Preparticipation Physical Examination

1. Preparticipation Physical Examination Deb Jacobson, M.D.

2. Goals and objectives • Eval general health status • Determine fitness for competition • Foster injury prevention • Discover diseases/injuries • Counsel on health-related issues

3. Detect conditions that may be life-threatening or disabling Determine sports specific skill level and conditioning Meet legal and insurance requirements Goals and objectives

4. PPE is NOT • Barrier to athlete participation • Purpose not to exclude but promote safety • Only 0.3-1.3% denied clearance • Only 3.2-13.5% require further evaluation • Not intended to substitute for regular health maintenance

5. Problems with PPE • Previously consisted of three H’s • Now has multiple objectives • No clear purpose • No standardization

6. Problems with PPE • Is PPE a good screening tool? • NO! Rarity of serious medical conditions found in millions of athletes screened • Does serve a purpose • Best guideline is PPE monograph published by Physician and Sportmed

7. Timing of PPE • Ideally should be 6-8 wks prior to preseason practice • Allows sufficient time to rehab injuries • Allows time for evaluation or correction of identified medical problems

8. Frequency of PPE • Most advocate full examination annually • Some say prior to every sports season • Some say prior to entering new school level with interim evaluation

9. Structure of PPE • Office-based vs... station-based • Advantages and disadvantages of each

10. History • Most important element of PPE • 75% of conditions evident from history • Only 39% of history given by athlete agreed with that of parent • Get parents involved!!!

11. History • Start w/ general medical questions • Hospitalizations and surgeries • Medications (including supplements, OTC, etc) • CV- 95% of sudden death in athletes under age 30 due to structural cardiac problems • history should include h/o syncope, chest pain, palpitations, dizziness w/exercise

12. History • Respiratory- wheeze, RAD, EIA, cystic fibrosis • Infectious disease- respiratory, skin, GI • Organs- paired, enlarged • Metabolic- DM, eating disorders, female triad, obesity, heat illness, steroid use, sickle cell • Neurologic- repeated concussions, seizure d/o, CP • Musculoskeletal- prior trauma or injury, rehab • Psych/soc- stress, depression, anxiety, pressure • Social- tobacco, alcohol, drugs, STD prevention

13. Exam • Vital signs, height and weight • Eyes- Visual acuity, pupils (document physiologic anisocoria) • ENT- general well-being • CV- BP, radial/femoral pulses, auscultation in supine and standing position for rate, rhythm, and murmurs. Further eval w/ maneuvers as needed. • AHA guidelines

14. Exam • Be aware of ranges of normal w/ the “athlete’s heart” • bradycardia • functional murmur • physiologic gallop • ECG abnormalities

15. Exam • Lungs- breath sounds, wheezing, ask about tobacco • Abdomen- masses, HSM • Genitalia • males- testicular presence/masses, hernia exam ONLY if indicated • females- not part of PPE • Skin- rashes, lesions, infections

16. Exam • Musculoskeletal- 90 second screening exam • see handout • Caveats • top to bottom • watch ROM • look for symmetry • focused joint exam if abnormality discovered or history suggests • can tailor exam for sports specific

17. Determining clearance • You picked up something abnormal on history or physical • What now? • Two good resources • “Contraindications to Athletic Participation”. Physician and Sportsmedicine, vol 24, no. 8 & 9 • 26th Bethesda Conference: Recommendations for Determining Eligibility for Competition in Athletes with CV Abnormalities. Medicine and Science in Sports and Exercise, 26(10), Supp, Oct ‘94

18. Medicolegal considerations • Failure to diagnose/improper clearance • Reggie Lewis, Hank Gathers • each state has own regulations, no universally accepted standard • Right to participate • Team M.D. often lose, courts rule with athlete under the Americans with Disabilities Act • Knapp v. Northwestern • Pahulu v. University of Kansas

19. Medicolegal considerations • Sexual harassment claims • have chaperone, document • Good Samaritan Status • does not apply in all states • must not accept any form of payment to be protected

20. Conclusion • Done correctly PPE can enhance safety of sports participation • Also provides teachable moment • Need standardization • Get involved- IT’S FUN

21. References • Glover, D.W. et al. The Preparticipation Physical Examination: Steps Toward Consensus and Uniformity. The Physician and Sportsmedicine, 27(8). • Herbert, D.L. Practice Guidelines Take Center Court. The Physician and Sportsmedicine, 24(3). • Mitchell, J.H. et al, editor, ACSM, ACC 26th Bethesda Conference: Recommendations for Determining Eligibility for Competition in Athletes with Cardiovascular Abnormalities. Medicine and Science in Sports and Exercise, 26(10). • Moeller, J.L. Contraindications to Athletic Participation: Respiratory and Central Nervous System Conditions. Physician and Sportsmedicine, 24(8): 47-58.

22. References • Moeller, J.L. Contraindications to Athletic Participation: Spinal, Systemic, Dermatologic, Paired Organ and Other Issues. Physician and Sportsmedicine, 24(9): 57-75. • Preparticipation Physical Evaluation Monograph, second edition. Joint publication of AAFP,AAP, AMSSM, AOSSM, AOASM. Physician and Sportsmedicine, publisher, 1996.