Pre-Participation Sports Physical Flashcards
goal of Preparticipation Physical Exam (PPE)
- promote the health and safety of student athletes
- creen for conditions that may be life-threatening or disabling and for conditions that may predispose to injury or illness
primary goals of PPE
- Identify and rehabilitate old musculoskeletal injuries
- Identify and treat conditions that interfere with performances (exercised-induced bronchospasm)
- Remove unnecessary restrictions on participation which can prevent children from establishing healthy lifestyle habits at a young age
secondary goals of PPE
- Counsel athletes on health-related issues
- Assess fitness level
- Ideal timing is 6-8 weeks before training starts, which allows time to further evaluate, treat, or rehab any identified problems
how often should PPE be performed?
annually
T/F: PPE can replace annual well child check
F - it cannot replace
- Parents sometimes expect the PPE to be a comprehensive evaluation of the athlete’s health
- Including areas unrelated to sports - Teenage sexuality, substance abuse, immunizations, among others
Methods of PPE
- Locker-room method
- Station method
- Office-based method
- Athletes traditionally line up single file, and physician examines each individually
- requires few personnel and can be performed with little preparation - little privacy is afforded
- Can be too noisy, auscultation can be hard
what PPE method
locker-room
- Divides the exam into several components with physicians, nurses, athletic trainers, and coaches assigned to a single task specific to individual components of the evaluation
- Ideal for large numbers
- Benefits are efficiency, inexpensive, and a good ability to identify abnormalities - little privacy afforded and may not provide for continuity of care
which PPE method
station method
pros and cons of office-based PPE method
- Advantage of an established provider-patient relationship in which medical history is known and continuity of care is fostered
- Disadvantages: lack of consistency among providers, potential unfamiliarity with the sport and its disqualifying conditions by the provider, and its lack of cost effectiveness
The PPE is routinely conducted by pediatric providers, yet many lack specific training in _____
sports medicine or the performance of these examinations
Clinican should be low threshold for referral
what is the most important part of the encounter, identifying 75% of medical issues that can restrict activity
- The medical history
- The athlete and the parents should complete the form together to obtain a thorough and accurate history
components of general MHx
- PMH, including current treatments if any
- Prior surgery
- Loss of function in any organ
- Any heat-related illness
- Current medications
- Immunization history
- Menstrual history
- Any rapid increase/decrease in body weight
types of sport with contact
- Basketball
- Rodeo
- Boxing
- Rugby
- Diving
- Ski jumping
- Downhill skiing
- Snowboarding
- Field Hockey
- Soccer
- Gymnastics
- Ultimate frisbee
- Tackle football
- Water polo
- Ice hockey
- Wrestling
- Martial Arts
componets of injury hx
- Past injuries, including msk injuries, concussions, spine injuries
- Loss of time from participation and current sequelae of prior injury (paresthesias from spinal injury)
- Previous exclusion from any sports for any reason
components of personal CV MHx
Aimed at identifying conditions that predispose athlete to sudden death
- Kawasaki disease?
- Heart infection?
- Chest pain or discomfort with exercise? Any chest pain?
- Syncope or near syncope associated with exercise?
- Excessive SOB or fatigue associated with exertion?
- History of heart murmur?
- History of elevated blood pressure?
- Any history of unexplained fever
- Any history of cardiac testing (EKG and ECHO)
components of Familial CV MHx
- Premature death before age 50 y/o d/t heart disease?
- Disability from heart disease in a close relative younger than 50 y/o?
- Family history of pacemaker?
- Knowledge of specific cardiac conditions: hypertrophic or dilated cardiomyopathy, long QT syndrome, Marfan syndrome, or arrhythmias
ROS - Rsp components (2)
- Asthma
- Exercise-induced bronchospasm
ROS - MSK sx ( 3)
- Back pain?
- Neck pain?
- Joint pain or stiffness?
ROS - CNS History (2)
- History of frequent or exertional headaches, seizure disorders, concussion or head injuries, burners/stingers?
- require further evaluation, rehabilitation, or informed decision making prior to clearance for sports participation - A history of previous concussions should be addressed
- Two grades: simple & complicated
- Complicated: amnesia, loss of consciousness, seizure, or prolonged symptoms
after a concussion, when can the child return to learn?
- once a child can concentrate on a task
- tolerate visual and auditory stimulation
- all for 30-45 minutes - a child can then return with academic adjustments if/as needed
- limited course load
- shortened classes
- increased rest time
- aids for learning
- postpone high stakes testing (ACT/SAT)
for concussion, when can the child return to play?
- complete consensus graduated “Return To Play (RTP)” protocol
- happens after period of cognitive/physical rest before competition
- recovered athletes complete course of non-contact exercise challenges of gradually increasing intensity
- Requirements to begin:
- successful return to school
- symptom free and off any meds to help with symptoms
- normal neuro exam
- baseline balance and cognitive function - if unavailable, use age-adjusted normative data
Retirement from contact/collision sports indications
- for pt’s with structural brain abnormality on neuroimaging
- nonresolving/prolonged neurocognitive deficits
when is Retirement from contact/collision sports accepted/appropriate
- increased recovery times
- A pattern of decreased threshold for repeat concussions especially when associated with persistent prolong sx
- Multiple concussions over the course of an athletic career
ALL should undergo ___ physical exam
- MSK
- If there is any history of injury or abnormalities, the joint or region should be examined in detail
- Also complete examination of high-risk areas (shoulder, knee, ankle)
- Should include general inspection, looking for any asymmetry
how to perform MSK exam
- Inspect for visual deformity, muscle mass, asymmetry, and swelling
- Palpate for localized areas of tenderness, warmth, and effusion
- Assess range of motion
- Test neurovascular status by evaluating muscle strength, sensation, reflexes, and pulses of involved limb
- Test joint stability
How to perform CV exam
- Measurement of blood pressure and resting pulse in the seated position
- Auscultation of heart murmur in supine and standing and with valsalva
- murmur gets louder - HCM
- murmur gets quieter - aortic stenosis/regurg - Location of PMI
- Palpation of radial and femoral pulses
- Physical stigmata of Marfan syndrome
traits of marfan syndrome
- Long arms, legs and fingers
- Tall and thin body type
- Curved spine
- Chest sinks in or sticks out
- Flexible joints
- Flat feet
- Crowded teeth
- Stretch marks on the skin that are not related to weight gain or loss
Measure for excessive height and observe for evidence of excessive long-bone growth (arachnodactyly, arm span > height, pectus excavatum) that suggests ?
marfan
Lens subluxations, severe myopia, retinal detachments and strabismus are associated with ?
marfans
what GU findings do not usually preclude sports participation, but can screen for testicular masses if the athlete is not receiving regular general examinations
Hernias and varicoceles
when assessing the abdomen, what are you looking for?
assess for hepatic or splenic enlargement
what are you assessing for during a skin exam?
Evidence of molluscum contagiosum, herpes simplex infection, impetigo, tinea corporis or scabies would temporarily prohibit participation in sports where direct skin-to-skin competitor contact occurs
is CV routine imaging needed?
- Routine use of ECG and echocardiogram in preparticipation cardiovascular screening in athletes remains a highly debated topic in sports medicine and sports cardiology
- AHA still does not recommend in asx athletes
- MCC of sudden cardiac death on the playing field (in US)
- Characterized by LVH with a wide array of clinical manifestations and hemodynamic abnormalities
- LV outflow obstruction
- Diastolic dysfunction
- Myocardial ischemia
- Mitral regurgitation
what CV condition?
HCM
Immediate referral to cardio for further evaluation
potential abnormalities on HCM PE
- Systolic Murmur - Turbulent flow of blood through a dynamic outflow tract obstruction
- 2nd R ICS and/or L sternal border - Harsh crescendo-decrescendo systolic murmur: pulmonic vs aortic valve stenosis
- Murmur increases with standing and decreases with squatting - AS
- May radiate axilla - Mitral regurg
- Lateral displacement of apical impulse
- Holosystolic murmur of mitral regurg at apex with radiation to axilla
Second most common cause of sudden death on the athletic field
Coronary Artery Abnormalities
MC coronary artery abnormality
left main coronary artery originating off the right sinus
Exercise with coronary artery abnormality leads to ?
expansion of aortic root and pulmonary trunk, which can cause coronary artery compression
s/s of ACA
- other congenital heart defects, particularly transposition of the great arteries, tetralogy of Fallot, and certain forms of pulmonary atresia.
- may begin in infancy or may not appear until later on in life.
- CP or dizziness and fainting during exertion possible
- may be asx until a severe event
- Positive family history
- Suspicious skeletal findings, or ophthalmologic complications
- Progressive scoliosis
- Dysrhythmias may be present
- The characteristic facies is long and thin, with down-slanting palpebral fissures
- Bifid uvula, high arched palate with crowded dentition
dx?
Marfan’s Syndrome
Most serious associated medical problems in Marfans in what part of the body?
heart
- Most serious concern is progressive aortic root dilation, which may lead to aneurysmal rupture and death
- Mitral valve prolapse
- progressive or acute valvular incompetence
Any history of hypertension requires ?
- investigation for secondary causes of hypertension and target organ disease
- An athlete who exercises may cause their blood pressure to rise even higher
- Ask about use of stimulants (caffeine, nicotine)
blood pressure must be examined on how many occassions?
3 different occasions
T/F: Athletes with prehypertension can participate in sports
T - Lifestyle modifications should be made in regards to healthy diet, weight management, and daily physical activity
sports participation for Stage 1 and Stage 2 HTN?
- Stage 1 with no end organ damage can participate with appropriate subspecialist referral
- Stage 2 should not be cleared to participate in competitive sports until their bp is evaluated, treated, and under control
T/F: Status asthmaticus is a nontraumatic cause of death in athletes
T
s/s of Exercise Induced Bronchoconstriction
- Coughing, wheezing, chest tightness, SOB
- Coughing most common and only symptom you can have
- Symptoms do not occur immediately at start
- Begin during and will usually be worse 5-10 minutes after stopping
- Some can have a second wave 4-12 hours after exercise
- Will not produce manifestations on resting exam
pathophys if exercise induced bronchoconstriction
- When you exercise, you breathe faster and deeper d/t increased oxygen demands
- Breath through mouth, causing air to be cooler than breathing through nose
- The dry/cold air is main trigger for airway narrowing - Exercise that exposes you to cold, pollution, high pollen counts, smoke/strong fumes can worsen sx
- Recent cold/URI
mgmt exercise induced bronchoconstriction
- albuterol inhaler 20 min before exercising
- Singulair (montelukast) works well in conjunction with this
- Do proper warm up
- Pay attention to respiratory status
Inappropriate Previous Restrictions
- DM: proper attention to diet, hydration, and insulin therapy; attention needed for activities >30 min; Endocrinologist involved
- enlarge liver/spleen - AVOID if acute, further eval for chronic
- obesity - No CI unless comorbid finding (severe HTN)
- Osgood Schlatter Disease
- Idiopathic Scoliosis
- Bleeding disorders
- Abnormal heart rhythms
- Cerebral palsy
- One eyed athlete
- Malignant neoplasm
- Poorly controlled seizures
- Organ transplant
- Sickle cell disease or trait
- Absent testicle
- Absent kidney
- Pain localized to tibial tubercle
- Common in boys 12-15 and girls 11-13
- Pain aggravated by quadriceps muscle movement
- Pain can become so severe that it can prohibit activity
- resolves spontaneously as athlete reaches skeletal maturity
- Not a CI to participation
dx? mgmt?
Osgood Schlatter Disease
NSAIDS, physical therapy, stretching hamstrings, and ice after workouts are helpful
Athletes in lean sports (dance, cheer, gymnastics, distance running) tend to be at higher risk of developing ?
nutrition
chronic energy deficit
what is the “female athlete triad”
In female athletes, the combination of low caloric intake with/without disordered eating, menstrual dysfunction, and low bone density
mgmt for female athlete triad
- exercise restriction + increasing energy intake -restores HPO function + bone health
- losing wt + amenorrhea/oligomenorrhea- reduce training by 25%, and increase daily intake 200-600 cal; F/u 1-2 weeks
- If weight gain achieved - exercise restriction reduced + equivalent incr caloric intake
This is also best accomplished with dietician
Athletes as young as ___ are taking performance-enhancing supplements
11
- Supplements contain impurities, and when taken inappropriately, may result in adverse side effects
- Muscle cramps, dehydration, abdominal bloating, tachycardia, arrhythmia, and even death
- Use should be discouraged
- Ask about and inform of ill effects during PPE
mgmt when athlete/parents disagrees with physician recommendations for restricting particiption
- Explain fully the reasons and have parent or patient sign document acknowledging you had this discussion
- If a second opinion is requested, encourage them to do so
- After this, it is ultimately another provider/team doctor’s decision
Recommendations for Participation
clearance to play
- Cleared for all sports without restrictions
- Cleared for all sports without restrictions with recommendations for further evaluation or treatment - optometrist, cardiologist, ortho, pulmonologist, etc
- Not cleared: pending further evaluation, for any sports, or for certain sports
