking, 43, 55–59 atherosclerotic, 46, 52
physical examination for, 60–61 ion channel disorders, 52–54
preparticipation cardiovascular evaluation CPVT. See Catecholaminergic polymorphic ventricular
limitations and, 61–62 tachycardia
sudden cardiac arrest or death. See Sudden cardiac CR-39 lenses, 104
arrest or death CRAFFT Screening Tool for Adolescent Substance
symptoms of, investigation of athletes with, 61 Abuse, 37, 154
syncope associated with, 58–59 Cross-sex hormone therapy, 194
Cardiovascular system. See also specific heart entries Cystic medial necrosis, 49
family history taking, 59–60
in female athletes, 171
history-taking questions, 43, 56t–58t ■■ D
personal history taking, 43, 55–59
physical examination of, 60–61 Delayed puberty, 37
Catecholaminergic polymorphic ventricular Deltoid, 135
tachycardia, 54, 58 Depression, 150–151, 150–152
CCN. See Cervical cord neurapraxia Dermatologic conditions. See also Skin infections
Center for Epidemiologic Studies-Depression, 151 acne, 127–128
Cerebral blood flow, 73 herpes simplex virus, 124
Cerebral palsy, 186, 188 key points regarding, 123
Cervical cord neurapraxia, 71, 75–76, 79t medical eligibility for participation, 125–128
Cervical spine, 134 skin infections. See Skin infections
CES-D. See Center for Epidemiologic Diabetes mellitus, 90–92
Studies-Depression Diabetic gastroparesis, 91
Chaperone, 29 Diabetic nephropathy, 91
Charitable immunity, 33–34 Diastolic murmur, 60t
Chest pain, 56 Dietary energy, 166
Children. See also Adolescents Diffuse cerebral swelling, 73
abuse and neglect of, mandatory reporting of, 33 Disability, athletes with
hypertension in, 55 Americans with Disabilities Act definition of, 179
sexual abuse of, 156 cognitive impairment, 181
solitary kidney in, 97b dermatologic function in, 187
Chlamydophila pneumoniae, 48 diagnostic imaging for, 188
Cholinergic urticaria, 95 evaluation methods for, 182
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Index 233
federal legislation for, 179 hypertrophic cardiomyopathy findings, 48

form for, 223 long QT syndrome findings, 53
functional assessment of, 188 myocarditis findings, 49
medical eligibility for, 189 screening uses of, 4–5
medical history for, 182–184 Electromyography, for brachial plexus injuries, 77
multidisciplinary approach for, 189 Electronic health record. See Electronic
musculoskeletal system in, 187 medical record
Paralympics, 181–182 Electronic medical record, 207
physical examination of, 184–188 Electronic preparticipation physical evaluation, 207
physical impairment, 180–181 Eligibility, medical. See Medical eligibility
Special Olympics, 181, 184, 189 E-mail, 28
sports benefits for, 179–180 Emergency information, 27–28
urogenital system in, 187 Empty can test, 135, 136f
Disabling conditions, 12 Energy availability, 166, 173
Dislocations, 146 Epstein-Barr virus, 97
Disordered eating, 164–165 Erythema, 170
Distal forearm fractures, 162 Ethical decision-making, 29–30
DO. See Doctor of osteopathic medicine Ethical issues, 29–30
Doctor of medicine, 15 Examination. See Physical examination
Doctor of osteopathic medicine, 15 Examiner qualifications, 15–16
Down syndrome, 182–183, 186, 188 Exculpatory waivers, 32
Dual energy x-ray absorptiometry, 172t, 172–173 Exercise collapse associated with sickle cell trait,
DXA. See Dual energy x-ray absorptiometry 101, 103
Dynamic exercises, 65 Exercise energy expenditure, 166
Dysmenorrhea, 167 Exercise-associated collapse, 59
Dyspnea Exercise-associated muscle cramps, 101
description of, 59 Exercise-induced anaphylaxis, 94–95
exercise-induced, 111 Exercise-induced bronchospasm
description of, 111–113
history taking, 113
■■ E medical eligibility and, 115
prevalence of, 112, 206
EAC. See Exercise-associated collapse tests for, 114
EAMCs. See Exercise-associated muscle cramps treatment of, 114
Eating disorders, 162, 165–166, 172t Exercise-induced dyspnea, 111
EBV. See Epstein-Barr virus Exercise-induced laryngeal obstruction
ECAST. See Exercise collapse associated with sickle asthma versus, 112–113
cell trait description of, 111
ECG. See Electrocardiography diagnosis of, 114
Echocardiography in female athletes, 171
arrhythmogenic right ventricular cardiomyopathy treatment of, 115
findings, 49 triggers for, 113
hypertrophic cardiomyopathy findings, 48 Exercise-related collapse, 100
myocarditis findings, 49 Exertion headaches, 81
sudden cardiac death screening, 4 Exertional angina, 56
universal screening, 4 Exertional heat illness, 98–101, 101b
Effort headache, 81 Exertional heat stroke, 99–100
Ehlers-Danlos syndrome, 144, 183 Exertional sickling, 204
EHS. See Exertional heat stroke Exertional syncope, 58–59
EIAn. See Exercise-induced anaphylaxis Eye disorders, 103–106
EIB. See Exercise-induced bronchospasm Eye injuries, 104
EID. See Exercise-induced dyspnea Eye protection, 104, 105b
EILO. See Exercise-induced laryngeal obstruction
Elbow
carrying angle of, 138f ■■ F
physical examination of, 136, 138f
ulnar collateral ligament of, 138f FABER test, 140, 140f
Electrocardiography FADIR test, 139–140, 140f
anorexia nervosa findings, 171 FAI. See Femoral acetabular impingement
arrhythmogenic right ventricular cardiomyopathy Familial dyslipidemia, 5
findings, 49 Familial hypercholesterolemia, 52
cardiovascular screening uses of, 63, 63f–64f Family Educational Rights and Privacy Act, 25–26
14_Index_231-240.indd 233 3/26/19 2:33 PM

234 Index
Family history Flexion, adduction, and internal rotation test. See

cardiovascular disorders, 59–60 FADIR test
heart-related questions, 43 FMS. See Functional Movement Screen
sudden cardiac arrest or death, 59–60 Food allergies, 94
Fat-free mass, 166 Food-dependent exercise-induced anaphylaxis, 95
Fatigue Forearm fractures, 162
exercise-related, 59 Forms
history-taking questions, 57t athletes with disability, 223
infectious mononucleosis-related, 97–98 medical eligibility, 225
FBN1 mutation, 50 medical history, 217–220
FDEIAn. See Food-dependent exercise-induced physical examination, 221
anaphylaxis Fractures
Female athlete triad, 162, 173 distal forearm, 162
Female athletes dual energy x-ray absorptiometry testing and, 172t
abdomen in, 171 medical eligibility of athlete with, 146
amenorrhea in, 132, 167–168 stress, 173–174
anemia in, 169–170 Fulminant rhabdomyolysis, 103
anterior cruciate ligament injuries in, 162–163 Functional hypothalamic amenorrhea, 168
bone stress injuries in, 161–162 Functional Movement Screen, 206
cardiovascular system in, 171 Functional movement tests, 143
disordered eating, 165–166
eating disorders in, 162, 165–166
elemental iron in, 165 ■■ G
energy availability in, 167–168, 173
ferritin levels in, 169–170, 205 GAD. See Generalized anxiety disorder
general assessment of, 170 Gastrointestinal system
genitalia of, 171 abdominal injuries, 117
gynecologic disorders in, 173–174 health issues of, 118t
head, eyes, ears, nose, and throat evaluation of, 170 physical examination of, 119
height measurements, 170 Gender, 193
hormone replacement therapy in, 169 Gender Affirmative Lifespan Approach, 196
iron levels in, 169–170 General medical conditions
lungs in, 171 allergies, 93–95
medical eligibility of, 173–174 anaphylaxis, 93–95
menstrual history of, 167–169 blood-borne pathogens, 92
musculoskeletal injury in, 161–163 diabetes mellitus, 90–92
musculoskeletal system in, 172 exertional heat illness, 98–101, 101b
neurological conditions in, 163–164 eye disorders, 103–106
nutrition status of, 162 immunizations, 106–107
nutritional concerns in, 164–166 infectious mononucleosis, 97–98
oligomenorrhea in, 167–168 key points regarding, 89
oral contraceptives in, 168–169 organ absence, 96, 97b
physical examination of, 170–173 sickle cell trait, 101–103
pregnancy in, 173–174 solitary organs, 96, 97b
respiratory system in, 171 surgical history, 95–96
return to play determinations for, 173 vision, 103–106
skin of, 171–172 weight concerns, 89–90
sport-related concussion in, 75 Generalized anxiety disorder, 152
transgender, 193–196 Generalized Anxiety Disorder 7-item scale, 37, 150,
underweight, 166 152
vegetarianism by, 165 Genitalia. See also Urogenital system
weight measurements, 170 of female athletes, 171
Femoral acetabular impingement, 139, 144 physical examination of, 119
Femoral artery pulse, 61 Girl athletes. See Female athletes
FERPA. See Family Educational Rights and Privacy Act Glide test, 140f
Ferritin, 169–170, 205 Good Samaritan statutes, 33–34
FFM. See Fat-free mass Graham Steele murmur, 60t
Fire ants, 94 Group-based examinations, 19
Flatfoot, 142–143 Growth charts, 166
Flexion, abduction, and external rotation test. See Guyon canal syndrome, 184
FABER test Gynecologic disorders, 173–174
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Index 235
■■ H Hypertrophic cardiomyopathy, 46–48, 59

Hypoglycemia, 91
Hand, 138
Hawkins test, 136, 136f
Hazing, 154–155 ■■ I
HBV. See Hepatitis B virus
HCM. See Hypertrophic cardiomyopathy Illness, predisposing conditions for, 12
HCV. See Hepatitis C virus IM. See Infectious mononucleosis
Head, eyes, ears, nose, and throat, 170 Immunizations, 106–107
Headaches, 81–82 Impetigo, 125
Health care home. See Medical home Indwelling urinary catheter, 183
Health information. See Personal health information Infectious diseases
Health Insurance Portability and Accountability Act personal health information regarding, sharing
description of, 16, 25–26 of, 28
Family Educational Rights and Privacy Act, 26 of skin. See Skin infections
Privacy Rule, 26 Infectious mononucleosis, 97–98, 118
Health supervision encounters, 214 Influenza vaccine, 106
Health supervision visits, American Academy of Informed consent, 32
Pediatrics recommendation for, 17 Infraspinatus, 135
Heart auscultation, 60 Inguinal hernia, 120
Heart disease, 58t Injuries
Heart murmurs abdominal, 117
history-taking questions, 57t anterior cruciate ligament. See Anterior cruciate
pathological, 61 ligament injuries
physical examination for, 60, 60t bone stress, 131–132, 161–162
physiological, 61 brachial plexus, 76–79, 79t–80t
Heartbeats, irregular, 57t eye, 104
Heat exhaustion, 100, 183 musculoskeletal. See Musculoskeletal injuries
Heat illness, exertional, 98–101, 101b predisposing conditions for, 12
Heat stroke Insomnia, 157
exertional, 99–100 Insomnia Severity Index, 157
history taking, 183 Inspiratory stridor, 113
HEENT. See Head, eyes, ears, nose, and throat Inspiratory-expiratory flow loop testing, 114
Height curves, 37 Insulin, 91
Heinz, W., 15, 18 Interim annual evaluations, 22–23
Hematuria, 118 International Classification of Diseases, Tenth Revision,
Hepatitis B virus, 92 Clinical Modification code, 3, 207
Hepatitis C virus, 92 International Olympic Committee, 194–195
Hepatomegaly, 98, 119 International Paralympics, 181–182
Hernia, inguinal, 120 Interpreters, 36–37
Herpes gladiatorum, 124–126 IOC. See International Olympic Committee
Herpes simplex virus, 124 Ion channel disorders, 52–54
High school sports Iron, 169–170
preparticipation physical evaluation and, 3, 18 Iron deficiency anemia, 165, 169, 205
state-based variations, 3 Israel, 199
Hip, 139f, 139–140
History
family. See Family history ■■ J
medical. See Medical history
Jefferson fractures, 79t
menstrual, 167–169
Joint National Committee on Prevention, Detection,
surgical, 95–96
Evaluation, and Treatment of High
HIV
Blood Pressure, 54
mandatory screening for, 92
screening for, 5
transmission of, 92
Hormone replacement therapy, 169 ■■ K
Human papillomavirus vaccine, 106 Kidneys
25-Hydroxyvitamin D, 165 abnormalities of, 120
Hypercarotenemia, 171 anomalies of, 182
Hypermenorrhea, 168 in athletes with disabilities, 182
Hypertension, 54–55, 202 solitary, 96, 97b, 120
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236 Index
King-Devick test, 74 Medical history

Klippel-Feil anomaly, 79t, 186 of athletes with disabilities, 182–184
Knapp v Northwestern University, 31 barriers to, 36–37
Knee, 140f–141f, 140–142 benefits of, 36
cardiovascular disorders, 55–60
forms for, 217–220
■■ L heart-related questions, 43
interpreters for, 36–37
Lachman test, 140, 141f medications, 93
Lactose intolerance, 165 musculoskeletal conditions detected with, 36
Landing Error Scoring System, 163 parental involvement in, 36
Larsen-Johansson disease, 147 physical examination and, 38
Lead-time bias, 204 refining of, 201
Left ventricular hypertrophy, 52, 56 research regarding importance of, 201
Legal risk, 33 sensitivity of questions, 202
Length bias, 204 supplements, 93
LESS. See Landing Error Scoring System Medical home, 13, 16
Life-threatening conditions, 12 Medical opinion, 30
Lift-off test, 135–136, 136f Medical release form, 27
Limited-contact sports, 40b Medications, review of, 93
Lipid profile, 5 Menarche, 172t
Long QT syndrome, 53t, 53–54 Meningitis, 107
Loss of consciousness, 57t Menorrhagia, 168
Low energy availability, 167–168 Menstrual cramping, 167
Lower-limb amputation, 187 Menstrual history, 167–169
Mental health conditions
anxiety disorders, 152, 152b
■■ M attention-deficit/hyperactivity disorder, 153
bullying, 154–155
Major depressive disorder, 150–151 in college students, 154
Male genitourinary examination, 119 depression, 150–151
Mandatory reporting, 33 hazing, 154–155
Marfan syndrome, 49–51, 50t–51t key points about, 149
MD. See Doctor of medicine major depressive disorder, 150–151
MDD. See Major depressive disorder mood disorders, 150–152
Measles, 107 sexual abuse, 155–156
Measles, mumps, and rubella vaccine, 107 sleep disorders, 156–157
Medial tibial stress syndrome, 142–143 social stigma associated with, 149
Median neurodynamic test, 77, 78f substance use and use disorders, 153–154
Medical conditions, general. See General medical Mental Health Screening Form-III, 154
conditions MHSF-III. See Mental Health Screening Form-III
Medical eligibility Migraine headaches, 81
for athletes with disability, 189 Mild traumatic brain injury, 72
and cardiovascular disorders, 64–66 Military service, 2
categories of, 38 MMR. See Measles, mumps, and rubella vaccine
changes in, 41 Modified milking maneuver, 138, 138f
considerations for, 39–41 Molluscum contagiosum, 125–126
and dermatologic conditions, 125–128 Mood disorders, 150–152
description of, 26 MTSS. See Medial tibial stress syndrome
determinations of, 38–39 Multidirectional instability, 136, 137f
ethics of, 30 Multiple sclerosis, 186
and exercise-induced bronchospasm, 115 Mumps, 107
of female athletes, 173–174 Musculoskeletal disorders
form for, 225 contusions, 146
legal aspects of, 30–32 developmental conditions, 146–147
and musculoskeletal disorders, 145–147 dislocations, 146
restrictions and limitations on, 30–32, 38, 41 fractures. See Fractures
and splenomegaly, 98 medical eligibility for participation, 145–147
and sport-related concussion, 73 sprains, 146
and urogenital disorders, 119–120 strains, 146
Medical Eligibility Form, 16, 27, 29, 225 subluxations, 146
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Index 237
Musculoskeletal injuries headaches, 81–82

description of, 131 key points about, 71
in female athletes, 161–163 medical questions regarding, 71
history for detecting of, 36 seizures, 80–81, 182
scoliosis, 134f sport-related concussion, 72–75, 163–164
Musculoskeletal system Neuropsychological assessment, 75
ankle ligaments, 142, 142f New-onset seizures, 81
anterior cruciate ligament, 132 NFHS. See National Federation of State High School
in athletes with disability, 187 Associations
box drop test, 144 N-methyl-d-aspartate receptors, 73
cervical spine, 134 Noncontact sports, 40b
elbow, 136, 138f Non-proliferative retinopathy, 91
evaluation of, 131 Non–rapid eye movement sleep. See Non-REM sleep
in female athletes, 172 Non-REM sleep, 157
functional movement tests, 143 Nonsteroidal anti-inflammatory drugs, for exercise-
hand, 138 induced anaphylaxis, 94–95
hip, 139f, 139–140 NPs. See Nurse practitioners
knee, 140f–141f, 140–142 Nurse practitioners, 15
lower extremity, 139–143 Nutrition status, of female athletes, 164–166
medical eligibility considerations, 145–147
overview of, 131–132
physical examination of ■■ O
deltoid strength, 135
joint-specific testing, 134–138 Obesity, 90, 157
lower extremity, 139–143 Obstructive sleep apnea, 157
overview of, 132, 134 Odontoid fractures, 79t
shoulder, 135f–137f, 135–136 Oligomenorrhea, 167–168, 173
upper extremity, 135–138 On-site specialists, 21
value of, 203 Open wound, 125
screening examination for, 132, 133f, 203 Oral contraceptives, 168
single-leg squat test, 143, 143f Organ(s)
sport-specific examination, 144–145 absence of, 96, 97b
thoracolumbar spine, 134f, 134–135 loss of, 118
vertical jump maneuver, 144f Organomegaly, 119
wrist, 138 Osgood-Schlatter disease, 142, 146
Myocardial bridging, 56 Osteoporosis, 165
Myocarditis, 48–49 Outcomes, 207
■■ N ■■ P
National Association of Intercollegiate Athletics, 17 PAHE. See Periodic athlete health evaluation
National Collegiate Athletic Association Pahulu v University of Kansas, 31
concussion assessment recommendations, 74 Panic attack, 152
depression and, 150 Panic disorder, 152
preparticipation physical evaluation recommenda- Paradoxical vocal cord motion disorder, 171
tions of, 2, 17 Paralympics, 181–182
transgender athletes and, 194 Parotid gland enlargement, 170
National Federation of State High School PAs. See Physician assistants
Associations, 2, 15, 123, 194 Patella apprehension test, 140, 140f
National Junior College Athletic Association, 17 Patellofemoral joint, 172
NCAA. See National Collegiate Athletic Association Patellofemoral joint pain, 143
Near syncope, 59 Patient Health Questionnaire, 37
Neck strengthening, 78 Patient Health Questionnaire version 2, 151
Neer impingement test, 136, 136f Patient Health Questionnaire version 4, 149–151,
Neisseria meningitidis, 107 217, 219
Neurally mediated syncope, 59 Patient Health Questionnaire version 9, 150
Neurocardiogenic syncope, 59 Patient Health Questionnaire adolescent version,
Neurological disorders 150–151
brachial plexus injuries, 76–79, 79t–80t PCP. See Primary care provider
cervical cord neurapraxia, 71, 75–76 PCS. See Postconcussion syndrome
in female athletes, 163–164 Periodic athlete health evaluation, 17
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238 Index
Peripheral nerve entrapment syndromes, 184 Pressure sores, 183, 187, 189
Peripheral neuropathy, 91 Preventive health visits. See Health supervision visits,
Personal health information American Academy of Pediatrics rec-
description of, 25–26 ommendation for
restrictions on, 28 Preventive services, 11
sharing of, 28 Primary amenorrhea, 118, 167
Pharyngeal “cobblestoning,” 113 Primary care provider, 16, 19
PHI. See Personal health information Primary cough headaches, 81
PHQ. See Patient Health Questionnaire Prior illness or injury, 12
PHQ-4. See Patient Health Questionnaire version 4 PROMIS Depression instruments, 37
Physical disability, 181 Prosthetic devices, 183
Physical examination Psychological health, 11
of athletes with disability, 184–188, 185b Public health information, 27–28
benefits of, 202–203 Pulmonary function, 111
for cardiovascular disorders, 60–61
of female athletes, 170–173
form for, 221 ■■ Q
medical history and, 38
musculoskeletal system. See Musculoskeletal sys- QT interval, 53–54, 54f
tem, physical examination of
of skin. See Skin examination
structured, 37–38 ■■ R
Physical health, 11
Radial artery pulse, 61
Physical impairment, 180–181
Radial neurodynamic test, 77, 78f
Physician assistants, 15
Rapid eye movement sleep. See REM sleep
Pittsburgh Sleep Quality Index, 157
REM sleep, 157
Polymenorrhea, 168
Rescue inhaler, 115
Popliteal angle, 139
Research, 199–207, 208b
Postconcussion syndrome, 71, 74
Respiratory system
Posterior drawer test, 141f
background on, 112–113
PPE. See Preparticipation physical evaluation
in female athletes, 171
Pregnancy, 173–174
history taking, 113
Preparticipation physical evaluation
key points about, 111
administration summary of, 20b
physical examination of, 113
of adolescents, 3
pulmonary function questions, 111
at collegiate level, 2
tests of, 114
conclusion regarding, 213–214
Rhabdomyolysis
coordinated medical team approach to, 22b
fulminant, 103
effectiveness of, 2
heat-related, 100
electronic, 207
sickle cell trait and, 102
frequency of, 17–18, 201
Rotator cuff
goals of, 11–13
impingement of, 136f
in group setting, 27
strength assessments for, 135, 136f
history of, 1
Russell sign, 172
interim annual evaluations, 22–23
Medical Eligibility Form, 16, 27, 29, 225
medical history, 5
methods of, 19–22 ■■ S
military service effects on, 2 SAHM. See Society for Adolescent Health and
need for, 199–202 Medicine
origins of, 1, 199 Scaphoid abdomen, 171
outcomes of, 207 Scoliosis, 134f
purpose of, 1, 3, 199 Screening tests. See also specific screening test
recommendations for, 2 cardiac, 206
screening tests added to, 63 “case finding” diagnostic tests versus, 4
setting of. See Setting of evaluation criteria for appraising of, 203b
standardized approach to, 1, 200 definition of, 203
state mandates for, 201 description of, 4–6
systematic approach to, 36 evaluation of, 4
timing of, 16 ferritin, 205
updating of, 199–200 HIV, 5
and youth sports, 2–3 iron deficiency anemia, 205
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Index 239
sudden cardiac death, 4 testicular injury caused by, 120

urine, 5 youth, 2–3, 200
value of, 4 Sport-related concussion, 72–75, 163–164
Second impact syndrome, 73 Sports participation
Secondary amenorrhea, 118, 167 restriction from, 27, 29–30
Seizures, 80–81, 182 socioeconomic status and, 200
SET. See Shin edema test Sprains, 146
Setting of evaluation SPT. See Shin palpation test
description of, 19–22 Spurling test, 77, 77f
legal ramifications of, 33 SRC. See Sport-related concussion
Sever disease, 146 State(s)
Sex, biological, 193 examiner regulations, 15
Sex-specific growth charts, 166 high school sports requirements and, 3
Sexual abuse, 155–156 preparticipation physical evaluation mandates, 201
Sexual assault, 155 volunteer settings and, 34
Sexual violence, 156 Static exercises, 64–65
Shared decision-making model, 66 “Stingers,” 76–78
Shin edema test, 142 Stinging insects, 94
Shin palpation test, 142 STOP-Bang questionnaire, 157
Shortness of breath, 57t Strains, 146
Shoulder Strength of Recommendation, 6t–7t, 127, 202
multidirectional instability screening, 136, 137f Stress fractures, 173–174
physical examination of, 135f–137f, 135–136 Stressors, 149
range of motion of, 135, 135f Student-athletes. See College student-athletes
rotator cuff, 135, 136f Subluxations, 146
Shoulder pain, 188 Substance use and use disorders, 153–154
Sickle cell deaths, exercise-associated, 4 Sudden cardiac arrest or death
Sickle cell disease, 102 aortic dissection as cause of, 49–50, 52
Sickle cell trait, 101–103, 205 aortic stenosis as cause of, 52
Single-leg squat test, 143, 143f arrhythmogenic right ventricular cardiomyopathy
Sinus of Valsalva, 48 as cause of, 46, 49
SIS. See Second impact syndrome causes of, 46b, 46–52
Skin examination coronary artery anomalies as cause of, 48
of athletes with disabilities, 187 coronary artery disease as cause of. See Coronary
of female athletes, 171–172 artery disease
Skin infections. See also Dermatologic conditions family history taking, 59–60
description of, 123–124 hypertrophic cardiomyopathy as cause of,
herpes simplex virus, 124 47–48
medical eligibility for participation, 125–128 incidence of, 45
prevention of, 127 Marfan syndrome, 49–51, 50t–51t
restrictions for athletes with, 127 myocarditis as cause of, 48–49
wrestling and, 126 risk-based differences, 45
Sleep disorders, 156–157 screening tests for, 4, 62
Society for Adolescent Health and Medicine, 11, 13 sex-specific differences, 45
Socioeconomic status, 200 in soccer players, 45
Solitary organs, 96, 97b sports as risk for, 45
SORT. See Strength of Recommendation Taxonomy statistics regarding, 45
Special Olympics, 181, 184, 189 Suicide, 150
Spina bifida occulta, 79t Supplements, 93
Spleen Supraspinatus, 135
rupture of, 97–98 Surgical history, 95–96
trauma to, 117–118 Syncope, 58–59
Splenomegaly, 97–98, 118 Systolic murmur, 60t
Spondylolisthesis, 146
Spondylolysis, 146
Sport(s) ■■ T
abdominal injuries caused by, 117
classification of, 40b, 65f Talar tilt test, 142f
eye injury risks, 105b Tanner staging, 119
high school Testicular disorders, 120
preparticipation physical evaluation and, 3, 18 Testicular examination, 119
state-based variations, 3 Therapeutic use exemption, 114
14_Index_231-240.indd 239 3/26/19 2:33 PM

240 Index
Thermoregulation, 183 Varus stress test, 140, 141f

Thoracolumbar spine, 134f, 134–135 Vasovagal syncope, 59
Tibial tubercle, 142 Vegetarianism, 165
Timing, 16 Ventricular tachycardia, catecholaminergic polymor-
Tinea corporis, 126 phic, 54, 58
Tinea gladiatorum, 125 Vertebral body compression fractures, 79t–80t
Tinel sign, 184 Vertical jump maneuver, 144f
Toe deformities, 143 Vestibular Ocular Motor Screening, 74
Torsades de pointes, 53 Vision, 103–106
Transgender athletes, 193–196 Vitamin D, 165
Transient brachial plexopathy. See Brachial plexus Vocal cord dysfunction, exercise-induced, 111
injuries Volunteer Protection Act of 1997, 34
Transient brachial plexus injuries. See Brachial plexus Vomiting, self-induced, 170
injuries VOMS. See Vestibular Ocular Motor Screening
Transient paraplegia. See Cervical cord neurapraxia
Transient quadriplegia/tetraplegia. See Cervical cord
neurapraxia ■■ W
Traumatic brain injury, mild, 72
Travel, 28–29 WADA. See World Anti-Doping Agency
Triiodothyronine, 168 Waivers, exculpatory, 32
TUE. See Therapeutic use exemption Warts, 125–126
WBGT. See Wet bulb globe temperature
Weight
■■ U body mass index, 89–90
concerns regarding, 89–90
Ulcers, 183 loss of, 165
Ulnar collateral ligament, 138f measurement of, 170
Underweight, 166 Wet bulb globe temperature, 100
Undescended testicle, 120 Wheelchairs, use of, 187
Universal precautions, 92 Women athletes. See Female athletes
Urogenital system. See also Genitalia World Anti-Doping Agency, 81, 195
in athletes with disability, 187 World Health Organization Wilson-Jungner criteria,
health issues of, 118t 203
inguinal hernia, 120 Wrestling, 126
key points regarding, 117 Wrist, 138
kidney abnormalities, 120
medical eligibility considerations, 119–120
testicular disorders, 120 ■■ Y
US Commission on Chronic Illness, 203
US Preventive Services Task Force, 202, 204, 205t, 206 Youth sports, 2–3, 200
US Selective Service, 2
USPSTF. See US Preventive Services Task Force
■■ Z
Zika virus, 174, 174t
■■ V
Vaccinations, 106–107
Valgus stress test, 140, 141f
14_Index_231-240.indd 240 3/26/19 2:33 PM

PPE PPE
PREPARTICIPATION
PPE PREPARTICIPATION PHYSICAL EVALUATION

PHYSICAL
EVALUATION 5th Edition
American Osteopathic Academy of Sports Medicine PREPARTICIPATION
THE AUTHORITATIVE RESOURCE FOR ATHLETIC SCREENING
The fifth edition of this best-selling resource provides Topics include PHYSICAL
EVALUATION
practical guidance for determining athletic medical • System-based examination: cardiovascular,
eligibility, optimizing sports participation safety, and nervous system, respiratory, gastrointestinal
promoting healthy lifestyles. and urogenital, dermatologic, musculoskeletal,
Developed by leading medical societies, PPE: mental health, and more
Preparticipation Physical Evaluation guides health care • Preparticipation physical evaluation timing,
professionals through the preparticipation physical setting, and structure
evaluation (PPE) process in the medical home for
young athletes from middle school through college.
• Medical history
questions ■ PREPARTICIPA
HISTORY FORM
TION PHYSICAL EVAL
UATION
5th Edition
This newly revised and expanded edition is adaptable • Medical eligibility
Note: Complete
and sign this form
Name: __________ (with your paren
_______________ ts if younger than
_______________ 18) before your
Date of exami _______________ appointment.
nation: _____
_______________ _________ Date
for a wide range of individual or institutional needs.

Sex assigned ___________ of birth: _____
considerations
at birth (F, M, Sport(s): _____ _______________
or intersex): ______ _______________ _________
___________ _______________
How do you identif _______________
List past and curren y your gender? ___
t medical condit (F, M, or other):
_______________ ions. __________ __________________
_______________ _______________ _
5th Edition
• Return to play
_______________ _______________
Have you ever _______________ _______________
had surger y? If _____ _______________
_______________
New in the Fifth Edition

_______________ yes, list all past
surgical proced _______________ __
_______________ ures. __________ _____ _______________
Medicines and _______________ _______________ _
supplements: List _______________ _______________
all current prescr _____ _______________ _____ __________
guidelines
_______________ iptions, over-th _______________
_______________ e-counter medic _______________
_______________ _______________ ines, and supple _
_______________ _______________ ments (herbal
_______________ _______________ and nutritional).
Do you have any
• New chapter on transgender athletes

allergies? If yes, _______________ _______________
please list all your _______________ _______________
_______________ allergies (ie, medic _______________ ______
• Medicolegal and
_______________ ines, pollens, _______________
_______________ _______________ food, stinging insects ______
_______________ _______________ ).
_______________ _______________
_______________ _____ _____
• New chapter on female athletes

_______________ _______________
_______________ ___________
Patient Health _______________
ethical concerns
Questionnaire ______
Over the last 2 Version 4 (PHQ-
weeks, how often 4)
have you been
bothered by any
• New section on mental health

of the following

Feeling nervou problems? (Circle
s, anxious, or Not at all respon se.)
• Future research
Not being able on edge Several days
to stop or contro 0 Over half the
l worrying days Nearly every
Little interest or 1 day
pleasure in doing 0 2
• Incorporating PPE into routine health

Feeling down, things 1 3
depressed, or 0 2
hopeless 1 3
needs
(A sum of ≥3 2
is considered 0
positive on either 1 3
subscale [quest 2
ions 1 and 2, 3
or questions 3 and
supervision care
GENERAL QUEST 4] for screening
IONS purposes.)
(Explain “Yes”
• Plus much more…

answers at the

Circle questio end of this form. HEART HEALTH
ns if you don’t QUESTIONS ABOUT
know the answe (CONTINUED YOU
1. Do you have r.) Yes )
any concerns No
• Updated content based on the most current

discuss with your that you would 9. Do you get
provider? like to light-headed or Yes No
than your friends feel shorter of
2. Has a provide during exercis breath
r ever denied e?
participation in or restricted your
sports for any 10. Have you
reason? ever had a seizure
3. Do you have
practice guidelines, consensus statements,

any ongoing medica ?
recent illness? l issues or HEART HEALTH
QUESTIONS ABOUT
HEART HEALTH YOUR FAMILY
QUESTIONS ABOUT 11. Has any Yes
family membe No

YOU r or relative died
4. Have you Yes problems or had of heart
ever passed out No an unexpected
and expert opinions

during or after or nearly passed sudden death or unexplained
exercise? out before age 35
drowning or unexpl years (including
5. Have you ained car crash)?
ever had discom
or pressure in fort, pain, tightne
your chest during ss,
exercise? 12. Does anyone
6. Does your in your family
have a genetic
• Developed to enhance the health and safety

heart ever race, problem such heart
or skip beats (irregu flutter in your as hypertrophic
chest, (HCM), Marfan cardiomyopath
lar beats) during syndrome, arrhyth y
7. Has a doctor exercise? ventricular cardiom mogenic right
ever told you that yopathy (ARVC
heart problem you have any syndrome (LQTS) ), long QT
s? , short QT syndro
me (SQTS),
of all athletes and establish a standardized

Brugada syndro

8. Has a doctor me, or catecho
ever requested morphic ventricu laminergic poly-
heart? For examp a test for your lar tachycardia
le, electrocardiog (CPVT)?
or echocardiogra raphy (ECG)
phy. 13. Has anyone
in your family
an implanted had a pacemaker
approach to PPE
defibrillator before or
age 35?
• English and Spanish versions of the History Form

EASY-TO-USE PREPARTICPATION PHYSICAL EVALUATION FORMS
• History Form (English and Spanish versions) • Athletes With Disabilities Form: Supplement to the American Osteopathic Academy of Sports Medicine
• Physical Examination Form Athlete History
• Medical Eligibility Form
For other pediatric resources, visit the American Academy of Pediatrics
at shop.aap.org.
AAP

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PPE PPE

PPE PREPARTICIPATION PHYSICAL EVALUATION

for a wide range of individual or institutional needs.

New in the Fifth Edition

• New chapter on transgender athletes

• New chapter on female athletes

• New section on mental health

American Academy of Family Physicians

• Incorporating PPE into routine health

• Plus much more…

American Academy of Pediatrics

• Updated content based on the most current ­

practice guidelines, ­consensus statements,

American College of Sports Medicine

and expert opinions

• Developed to enhance the health and safety

of all athletes and establish a standardized

American Medical Society for Sports Medicine

• English and Spanish versions of the History Form

American Academy of Family Physicians

American Academy of Pediatrics

American College of Sports Medicine

American Medical Society for Sports Medicine

American Orthopaedic Society for Sports Medicine

American Osteopathic Academy of Sports Medicine

00_FM_i-viii.indd 1 3/20/19 4:21 PM

American Academy of Pediatrics

Printed in the United States of America

00_FM_i-viii.indd 2 3/20/19 4:21 PM

00_FM_i-viii.indd 3 3/20/19 4:21 PM

American Academy of Pediatrics

American College of Sports Medicine

American Medical Society for Sports Medicine

American Orthopaedic Society for Sports Medicine

American Osteopathic Academy of Sports Medicine

National Federation of State High School Associations

00_FM_i-viii.indd 4 3/20/19 4:21 PM

CHAPTER 7. FEMALE ATHLETES.............................................................161

00_FM_i-viii.indd 5 3/20/19 4:21 PM

The preparticipation physical evaluation (PPE) is used in a variety of settings to determine

00_FM_i-viii.indd 7 3/20/19 4:21 PM

00_FM_i-viii.indd 8 3/20/19 4:21 PM

01_ch01_1-10.indd 1 3/20/19 3:59 PM

01_ch01_1-10.indd 2 3/20/19 3:59 PM

01_ch01_1-10.indd 3 3/20/19 3:59 PM

■■ ROUTINE SCREENING TESTS

01_ch01_1-10.indd 4 3/20/19 3:59 PM

among US athletes that warrant screening.43 Electrocardiographic screening is well

Although the literature is lacking well-controlled prospective trials, the

01_ch01_1-10.indd 5 3/20/19 3:59 PM

• Addresses medicolegal and ethical concerns

Table 1-1. Strength of Recommendation Taxonomy (SORT)

Good quality patient- Validated clinical SR/meta-analysis of SR/meta-analysis of

01_ch01_1-10.indd 6 3/20/19 3:59 PM

Table 1-1. Strength of Recommendation Taxonomy (SORT) (continued )

Limited quality Unvalidated clinical SR/meta-analysis of SR/meta-analysis of

Consistency Across Studies

• Updated content based on the most current

practice guidelines, consensus statements,