A standardized process for conducting the preparticipation physical examination is needed to ensure a safe playing environment for athletes and to help identify those conditions that may predispose an athlete to injury or sudden death, says the National Athletic Trainers' Association in a new position statement.

While PPEs - or what used to be called sports physicals - are required as a condition for participation in school sports and are routinely used to identify conditions that put athletes at risk, there has been continued debate as to their effectiveness. 

In addition, "the different organizations charged with developing and revising the PPE - from state high school associations to medical associations, state health and education departments to legislators - often have different missions," says Kevin Conley, PhD, ATC, associate professor and director of Athletic Training Education at the University of Pittsburgh and lead author of the statement, "which can lead to confusion."

The issuance by the NATA of a position statement advocating for adoption of its PPE form, however, could have precisely the opposite effect, to the extent it competes with a PPE form developed by six national medical societies in 2010 (PPE Monograph), which at least those medical societies are advocating as the standard towards which the nation should move.

A 2014 survey [1] (Madsen NL, 2014), for instance, found that only 23 states mandate a single statewide form, and only 8 use a form that is consistent with the PPE Monograph, meaning that only 11% of US high school athletes are guaranteed to receive a PPE that is fully consistent with what the medical societies view as a national standard.

Because the PPE represents the sole source of medical evaluation for 30 percent to 88 percent of children and adolescents annually, Conley said the NATA is recommending "a standardized PPE process to determine risk factors and ascertain that athletes are physically and mentally prepared for sports participation."

Based on current and scientific evidence and best practices, the NATA has developed the following PPE guidelines designed for physicians, athletic trainers, and other health care professionals to apply, regardless of the sport or an athlete's performance goals, designed to identify conditions that may threaten the health and safety of participants in organized sports or require further evaluation and intervention, or even disqualification.

Medical and Family History: "Cornerstone" of PPE

A comprehensive medical and family history [2] should be obtained from each participant and remains the cornerstone of the PPE. Research suggests that such a history identifies 75 percent of problems that affect initial athletic participation. 

The history should:

• take into account the areas of greatest concern for sports participation, particularly the American Heart Association's recommendations for preparticipation cardiovascular screening of competitive athletes;
• be reviewed carefully, and both the athletes and parents should be questioned and reconfirm their responses.
• pay particular attention to musculoskeletal injuries, often common causes for restriction or disqualification, as well as prior surgeries or related underlying conditions that might predispose an athlete to injury.

Physical Examinations recommended

A general physical examination is recommended and should include a check of vital signs (e.g. height, weight and blood pressure; visual acuity, cardiovascular/pulmonary, abdominal, neurologic and general medical and musculoskeletal examinations). Although another provider may record the initial vital signs for efficiency, the data should always be reviewed by the physician. Further examination should be based on potential concerns uncovered during the history.

Cardiovascular screening for risk factors

• Specific questions regarding risk factors and symptoms of a cardiovascular disease should be asked during the history portion of the PPE (see box below). As noted earlier, a positive response to any question should be confirmed and further evaluation conducted if necessary.
• Auscultation - or listening to - the heart should be performed initially with the patient in both standing and supine positions and during squat-to-stand motions to clarify any type of murmur. 
• Although echocardiography (ECG) is not considered a routine part of a PPE screening, the results may have benefits in some cases. ECGs and stress tests remain the most commonly recommended diagnostic tests for patients with an abnormal cardiovascular history or exam.

Neurologic screening

• A thorough neurologic screening is necessary if the athlete has a history of concussions [3], seizure disorder, cervical spine stenosis or spinal cord injury.
• The athlete should be evaluated for full range of neck motion. Symptoms such as weakness, paresthesia (e.g. tingling, tickling, prickling, pricking, or burning of a person's skin) or numbness in the arms, hands or legs should prompt further testing.
• Individuals playing sports that are associated with a high risk of concussions may be considered for baseline neuropsychological testing [4] during the PPE.  Although there is no magic number [5] of concussions that disqualifies an athlete from further participation in contact sports, the NATA says that athletes with a history of three or more concussions or delayed recovery may need to be considered for temporary or permanent disqualification from contact sports.

Orthopaedic screening

• The musculoskeletal history screening and physical examination can be combined for athletes who have no previous injuries. If the athlete has any signs or symptoms of pain or tenderness, or reduced range of motion [6] during the general exam, a site-specific exam should be performed.
• The exam should be used to identify conditions that would make sports participation unsafe and to facilitate programs for injury prevention.
• Clearance for participation must be based on the degree and type of injury and the requirements of the sport. [7] Additionally, protective padding, taping or bracing may allow the athlete to compete safely.

General medical screening

The use of routine laboratory or other screening tests such as urinanalysis, complete blood count or chemistry profile during the PPE is not supported by current studies.

However, appropriate tests and screenings may be warranted for athletes who have a history of anemia, diabetes mellitus type 1 or 2, sickle cell trait, [8] cardiovascular conditions or exercise-induced bronchospasms [9]; or are female and have abnormal menstrual cycles.

Medication use

• All medications and supplements currently used by the athlete should be reviewed during the physical exam.
• Listed medications may alert the examiner to medical conditions that have not been disclosed on health forms.
• Athletes and parents should be questioned on the use of prescription and over-the-counter medications, energy drinks [10] that can affect athletic performance and banned substances (e.g. anabolic-androgenic steroids).

Nutritional assessment

• Sports medicine providers should be familiar with the current NATA position statement that outlines the prevention, detection and management of disordered eating [11] in athletes; 
• Ensuring proper nutrition is essential for optimal athletic performance and should be addressed during the PPE.
• The athlete's height and weight should be evaluated for under-nutrition or obesity, and concerns about disordered eating should be pursued.

Heat and hydration-related illness risk factors

• Current consensus guidelines for heat acclimatization [12] in secondary school athletes should be reviewed.
• Questions related to previous problems associated with heat acclimatization should be included in the medical history form. 
• Education about preventing its onset and maintaining proper hydration [13] should be provided.

Mental health considerations

• As part of the health history portion of the PPE, questions to determine the mental health status of the athlete should be included along with a plan for referral and follow-up.
• Added visibility that athletes receive due to sports participation may contribute to a mental health concern and require further attention.
• The athletic trainer working with team coaches and school mental health professionals will help to ensure the athlete receives appropriate care.

Administration/timing

• Privacy must be respected at all times when the findings of the PPE are communicated. Written authorization must be provided by the athlete or the legal guardian if the athlete is a minor and before any private health information is released.
• The PPE may be conducted 4-6 weeks before preseason training begins to allow time for proper follow-up of findings requiring additional evaluation. It is also practical to conduct the PPE on the day preseason training begins or the day before because athletes usually report one to two days early. Because of this short timeline, clearance for some athletes who require additional evaluation may be delayed.
• A complete PPE should be performed at each new level of participation. When warranted during interim years, a review of the medical history and subsequent evaluation should be conducted.
• The form 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") should serve as the minimal template for a standardized PPE instrument.

Methods

• The PPE can be conducted either by the athlete's personal physician or as part of a large-scale group screening.
• Examination by the athlete's personal physician has clear advantages including:
  • continuity of care given the established relationship;
  • the physician's familiarity with the athlete's medical and family health history;
  • access to past medical records that can be compared with current status;
  • affording the opportunity for a more honest disclosure of new problems or behaviors that may affect the athlete's performance.
• Examination in a group setting may be beneficial as many athletes do not have primary care physicians or do not have the monetary means to seek a one-on-one physician clinical visit. For these athletes, the group PPE offered by the school may be the only means of receiving an adequate PPE.  To ensure quality, the following factors should be considered:
  • encouraging all athletes to complete a thorough, standardized health history questionnaire which should be completed in its entirety and honestly, with the assistance of a parent or guardian, and reviewed by the same physician conducting the physical examination 
  • a well-rounded medical team should be assembled to conduct the exams, often including primary care sports medicine physicians and orthopaedic specialists, and sometimes including a sport cardiologist and other specialist consultants;

Determining clearance

Clearing an athlete to participate in a sport should be based on previously published guidelines and the best evidence available. Team physicians and institutions have the legal right to restrict an individual from athletic participation, provided the decision is individualized, reasonably made and based on competent medical evidence.

The team physician should review the following questions as to the athlete's ability to meet the criteria for participation:

1. Does the athlete pose an unacceptable risk or place the athlete at increased risk for further injury?
2. Does the condition place other participants at risk for injury?
3. Can the athlete safely participate with treatment (eg, medication, rehabilitation, bracing, padding)?
4. Can limited participation be allowed while treatment  is being completed?
5. If clearance is denied for certain sports or sport categories only, in which activities can the athlete safely participate? 

"A standardized approach to PPEs is most desirable and should be conducted by a licensed physician with the participation of athletic trainers and health care professionals committed to the same standard of care,"  says Conley. "These suggested guidelines offer a comprehensive approach that we hope will be seriously reviewed and adapted by other sports and health organizations at the state and national levels. Ensuring safe participation and reducing the risk of acute, chronic or catastrophic injury or death remains our primary goal."

For a full copy of the position statement, click here. [14] 

Conley KM, Bolin DJ, Carek PJ, Konin JG, Neal TL, Violette D. National Athletic Trainers' Association Position Statement: Preparticipation Physical Examination and Disqualifying Conditions. J Athl Tr. 2014;49(1):102-120. doi:10.4085/1062-6050-48.6.05.

Madsen NL, Drezner JA, Salerno JC. The Preparticipation Physical Evaluation: An Analysis of Clinical Practice. Clin J Sports Med. 2014; 24(2):142-149.

Material from the NATA's press release on the PPE position statement was used in the preparation of this article.

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