Rider:
Important injury prevention tool but not foolproof
A consensus of experts has emerged that a thorough pre-participation exam or evaluation
(PPE) is the primary means of identifying athletes at risk of sports injury and initiating preventative measures. (1)
The main objectives of the PPE are to:
- screen for medical conditions that put the athlete at risk for serious harm or even death, such as
congenital heart defects that predispose an athlete to sudden cardiac death , or disabling medical conditions, such as a history of concussions (3),
- screen athletes for medical or musculoskelatal conditions that may predispose them to injury or illness and affect sports participation, such as asthma or the female athlete triad ;
- educate athletes, parents, and guardians about the risks and benefits of sports participation.
Parents need to understand, however, that the ability of PPEs to detect the kind of cardiac
abnormalities that can predispose athletes to sudden cardiac death is limited. In fact, the American Heart Association admits that screening by history-taking and physical
examination alone (without non-invasive testing) is insufficient to
guarantee detection of many critical cardiovascular abnormalities in
large populations of young athletes.
No National Standard
There a number of problems with PPEs, primarily because
national standards do not exist , and the PPE is often incompletely and inconsistently performed
(1).
- A 2014 study (4) found that only 11% of athletes receive a PPE consistent with the recommended national form;
- Some states have no standardized questionnaires for the history
and physical examination components of a PPE, and the screening forms used in some states contained four or fewer of the AHA cardiac screening questions;
- In
1999, only 17.2% of the PPE forms in one high school study (6) asked
questions about exercise-related cardiac symptoms, a previous diagnosis
of a heart murmur or high blood pressure, and about family history of
heart attack before age 50 or sudden cardiac death (three main
components of the cardiac history portion of the PPE recommended by the
AHA);
- Less than one high school
in five in uses the most up to date form containing all the elements
developed and recommended by the American Academy of Family Physicians,
American Academy of Pediatrics, American College of Sports Medicine,
American Medical Society for Sports Medicine, American Orthopaedic
Society for Sports Medicine and the American Osteopathic Academy of
Sports Medicine (the "five-society monograph")(1); and
- The
person allowed to perform a PPE also varies from state to state: 21
states allow a PPE to be conducted by a nurse or physician's assistant;
and 11 states allow chiropractors to perform a PPE.
- A PPE is often not a requirement for those participating in club-based or youth sports.
My advice is to make sure that whoever performs your child's PPE asks the right questions even if they aren't required.
Goals and Objectives
A PPE has the following goals and objectives:
- Meet
legal [every state requires a PPE before
participation in interscholastic sports], insurance or club mandates.
- Maintain and promote health and safety of athlete in training and
competition by:Identifying conditions that may limit participation or
predispose an athlete to injury, disability, or (in rare cases) death
- Evaluating overall fitness (the examiner may recommend a conditioning/strengthening program );
- Treating current injuries, and preventing future injuries (such as overuse injuries)
- Help
athletes to participate safely, not to disqualify them from
competition. Studies show that only 0.3 to 1.3% of athletes are denied
clearance as a result of a PPE.
- Educate athlete on variety of health topics (time constraints often limit the opportunity for education)
- Give athlete chance to discuss health goals as they relate to their own athletic performance
Who should conduct the PPE?
A child's primary care
physician is usually well-qualified to conduct a PPE, given his or her
broad training and because he or she knows when to consult with
specialists if problems requiring further clinical expertise are
detected (2).
Parents should not assume,
however, that their child's doctor knows how to conduct a complete PPE
and should make sure their child's doctor is knowledgeable about the
required elements in today's PPE, which is much more sophisticated than
the general health exam previously used.
Parents should ask their child's doctor for the manual
Preparticipation Physical Evaluation
developed jointly by the American Academy of Family Physicians, the
American Academy of Pediatrics, the American Medical Society for Sports
Medicine, and the American Osteopathic Academy of Sports Medicine,
which includes specific questions to ask in taking a medical history
and instructions on how to conduct a sports-related musculoskeletal
examination (see below)
Where should a PPE be performed?
There are three basic types of settings for the PPE: office-based,
assembly line, and station, each with its own advantages and
disadvantages:
1. Office-Based (primary care physicians in the office)(considered the ideal location for the PPE)(2)
- Advantages:
- Familiarity with patient:
The doctor's familiarity with the athlete makes it easier to complete
the PPE form more thoroughly because a complete medical history from
prior exams should be available.
- Privacy which facilitates open communication: The doctor may have more time and privacy to educate and counsel the athlete on sensitive health issues (drugs, alcohol, use of performance enhancing drugs , female athlete triad etc.)
- Continuity of care:
If athlete has seen the same doctor year after year, the continuity of
care offers a critical advantage in detecting, evaluating and treating
conditions discovered during the PPE.
- Disadvantages
- Time constraints:
The doctor's busy office schedule may allow for only a short general
health screen, which may not be adequate to detect conditions
predisposing an athlete to injury.
- Lack of expertise:
A primary care physician may lack interest in or knowledge of
sports-related medical problems, and may feel uncomfortable or
unqualified to determine whether an athlete should receive medical
clearance to play sports.
- No continuity of care: An athlete may not have an ongoing relationship with a particular physician or practice.
- Cost. Not all athletes can afford private, office-based PPE (high co-pay or deductible or no health insurance coverage at all)
2. Assembly-line (single physician examines one athlete after the other)
- Advantages:
- Disadvantages
- Possible communication problems
- Lack of individual attention
- Increased risk that insufficient medical history will be takenl
- Lack of continuity from year to year (assuming different physicians conduct exams)
3. Station (multiple examiners conduct discrete portions of PPE in sequence)
- Advantages:
- Time- and cost-efficient: Hundreds of PPEs can be performed in single day with well-trained staff.
- Better communication:
An athlete may talk more openly with medical personnel in a "team"
setting. A station-exam is likely to impart greater knowledge to all
members of medical team and coaches of individual athlete's medical
condition)
- Specialized expertise: The station approach allows the use of
physicians with specialized expertise (cardiologist, orthopedist etc.).
- Disadvantages:
- Noise and confusion. The setting itself can become confusing and noisy.
- Lack of privacy: An athlete may be reluctant to discuss intimate personal health concerns in such an open setting
- Time constraints: An athlete may feel rushed. Time constraints may restrict the opportunity to educate and counsel athlete.
- Care may be compromised:
The lack of time and privacy may make it difficult for the athlete and
his parents to fully understand the need for additional testing or
basis for disqualification. Coordination of care may be compromised
because medical personnel may not know athlete previously.
Exam timing
Experts differ on how often an athlete should have a PPE:
- Six
weeks before pre-season: The five-society monograph recommends that the
PPE be performed six weeks before pre-season begins to allow adequate
to correct problems identified through rehabilitation or conditioning
program.
- Annually or less? Some
experts believe a full PPE should be performed annually, while the AHA
recommends obtaining a comprehensive personal and family history from
an athlete entering high school or college, with an interim history and
blood pressure check each year for the next 3 to 4 years, significant
changes or abnormalities triggering another physical exam and further
testing. For the high school athlete, the AHA recommends a complete
physical every 2 years.
PPE: Components of Exam
- Medical history. Providing a complete medical history is
the most critical component of the PPE. Because athletes tend to forget
important information (3) and because parents have great knowledge of
family medical history, the form should be completed by both athlete
and parent. Especially important is the taking of a detailed and structured concussion history (3), any history of heat illness (5) determining if the athlete has sickle cell trait, which exposes him or her to the risk of a life-threatening condition callled exertional sickling .
- Physical Exam (key components)
- Height and weight. A sudden weight change may indicate the presence of disordered eating/female athlete triad or use of performance enhancing drugs (large gain in muscle mass that cannot be explained by weight training alone)
- Eyes, ears, nose, throat: Visual acuity, pupil size, visual correction.
Bloodshot eyes or discolored teeth may be signs of an eating disorder
- Cardiovascular (blood pressure, pulse, listening to the heart to check for murmur, hypertrophic cardiomyopathy ). In contrast to some other countries (such as Italy), the standard of
care in the United States, according to American Heart Association, is
not to include an electrocardiogram (EKG) or echocardiogram (ultrasound
of heart) as a routine part of the PPE in the belief that a complete
and careful personal and family history
and physical exam designed to identify or raise suspicion of heart
problems are most cost-effective, particularly in light of the fact
that the ability to detect life-threatening cardiac abnormalities is
only marginally improved by additional non-invasive testing, which
often leads to false positive results in athletes because of their
intense training. Only athletes who have symptoms or significant family medical history
should be further evaluated with specific diagnostic tests (i.e. echocardiogram etc.). Remember also that sudden cardiac death in youth
athletes is extremely rare (about 300 deaths per year). [For more on the debate over whether an EKG should be a routine part of the pre-participation physical examination, click here ].
- Lungs
- Abdomen
(infectious mononucleosis should rule out contact or strenuous sports
participation for at least 3 weeks after onset due to risk of spleen
rupture)
- Skin (Impetigo, herpes simplex, scabies, rashes, infections ,
and infestations; increased acne, especially on back, face and chest,
abnormally large breasts in males (gynecomastia), stretch marks
(cutaneous striae)) may indicate steroid use )
- Musculoskeletal. There are three different types of screening exams:
- General
(quick assessment of range of motion, gross muscle strength, and muscle
asymmetry, identification of significant injuries; appropriate for
athletes with no injury symptoms)
- Joint-specific
testing (much more thorough than general screen but significantly more
time consuming; perform only if athlete has symptoms of current injury
or history of previous injury, weakness or instability)
- Sport-specific
testing (focus on areas of greatest stress for particular sport; for
example, runners would be assessed for knee and ankle instability,
strength and flexibility; recommended only for highly competitive
athletes)
-
Neurologic: Only performed if musculoskeletal exam is abnormal or on athletes with a history of concussions .
Conditions limiting participation
The ultimate decision on whether to participate is for the athlete and his or her parents to make.
The following abnormalities may make it unsafe for your child to participate in sports:
- Acute illness
- Blood-borne pathogens.
Because the risk of transmission is so low (less than 1 in 1,000,000
games), HIV-positive athletes may participate unless their health is
compromised.
- Heart disease
(hypertrophic cardiomyopathy (HCM), rhythm and conduction abnormalities,
systemic hypertension, and valvular heart disease, but not benign
functional murmur or mild mitral valve prolapse)
- Skin (contagious lesions or skin conditions should rule out participation in contact sports)
- Eating disorder/female athlete triad
- Eyes
(functionally one-eyed athletes permitted only in sports that allow
protective eyewear and do not involve projected objects (swimming,
track and field, gymnastics, and not allowed to participate in
wresting, boxing, or martial arts)
- Pregnancy (no contact, collision, or strenuous sports)
- Kidney (no high-contact sports for one-kidney athletes; flack jacket for moderate contact sports)
- Musculoskeletal (depending on degree and type of injury, risk to athlete and demands of sport)
- Seizure disorder
(one or more seizures within last 6 months held out of competition,
especially in high-risk sports (skiing, gymnastics, high diving,
collision sports, shooting, archery)
- Asthma (but only if symptoms not controlled)
1. Valovich McLeod TC, Decoster LC, Loud KJ, Micheli LJ, Parker JT, Sandrey
MA, White C. National Athletic Trainers' Association Position
Statement: Prevention of Pediatric Overuse Injuries. J Ath. Tr.
2011;46(2):206-220.
2. Preparticipation Physical Evaluation Working Group. Preparticipation Physical Evaluation. 4th ed. Grove Village, IL: American Academy of Pediatrics; 2010.
3. McCrory P, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013;47:250-258.
4. Madsen NL, Drezner JA, Salerno JC. The Preparticipation Physical Evaluation: An Analysis of Clinical Practice. Clin J Sports Med. 2014; 24(2):142-149.
5. Kucera KL, Klossner D, Colgate D, Cantu RC. Annual Survey of Football Injury Research 1931-2013 . National Center for Catastrophic Sports Injury (March 2014)
6. Gómez JE, Lantry BR, Saathoff KN. Current use of adequate preparticipation history forms for heart disease screening of high school athletes. Arch Pediatr Adolesc Med. 1999:153:723-6
Updated and revised July 22, 2015
Teaser title:
Pre-Participation Physical Evaluations (PPEs): A Primer for Parents
Teaser text:
Most experts agree that you should have your child undergo a thorough
pre-participation physical evaluation or exam (PPE) every year. Not only can a PPE be an
effective tool in identifying athletes who should not be playing sports
because they have congenital heart defects or a history of concussions,
but it is also useful in identifying medical problems effecting sports
participation, such as asthma or the female athlete triad.