The Student Athlete: The Sports Pre-participation Physical Examination(PPE)

What is the purpose of the sports pre-participation physical examination?

The main goal of the sports preparticipation physical is to assess athletes for risks of medical complications and injury due to known and unknown medical conditions. To accurately asses their risk, the healthcare provider reviews patient and parent provided history (personal and familial), performs a physical evaluation and completes a work up as indicated by the history and physical. The systems that are most common culprits for adverse outcomes in relation to sports participation are: the cardiovascular system, musuloskeletal system and nervous system.

When is the sports PPE completed?

In general, the sports physical should occur as close as possible before the start of sports participation, while logistically, it may be ideal to obtain it within 2-4 months prior to participation. Most states require a full sports physical (history and physical) completed every 12 months.

What happens during the sports PPE?

The pre participation physical is divided into two major components:

1. The History: the examiner obtains information about the patient’s physical and mental condition and to identify any symptoms that may suggest current injury or unknown medical conditions.

   • Personal History/Review of Systems

     • Medical conditions/symptoms affecting the heart, lungs, msk, testes, kidneys, eyes, nervous system etc

       • important to asses for symptoms with exertion

         • dizziness or light headedness

         • passing out

         • chest pain

         • palpitations (noticeable sensation of heart beating)

         • difficulty breathing

         • exhaustion out of proportion to level of physical activity.

       • Current symptoms

         • MSK- pain and/or stiffness in neck, back, other joints

         • Problem with concentration, sleep

         • Headaches

     • Surgical history

     • Medication/ Supplement use

     • Diet and Exercise history; Weight changes. Perception of weight.

     • Injury history: MSK, Concussions, nervous system,

     • Cardiovascular

       • inflammatory heart conditions

       • murmur

       • high blood pressure

       • high cholesterol

       • arrhythmia

       • syncope (passing out)

       • Family History of arrhythmia, cardiomyopahty etc

2. The Physical

   • Problem Focused (MSK)

     • Detailed examination of any areas that were mentioned in history to be a source of problem (past/present)

     • Observe for any asymmetries in static or dynamic movement (limbs, neck, hip, and torso)

       • Any shoulder/ hip height asymmetries earns an evaluation and restriction of contact sport participation as the source may vary from muscular to neuromuscular.

       • Any swelling’s cause should be evaluated prior to clearance

     • Observe active (patient initiated) and passive ( examiner initiated) movements

       • any restriction of movement ± pain requires further evaluation and restriction of participation.

       • Specialized movements

         • duck walk

         • single foot hop

     • Test strength with resisted ROM

     • Cardiovascular

       • Blood pressure and resting heart rate

         • Right arm

       • Pulse symmetry and quality

       • Signs of syndromes that are associated with cardiac issues (i.e. Marfan’s, homocysteinuria)

     • Growth Parameters

       • Height

       • Weight

     • Eyes

       • Visual acuity in one or both eyes worse than 20/40 should be referred without restriction but use of protection.

     • Skin

       • Contagious skin conditions warrants restriction to prevent spread particularly in contact sports. If lesions can be covered participation may resume or when completely resolved.

     • GI

       • Enlarged organs on examination warrants exclusion.

     • GU

       • Testicular descension is important to note, is unilateral undescended testicle evaluation by urology is warranted along with use of protective cup to allow participation particularly in contact sports.

3. Work Up (as indicated)

   1. Labs

      1. CBC if history concerning for anemia

   2. Cardiovascular Evaluation

      1. indicated if history and/or physical demonstrate risk for cardiovascular problems. Best to be undertaken by a pediatric cardiologist with restriction until clearance.

   3. Radiographs

      1. Maybe indicated for asymmetries and pain noted on evaluation

Common reasons for restriction of sports participation?

Some Conditions that warrant restriction:

• Uncontrolled hypertension stage 2 or with end organ sequelae require restriction form highly static activities (i.e. weightlifting, gymnastics, wrestling, boxing, rock climbing, rowing, cycling etc

• Congenital heart disease: on the recommendation of specialist.

• MSK injury that has not been appropriately diagnosed and/or rehabilitated.

• Prior Concussions: restriction is individualized and likely for multiple in a short period with progressively worsening symptomology and/or resolution/persistence of symptoms.

• Neck injuries: On the recommendation of the treating specialist.

• Malnourishment in the setting of abnormal menses (Female Triad) warrants exercise restriction to prevent worsening consequences.

• Diabetes: especially insulin dependent participants require special instructions for insulin and glucose monitoring peri-exercise, directed by their specialist.

• Sickle Cell trait: Given the increased risk for death from strenuous physical activity, significant education on prevention of dehydration and heat illness should be given and reiterated.

• Single kidney: Shared decision making once benefits and risks have been thoroughly discussed with patient and parent/ legal guardians.

Source: UpToDate