Pre-participation Sports Evaluation

Question 1

Goal of a Pre-participation Physical Evaluation (PPE)

Answer 1

Promote health & safety of athletes

Question 2

Primary and secondary objectives of a Pre-participation Physical Evaluation (PPE)

Answer 2

– Primary objectives
* screen for life threatening or disabling conditions
* screen for conditions that may predispose to injury or illness
– Secondary objectives
* establish medical home
* determine the general health of the individual
* assess fitness for specific sports
* counseling on injury prevention & health-related issues

Question 3

How far in advance to training should a Preparticipation Physical evaluation (PPE) be done ideally?

Answer 3

• Schedule the examination ~6-8 weeks
  before training starts.
  – Allows time to evaluate, treat, or
  rehabilitate any identified problems

Question 4

Preparticipation History

Answer 4

The history is the MOST IMPORTANT part of the encounter

• Identifies the majority of medical & musculoskeletal conditions
• 2019 Update recommendations
  – Ask about bullying, drug or alcohol use, & birth control
  – Inquire about sexual identity at birth & gender identification

Question 5

Preparticipation History CARDIOVASCULAR risks

Answer 5

Sudden cardiac arrest is the leading cause of death in young athletes, accounting for
75% of all sudden deaths

Question 6

12-point screen for cardiovascular preparticipation history

Answer 6

– Personal Medical History
1. Chest pain or discomfort with exercise?
2. Syncope or near syncope associated with
exercise?
3. Excessive shortness or breath or fatigue
associated with exertion?
4. History of heart murmur?
5. History of elevated blood pressure?
– Family Medical History
6. Premature death (<50 years-old) due to heart disease
7. Disability from heart disease in a close relative <50 years-old
8. Specific cardiac conditions: hypertrophic or dilated cardiomyopathy, long QT
syndrome, other ion channelopathies, Marfan syndrome, or arrhythmias
– Physical Examination
9. Auscultation of heart murmur in supine & standing position
10. Palpation of radial & femoral pulses
11. Brachial blood pressure taken in seated position
12. Physical stigmata of Marfan syndrome

Question 7

_____ is the leading cause of death in young athletes, accounting for 75% of all sudden deaths

Answer 7

Sudden cardiac arrest

Question 8

Physical stigmata of Marfan syndrome

Answer 8

– Tall, lean, lanky build with disproportionately long arms & legs, slender fingers & toes
– Loose & flexible joints
– May have myopia (nearsightedness) or other vision problems
– Long, thin face; deep-set eyes; a small bottom jaw; a high, arched roof of the
mouth & crowded teeth.
– May have an abnormal curve to their spine or a different shape to their chest.

Question 9

Preparticipation History: CENTRAL NERVOUS SYSTEM

Answer 9

• Frequent or exertional headaches, seizure
  disorders, concussion, recurrent stingers/burners,
  or cervical cord neuropraxia may affect clearance
• Preseason concussion screen: standardized assessment for concussion

Question 10

Preparticipation History: Chronic diseases

Answer 10

• Note a history of chronic diseases & elicit pertinent follow-up information
  – Eg. Reactive airway disease, exercise-induced asthma, diabetes, renal disease,
  liver disease, chronic infections, or hematologic diseases

Question 11

Preparticipation History: Surgical history

Answer 11

• Surgical history may influence participation in certain sports
• Full recovery without long-term impact on performance prior to clearance

Question 12

Preparticipation History: Infectious disease

Answer 12

• Infectious mononucleosis in the last month?
  – Risk for splenic rupture ↑ the first 3 weeks of illness
• With or without trauma
• D/C physical activity during the first month after onset
• Serial abdominal U/S to assess spleen size for return to play decisions

Question 13

Preparticipation History: MUSCULOSKELETAL LIMITATIONS & PRIOR INJURIES

Answer 13

• Inquire about joints with limited ROM, muscle weakness, & prior injuries
• Pain/soreness after activity may reflect overuse syndromes/tendonitis

Question 14

Preparticipation History: MENSTRUAL HISTORY IN FEMALES

Answer 14

• Female athlete triad
  – Disordered Eating
  – Amenorrhea
  – Osteoporosis

Question 15

Preparticipation History: NUTRITIONAL ISSUES

Answer 15

• Inquire about methods the athlete uses to maintain, gain, or lose weight.
• Eating disorders or inadequate nutritional intake lead to persistent or recurrent
  injury, including stress fractures.
• Vitamin D deficiency has become ↑ common in female athletes due to inadequate
  dietary intake &/or ↓ sunlight exposure.

Question 16

Preparticipation History: Medication history

Answer 16

• Prescription, OTC medications, &
  supplements
• May reveal problems omitted in the
  history
• May provide opportunity to discuss the
  drawbacks of performance-enhancing
  compounds such as anabolic steroids,
  creatine, stimulants, & narcotics

Question 17

Physical Examination: General

Answer 17

• Patient stands in front of examiner
  – evaluate both front & back along with posture
• General body habitus
• Observe for asymmetry in muscle bulk, scars, or unusual postures
• Observe patient movement

Question 18

Physical Examination: Neck

Answer 18

• Evaluate ROM
  – Flexion/Extension (chin to chest, look at the ceiling)
  – Rotate from side to side & laterally bend (ear to shoulder)
• Observe for asymmetry, lack of motion, or pain with movement

Question 19

Physical Examination: Shoulder and upper extremity

Answer 19

• Observe clavicles, shoulder position, scapular position, elbow position, & fingers
• ROM screening
  – Fully abduct arms with palms supinated
  – Internally & externally rotate shoulder
  – Flex & extend wrist, pronate & supinate wrist, flex & extend fingers
• Manual muscle testing
  – Shrug shoulders (testing trapezius)
  – Abduct to 90 degrees (testing deltoid)
  – Flex elbow (testing biceps)
  – Extend elbow over head (testing triceps)
  – Test wrist flexion & extension
  – Have patient grasp fingers

Question 20

Physical Examination: Back

Answer 20

• General inspection (scoliosis or kyphosis)
• ROM screening:
  – Touch toes with knees straight (spine flexion & hamstring ROM)
  – Rotation, side bending, & spine extension (seated)

Question 21

Physical Examination: Gait & Lower Extremity

Answer 21

• Gait
  – Walk short distance normally (symmetry, heel-toe gait pattern, look at all joints
  involved in gait & leg lengths, evidence of joint effusions or pain).
• Toe-walk & heel-walk for short distance
• Check tandem walking (balance beam walking)
• Squat
• Duck Walk

Question 22

Physical Examination: Skin

Answer 22

– Contagious lesions (Ex// herpes, impetigo)

Question 23

Physical Examination: ABDOMEN

Answer 23

– Hepatosplenomegaly

Question 24

Physical Examination: GU System

Answer 24

– Testicular abnormalities or hernias

Question 25

Physical Examination: Neurologic system

Answer 25

Coordination, gait, & mental processing

Question 26

Physical Examination: Sexual maturity

Answer 26

Tanner stage

Question 27

After completing the medical evaluation, the clinician make recommendations about
sports clearance:

Answer 27

– Medically eligible for sports without restrictions
– Medically eligible for sports without restriction, but further evaluation needed
– Medically eligible for certain sports listed on the form
– Not medically eligible for any sports, pending further evaluation
– Not medically eligible for any sports