PREPARTICIPATION PHYSICAL EVALUATION Flashcards
What is the PPE (preparticipation physical evaluation)
sports physical…
- this is an important first step in assisting athletes in maintaining health and ensuring safe participation in training & competition
- wide variation in recommendations / requirements of what makes up a PPE
most PPE recommendations carry a level____ supported data recommendations
level C
STATE DIFFERENCES: MONTANA VS TEXAS
o Montana = annual exam completed after May 1st for next year - can be performed by any licensed medical professional
o Texas = need 2 forms (medical HX & PE). Medical hx completed yearly, but PE performed every other year unless yes to any hx questions that warrant PE
OBJECTIVES OF PPE
- primary (essential) vs secondary (ideal)
o Primary or Essential
⦁ This is the only medical contact for 30-88% of these adolescents (not getting other contact with any other medical professional that year other than for PPE)
⦁ To detect conditions that may limit participation
⦁ To detect conditions that may predispose patient to injury
⦁ Meet legal & insurance requirements
o Secondary or Ideal Objectives
⦁ Assessing general health & identifying health risk behaviors (ie: CV health, mental health
⦁ Assess physical maturity
⦁ Determine fitness & performance level
TIMING & FREQUENCY OF PPE
- Should be performed at least 6 weeks before starting sports season to allow adequate time to address any issues
- Montana regulations = must be done annually for high school athletes
- Need a comprehensive baseline PPE before initiating a sports season
- Subsequent annual PPEs may be limited to recent injuries that may have occurred (focus on that), but also includes a review of Cardiopulmonary system
PPE should be formed at least _________ before starting sports season to allow adequate time to address any issues
6 weeks
Need a comprehensive ____________ before initiating a sports season
baseline PPE
- Subsequent annual PPEs may be limited to recent injuries that may have occurred (focus on that), but also includes a review of ____________ system
Cardiopulmonary
PPE FORMAT
OFFICE-BASED VS GROUP SCREENING
o OFFICE BASED
⦁ Advantages = physician-patient familiarity, privacy, and continuity of care
⦁ Disadvantages = cost, limited appointment time, and lack of communication back to the school’s athletic staff
o GROUP SCREENING
⦁ Advantages = specialized personnel, time, and cost-efficiency
⦁ Disadvantages = rushed, lack of privacy, and potential for poor follow-up of identified problems
⦁ Mayo Clinic study of PPE - found that station type formats (group screening) = effective and safe
advantages & disadvantages to an office-based PPE
⦁ Advantages = physician-patient familiarity, privacy, and continuity of care
⦁ Disadvantages = cost, limited appointment time, and lack of communication back to the school’s athletic staff
advantages & disadvantages to a group screening PPE
⦁ Advantages = specialized personnel, time, and cost-efficiency
⦁ Disadvantages = rushed, lack of privacy, and potential for poor follow-up of identified problems
⦁ Mayo Clinic study of PPE - found that station type formats (group screening) = effective and safe
cornerstone of PPE
history
may identify 75% of problems affecting athletes
key history questions of PPE = focus on
CARDIOVASCULAR QUESTIONS
Cardiovascular Questions of PPE
⦁ Identifies hypertrophic cardiomyopathy - leading cause of sudden cardiac death in athletes
⦁ Marfans (leads to aortic rupture)
⦁ Premature atherosclerosis
EKG DEBATE IN PPEs
not currently used on all athletes; consensus = not cost effective or time-effective. Don’t have resources for pediatric cardiologists to read all of these EKGs, so general consensus = not needed
MOST COMMON CARDIOVASCULAR CAUSE OF SUDDEN DEATH
HYPERTROPHIC CARDIOMYOPATHY
CARDIOVASCULAR CAUSES OF SUDDEN DEATH
⦁ Hypertrophic cardiomyopathy = MC*** ⦁ Anomalies of the coronary arteries ⦁ Atherosclerotic Heart Disease ⦁ Marfan's Syndrome ( --> aortic rupture) ⦁ Aortic Stenosis ⦁ Mitral Valve Prolapse
what is hypertrophic cardiomyopathy
- Primarily a disease of the myocardium with hypertrophy without any obvious cause
- FREQUENTLY ASYMPTOMATIC until sudden cardiac death
- May be identified by ECG or PE
danger of hypertrophic cardiomyopathy is that it is frequently
ASYMPTOMATIC until sudden cardiac death
Hypertrophic cardiomyopathy may be identified via:
- EKG
- PE
specific CV questions from PPE
⦁ Have you ever passed out during exercise?
⦁ Have you ever been dizzy or lightheaded during or after exercise?
⦁ Chest Pain during or after exercise?
⦁ Have you ever passed out during or after exercise?
⦁ Have you ever noticed a racing heart or skipped beats?
⦁ Have you ever been told you have a heart murmur or heart condition?
IF YES TO ANY OF THESE QUESTIONS —> FULL CV WORK-UP
PPE PHYSICAL EXAM
- Should be comprehensive, however, focused on any pertinent findings from HX
- Should not be in such an environment that specific findings of concern cannot be adequately addressed at the time
BP values during PE
if pt is < 10 =
if pt > 10 =
pt < 10 = > 125/75
pt > 10 = > 135/85
Palpation of UE & LE pulses
⦁ brachial - femoral delay may mean
coarctation of the aorta
MURMURS DURING PPE EXAM
- Heart auscultation in 2 positions, and with provocative maneuvers - may help detect murmurs
⦁ Valsalva, Position change - Location of Murmur
- Precordial Palpation (increased)
- PMI displaced laterally
the only level A recommendation with PPE
MSK EXAM
MSK EXAM
- This is the ONLY LEVEL A RECOMMENDATION
- Orthopedic Screening 9: The MSK hx screening & exam can be combined for asymptomatic athletes with no previous injuries
- If athlete has had a previous injury or has signs of an injury = the relevant elements of a site specific exam should be performed
It is important to identify musculotendinous bone or joint problems that may limit athletic participation or predispose to injury
such as:
⦁ shoulder instability
⦁ ACL deficiency
⦁ un-rehabbed ankle instability*** - predisposed to future injuries
- Any positive responses in history = requires a thorough evaluation
- Screening for flexibility
- Screening for general neurologic exam & Scoliosis
in a mayo study, 1/2 of all disqualifications from further participation were related to ________
MSK ISSUES
major concern if found in PPE MSK exam
- unrehabbed ankle instability = predisposed to future injuries
routine screening tests needed for PPE?
- The use of routine screening tests is not recommended and remains unproven
⦁ CBC, UA, CMP, Sickle cell trait
⦁ Electrocardiogram / Echocardiogram; Current recommendation = good screening tool, but not practical / cost effective
⦁ Radiographs / MRIs = not unless indicated by focused MSK exam
perform 90 second MSK exam
⦁ Neck ROM
⦁ Shoulder passive / active ROM
⦁ Supine - examine Hip / knee
⦁ Ankle instability / examination
CLEARANCE FOR PARTICIPATION
- Providers must be familiar with the demands of specific sports
- Consider these questions
⦁ Will the problem increase the athlete’s risk of morbidity / mortality?
⦁ Will other participants be at risk of morbidity?
⦁ Will further evaluation, treatment or rehab allow full participation?
⦁ Could the athlete be allowed limited participation?
SPECIFIC MEDICAL CONDITIONS THAT REQUIRE FURTHER EVAL
o Heart Murmurs
⦁ any new undiagnosed heart murmur
⦁ need documentation & clearance for any previously identified heart murmur
o Family Hx of Wolff-Parkinson-White (extra electrical pathway in heart - delta wave)
o Arrhythmias
o Strong concern for Marfan Syndrome (phenotype characteristics)
o HIV
⦁ cleared, but health care personnel must use universal caution
o Absence of Kidney
⦁ cleared, but with counseling & protection for contact (have to be on supplements)
o Mono
⦁ NOT cleared for contact with any concern for splenic enlargement / active disease
⦁ 84% are normal at 1 month
o Sickle Cell Trait
⦁ Unlikely that the patient has an increased risk of sudden death or other medical problems, with the exception of at extreme conditions of heat / humidity / elevation
OTHER CONCERNS
- mental health
- supplements / medications
o Mental Health
⦁ should we be including more questions?
⦁ what is the referral process?
⦁ what about clearance of athletes who are positive for mental health concerns?
o Supplements / Medications
⦁ unique opportunity to counsel patients on supplements
⦁ counsel on energy drinks / performance enhancers
FEMALE ATHLETE TRIAD (3)
1) Eating disorder (anorexia nervosa or bulimia)
2) Amenorrhea
3) Osteopenia / Osteoporosis (lack of estrogen leads to lack of bone development)
SIGNS / SYMPTOMS OF FEMALE ATHLETE TRIAD
SIGNS / SYMPTOMS
- Thin appearance
- Highly concerned with food / body
- Decreased performance
- Stress fractures
Mental Health Counseling / Treatment
OSGOOD SCHLATTER’S DISEASE
- Osteochondritis of the patellar tendon at the tibial tuberosity from OVERUSE (repetitive stress) or small avulsions due to quadriceps contraction
MC cause of chronic knee pain in young, active adolescents
- occurs in immature athletes
- more common in males (10-15) with “growth spurts” - the bone grows faster than soft tissue, so quadriceps contraction is transmitted through the patellar tendon to the tuberosity
MC CAUSE OF CHRONIC KNEE PAIN IN YOUNG, ACTIVE ADOLESCENTS
OSGOOD SCHLATTER DISEASE
clinical manifestations of Osgood-Schlatter disease
- activity-related knee pain / swelling - usually asymptomatic at rest
- painful lump below the knee - tenderness to the anterior tibial tubercle
can be unilateral or bilateral
treatment for Osgood-schlatters
usually resolves with time
- RICE
- NSAIDS
- Quadriceps stretching
- surgery only in refractory cases (but only done after growth plate has closed)
__________ is less common that Osgood-schlatters
Sever’s disease
SEVER’S DISEASE
Calcaneal apophysitis
- less common than Osgood Schlatters
- Involves the Achilles & Calcaneal growth plate - have pain at back of heel where achilles tendon attaches to calcaneous
- bone grows faster than muscles / tendons / ligaments, so when the muscles and tendons can’t grow fast enough, they get stretched
- if child is active / athlete = extra strain on already overstretched tendons. This leads to swelling and pain at the point where the tendons attach to the growing part of her heel.
signs / symptoms of sever’s disease
- pain / swelling / redness in one or both heels
- Tenderness and tightness in the back of the heel that feels worse when the area is squeezed
- Heel pain that gets worse after running or jumping, and feels better after rest
other risk factors for sever’s disease
overweight / obese
pronation
TREATMENT FOR SEVER’S DISEASE
RICE, heel lift, corrective orthotics, stretching
CASE #1
20y/o - 1 year hx of locking knee with certain activities. Hx of locking with lifting activities (usually squatting). Has to manually unlock the knee. Started 1 year ago at end of football. Occurs occasionally, and does well when knee is not locked. No swelling, no giving out
- need to ask previous hx or surgeries (had a meniscus repair a year ago)
- PE = do McMurray’s test (good test for meniscus). Do full motion tests with knee
- want to palpate joint lines (has lateral joint line pain, no medial joint line pain), no patellar pain; no crepitation, no catching/locking on McMurray’s test…
LIKELY HAS LATERAL MENISCUS TEAR
- needs an MRI
which meniscal tear is more common
medial
medial meniscal tear is 3x more common than lateral
depends on where the joint line pain is
MENISCAL TEARS
- degenerative
- medial more common - due to bony attachments
- *Locking
- popping
- “giving way”
- effusion after activities
- joint line tenderness (medial or lateral)
***McMURRAY’S SIGN (pop or click when tibia is externally and internally rotated
Apley’s Compression Test = patient lies prone with leg flexed at knee (lower leg is pointing up) - compress down on foot while holding down distal thigh, and rotate leg externally (valgus - tests medial meniscus) or internally (varus - tests lateral meniscus)
TREATMENT
- NSAIDS
- partial weight bearing until orthopedic f/u
- arthroscopy (surgical procedure to examine the joint and treat damage if needed)
test for knee meniscus tear
mcmurray’s test - patient lies supine with knee flexed
external rotation of lower leg - knee goes inward, foot goes outward (valgus) -tests medial meniscus
internal rotation of lower leg - knee goes outward, foot goes inward (varus) - tests lateral meniscus
will have clicking / catching / popping
Apley’s compression test - patient lies prone with knee flexed. compress on foot that is up in the air and hold distal posterior thigh down, then rotate
- external rotation of tibia tests medial meniscus
- internal rotation of tibia tests lateral meniscus
McMurray’s test
for meniscus tears
- valgus for medial meniscus
- varus for latera l meniscus
shoulder subluxation
partial dislocation of the shoulder
Labral tear (labrum = lines the glenoid cavity for the humeral head to properly fit into the glenoid socket) test
O’briens test
what test can be done for shoulder instability (dislocation or subluxation)
apprehension test - patient supine and by compression on shoulder joint, can bring arm back farther than when patient was standing and tried to bring arm bent at 90 degrees backwards
BONY BANKART LESION
when some of the glenoid bone is broken off with the anterior labrum tear - so have shoulder instability or dislocation as well as tear as well as broken off glenoid bone
ACL INJURIES
- MC knee ligament injury
- many are associated with meniscal tears
S/S
- Pop
- swelling - hemarthrosis
- knee buckling
- inability to bear weight
more common in women
Most sensitive test = Lachman’s test
Treatment = therapy vs surgical - depends on activity level of the patient
- can aspirate knee for blood first if needed
CAR ACCIDENT - KNEE HIT THE DASHBOARD
PCL TEAR
