The Comprehensive Sports Physical (Pre Participation Exam)

Exams

Sports, Health, and Preparation

Participation in organized physical activity including sports can be an important part of development, socialization, and overall health. Participation in these activities is increasing amongst children in the United States every year and at increasingly younger ages. Children who are involved in these activities have been shown to have decreased rates of obesity, improved overall health, and greater academic achievement as compared to peers who do not. While the benefits of organized physical activity is very apparent, the risks involved are also well known. Sprains, strains, overuse injuries and concussions are well known risks of sports participation and are to some degree non-preventable and acceptable risks. Other conditions are less visible, more dangerous, and may only be reduced with thorough medical screening. It is important that we do what we can to maximize the benefits and minimize the risks involved inherent to physical activity and magnified in competitive sports. This post will discuss the pre-participation physical exam (PPE), its purpose, what’s involved, as well as new possibilities for the future.

The Pre-participation Physical Exam (PPE)

The primary purpose of the PPE is to minimize the risks inherent in physical activity and to identify conditions in participants that increase the risk of injury or that may be life threatening. The PPE also provides an opportunity to maximize the benefits of sports participation and to maximize sports performance in the long term. Many of the components of the PPE are well known to anyone who has participated in sports. Review of medical history and family medical history as well as a thorough physical exam provide good insight into the potential risk factors an athlete may face. Major concerns that are addressed include family history of heart disease or sudden cardiac death at a young age, diseases of the lungs such as asthma, and prior head or neck injuries. It has been recommended that the PPE be performed 6 weeks prior to participation if possible – this allows time for any issues uncovered in the exam to be addressed while limiting any time missed in the activity. Routine blood work and studies for the heart and lungs are not currently part of the PPE, but new research provides evidence that there may be benefits for some forms of screening.  It is also important to note that the PPE is not intended to replace a routine medical examination by a primary care provider, but is meant to be augmentative to yearly health exams.

Important Considerations for Athletes

The Brain

Concussion research, awareness, and knowledge has increased tremendously over the last decade as has current management and therapy for concussion. Knowing about prior history of concussion and head injuries and any ongoing symptoms can help identify athletes that may be at greater risk for further injury or long term effects of future injuries. Neurocognitive testing prior to sports participation provides a great baseline level of functioning for athletes. It is very valuable to have this baseline in the event of a concussion both to evaluate the extent of injury and to monitor the recovery process.  Although computerized neurocognitive testing remains the mainstay of baseline testing at time a number of other tests involving balance, visual, and reaction time performance are also being done.  It is universally agreed that baseline concussion testing is most critical for contact or highrisk sports, but has been used in all athletes. Many schools are now requiring athletes to do this testing prior to sports participation for contact sports.

The Lungs

Roughly 10% of children experience asthma symptoms at some point in childhood. Asthma certainly can interfere with physical activity and decrease sports performance; a severe asthma exacerbation can also be fatal in the worse cases. Along with asthma, exercise induced bronchospasm are the most common pulmonary conditions in athletes. It is important to know about any cough, wheeze, or shortness of breath brought on by exercise in order to screen for these conditions. Routine pulmonary function tests (tests that help uncover conditions like asthma) are not currently part of routine screening for athletes, but instead are reserved for those athletes whose history or exam suggest they may be at greater risk.  The symptoms of exercise induced bronchospasm and asthma can be very well treated once they are diagnosed, so it is important athletes with respiratory symptoms are screened for this.

The Heart

While very rare, most fatalities in young athletes during participation in sports occur in the setting of pre-existing heart conditions. For this reason, getting a personal and family history any cardiac conditions is very important. Important signs and symptoms to consider include chest pain during exercises, a history of loss of consciousness during exertion, unexpended lightheadedness during exercise, or undue shortness of breath. Any history of previous studies of the heart such as an echocardiogram or ECG and the reason the studies were done may be important. Family history of heart problems at a young age or sudden death at a young age should be discussed. Again, sudden cardiac death in sports is rare, but it is important to rule out potentially dangerous heart problems. An electrocardiogram (ECG) is a study that uses the electrical current of the heart to give an abundance of information about how an individual’s heart is working. Currently in the United States it is not recommended to obtain routine ECG’s during a PPE. However, some research suggests that routine ECG’s may be called for (in particular in high risk athletes) and this is discussed further below.

Other important considerations

There are many other important opportunities that a PPE presents. It can be beneficial to discuss previous musculoskeletal injuries, how to prevent re-injury, and what activities might be best to avoid. It is also important to know about medications used, previous surgeries, and previous restrictions from sports participation. Skin conditions are common reasons to be sidelined from competition and can be brought to your physician’s attention for treatment or referral. The PPE may also be a good chance to discuss your diet and social habits, which are an important part of your sports performance as well as injury prevention.

Should ECG be included in the PPE?

Currently in the U.S. the electrocardiogram, or ECG, is not a standard component of the PPE, though individuals deemed a higher risk based on history and physical exam may still require one. The purpose of the ECG is to uncover potentially fatal cardiac abnormalities prior to participation in sports.  Multiple long term studies conducted in Italy over the past 40 years have demonstrated a reduced risk of sudden cardiac death in athletes who were screened with exam and ECG. In Italy, Israel, and some other European countries, an ECG has become a standard part of this exam. While it may seem that we should do everything possible to prevent a sudden cardiac death in a young athlete, there are many important considerations when using screening tools and there are those who argue both for and against including the ECG as a standard part the PPE. While obtaining an ECG is relatively inexpensive, the costs of obtaining ECG’s on all athletes entering sports would be significant. Some who argue for including ECGs suggest that a one time study could be performed as an athlete enters sports for the first time – this would keep the costs down while still providing a baseline and providing valuable prevention. Not all costs are monetary, however. Some who argue against regular ECG use in the PPE have concerns about false positives, or ‘abnormal’ findings in an individual who is in all actuality healthy. This could lead to a normal, healthy individual being excluded from sports participation or require them to undergo further studies that would be unnecessary and have potential risks themselves. It may be that we see an increased role of the ECG in the near future in the PPE, perhaps not universally at first, but for those athletes deemed at higher risk such as basketball, soccer, and track.  A recent NCAA study done at the University of Washington deemed African American basketball players as the highest risk athletes.

Nutrition

The PPE also provides an opportunity to discuss nutrition. In terms of sports, we often think of nutrition in terms of optimizing performance; nutrition can be an important part of injury prevention as well. Vitamin D and calcium are nutrients that are important for many human functions, perhaps best known for their role in bone health. As you can imagine, deficiencies in either of these nutrients can lead to improper bone development, which in turn can lead to greater risk of injury. A diet rich in dairy will likely give plenty of both of these nutrients, while those athletes who don’t or can’t eat dairy will need to look for other sources. Other common questions from athletes include concerns about how much protein or total calories to consume, when to eat, and proper fluid intake.  Iron intake or folate may be important questions in female athletes.  Additionally, sports often put a lot of pressure on young athletes, and occasionally create unhealthy eating habits. The PPE is an important chance to answer these questions and address any concerns.  Look to our handouts for further information on these nutrients and sports nutrition in general to help prevent injuries and maximize performance.

By Jacob Sup and Mo Mortazavi, MD
References:

Intensive training and sports specialization in young athletes. American Academy of Pediatrics. Committee on Sports Medicine and Fitness. Pediatrics 2000; 106: pp. 154-157

American Academy of Family Physicians (AAFP) , American Academy of Pediatrics (AAP) , American College of Sports Medicine (ACSM) , American Medical Society for Sports Medicine (AMSSM) , American Orthopaedic Society for Sports Medicine (AOMMS) , and American Osteopathic Academy of Sports Medicine (AOASM) : The preparticipation physical evaluation. American Academy of Pediatrics, 2010. pp. 1-155

Rifat S., Ruffin M.T., and Gorenflow D.W.: Disqualifying criteria in a preparticipation sports evaluation. J Fam Pract 1995; 41: pp. 42-50

Harmon, Kimberly G. et al. Should Electrocardiograms Be Part of the Preparticipation Physical Examination? PM&R, 2016-03-01, Volume 8, Issue 3, Pages S24-S352016 American Academy of Physical Medicine and Rehabilitation

Purcell, Laura K. Paediatric Child Health. 2013 Apr; 18(4): 200–202. Sport nutrition for young athletes, Canadian Paediatric Society, Paediatric Sports and Exercise Medicine Section

Sports, Health, and Preparation

Participation in organized physical activity including sports can be an important part of development, socialization, and overall health. Participation in these activities is increasing amongst children in the United States every year and at increasingly younger ages. Children who are involved in these activities have been shown to have decreased rates of obesity, improved overall health, and greater academic achievement as compared to peers who do not. While the benefits of organized physical activity is very apparent, the risks involved are also well known. Sprains, strains, overuse injuries and concussions are well known risks of sports participation and are to some degree non-preventable and acceptable risks. Other conditions are less visible, more dangerous, and may only be reduced with thorough medical screening. It is important that we do what we can to maximize the benefits and minimize the risks involved inherent to physical activity and magnified in competitive sports. This post will discuss the pre-participation physical exam (PPE), its purpose, what’s involved, as well as new possibilities for the future.

The Pre-participation Physical Exam (PPE)

The primary purpose of the PPE is to minimize the risks inherent in physical activity and to identify conditions in participants that increase the risk of injury or that may be life threatening. The PPE also provides an opportunity to maximize the benefits of sports participation and to maximize sports performance in the long term. Many of the components of the PPE are well known to anyone who has participated in sports. Review of medical history and family medical history as well as a thorough physical exam provide good insight into the potential risk factors an athlete may face. Major concerns that are addressed include family history of heart disease or sudden cardiac death at a young age, diseases of the lungs such as asthma, and prior head or neck injuries. It has been recommended that the PPE be performed 6 weeks prior to participation if possible – this allows time for any issues uncovered in the exam to be addressed while limiting any time missed in the activity. Routine blood work and studies for the heart and lungs are not currently part of the PPE, but new research provides evidence that there may be benefits for some forms of screening.  It is also important to note that the PPE is not intended to replace a routine medical examination by a primary care provider, but is meant to be augmentative to yearly health exams.

Important Considerations for Athletes

The Brain

Concussion research, awareness, and knowledge has increased tremendously over the last decade as has current management and therapy for concussion. Knowing about prior history of concussion and head injuries and any ongoing symptoms can help identify athletes that may be at greater risk for further injury or long term effects of future injuries. Neurocognitive testing prior to sports participation provides a great baseline level of functioning for athletes. It is very valuable to have this baseline in the event of a concussion both to evaluate the extent of injury and to monitor the recovery process.  Although computerized neurocognitive testing remains the mainstay of baseline testing at time a number of other tests involving balance, visual, and reaction time performance are also being done.  It is universally agreed that baseline concussion testing is most critical for contact or highrisk sports, but has been used in all athletes. Many schools are now requiring athletes to do this testing prior to sports participation for contact sports.

The Lungs

Roughly 10% of children experience asthma symptoms at some point in childhood. Asthma certainly can interfere with physical activity and decrease sports performance; a severe asthma exacerbation can also be fatal in the worse cases. Along with asthma, exercise induced bronchospasm are the most common pulmonary conditions in athletes. It is important to know about any cough, wheeze, or shortness of breath brought on by exercise in order to screen for these conditions. Routine pulmonary function tests (tests that help uncover conditions like asthma) are not currently part of routine screening for athletes, but instead are reserved for those athletes whose history or exam suggest they may be at greater risk.  The symptoms of exercise induced bronchospasm and asthma can be very well treated once they are diagnosed, so it is important athletes with respiratory symptoms are screened for this.

The Heart

While very rare, most fatalities in young athletes during participation in sports occur in the setting of pre-existing heart conditions. For this reason, getting a personal and family history any cardiac conditions is very important. Important signs and symptoms to consider include chest pain during exercises, a history of loss of consciousness during exertion, unexpended lightheadedness during exercise, or undue shortness of breath. Any history of previous studies of the heart such as an echocardiogram or ECG and the reason the studies were done may be important. Family history of heart problems at a young age or sudden death at a young age should be discussed. Again, sudden cardiac death in sports is rare, but it is important to rule out potentially dangerous heart problems. An electrocardiogram (ECG) is a study that uses the electrical current of the heart to give an abundance of information about how an individual’s heart is working. Currently in the United States it is not recommended to obtain routine ECG’s during a PPE. However, some research suggests that routine ECG’s may be called for (in particular in high risk athletes) and this is discussed further below.

Other important considerations

There are many other important opportunities that a PPE presents. It can be beneficial to discuss previous musculoskeletal injuries, how to prevent re-injury, and what activities might be best to avoid. It is also important to know about medications used, previous surgeries, and previous restrictions from sports participation. Skin conditions are common reasons to be sidelined from competition and can be brought to your physician’s attention for treatment or referral. The PPE may also be a good chance to discuss your diet and social habits, which are an important part of your sports performance as well as injury prevention.

Should ECG be included in the PPE?

Currently in the U.S. the electrocardiogram, or ECG, is not a standard component of the PPE, though individuals deemed a higher risk based on history and physical exam may still require one. The purpose of the ECG is to uncover potentially fatal cardiac abnormalities prior to participation in sports.  Multiple long term studies conducted in Italy over the past 40 years have demonstrated a reduced risk of sudden cardiac death in athletes who were screened with exam and ECG. In Italy, Israel, and some other European countries, an ECG has become a standard part of this exam. While it may seem that we should do everything possible to prevent a sudden cardiac death in a young athlete, there are many important considerations when using screening tools and there are those who argue both for and against including the ECG as a standard part the PPE. While obtaining an ECG is relatively inexpensive, the costs of obtaining ECG’s on all athletes entering sports would be significant. Some who argue for including ECGs suggest that a one time study could be performed as an athlete enters sports for the first time – this would keep the costs down while still providing a baseline and providing valuable prevention. Not all costs are monetary, however. Some who argue against regular ECG use in the PPE have concerns about false positives, or ‘abnormal’ findings in an individual who is in all actuality healthy. This could lead to a normal, healthy individual being excluded from sports participation or require them to undergo further studies that would be unnecessary and have potential risks themselves. It may be that we see an increased role of the ECG in the near future in the PPE, perhaps not universally at first, but for those athletes deemed at higher risk such as basketball, soccer, and track.  A recent NCAA study done at the University of Washington deemed African American basketball players as the highest risk athletes.

Nutrition

The PPE also provides an opportunity to discuss nutrition. In terms of sports, we often think of nutrition in terms of optimizing performance; nutrition can be an important part of injury prevention as well. Vitamin D and calcium are nutrients that are important for many human functions, perhaps best known for their role in bone health. As you can imagine, deficiencies in either of these nutrients can lead to improper bone development, which in turn can lead to greater risk of injury. A diet rich in dairy will likely give plenty of both of these nutrients, while those athletes who don’t or can’t eat dairy will need to look for other sources. Other common questions from athletes include concerns about how much protein or total calories to consume, when to eat, and proper fluid intake.  Iron intake or folate may be important questions in female athletes.  Additionally, sports often put a lot of pressure on young athletes, and occasionally create unhealthy eating habits. The PPE is an important chance to answer these questions and address any concerns.  Look to our handouts for further information on these nutrients and sports nutrition in general to help prevent injuries and maximize performance.

By Jacob Sup and Mo Mortazavi, MD
References:

Intensive training and sports specialization in young athletes. American Academy of Pediatrics. Committee on Sports Medicine and Fitness. Pediatrics 2000; 106: pp. 154-157

American Academy of Family Physicians (AAFP) , American Academy of Pediatrics (AAP) , American College of Sports Medicine (ACSM) , American Medical Society for Sports Medicine (AMSSM) , American Orthopaedic Society for Sports Medicine (AOMMS) , and American Osteopathic Academy of Sports Medicine (AOASM) : The preparticipation physical evaluation. American Academy of Pediatrics, 2010. pp. 1-155

Rifat S., Ruffin M.T., and Gorenflow D.W.: Disqualifying criteria in a preparticipation sports evaluation. J Fam Pract 1995; 41: pp. 42-50

Harmon, Kimberly G. et al. Should Electrocardiograms Be Part of the Preparticipation Physical Examination? PM&R, 2016-03-01, Volume 8, Issue 3, Pages S24-S352016 American Academy of Physical Medicine and Rehabilitation

Purcell, Laura K. Paediatric Child Health. 2013 Apr; 18(4): 200–202. Sport nutrition for young athletes, Canadian Paediatric Society, Paediatric Sports and Exercise Medicine Section

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