The Preparticipation Physical Evaluation

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The Preparticipation Physical Evaluation
Kevin deWeber, MD, FAAFP Sports Medicine
Fellowship Director USUHS/DeWitt
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Introduction

• The preparticipation physical examination (PPE)
  has become an annual undertaking in the sports
  medicine community.
• Approximately 6 million high school athletes and
  over 300,000 collegiate athletes participate in
  some form of organized sport.
• At the high school level, 50 out of 51
  interscholastic sports governing bodies require
  athletes to have some form of a PPE before they
  can participate.

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Introduction

• 1992 first PPE Monograph.
• Updated in 1996 and 2004
• Template for the preparticipation history and
  physical examination.
• Widely accepted but not standardized nationally

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The Preparticipation Physical ExaminationOverview

• Resources, Goals Objectives of PPE
• Timing, Setting, Structure of PPE
• Important Aspects of Medical History
• Key Points of Physical Exam
• Determining Clearance for Sports
• The PPE and Evidence-Based Medicine

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The Preparticipation Physical ExaminationOverview

• Resources, Goals Objectives of PPE
• Timing, Setting, Structure of PPE
• Important Aspects of Medical History
• Key Points of Physical Exam
• Determining Clearance for Sports
• The PPE and Evidence-Based Medicine

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ResourcesPreparticipation Physical Evaluation
Monograph 3rd Edition

• American Academy of Family Physicians
• American Academy of Pediatrics
• American College of Sports Medicine
• American Medical Society for Sports Medicine
• American Orthopedic Society of Sports Medicine
• American Osteopathic Academy of Sports Medicine

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Resources36th Bethesda Conference Guidelines

• Recommendations for Determining Eligibility for
  Competition in Athletes with Cardiovascular
  Abnormalities 2005
• Congenital heart disease
• Aquired valvular heart disease
• Hypertrophic cardiomyopathy, myocarditis, and
  other myopericardial diseases and mitral valve
  prolapse
• Systemic hypertension
• Coronary artery disease
• Arrhythmias

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ResourcesAmerican Academy of Pediatrics
Statements and Guidelines

• Committee on Sports Medicine and Fitness Medical
  Conditions Affecting Sports Participation.
  Pediatrics Vol. 107 No. 5 May 2001, 1205-1209.
• Pediatric Blood Pressure Tables
• http//www.cc.nih.gov/ccc/pedweb/pedsstaff/bptable
  1.PDF
• AAP Policy Statements
• Athletic Participation by Children and
  Adolescents Who Have Systemic Hypertension
• Cardiac Dysrhythmias and Sports

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ResourcesAmerican College of Cardiology

• Recommendations and Considerations Related to
  Preparticipation Screening for Cardiovascular
  Abnormalities in Competitive Athletes 2007
  Update
• 12 items
• 8 personal or family history
• 4 physical examination
• 1 abnormal should trigger a referral

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Goals Objectives of PPEPrimary Objectives

• 1. Detect conditions that may predispose athlete
  to injury
• Medical Conditions

• Musculoskeletal Conditions

• Limb Alignment
• Previous Injury

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Goals Objectives of PPEPrimary Objectives

• 1. Detect conditions that predispose athlete to
  injury
• 2. Detect possible life-threatening or disabling
  conditions

• Hypertrophic Cardiomyopathy
• Marfans Syndrome

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Goals Objectives of PPEPrimary Objectives

• 1. Detect conditions that predispose athlete to
  injury
• 2. Detect possible life-threatening or disabling
  conditions
• 3. Satisfy Legal or Insurance Requirements

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Goals Objectives of PPESecondary Objectives

• 1. Determine general health of the athlete
• Not meant to replace routine medical care

• PPE is the only routine care for 78 of
  athletes

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Goals Objectives of PPESecondary Objectives

• 1. Determine general health of the athlete
• 2. Counsel the athlete

• Training
• Nutrition
• Tobacco
• Alcohol
• STDs
• Contraception

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Goals Objectives of PPESecondary Objectives

• 1. Determine general health of the athlete
• 2. Counsel the athlete
• 3. Assess fitness level for specific sports

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The Preparticipation Physical Examination Sudden
Death in Athletes

• What are you looking for?

• 51 male to female death rate
• College death rates twofold higher than H.S.
• Cardiac causes 56 of deaths age lt35
• Most sudden deaths in football and basketball

• Incidence 1200,000 high school athletes

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The Preparticipation Physical Examination Causes
of Sudden Death in Athletes

• Older Athletes (gt35yrs)
• Atherosclerotic coronary artery disease gt80

• Young Athletes (lt35yrs)
• Cardiac 56
• Blunt trauma 22
• Commotio cordis 2
• Heat stroke, drugs, pulmonary 2 each
• Misc 4 (rhabdo, epilepsy, drowning, lightning)
• ?? 8

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Etiologies for sudden CARDIAC death in athletes
lt35

• Cardiovascular
• Hypertrophic Cardiomyopathy (HCM) 36
• Coronary artery anomalies 17
• Possible HCM 2
• Myocarditis 1
• ARVC 1
• Ion channelopathies 1
• Miscellaneous 42 (CAD, Ao rupture, AS, dilated
  CM, WPW, ??)

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The Preparticipation Physical ExaminationOverview

• Resources, Goals Objectives of PPE
• Timing, Setting, Structure of PPE
• Important Aspects of Medical History
• Key Points of Physical Exam
• Determining Clearance for Sports
• The PPE and Evidence-Based Medicine

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Timing, Setting Structure of PPE Frequency
Timing

• High School Athletes
• CV screening prior to athletic participation
• Repeat exam every 2 years
• Interim history in non-exam years
• History reviewed for significant changes

• Collegiate Athletes
• CV screening prior to athletic training
  competition
• Interim history and BP measurement in subsequent
  3-4 years
• History BP reviewed for significant changes

• Local customs trump national recommendations
• State law
• School districts athletic conferences
• Insurance companies

1998 American Heart Association Recommendations
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Timing, Setting Structure of PPE Frequency
Timing

• Timing
• At least 6 weeks prior to pre-season practice
• Allow adequate time for
• further evaluation
• rehabilitation

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Timing, Setting Structure of PPE Setting
Structure
Office Based

• Advantages
• privacy
• continuity of care
• Disadvantages
• time
• cost
• no communication with coach or trainer
• different levels of examiner expertise

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Timing, Setting Structure of PPE Setting
Structure

• Advantages
• cost effective
• efficient
• variety of specialists
• Disadvantages
• noisy
• confusing for athlete
• poor continuity and/or follow-up

Station Based/Group
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The Preparticipation Physical ExaminationOverview

• Resources, Goals Objectives of PPE
• Timing, Setting, Structure of PPE
• Important Aspects of Medical History
• Key Points of Physical Exam
• Determining Clearance for Sports
• The PPE and Evidence-Based Medicine

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Case 1, and Youre the sports physical doc!

• 17 yo HS football player
• Needs form signed to be able to play
• 10 questions about PMH
• Space for exam findings and sig block
• What do you do?

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• Always use a good form!

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Important Aspects of Medical HistoryComplete
Medical History

• Pulmonary / Asthma
• Protective devices
• Eyes and vision
• Musculoskeletal system
• Weight / Eating disorders
• Psychosocial concerns
• Immunizations
• Menstrual history

• Chronic illness / Injuries
• Hospitalizations / Surgeries
• Medication use
• Allergy
• Cardiovascular system
• Skin
• Neurologic system
• Heat illness

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The Preparticipation Physical ExaminationMedical
History

• 75 of athletes problems identified by medical
  history

• 39 of histories given by athlete agreed with
  information from parents

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Important Aspects of Medical History
Supplements are not Medicines

• Supplements Ergogenic Aids
• Vitamins
• Minerals
• Amino acids
• Protein
• Creatine
• Anabolic Steroids

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Important Aspects of Medical History Allergy

• Allergies to medication
• Insect allergies
• Need to have Epi kit on hand
• Inquire about asthma or exercise induced asthma
• Prevalence of undiagnosed EIA 3-14
• Exercise induced anaphylaxis or urticaria

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Important Aspects of Medical History
Cardiovascular System

• Careful attention to cardiovascular history is
  paramount!

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Case 4 youre the doc

• 21 yo basketball player
• Hx
• near-syncope with exertion
• Dad died suddenly age 48, ? cause
• Exam normal
• What do you do?

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• 1 abnormal CV history item should trigger a
  referral
• 12 C-V items
• 8 personal or family history
• 4 physical examination
• Recommendations and Considerations Related to
  Preparticipation Screening for Cardiovascular
  Abnormalities in Competitive Athletes 2007
  Update

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Important Aspects of Medical History
Cardiovascular System
Ask Every Athlete

• Have you ever passed out or almost passed out
  DURING exercise?
• Have you ever passed out or almost passed out
  AFTER exercise?
• Have you ever had discomfort, pain, or pressure
  in your chest during exercise?
• Does your heart race or skip beats during
  exercise?

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Important Aspects of Medical History
Cardiovascular System
Ask Every Athlete

• Has a doc every told you that you have
• High BP?
• High cholesterol?
• A heart murmur?
• A heart infection?
• Has a doctor every ordered a test for your heart?
• Has anyone in your family died for no apparent
  reason?

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Important Aspects of Medical History
Cardiovascular System
Ask Every Athlete

• Has any family member or relative died of heart
  problems or sudden death before age 50?
• Does anyone in your family have
• Marfan syndrome?
• Long-QT syndrome or channelopathies?

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Important Aspects of Medical History Skin

• Contact sports
• Herpes
• Tinea
• Folliculitis
• Acne

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Important Aspects of Medical History Neurologic
System
Second in Importance only to Cardiovascular

• Concussion
• Not just knocked out
• How many?
• Post-concussive symptoms?
• Seizures
• Stingers Burners
• Headaches

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Important Aspects of Medical History Neurologic
System

• Further evaluation required for
• Recurrent burners/stingers
• Recurrent or severe concussions
• Unresolved neurologic signs or symptoms
• Transient quadriplegia

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Important Aspects of Medical History Heat Illness

• Heat disorders can be recurrent
• Prior history of heat stroke
• FH of malignant hyperthermia
• Increased risk with
• Ephedrine
• Caffeine
• Psychomotor stimulants
• Sickle cell trait

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Important Aspects of Medical History Eyes
Vision

• Functionally one-eyed

• Best corrected vision is worse than 20/40 in one
  eye
• May compete with counseling and protection
• History of eye injury or eye surgery
• RPK, Lasik
• Sport specific eye protection

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Case 2, youre the doc

• 21 yo college soccer player, 6 wks preseason
• Complete PPE last year
• Ankle injury during Spring, mostly better
• Long PPE form o/w negative
• What do you do?

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Important Aspects of Medical History
Musculoskeletal System

• Treatment program for past and present injuries?
• Did they complete rehab program?
• Cleared by treating physician?

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Important Aspects of Medical History Menstrual
Disorders

• Amenorrhea
• Primary - absence of menarche at age 16
• Secondary - missing at least 3 consecutive
  periods in a previous menstruating female
• Rule out pregnancy before clearance
• Oligomenorrhea
• gt35 days between menses
• Less than 4 menses per year increases risk of
  stress fracture

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Important Aspects of Medical History Nutrition
Eating Disorders

• Female athletes most common (101)
• Female Athlete Triad amenorrhea, eating
  disorder, osteopenia
• Inquire about menstrual history, exercise
  patterns, stress fracture
• Higher risk in sports with
• weight classes
• judging influenced by appearance
• leanness requirements for optimal performance

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Important Aspects of Medical History
Psychological Stressors

• Stress?
• Affirmative response needs close follow-up and/or
  counseling

• Counsel about unhealthy behaviors
• Alcohol
• Tobacco
• Illicit drug use
• Sexual habits

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Important Aspects of Medical History
Immunizations

• Delinquent immunizations do not disqualify athlete

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The Preparticipation Physical ExaminationOverview

• Resources, Goals Objectives of PPE
• Timing, Setting, Structure of PPE
• Important Aspects of Medical History
• Key Points of Physical Exam
• Determining Clearance for Sports
• The PPE and Evidence-Based Medicine

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The Preparticipation Physical ExaminationHeight
and Weight

• Measure and record
• Thin patients ask about recent weight loss,
  eating habits, or body image
• Look for growth disturbance

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The Preparticipation Physical ExaminationThe
Physical Exam

• Sport-specific Exam
• Examines problem areas identified in history

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The Preparticipation Physical ExaminationHEENT

• Visual acuity with Snellen chart
• 20/40 or better in each eye with or without
  corrective lenses
• Eye protection for specific eye problems
• Pupils - check for anisocoria
• Signs of eating disorder
• oral ulcers, gingival atrophy, decreased enamel

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The Preparticipation Physical ExaminationHEENT

• High-arched palate - Marfans syndrome
• Braces - need mouth guards
• Tympanic membranes
• Otitis externa - swimmers
• Otic barotrauma - scuba and sky divers
• Nasal polyps or deviated septum

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The Preparticipation Physical ExaminationCardiova
scular System

• Blood pressure with appropriately sized cuff
• If elevated, repeat in few min
• If still high, after lying down for 10-15 min
  ask about stimulants
• Palpation of radial and femoral pulses
• Coarctation of the aorta
• Blood pressure norms are height (not weight)
  dependent

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The Preparticipation Physical ExaminationCardiova
scular System

• Normal
• systolic ejection murmur
• begins after first heart sound
• ends before the second heart sound
• crescendo-decresendo profile
• normal inspiratory S2 split
• normal dynamic assessment

• Quiet, well-lighted room
• Sitting or standing
• Palpation - PMI, thrills
• Splitting
• Dynamic exam
• Pathologic vs Normal

• Suspicious
• diastolic, holosystolic, or continuous
• grade III or greater in intensity
• abnormal S2 splitting
• abnormal dynamic assessment

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The Preparticipation Physical ExaminationCardiova
scular System

• Arrhythmias - need EKG
• Irregular beats that disappear with exercise -
  usually benign
• Multifocal PVCs, doublets, triplets - refer to
  cardiology
• 36th Bethesda Conference guidelines
• Excellent resource for cardiovascular work-up
  and clearance to play

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The Preparticipation Physical ExaminationLungs

• Wheezes or rubs need further evaluation
• Normal exam does not exclude disease

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The Preparticipation Physical ExaminationAbdomen

• Supine exam - all 4 quadrants
• Red Flags
• Masses
• Enlarged Liver
• Enlarged Spleen
• Tenderness
• Rigidity

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The Preparticipation Physical ExaminationGenitali
a

• Male
• Testicular Masses
• Unilateral Testis
• Contact sports
• Inguinal hernia
• Self-exam education

• Females
• DEFER (unless indicated by history)

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Case 5, Youre the doc

• 35 yo elite wrestler, Olympic Trials next week
• Rash on leg--vesicular, unilateral, red base
• What do you do?

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The Preparticipation Physical ExaminationSkin

• Atopy
• Infections
• impetigo
• furuncles/carbuncles
• herpes
• tinea
• Infestations
• scabies
• louse
• Suspicious nevi

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The Preparticipation Physical ExaminationMusculos
keletal System

• Three options
• General Screening
• Joint Specific
• Sport Specific

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The Preparticipation Physical Examination General
Screening Exam

• For asymptomatic athletes with no previous injury
• ROM, strength, symmetry
• 14 step exam
• 2 minutes to complete

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The Preparticipation Physical Examination Joint
Specific Testing

• For athletes with
• Previous injury
• Symptoms of pain, instability, or atrophy
• Problems noted in history or general screening
  exam

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The Preparticipation Physical Examination Sport
Specific Exam

• Focus on high risk joints in a given sport
• Strength, endurance, and flexibility tests
• Shoulder
• swimmers, throwers, tennis
• Knee
• football, basketball, soccer

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The Preparticipation Physical Examination
Neurologic System

• Recurrent stingers/burners
• cervical spine exam
• upper extremity strength
• radiographs
• Multiple or severe concussions
• Exam of cranial nerves, motor, cerebellar, and
  cognitive function
• ? Preseason SAC, Neuropsychiatric Assessment

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The Preparticipation Physical Examination Marfan
ScreeningConsider referral to Genetics if the
following are present

• In a male gt6 tall, or female gt510, any TWO of
  the following
• Family history of Marfan
• Murmur or mid-systolic click
• Kyphoscoliosis
• Anterior thoracic deformity
• Arm span gt height
• Myopia
• Ectopic lens

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The Preparticipation Physical Examination
Routine Screening Tests

• Not recommended in asymptomatic athletes
• Test for conditions as clinically indicated

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Case 3, youre the doc

• 28 yo recreational hockey player
• Testicular cancer 2 yrs ago, L orchiectomy
• Long PPE form negative
• Exam one testicle, one prosthesis, o/w normal
• What do you do?

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The Preparticipation Physical ExaminationOverview

• Resources, Goals Objectives of PPE
• Timing, Setting, Structure of PPE
• Important Aspects of Medical History
• Key Points of Physical Exam
• Determining Clearance for Sports
• The PPE and Evidence-Based Medicine

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The Preparticipation Physical Examination
Determining Clearance

• The most important and most difficult decision in
  the PPE
• 3 options
• Unrestricted clearance
• Clearance after further evaluation or
  rehabilitation
• Not cleared for certain sports or for all sports

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The Preparticipation Physical Examination
Critical Questions in Clearance

• Does the problem place the athlete at increased
  risk for injury?
• Is another participant at risk for injury because
  of the problem?
• Can the athlete safely participate with
  treatment?
• Medication, rehabilitation, bracing, or padding

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The Preparticipation Physical Examination More
Clearance Questions

• Can limited participation be allowed while
  treatment is being completed?

• If clearance denied for certain sports only, in
  what activities can the athlete safely
  participate?

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The Preparticipation Physical Examination
Determining Clearance

• Clearance best determined by understanding
  demands of the activities
• Ensure complete understanding communication
  between
• athlete
• parents
• coaches
• trainers
• administrators
• Protect confidentiality

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The Preparticipation Physical Examination
Determining Clearance

• Medical Conditions Affecting Sports
  Participation.
• American Academy of Pediatrics, Pediatrics. May
  2001107(5)

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The Preparticipation Physical Examination
Disqualification Criteria

• 36th Bethesda Conference Guidelines
• Disqualify
• Severe untreated hypertension (gt180/110) or BP
  greater than 99 for age and height
• Mitral valve prolapse if
• syncope due to arrhythmia, family hx of sudden
  death due to MVP, prior embolic event, arrhythmia
  worsened by exercise, regurgitation
• Hypertrophic Cardiomyopathy

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Common Clearance Concerns

• Murmurs
• High Blood Pressure
• The Marfanoid Appearance

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The Preparticipation Physical Examination
Appropriate Referrals

• If in doubt--Refer
• Cardiologist
• Neurologist
• Neurosurgeon
• Orthopaedic surgeon
• Sports Medicine Specialist

• The Sports Medicine doc is your friend!

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The Preparticipation Physical ExaminationOverview

• Resources, Goals Objectives of PPE
• Timing, Setting, Structure of PPE
• Important Aspects of Medical History
• Key Points of Physical Exam
• Determining Clearance for Sports
• The PPE and Evidence-Based Medicine

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Preparticipation Evaluation An Evidence Based
Review

• The PPE is not implemented adequately or
  uniformly in the United States.
• Research as to the effectiveness of the PPE is
  extremely limited.
• There is an urgent need for a National Standard.

Wingfield K, et al Preparticipation Evaluation
An Evidence Based Review. Clinical Journal of
Sports Medicine 200414(3) 109-122.
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Preparticipation Orthopedic Screening Evaluation

• There is no evidence linking any findings on
  clinical examination to an increase or decrease
  in the likelihood of future injuries.
• There is no evidence that increasing the scope of
  the examination would enhance its predictive
  value.

Garrick JG Preparticipation Orthopedic Screening
Evaluation. Clinical Journal of Sports Medicine
200414(3) 123-126.
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The Preparticipation Physical Examination
Conclusion
Opportunities in the PPE

• Enhance the safety of sports participation
• Provide teachable moments
• Establish foundation for a trusting relationship
  between the physician athlete

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Questions?
Sports Medicine Fellowship Director