The Sports Physical

Valerie Robinson D.O.

The goal of the preparticipation sports

physical is to maximize safety of participants. Identify life-threatening medical problems. Identify and treat other medical problems that

may interfere with participation. (e.g. asthma, HTN)

Identify previous injuries and try to prevent subsequent injuries

It does not substitute for a well child check.

The Goals

Most schools require annual physicals Exam 4-6 weeks before sports season starts May be done by the PCP May be done in a station approach at locations

set up by the school or local health department

Targeted medical hx Targeted family hx Target physical Emphasis on musculoskeletal and cardiovascular Labwork is not necessary

The Exam

Given that 30-78% of adolescents have a

sports physical in lieu of a well child check, it may be appropriate to take the time to perform a complete check-up as well.

If performed in a private office, the physician may ask about drug use, sexual activity, violence, and mental health (e.g. depression or bullying) as part of a comprehensive check-up

Medical history

Seizure, excess fatigue, shob Injury history

Where, when, lingering effects?, LOC Pain, paresthesia, decreased ROM

Cardiovascular history HTN, murmur, dyslipidemia, myocarditis, endocarditis, rheumatic

fever, syncope, near-syncope, angina, palpitations Family history

Especially cardiac or sudden death, Marfan’s, syncope, SIDS Surgical history Medications Immunization history Menstrual history History of weight changes

The History

Vitals, BMI

Low BMI, bradycardia, hypotension, hypothermia are symptoms of an eating disorder

HEENT – need acuity test If corrected acuity <20/40, need protective eyewear

Lungs - auscultate Abdomen - splenomegaly Genitals – testes, discuss cup Skin – anything contagious? (herpes, varicella,

scabies, tinea corpora, molluscum contagiosum) Lymphatic – lymphadenopathy, splenomegaly Neuro – cranial nerves, focal defecits

The Physical

Pulse and BP, right arm while sitting Auscultation done supine and standing

Innocent murmur – systolic, decreases when standing Hypertrophic cardiomyopathy – may have no murmur.

Systolic, increases when standing and with Valsalva, decreases with squatting

Aortic stenosis – ejection murmur, split S2, murmur may radiate to carotids

Mitral prolapse – midsystolic click, poss late systolic murmur

Locate PMI Asymptomatic bradycardia (40-50 bpm)may be

present in fit athletes - does not preclude activity EKG is not recommended for screening purposes

The Physical The Cardiac Exam

If hx of injury, pay special attention to area

involved Look for asymmetry Look for swelling, bruising, deformities Watch for and ask about pain during exam Test for weakness Look for atrophy and watch for fasciculations

The PhysicalMusculoskeletal

Shoulder

Full abduction, flexion, external rotation Resisted flexion and abduction, apprehension

test Elbow

Flexion, extension, supination, pronation Hands

Flexion and extension of fingers, grip strength Neck

Flexion, extension, rotation, sidebending

The PhysicalMusculoskeletal 2

Back

Look for scoliosis, spondylolysis Flexion, extension, rotation

Hip Flexion, extension, walk “Duck walk” tests the hip and knee

Knee Flexion, extension, walk, “duck walk” Check for Osgood-Schlatter

Ankle Hop several times on each foot

The PhysicalMusculoskeletal 3

HTN DM 1 or 2 Asthma Exercise-Induced Bronchospasm

Dx by H&P. Spirometry or exercise challenge as indicated

Eating disorders Treat psych. Cut exercise in half, esp. if 85% of IBW

Musculoskeletal injuries Physical rehabilitation Plan for return to activities. “Start low. Go slow.”

Tx Before Participating

Mitral prolapse – May participate UNLESS

Hx of syncope Fam hx of sudden death d/t prolapse Arrhythmias Moderate or greater mitral regurg Hx of emboli

Uncontrolled HTN Fever

Relative Contraindications

Sudden death in the young athlete occurs with a

prevalence between 1:100,000 and 1:300,000. 90% of deaths are in males, median age 17 Causes:

Hypertrophic cardiomyopathy Wolff-Parkinson-White – delta waves, SVT Long QT syndrome Aortic stenosis – more common in Marfan’s Commotio cordis – precordial blow disrupts heart rhythm Coronary artery anomalies Right ventricular hypertrophy Myocarditis Aortic rupture

Sudden Death

Albert C Hergenroeder, MD et al. “The

preparticipation sports examination in children and adolescents.” UpToDate. Updated July 11, 2012. www.uptodate.com

Stephen G. Rice, MD, PhD, MPH et al. “Medical Conditions Affecting Sports Participation.” Pediatrics Vol. 121 No. 4 April 1, 2008 , pp. 841 -848. Retrieved from http://pediatrics.aappublications.org

Form: “Preparticipation Physical Evaluation Forms.” American Academy of Pediatrics. http://www.aap.org/en-us/professional-resources/practice-support/Pages/Preparticipation-Physical-Evaluation-Forms.aspx

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