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Pre-Participation Physical Evaluations (PPEs): A Primer for Parents

Important injury prevention tool but not foolproof

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.