The Preparticipation Sports Evaluation Andrew R. … · institution’s legal and liability...

DOI: 10.1542/pir.32-5-e532011;32;e53Pediatrics in Review

Andrew R. Peterson and David T. BernhardtThe Preparticipation Sports Evaluation

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The Preparticipation Sports EvaluationAndrew R. Peterson, MD,

MSPH,* David T.

Bernhardt, MD†

Author Disclosure

Drs Peterson and

Bernhardt have

disclosed no financial

relationships relevant

to this article. This

commentary does not

contain a discussion

of an unapproved/

investigative use of a

commercial

product/device.

Objectives After completing this article, readers should be able to:

1. Perform a preparticipation history and physical examination and identify children andadolescents who may be at increased risk of morbidity or mortality from sportsparticipation.

2. Recognize that many adolescents make infrequent contact with the medical systemand that the mandatory preparticipation evaluation serves as an opportunity to addressmedical issues not necessarily associated with sports participation.

3. Know the conditions that should be evaluated by a cardiologist before sportsparticipation.

4. Discuss the importance of assessing and documenting neurocognitive function in apreparticipation sports examination.

5. Understand that disqualification from one sport does not imply disqualification fromall sports.

IntroductionSports participation among people of all ages has increased steadily over the past 4 decades.This trend generally has been considered to be a positive development, with conventionalwisdom asserting that sports participation teaches leadership and cooperative skills thathave a lifelong impact. In addition, as the obesity pandemic worsens, organized sportsparticipation and unstructured play or physical exercise can be a source of needed physicalactivity for children and adolescents. The pediatrician often is asked to evaluate a child’s oradolescent’s suitability for sports participation. The purpose of this evaluation has re-mained constant since it was first described in 1978. (1)(2) The goals are to fulfill theinstitution’s legal and liability requirements, provide some assurance to coaches thatathletes will start the season at an acceptable level of health and fitness, provide anopportunity to discover treatable conditions, and aid in predicting and preventing futureinjuries. The evaluation should be practical and applicable to all sports. The specificobjectives of the evaluation can vary, depending on viewpoint, which can create a situationin which parents, athletes, clinicians, and sponsoring institutions or organizations havediscordant expectations. Parents may want to ensure the health and safety of their child.Clinicians may seek to provide preventive care and anticipatory guidance. Institutions and

organizations may want to limit or transfer their liability for injuriesor illnesses caused or worsened by sports participation. Finally, theathletes may just want to have their paperwork signed so they cango play with their friends. The clinician should coordinate andaddress the goals of parents, athletes, and organizations whilepromoting safe participation in physical activity.

The utility of the sports preparticipation evaluation (PPE) hasbeen questioned in recent years. Very few athletes are disqualifiedfrom sports on the basis of findings from the PPE. In the largestevaluation of the PPE, only 1.9% of 2,729 high school athleteswere disqualified from sports participation and only 11.9% requiredany type of follow-up evaluation. (3) A recent systematic review ofthe literature identified 310 studies of the PPE and concluded that

*Department of Pediatrics, University of Iowa, Iowa City, IA.†Departments of Pediatrics and Orthopedics and Rehabilitation, University of Wisconsin, Madison, WI.

Abbreviations

ADHD: attention-deficit/hyperactivity disorderAHA: American Heart AssociationDM1: type 1 diabetes mellitusEIB: exercise-induced bronchospasmNCT: neurocognitive testingPPE: preparticipation evaluationTUE: therapeutic use exemptionVCD: vocal cord dysfunction

Article sports medicine

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the evaluation likely does little to prevent morbidity andmortality in screened athletes and is ineffective for iden-tifying athletes at risk for sudden cardiac death or ortho-pedic injuries and at detecting exercise-induced bron-chospasm (EIB). (4) However, use of the PPE isendorsed by the American Academy of Pediatrics, Amer-ican Academy of Family Physicians, and American Col-lege of Sports Medicine because it allows for establish-ment of a medical home, updating of immunizations,identification and management of chronic health condi-tions, and provision of anticipatory guidance related tosports and other lifestyle risk factors.

Structure of the EvaluationThe PPE is required before practice and play by mostsporting organizations. The requirement is typically inplace to shield the organization from liability and toensure that the athlete can participate safely in sports.The evaluation is required by law in many states andsome countries. Nearly all high-school and middle-school athletes are required to obtain signed documen-tation of a completed examination every 1 to 2 academicyears. Athletes engaged in club- or federation-level sportsare also often required to have documentation of anevaluation, but this practice varies regionally and bysport. Rarely, sports competitions not affiliated withinstitutions or federations (eg, open races or tourna-ments) require documentation of the athlete’s suitabilityfor competition. Generally, open or free play (such as onan open playground) does not require such documenta-tion. However, the 2010 PPE Monograph emphasizesthat clinicians should perform a PPE-type evaluation onall patients when promoting physical activity. (5)

Most institutions and organizations that require anevaluation strictly prevent participation until proper doc-umentation has been obtained. This practice seems to bedue to a sense that protection from liability is not presentuntil there is “proof” that the athlete is safe to participate.(6)(7) Although this concept has not been legally tested,a 1990 New York State Appellate Court decision (Mur-phy v. Blum) suggests that the issue of transfer of liabilitydepends on the specifics of the relationship between theorganization and the physician as well as between thephysician and the athlete. (8)

The athlete should be encouraged to schedule thePPE well in advance of the season, ideally at least 6 weeksbefore the start of practice. This timing allows sufficienttime for full evaluation of issues that may arise during theinitial visit. It also allows implementation of injury pre-vention programs or rehabilitation of injuries before thestart of the season. The clinician should not be pressured

into premature clearance of an athlete before appropriateevaluation is completed.

The PPE can be completed in any of several formats,each of which has advantages and shortcomings. Themost common and ideal format is the office-based PPE inwhich an athlete visits his or her primary care clinician inthe office. The advantages of this strategy include im-proved continuity of care, access to medical records, timefor anticipatory guidance, and ease of arrangingfollow-up diagnostic tests and treatment. The primarydisadvantages are the time burden and cost of an officevisit in addition to the possible limited availability ofappointments before the start of sports seasons.

To alleviate the time and cost burden of the PPE, theother strategy commonly employed is the station-basedPPE. With this approach, the athlete cycles through aseries of stations at which a single aspect of the evaluationis performed. Separate stations may address vital signs,visual acuity screening, medical history and physical ex-amination, orthopedic history and physical examination,updating immunizations, and finally meeting with a cli-nician to review all of the accumulated data and make adecision regarding clearance. This approach is very effi-cient, can be inexpensive, and allows specialty care ateach of the stations, limiting the need for a specialist.Entire teams or schools can be evaluated in a singlesession, reducing the administrative burden of schedul-ing each athlete privately.

However, there are significant disadvantages to thestation-based approach. Continuity of care is severelylimited, including access to previous medical records.Coordination of care may be difficult for issues requiringfollow-up. There is less privacy and time for anticipatoryguidance, and the athlete may be less likely to discusssensitive issues. Finally, athletes who previously havebeen disqualified from sports participation may attemptto take advantage of unfamiliar clinicians and use thestation-based format as a second chance to get cleared.

Obtaining the Medical HistoryThe history portion of the PPE is similar to the history ina typical health supervision visit for a child or adolescentof the same age. Although several efficient screeningtools that have been designed specifically for the PPE areendorsed by multiple professional societies, they shouldnot replace more extensive history collection when it iswarranted. The history form from the 2010 PPE Mono-graph is shown in Figure 1.

It is important to explore the past medical, surgical,family, social, and developmental histories, much as itwould be done for a nonsports-related evaluation. It is

sports medicine preparticipation sports evaluation

e54 Pediatrics in Review Vol.32 No.5 May 2011



Figure 1. History form for preparticipation evaluation.




also important to interview a parent or guardian, ifavailable, because athlete and parent histories are ofteninconsistent. (9)(10)

Some aspects of the history require additional atten-tion. Although the following list is not comprehensive, itrepresents some of the most common challenges to theclinician during the PPE.

CardiovascularThe component of the PPE that receives the most atten-tion from parents, coaches, administrators, the medicalliterature, and the popular press is the cardiovascularevaluation. Although a comprehensive discussion of thecontroversy surrounding preparticipation cardiovascularscreening is beyond the scope of this article, Pediatrics inReview has published a summary of the topic, (11)(12)and clear guidelines from the American Heart Associa-tion (AHA) discuss the controversy surrounding theevaluation and the role of preparticipation electrocardi-ography and echocardiography. (13) The AHA-recommended components of the preparticipation car-diovascular evaluation are listed in the Table.

Several red flags that may appear in the past medicaland family history should prompt further investigation.Known congenital heart disease, cardiac channelopathies(such as long QT or Brugada syndrome), any history ofmyocarditis, and coronary anomalies such as thosecaused by Kawasaki disease should be evaluated by acardiologist before sports participation. A personal his-tory of syncope, near-syncope, chest pain, palpitations,or excessive shortness of breath or fatigue with exertionshould prompt a more thorough evaluation, either by theprimary clinician or a cardiologist. Postexertional syn-cope is a common occurrence that is frequently elicited inthe PPE history. This benign condition should be differ-entiated from exercise-associated collapse, which occursduring exertion and is an ominous sign of hemodynam-ically significant cardiovascular disease or ventriculartachyarrhythmias. All patients who experience syncopeshould undergo electrocardiography, with further test-ing on a case-by-case basis.

A family history of early sudden cardiac death, Marfansyndrome, cardiomyopathy, and arrhythmias (especiallylong QT syndrome) should prompt further cardiovascu-lar evaluation. Particular attention should be paid to anyfamily history of unexplained or poorly characterizeddeaths, such as from drowning, unexplained motor vehi-cle crashes, or seizures. These events may represent un-recognized sudden cardiac death.

MusculoskeletalThe musculoskeletal history is a remarkably sensitivemethod for identifying abnormalities and injuries. Go-mez and associates (14) found the sensitivity of a basicmusculoskeletal history to be 92%, which compares fa-vorably with the estimated 75% sensitivity of a generalmedical history. Inquiring about current injuries and ahistory of injuries requiring evaluation, casting, bracing,surgery, or missed practice or play captures nearly allmusculoskeletal abnormalities that require evaluation ortreatment before sports participation. A sports medicinespecialist may ask about specific orthopedic injuries thatare unique or common to the athlete’s sport, but thisinquiry generally is not necessary for a primary carescreening evaluation.

MedicationsA review of the athlete’s list of current and past medica-tions may provide clues to chronic or recurring medicalconditions that may affect sports participation. In addi-tion, the athlete’s institution or governing sports feder-ation may ban some medications and substances. A com-prehensive review of banned substances is beyond thescope of this article. In general, the athlete is responsiblefor knowing what medications may be banned in his orher sport. The clinician may assist athletes by directingthem to their governing body’s website and bannedsubstance list. Physicians who frequently care forcollege-, national-, and international-level athletesshould be aware of the substances that are banned by theNational Collegiate Athletic Association (15) and theWorld Anti-Doping Agency. (16) Comprehensive lists ofbanned substances can be found at: http://www.ncaa.org/wps/wcm/connect/public/ncaa/student-athlete�experience/ncaa�banned�drugs�list andhttp://www.wada-ama.org/en/World-Anti-Doping-Program/.

Some medications can be taken if the athlete has atherapeutic use exemption (TUE) on file. In some cases,special testing may need to be obtained to meet therequirements of the TUE. TUEs should be filed wellbefore the start of the season to avoid the possibility ofmiscommunication or a gap in treatment of chronicmedical conditions. Often, a permitted medication canbe substituted for a banned substance.

Use of alcohol, tobacco, and other recreational drugsis common among teenagers, including athletes. It isuseful to discuss these substances when discussing med-ications, vitamins, and supplements that the athlete maybe taking.





DermatologicAthletes in certain sports are at addi-tional risk for dermatologic conditionsassociated with their environment orcontact with other athletes. Openwounds should be cleaned and cov-ered for practice and play to reduce therisk of blood-borne pathogen trans-mission. Methicillin-resistant Staphylo-coccus aureus infections have receivedconsiderable attention because theycan result in necrotizing fasciitis, sep-sis, and even amputation. Skin infec-tions such as impetigo, molluscumcontagiosum, tinea, and herpes sim-plex infection are common in sportsthat involve close skin-to-skin contact,such as wrestling and rugby. Each ofthese conditions requires treatment tominimize the risk of transmission.

Many sport federations have spe-cific regulations for how skin infec-tions should be treated and how longathletes should be asymptomatic orunder treatment before returning topractice and competition. Some ath-letes and teams use prophylactic dosesof antiviral medications, such as acy-clovir, for prevention of herpes out-breaks during the season. This practice has not beensystematically evaluated but anecdotally does seem effec-tive for decreasing herpes gladiatorum transmissionamong wrestlers.

Athletes who practice and compete in the sun shoulduse a sun block lotion to minimize their risk of sundamage and skin cancer. Controversy surrounds the ap-propriate sun protection factor for outdoor athletes. Ingeneral, any over-the-counter sun block applied liberallyand frequently provides sufficient protection. Athleteswho have already had significant sun exposure require acareful examination of the sun-exposed skin to monitorfor skin cancer and precancerous lesions.

NeurologicAlthough sports-related concussions are most commonin contact and collision sports, all athletes should beasked about a personal history of concussion or otherhead injury. Often, directed questions about head inju-ries are required to elicit a history of concussion becausemany athletes do not consider an injury in which therewas no loss of consciousness to be a concussion. Specif-

ically, the clinician should ask about any type of headinjury, feeling “dazed” or “foggy,” memory loss, head-aches following a hit to the head, difficulty playing orpracticing following a hit to the head, and any type ofinjury that resulted in a loss of consciousness. The clini-cian should be attuned to the fact that the presentingsigns and symptoms of concussion can be subtle.

If the athlete does provide a history of concussion,more detailed questioning is required to determine thepresence or absence of frequent concussions, prolongedpostconcussion symptoms, and concussions that oc-curred with seemingly trivial trauma. Athletes who havehad rare, mild concussions that resolved spontaneouslydo not need additional evaluation. For athletes who havehad frequent concussions, are more easily concussed, orhave had prolonged postconcussive symptoms, carefuldiscussion with the athlete and family is necessary tounderstand the risks of repeated concussions. A symp-tomatic athlete should never be allowed to return to play,and a graduated, stepwise approach should be used forreturning to physical activity. (17)

Obtaining baseline computer-based neurocognitive

Table. The 12-element American HeartAssociation Recommendations forPreparticipation Cardiovascular Screeningof Competitive AthletesMedical History

• Personal history–Exertional chest pain/discomfort–Unexplained syncope/near-syncope–Excessive exertional and unexplained dyspnea/fatigue associated withexercise

–Prior recognition of a heart murmur–Elevated systemic blood pressure

• Family history–Premature death (sudden and unexpected, or otherwise) before age 50years due to heart disease in first-degree relative

–Disability from heart disease in a close relative younger than 50 years ofage

–Specific knowledge of certain cardiac conditions in family members:hypertrophic or dilated cardiomyopathy, long QT syndrome and other ionchannelopathies, Marfan syndrome, and clinically important arrhythmias

Physical Examination

• Heart murmur• Femoral pulses to exclude aortic coarctation• Physical stigmata of Marfan syndrome• Brachial artery blood pressure (sitting position)

Data from American Heart Association, Inc.




testing (NCT) before the start of the season is contro-versial. Although clinical assessment should be the main-stay of concussion evaluation, NCT increases the sensi-tivity for detecting residual concussion symptoms. (18)Specifically, if baseline NCT is available when a con-cussed athlete clinically appears ready to return to play,repeat NCT can provide an objective measurement of hisor her recovery. However, NCT has poor specificity forconcussion, and the utility of postinjury NCT in anathlete who does not have a baseline study is controver-sial.

“Stingers,” also called “burners,” are injuries to thebrachial plexus caused either by direct trauma or a trac-tion injury. Symptoms are typically brief. Athletes whohave had stingers with persistent symptoms of arm pain,paresthesia, or weakness may have more significant inju-ries to the brachial plexus or cervical nerve root injury.No athlete should be permitted to return to practice orplay who has persistent symptoms.

Cervical cord neurapraxia, also called transient quad-riplegia, is a frightening condition characterized by tem-porary loss of motor control, with or without loss ofsensation or paresthesia, caused by transient compressionof the cervical spinal cord due to forced hyperextension,hyperflexion, or axial loading. The condition is morecommon in athletes who have cervical spinal stenosis.(19) Episodes are transient and typically last less than15 minutes. It is very rare for symptoms to last longerthan 48 hours. There is no increased risk of permanentspinal cord injury following a single episode, (19)(20)but athletes who have multiple episodes or persistentsymptoms require additional evaluation. Those who arefound to have instability, fractures, or degenerativechanges in the cervical spine should not be allowed toreturn to contact or collision sports. Although athleteswho have cervical spinal stenosis are at increased risk ofcervical cord neurapraxia, it is unknown if they are atincreased risk for permanent spinal cord injury. Whetherathletes who have spinal stenosis should be allowed toplay contact sports is controversial and should be evalu-ated on a case-by-case basis by a qualified physician.

Heat IllnessHeat illness kills more than 1,000 people in the UnitedStates every year. (21) Athletes who have had a history ofheat illness are at risk for future heat illness, includingheat stroke. Once identified, the athlete can take mea-sures to assure proper hydration and acclimatization tominimize their risk. In addition, stimulants and antihis-tamines increase the risk of heat illness and should be

avoided, if possible, during training and competition inwarmer weather.

OphthalmologicAthletes who require corrective lenses for sports partici-pation may need to work with an optometrist or ophthal-mologist to ensure that they have appropriate lenses forsport. Some sports, such as wrestling, boxing, and rugby,do not allow eyewear, so athletes in need of correctivelenses must use contact lenses. Athletes whose best-corrected vision is worse than 20/40 in one eye (alsoreferred to as “functionally one-eyed”) must wear Amer-ican Society for Testing and Materials-approved protec-tive eyewear. (22)

Athletes who practice and compete in the sun or onthe snow should wear ultraviolet-blocking eyewear toprevent acute photoretinitis and possibly decrease thechance of developing cataracts. In addition, any baselineocular abnormality or normal variant should be docu-mented. Being aware of baseline anisocoria or abnor-mally shaped pupils can help to prevent an unnecessaryevaluation if the athlete presents later with a head or eyeinjury.

PulmonaryAthletes who have baseline lung disease may requireadditional evaluation or a change in their treatmentregimen before the season. Athletes who have knownEIB should have an active prescription for a bronchodi-lator such as albuterol. Such athletes may benefit fromhaving multiple inhalers to keep in multiple settings,such as at home, at school, and with their coach orathletic trainer. In general, athletes who have isolatedEIB do not benefit from inhaled corticosteroids. How-ever, there is significant overlap between asthma andEIB. In general, if an athlete has symptoms in othersettings and the EIB is poorly controlled with broncho-dilator monotherapy, adding a controller medication,such as an inhaled corticosteroid, may be beneficial. (23)

Some athletes compete in sports or under federationrules that require them to obtain a TUE before usingbronchodilators. As mentioned, it is important to obtainappropriate pulmonary function tests and to completethe TUE paperwork well in advance of the season.

Vocal cord dysfunction (VCD) is another commonrespiratory complaint among athletes. Triggers or asso-ciated risk factors for VCD include allergic rhinitis, gas-troesophageal reflux disease, anxiety, and poorly con-trolled asthma. The diagnosis can be made with a historyof isolated inspiratory stridor (typically worse in compe-tition situations) or with laryngoscopy. Most athletes can





control their symptoms with special breathing tech-niques that require intensive teaching and are best taughtby speech therapists or other professionals who are famil-iar with VCD. Like other chronic medical conditions,gaining control of VCD symptoms before the start of thesports season is important for increasing the likelihood ofsuccess.

A history of other chronic pulmonary diseases, such ascystic fibrosis or chronic lung disease due to bronchopul-monary dysplasia, should not automatically disqualify achild or adolescent from sports participation. Carefulpartnership and close follow-up with a pulmonologist orother clinician who is familiar with the specific disorder isessential. It may be reasonable to dissuade children andadolescents who have severe lung disease from participat-ing in sports that impose a high cardiovascular demandand steer them toward sports in which they are morelikely to find success.

GastrointestinalAlthough gastrointestinal complaints are commonamong children and adolescents, very few require dis-qualification or modified sports participation. Diarrheamay put the athlete at increased risk of dehydration, butdehydration usually can be prevented with increased fluidintake. Gastroesophageal reflux disease can worsen withincreased physical activity but usually can be controlledwith diet modification. Gastric acid-suppressing medica-tions (histamine-2 receptor blockers and proton pumpinhibitors) may be necessary in some patients. Becauseinflammatory bowel disease can cause a profound anemiathat can make physical activity more difficult and impairperformance, close follow-up with a gastroenterologistto help ensure good control of symptoms is essential.

Infectious DiseaseMononucleosis and mononucleosis-like infection causedby viral infections (typically Ebstein-Barr virus, but occa-sionally cytomegalovirus) can cause splenomegaly andput the athlete at increased risk for splenic rupture. Anyathlete who has mononucleosis should be disqualifiedfrom practice and competition in any sport in whichthere is a risk of abdominal trauma. Most athletes are safeto return to sport by 3 to 4 weeks after the start ofsymptoms. (24)

Blood-borne pathogens, including human immuno-deficiency virus and infectious hepatitis, should notprompt disqualification from sports. (25) The athletemay participate in any sport that his or her health allows.Universal precautions should be used for all athletes, and

skin lesions should always be covered properly, regardlessof any known or suspected infectious disease.

GenitourinaryFew components of the genitourinary history shoulddisqualify an athlete or require modified participation.Athletes who have a solitary or horseshoe kidney requireindividual assessment for contact and collision sports.(26) Protective equipment may be necessary to protectthe remaining kidney, and the risks of injury should beweighed carefully against the benefits of contact or col-lision sport participation. Inguinal hernias may worsenwith increased physical exertion, especially in sports suchas weightlifting that impose a high static demand (in-creased muscle tension with relatively no change in mus-cle length or joint mobility). Females who experienceamenorrhea or oligomenorrhea should be assessed foreating disorders and impaired bone health. Female ado-lescents who exercise intensively or play sports (especiallythose sports that emphasize leanness) are at risk fordeveloping the “female athlete triad” of disordered eat-ing, amenorrhea, and osteoporosis that is associated withsignificant health problems later in life.

PsychologicalEating disorders are common among athletes in weight-restricted and esthetic sports. Many athletes do not meetdiagnostic criteria for anorexia nervosa or bulimia ner-vosa but clearly have disordered eating patterns. Theycan be diagnosed as having eating disorder not otherwisespecified, which has been included in the most recentversion of the Diagnostic and Statistical Manual of Men-tal Disorders. (27) Screening for disordered eatingshould be performed as part of every PPE. Several vali-dated screening instruments are available, but the mostcommonly used is the 26-item Eating Attitudes Test.(28) Screening tools for disordered eating generally as-sess the patient’s body image and screen for abnormaleating behaviors, such as irrational avoidance of certainfoods, ritualistic approaches to meals (eg, very slow eat-ing, cutting food into very small pieces, extraordinarycalorie counting), vomiting, or engaging in excessiveexercise after meals.

Disordered eating is one of the three elements of thefemale athlete triad, along with amenorrhea and de-creased bone mineral density. The presence of any one ofthese conditions should prompt the clinician to evaluatefor the other two. The female athlete triad puts theathlete at risk for stress fractures. Although not an abso-lute contraindication to sports participation, complica-tions of an eating disorder (including electrolyte abnor-




malities and cardiac rhythm disturbances) need to bemonitored. A multidisciplinary team, including physi-cians, dietitians, and mental health professionals, is essen-tial for the necessary care of an athlete who has an eatingdisorder.

Depression and anxiety are common mental healthproblems that can appear in athletes. Unless severe, theseconditions should not disqualify the athlete from sportsparticipation. Mental health professionals may help theathlete to cope better with his or her psychologicalsymptoms. Often, athletes can be persuaded to use men-tal health services by discussing the possible performanceimprovements that might come from controlling theirdepression or anxiety.

The prevalence of attention-deficit/hyperactivity dis-order (ADHD) among athletes is similar to the preva-lence among other children and adolescents of the sameage. Stimulant medications are a common treatment butmay require a TUE or documentation of ADHD testingbefore the start of the sports season.

ImmunizationThe PPE provides an opportunity to review the immu-nization history and provide catch-up immunizations.Although missing immunizations should not be criteriafor sports disqualification, athletes and clinicians shouldbe aware that some immunizations are required byschools and colleges for enrollment. In addition, athleteswho are competing internationally may need documen-tation of specific immunizations to gain entry into certaincountries.

The Physical ExaminationThe PPE physical examination varies little from the stan-dard health supervision evaluation, although a few com-ponents require additional attention in the athlete.

Vital SignsThe vital signs of an athlete may be different from what aclinician is used to seeing in nonathletes. A child oradolescent who has a high degree of cardiovascular fit-ness may have bradycardia and a wide pulse pressure.Respiratory rate may be lower than expected when rest-ing but may be elevated for several hours after exercise.Body mass index may be an inaccurate method of screen-ing for overweight and obesity in some athletes who arevery muscular. The blood pressure should be normal.Elevated blood pressure in children and adolescents,regardless of sports participation, requires evaluation andtreatment. For idiopathic or “essential” hypertension,one of the first-line treatments is exercise. Athletes who

have mild-to-moderate hypertension (�95th percentilefor age, sex, and height) require evaluation but should beencouraged, rather than prohibited, from participating insports. Athletes who have severe hypertension (charac-terized as �5 mm Hg over the 99th percentile for age,sex, and height) should be disqualified from sports char-acterized by a high static demand and avoid heavy weighttraining and powerlifting. (29)(30)

Head and NeckCorrected visual acuity should be better than 20/40 inboth eyes. If not, protective lenses are required for con-tact sports participation. (22) Auricular cartilage damageshould prompt the clinician to remind the athlete to useear protection for sports such as wrestling and rugby.Nasal septum damage should prompt referral to an oto-laryngologist. Dental carries may indicate overuse ofsports drinks or eating disorders such as bulimia.

CardiovascularThe AHA-recommended elements of the cardiovascularevaluation are listed in the Table. In general, any cardiacabnormality that is not clearly benign should be fullyevaluated before sports participation. A pediatric cardiol-ogist who is familiar with the demands of sport partici-pation should perform the follow-up evaluation. It is bestto avoid ordering echocardiography and other advancedcardiac testing from facilities that are unfamiliar withcongenital heart disease and sport participation in chil-dren.

GenitourinaryThe female genitourinary examination is not a standardpart of the PPE. However, any concerns raised by find-ings on the patient’s history should be evaluated appro-priately. Males should have two descended testicles. Anymale who has an undescended or absent testicle shouldbe evaluated by a urologist. Athletes who have only onefunctional testicle may participate in all sports but shouldbe encouraged to use a protective cup to decrease the riskof injury in contact or collision sports. The PPE allowsthe clinician an opportunity to discuss testicular self-examination with the older adolescent. Males who have ahistory of groin pain should be evaluated for an inguinalhernia with a digital examination of the inguinal ring.Asymptomatic athletes do not need to be screened forhernias. (5)

DermatologicAny infectious skin condition should be treated beforethe athlete’s return to sport. Any skin lesions that are





suspicious for malignancy should be removed and evalu-ated by a pathologist.

NeurologicAny history of neurologic injury, including concussionsand stingers, should prompt a detailed neurologic eval-uation. The assessment should include cognitive func-tion, cranial nerves, sensation, strength, tone, reflexes,and cerebellar function. Any abnormality should be eval-uated thoroughly before sports participation.

MusculoskeletalClinicians often feel compelled to perform a detailedmusculoskeletal examination on athletes who present fora PPE. However, as discussed, the physical examinationadds little diagnostic value to the orthopedic history.(14) A cursory evaluation of strength and range of mo-tion is sufficient for athletes who have no musculoskeletalcomplaints. Focused, detailed examinations of specificjoints can be reserved for evaluating previous injuries orcurrent complaints.

The Laboratory EvaluationNo screening laboratory or imaging tests are required aspart of a routine PPE. Significant controversy surroundsthe use of screening echocardiography and electrocardi-ography to detect occult congenital heart disease. (13) Inaddition, the utility of testing for hemoglobinopathies,anemia, bleeding disorders, infectious diseases, cardio-vascular risk factors (such as hypercholesterolemia), andother chronic diseases that may affect athletic perfor-mance or general health is unclear.

Special SituationsFewer than 2% of PPEs result in disqualification of theathlete from sport. However, many medical conditionsrequire adaptation or close monitoring for complicationsrelated to sports participation. In addition, sporting ac-tivities are heterogeneous in their physical and cardiovas-cular demands as well as in their level of contact. Certainmedical conditions may be incompatible with particularstatic or dynamic (changes in muscle length or jointmobility with relatively small change in muscle tension)demands or with the risks associated with contact orcollision sports. A comprehensive review of the medicalconditions affecting sports participation is beyond thescope of this article, but several conditions that fre-quently come to clinical attention during the PPE arediscussed. This list is far from exhaustive, and the readerwho is interested in learning more about the specificdemands of sports participation and how many common

and uncommon medical conditions affect sports partici-pation should see the American Academy of PediatricsCouncil on Sports Medicine and Fitness’s report on“Medical Conditions Affecting Sports Participation.”(26)

SeizuresThe child or adolescent who has a well-controlled seizuredisorder should not be disqualified from sports participa-tion. (26) In these athletes, the risk of having a seizureduring practice or competition is very low, partially dueto their already low seizure frequency but also due to theantiepileptic effects of exercise. It is sometimes surprisingto officials and policy makers that athletes who haveknown seizure histories can be allowed to participate incontact and collision sports and in sports where theywould seem to be at increased risk of injury should theyhave a seizure. The clinician may need to advocate for theathlete in such situations. A useful point of reference isthe individual state’s legal seizure-free interval beforeindividuals who have epilepsy are allowed to return todriving. In most states, it is 3 to 6 months.

Children and adolescents who have poorly controlledepilepsy also benefit from physical exercise, but more caremust be taken to ensure the safety of these athletes andthose around them. An individual assessment should bemade to determine the athlete’s suitability for contactand collision sports. The following sports should beavoided:

● Archery● Power lifting● Riflery● Swimming● Weight lifting● Weight training● Sports involving heights (eg, parachuting, hang-

gliding)

Down SyndromeDown syndrome, also known as trisomy 21, is a geneticsyndrome involving multiple congenital anomalies. Chil-dren born with Down syndrome often require interdis-ciplinary care to maximize their health outcomes andquality of life, regardless of sports participation. Of note,instability of the cervical spine (primarily atlantoaxialinstability, but also occipitoatlantal instability) has beenreported in up to 30% of patients who have Downsyndrome. (31) The Special Olympics® organizationrequires radiographic evaluation of the cervical spinebefore sports participation. It is common for patients




who have had normal cervical spine radiographs to ac-quire cervical instability. For this reason, patients whohave Down syndrome should be prohibited from partic-ipating in collision sports regardless of the radiographicappearance of their spines. However, no other limita-tions need be imposed for patients who have normalcervical spine radiographs. Patients who have radio-graphic evidence of cervical instability but no neurologicsigns or symptoms should be disqualified from “neck-stressing” sports. Special Olympics considers diving,gymnastics, butterfly stroke, high jumping, soccer, andpentathlon to be “neck-stressing.” Athletes who haveDown syndrome and cervical instability may use a cervi-cal collar, but this practice does not change their sportrestriction.

Down syndrome is associated with other abnormali-ties that may influence sports participation, such as car-diac abnormalities (septum defects in particular), cata-racts, diabetes, thyroid disease, hip and patellarinstability, and foot abnormalities. Each of these condi-tions, if present, requires evaluation before sports partic-ipation. However, no other special precautions need tobe taken for these children.

Acute Febrile IllnessAthletes who have a fever should be prohibited frompractice and competition. (26) Fever puts the athlete atrisk for acute heat illness (due to increased heat storage),reduced maximal exercise capacity, and hypotension(due to decreased peripheral vascular tone and possiblydehydration).

Type 1 Diabetes MellitusAthletes who have type 1 diabetes mellitus (DM1) arepermitted to participate in any sport without restriction.(26) However, DM1 monitoring and treatment oftenbecomes more complex with the varying demands oforganized sports. Careful evaluation and monitoring ofblood glucose, diet, insulin types and doses, and hydra-tion status are essential. Blood glucose should bechecked more frequently than usual. At a minimum,athletes who have DM1 should measure their bloodglucose every 30 minutes during continuous exercise,15 minutes after completion of exercise, and at bedtime.For optimum control and performance, many athleteswho have DM1 find that they need to measure theirblood glucose and modulate their insulin and carbohy-drate intake frequently. Insulin pumps and rapid-actinginsulins have allowed athletes to fine-tune their glycemiccontrol much more effectively than in the past. It is notuncommon for athletes who have DM1 to develop com-

plex treatment plans involving both pump and injectableinsulin therapy.

The Disabled AthleteDisabled athletes may face special challenges, but theclinician should encourage exercise and sports participa-tion for the same reasons they are encouraged in able-bodied athletes. (5) Good communication among ath-letes, coaches, parents, and clinicians is essential forensuring safe and successful sports participation. Thesupplemental history form from the 2010 PPE mono-graph (Fig. 2) can help to facilitate this communication.

When to Disqualify an Athlete From SportsParticipationAlthough most complaints and abnormalities identifiedduring the PPE are not absolute contraindications tosports participation, several conditions should promptdisqualification from sport. Most of these are cardiovas-cular conditions and have been outlined in the 36thBethesda Conference guidelines: (32)

● Pulmonary vascular disease with cyanosis or a hemody-namically significant right-to-left shunt

● Severe pulmonary stenosis (untreated)● Severe aortic stenosis or regurgitation (untreated)● Severe mitral stenosis or regurgitation (untreated)● Any cardiomyopathy● Vascular Ehlers-Danlos syndrome● Coronary anomalies (especially anomalous coronary

origins)● Catecholaminergic polymorphic ventricular tachycar-

dia● Acute pericarditis● Acute myocarditis● Acute Kawasaki disease

Although the guidelines from the 36th Bethesda con-ference only comment on disqualification for thesespecific conditions, any cardiovascular disease shouldbe thoroughly evaluated and treated by a pediatriccardiologist to ensure the athlete’s safe participation insports.

In addition to cardiac abnormalities, any conditionthat cannot be well controlled and puts the athlete at riskof significant injury or death or endangers the health ofteammates or competitors requires further evaluation ordisqualification from sport. For example, a musculoskel-etal injury that impairs the athlete’s ability to protecthim- or herself during practice and competition shouldprompt disqualification until the athlete is safely able toreturn to play. For a discussion of the evaluation and





Figure 2. Supplemental history form for athletes who have special needs.




management of specific sports-related injuries, please seethe recent Pediatrics in Review article, “Managing SportsInjuries in the Pediatric Office.” (33)

In performing the PPE, the clinician’s first responsi-bility is to ensure the health and safety of the patient.However, the physical and psychological benefits of ex-ercise and sport participation should weigh heavily ondecisions to disqualify an athlete from sport.

References1. Garrick JG. Preparticipation orthopedic screening evaluation.Clin J Sport Med. 2004;14:123–1262. Garrick JG, Requa RK. Injuries in high school sports. Pediatrics.1978;61:465–4693. Smith J, Laskowski ER. The preparticipation physical examina-tion: Mayo Clinic experience with 2,739 examinations. Mayo ClinProc. 1998;73:419–4294. Hulkower S, Fagan B, Watts J, Ketterman E, Fox BA. Clinicalinquiries: do preparticipation clinical exams reduce morbidity andmortality for athletes? J Fam Pract. 2005;54:628–6325. Bernhardt DT, Roberts WO, American Academy of FamilyPhysicians, American Academy of Pediatrics. PPE: PreparticipationPhysical Evaluation. 4th ed. Elk Grove Village, IL: American Acad-emy of Pediatrics; 2010

6. Herbert DL. Legal Aspects of Sports Medicine. 2nd ed. Canton,OH: PRC Publishers; 19957. Gallup EM. Law and the Team Physician. Champaign, IL:Human Kinetics Publishers; 19958. Murphy v Blum, 160 AD 2d 914: NY, Apellate Div, (1990)9. Risser WL, Hoffman HM, Bellah GG Jr. Frequency of prepar-ticipation sports examinations in secondary school athletes: are theUniversity Interscholastic League guidelines appropriate? Tex Med.1985;81:35–3910. Carek PJ, Futrell M, Hueston WJ. The preparticipation phys-ical examination history: who has the correct answers? Clin J SportMed. 1999;9:124–12811. Singh A, Silberbach M. Consultation with the specialist: car-diovascular preparticipation sports screening. Pediatr Rev.2006;27:418–42412. Vitiello R. Commentary: the value of the ECG in the prepar-ticipation sports physical examination: the Italian experience. Pedi-atr Rev. 2006;27:e75–e7613. Maron BJ, Thompson PD, Ackerman MJ, et al. Recommen-dations and considerations related to preparticipation screening forcardiovascular abnormalities in competitive athletes: 2007 update: ascientific statement from the American Heart Association Councilon Nutrition, Physical Activity, and Metabolism: endorsed by theAmerican College of Cardiology Foundation. Circulation. 2007;115:1643–145514. Gomez JE, Landry GL, Bernhardt DT. Critical evaluation ofthe 2-minute orthopedic screening examination. Am J Dis Child.1993;147:1109–111315. NCAA Drug Testing Program. Accessed February 2011 at:http://www.ncaa.org/wps/wcm/connect/public/ncaa/student-athlete�experience/ncaa�banned�drugs�list16. World Anti-Doping Agency. Accessed February 2011 at:http://www.wada-ama.org/17. McCrory P, Meeuwisse W, Johnston K, et al. Consensusstatement on concussion in sport: the 3rd International Conferenceon Concussion in Sport held in Zurich, November 2008. Br J SportsMed. 2009;43(suppl 1):i76–i9018. Van Kampen DA, Lovell MR, Pardini JE, Collins MW, Fu FH.The “value added” of neurocognitive testing after sports-relatedconcussion. Am J Sports Med. 2006;34:1630–163519. Pavlov H, Torg JS, Robie B, Jahre C. Cervical spinal stenosis:determination with vertebral body ratio method. Radiology. 1987;164:771–77520. Torg JS, Pavlov H, Genuario SE, et al. Neurapraxia of thecervical spinal cord with transient quadriplegia. J Bone Joint SurgAm. 1986;68:1354–137021. Centers for Disease Control and Prevention. Heat-relatedDeaths — United States, 1999–2003. MMWR Morb Mortal WklyRep. 2006;55:796–79822. Protective eyewear for young athletes. Pediatrics. 2004;113:619–62223. Expert Panel Report 3 (EPR-3): guidelines for the diagnosisand management of asthma-summary report 2007. J Allergy ClinImmunol. 2007;120(5 suppl):S94–S13824. Putukian M, O’Connor FG, Stricker P, et al. Mononucleosisand athletic participation: an evidence-based subject review. ClinJ Sport Med. 2008;18:309–31525. Committee on Sports Medicine and Fitness. American Acad-emy of Pediatrics. Human immunodeficiency virus and otherblood-borne viral pathogens in the athletic setting. Pediatrics.1999;104:1400–1403

Summary• In general, the evidence base for the PPE is limited.

(5)• The clinician should coordinate and address the

goals of parents, athletes, and organizations whilepromoting safe participation in physical activity.

• Based on at least fair evidence, the PPE does little toprevent morbidity and mortality in athletes. (4)

• Based on expert opinion, the PPE is best performedwell in advance of the competitive season. (5)

• Based on expert opinion, the office-based PPE ispreferable to the station-based approach. (5)

• Based on at least fair evidence, clinicians shouldfocus on the medical and musculoskeletal historybecause most conditions that affect participation areelicited from that history. (5)(13)(14)

• Based on expert opinion, athletes who have suffereda concussion should not be allowed to return to playwhile symptomatic and should follow a stepwiseprogression of graduated return to full activity. (17)

• Based on expert opinion, screening echocardiographyand electrocardiography should not be routine partsof the PPE. (13)

• Based on expert opinion, athletes who have lost apaired organ may compete in any sport with properprotective equipment. (22)(26)

• Based on expert opinion, most athletes who havechronic medical conditions can compete safely inmost sports. (26)





26. Rice SG. Medical conditions affecting sports participation.Pediatrics. 2008;121:841–84827. American Psychiatric Association Task Force on DSM-IV. Diag-nostic and Statistical Manual of Mental Disorders. DSM-IV-TR. 4thed. Washington, DC: American Psychiatric Association; 200028. Garner DM, Olmsted MP, Bohr Y, Garfinkel PE. The EatingAttitudes Test: psychometric features and clinical correlates. PsycholMed. 1982;12:871–87829. McCambridge TM, Benjamin HJ, Brenner JS, et al. Athleticparticipation by children and adolescents who have systemic hyper-tension. Pediatrics. 2010;125:1287–129430. The fourth report on the diagnosis, evaluation, and treatment

of high blood pressure in children and adolescents. Pediatrics.2004;114(2 suppl):555–57631. Winell J, Burke SW. Sports participation of children withDown syndrome. Orthop Clin North Am. 2003;34:439–44332. Pelliccia A, Zipes DP, Maron BJ. Bethesda Conference#36 and the European Society of Cardiology consensus recom-mendations revisited: a comparison of U.S. and European crite-ria for eligibility and disqualification of competitive athletes withcardiovascular abnormalities. J Am Coll Cardiol. 2008;52:1990–199633. Metzl JD. Managing sports injuries in the pediatric office.Pediatr Rev. 2008;29:75–84

HealthyChildren.org Parent Resources from AAPThe reader is likely to find material to share with parents that is relevant to this article bygoing to this link: http://www.healthychildren.org/English/healthy-living/sports/Pages/default.aspx




DOI: 10.1542/pir.32-5-e532011;32;e53Pediatrics in Review

Andrew R. Peterson and David T. BernhardtThe Preparticipation Sports Evaluation

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