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The Preparticipation Physical Evaluation

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Title: The Preparticipation Physical Evaluation


1
The Preparticipation Physical Evaluation
Kevin deWeber, MD, FAAFP Sports Medicine
Fellowship Director USUHS/DeWitt
2
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.

3
Introduction
  • 1992 first PPE Monograph.
  • Updated in 1996 and 2004
  • Template for the preparticipation history and
    physical examination.
  • Widely accepted but not standardized nationally

4
The Preparticipation Physical Examination Overview
  • 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

5
The Preparticipation Physical Examination Overview
  • 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

6
Resources Preparticipation 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

7
Resources 36th 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

8
Resources American 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

9
Resources American 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

10
Goals Objectives of PPE Primary Objectives
  • 1. Detect conditions that may predispose athlete
    to injury
  • Medical Conditions
  • Musculoskeletal Conditions
  • Limb Alignment
  • Previous Injury

11
Goals Objectives of PPE Primary Objectives
  • 1. Detect conditions that predispose athlete to
    injury
  • 2. Detect possible life-threatening or disabling
    conditions
  • Hypertrophic Cardiomyopathy
  • Marfans Syndrome

12
Goals Objectives of PPE Primary Objectives
  • 1. Detect conditions that predispose athlete to
    injury
  • 2. Detect possible life-threatening or disabling
    conditions
  • 3. Satisfy Legal or Insurance Requirements

13
Goals Objectives of PPE Secondary 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

14
Goals Objectives of PPE Secondary Objectives
  • 1. Determine general health of the athlete
  • 2. Counsel the athlete
  • Training
  • Nutrition
  • Tobacco
  • Alcohol
  • STDs
  • Contraception

15
Goals Objectives of PPE Secondary Objectives
  • 1. Determine general health of the athlete
  • 2. Counsel the athlete
  • 3. Assess fitness level for specific sports

16
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

17
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

18
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, ??)

19
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20
The Preparticipation Physical Examination Overview
  • 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

21
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
22
Timing, Setting Structure of PPE Frequency
Timing
  • Timing
  • At least 6 weeks prior to pre-season practice
  • Allow adequate time for
  • further evaluation
  • rehabilitation

23
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

24
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
25
The Preparticipation Physical Examination Overview
  • 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

26
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?

27
  • Always use a good form!

28
Important Aspects of Medical History Complete
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

29
The Preparticipation Physical Examination Medical
History
  • 75 of athletes problems identified by medical
    history
  • 39 of histories given by athlete agreed with
    information from parents

30
Important Aspects of Medical History
Supplements are not Medicines
  • Supplements Ergogenic Aids
  • Vitamins
  • Minerals
  • Amino acids
  • Protein
  • Creatine
  • Anabolic Steroids

31
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

32
Important Aspects of Medical History
Cardiovascular System
  • Careful attention to cardiovascular history is
    paramount!

33
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?

34
  • 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

35
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?

36
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?

37
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?

38
Important Aspects of Medical History Skin
  • Contact sports
  • Herpes
  • Tinea
  • Folliculitis
  • Acne

39
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

40
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

41
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

42
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

43
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?

44
Important Aspects of Medical History
Musculoskeletal System
  • Treatment program for past and present injuries?
  • Did they complete rehab program?
  • Cleared by treating physician?

45
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

46
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

47
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

48
Important Aspects of Medical History
Immunizations
  • Delinquent immunizations do not disqualify athlete

49
The Preparticipation Physical Examination Overview
  • 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

50
The Preparticipation Physical Examination Height
and Weight
  • Measure and record
  • Thin patients ask about recent weight loss,
    eating habits, or body image
  • Look for growth disturbance

51
The Preparticipation Physical Examination The
Physical Exam
  • Sport-specific Exam
  • Examines problem areas identified in history

52
The Preparticipation Physical Examination HEENT
  • 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

53
The Preparticipation Physical Examination HEENT
  • 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

54
The Preparticipation Physical Examination Cardiova
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

55
The Preparticipation Physical Examination Cardiova
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

56
The Preparticipation Physical Examination Cardiova
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

57
The Preparticipation Physical Examination Lungs
  • Wheezes or rubs need further evaluation
  • Normal exam does not exclude disease

58
The Preparticipation Physical Examination Abdomen
  • Supine exam - all 4 quadrants
  • Red Flags
  • Masses
  • Enlarged Liver
  • Enlarged Spleen
  • Tenderness
  • Rigidity

59
The Preparticipation Physical Examination Genitali
a
  • Male
  • Testicular Masses
  • Unilateral Testis
  • Contact sports
  • Inguinal hernia
  • Self-exam education
  • Females
  • DEFER (unless indicated by history)

60
Case 5, Youre the doc
  • 35 yo elite wrestler, Olympic Trials next week
  • Rash on leg--vesicular, unilateral, red base
  • What do you do?

61
The Preparticipation Physical Examination Skin
  • Atopy
  • Infections
  • impetigo
  • furuncles/carbuncles
  • herpes
  • tinea
  • Infestations
  • scabies
  • louse
  • Suspicious nevi

62
The Preparticipation Physical Examination Musculos
keletal System
  • Three options
  • General Screening
  • Joint Specific
  • Sport Specific

63
The Preparticipation Physical Examination General
Screening Exam
  • For asymptomatic athletes with no previous injury
  • ROM, strength, symmetry
  • 14 step exam
  • 2 minutes to complete

64
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

65
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

66
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

67
The Preparticipation Physical Examination Marfan
Screening Consider 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

68
The Preparticipation Physical Examination
Routine Screening Tests
  • Not recommended in asymptomatic athletes
  • Test for conditions as clinically indicated

69
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?

70
The Preparticipation Physical Examination Overview
  • 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

71
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

72
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

73
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?

74
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

75
The Preparticipation Physical Examination
Determining Clearance
  • Medical Conditions Affecting Sports
    Participation.
  • American Academy of Pediatrics, Pediatrics. May
    2001107(5)

76
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

77
Common Clearance Concerns
  • Murmurs
  • High Blood Pressure
  • The Marfanoid Appearance

78
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!

79
The Preparticipation Physical Examination Overview
  • 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

80
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.
81
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.
82
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

83
Questions?
Sports Medicine Fellowship Director
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