The Pre-Participation Sports Examination General & Special Needs Populations

1. The Pre-Participation Sports ExaminationGeneral & Special Needs Populations Jeffrey A Zlotnick MD CAQ FAAFP Asst. Clinical Professor Family and Primary Care Sports Medicine UMDNJ - Robert Wood Johnson Medical School UMDNJ - New Jersey Medical School Philadelphia College of Osteopathic Medicine Medical Consultant – “Healthy Athletes Initiative” Special Olympics NJ NJ Academy of Family Physicians

2. The Pre-Participation Exam • Primary Goal is the Health and Safety of the athlete • Objective is to be INCLUSIVE, not to try to exclude participation • NOT a substitute for the regular health examinations by the Primary Care Physician Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

3. Primary Objectives • Detect conditions that may limit participation • Atlanto-axial instability in Down’s • Heart murmurs: Innocent vs. HCM • Detect conditions that may lead to injury • Lack of physical conditioning, weak muscles • Poor exercise tolerance, heat intolerance • High amount of major joint problems ex; “Miserable Misalignment Syndrome” • Meet legal and insurance requirements Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

4. Secondary Objectives • Assess the general health of the athlete • May be the ONLY opportunity you will have to see this patient & go into issues such as immunizations, substance abuse, birth control • Counsel the athlete on health related issues • Assess growth & development • Tanner staging can be helpful where less mature athlete is playing against a more mature athlete: HIGH risk for injury in contact sports (Exam can be embarrassing) • Assess fitness level & performance • Help identify weaknesses that may increase chances of injury ex; Swimmers with weak pectorals muscles Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

5. Timing • Best done at a MINIMUM of SIX weeks prior to the start of practices • Gives time to identify & correct problems that were noted on the exam Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

6. Frequency • Vary from before each season to every “few” years (“few” is variable) • Optional: short interval history and go after specific changes or problems • Once yearly is the most popular Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

7. Methods • Private office by Primary Care Physician • Multi-station exam with different providers of various types (physicians, nurses, PA’s) • Each type has its advantages and disadvantages • In-school physical • Currently not in NJ to get athletes to have a “Medical Home”. However, there are exceptions Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

8. Private Office Advantages • PCP knows the PMHx, the FHx, Immunizations • Less likely to overlook problems • Young athlete will be more willing to discuss sensitive issues with a known person • Easier/Less embarrassing to do GU exam (if indicated) • Less chance that abnormalities found will be overlooked and not followed up on Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

9. Private Office Disadvantages • Many athletes don’t have a PCP • Limited time for appointments: Time consuming • Varying levels of knowledge and interest in sport specific problems • Must be well versed in Sports-specific demands • Greater cost: Many can’t afford • Higher income athletes will tend to go to different specialists for each problem found • Tendency for poor communication between the PCP and the school athletic staff • Many un-indicated disallowed athletes Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

10. Multi-StationAdvantages • Cost-effective and easy to screen large numbers of athletes • Specialized personnel at each station • Usually 5-6 stations • Good communication with the school athletic staff since the Coach & AT’s are usually part of the team Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

11. Multi-Station Disadvantages • Requires a large amount of space • Hurried, noisy, with minimal privacy • Difficult for GU exam, Heart murmurs • Continuity of care easily lost, problems noted are NOT followed up upon • Lack of communication with parents • Particular consultant may put unreasonable demands on an athlete • Varying level of training of school physicians Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

12. Station Sign-in, Ht/Wt, Vital signs, Vision History review, Physical (medical, orthopedic, & neurological) assessment/clearance Personnel Coach, Trainer, Nurse, volunteer Physician Multi-Station Required Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

13. Station Specific orthopedic exam Flexibility Body composition Strength Speed, agility, power, endurance, balance Personnel Physician Trainer or therapist Physiologist Trainer, coach, therapist, physiologist Trainer, coach, physiologist Multi-Station Optional Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

14. MEDICAL HISTORY IS KEY!! • Statistics show that a good history will identify 63-74% of medical problems!! • Statistics also show that information from the athlete agrees with the parents ONLY 39% of the time!! Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

15. Key Questions Need to be asked or put on a questionnaire that is reviewed

16. Ever been treated in a hospital or had surgery? • Important to know number and severity of Traumatic Brain Injuries (concussions) • Determine if certain medical conditions are under control enough to allow or limit participation • Diabetes, Asthma • Has enough time been allowed to heal and rehabilitate from surgery? Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

17. Taking any Rx’s, OTC’s, Drugs? • History of Rx’s important to assess control • Diabetes, Asthma • Does the athlete require any emergency drugs that the coach/AT will need to know about AND how to use them!! • Get information on birth control measures, menstrual history • Amenorrhea in women athletes can lead to a high risk of stress fractures (Female Athletic Triad) • Good way to introduce talk on STD’s Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

18. Taking any Rx’s, OTC’s, Drugs 2 • Get information on OTC use as athletes tend to abuse these: • OTC asthma, decongestants, diet pills can cause increased heart rate and arrhythmia's • NSAID’s can cause increased bleeding • Laxatives (wrestlers) can cause electrolyte abnormalities • Try to get history of illicit drug use • Alcohol, tobacco, marijuana, steroids Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

19. Allergies? • Drugs • Know what can and CAN’T be given in case of an emergency • Bees, Insects - important in outdoor sports • Need to carry an EpiPen? Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

20. Skin Problems, Rashes? • Mainly looking for herpes, scabies, lice, molluscum contagiosum • Impetigo, herpes and others can be spread by mats, helmets, towels • Acne and other atopic conditions can be exacerbated by clothing or equipment Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

21. History of Head Injury, LOC, Seizure, “Burners or Stingers”? • Seizure history (epilepsy?) • LOC & HA Hx important to determine ability to resist Traumatic Brain Injury & risk for Second Impact Syndrome • Burners/stingers are Brachial plexus injuries • Usually resolve but are occasionally permanent • Cervical cord neuropraxia w/ transient quadriplegia: Rare! • Associated w/ cervical stenosis, congenital fusions, cervical instability, disc problems Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

22. ANY History of Recurrent burners/stingers, or transient quadriplegia? NEED Cervical spine films BEFORE being allowed to participate!!

23. Concussion? • Traumatic Brain Injury (concussion) • High School 5.5% of injuries • College 1.6-6.4% • Major sports: • Football, Boxing, Hockey, Soccer • TBI is cumulative! Can negatively affect: • Cognitive Function (“Punch Drunk”) • Memory • Ability to learn • Reaction time • Increased risk of Second Impact Syndrome • Primarily younger (pre-adolescent) athletes Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

24. Heat or muscle cramps? • History of dizziness or passing out during activities in the heat • Determines ability to tolerate heat or prolonged events • Marathons Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

25. Difficulty Breathing? • During or after activity? • Seasonal: allergies vs. asthma • Also could be cardiac • HCM • Valvular disease • Arrhythmia's Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

26. Special Equipment/Braces? • Inspect for fit & function • Risk to other players? Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

27. Problems with Eyes/Glasses? • Is athlete “single-eyed” • Less than 20/50 as best in one eye • Hx of orbital fractures Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

28. Sprains/ Strains/ Fractures/ Dislocations? • Need to determine need for rehabilitation PRIOR to being allowed to participate Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

29. Other Questions • Medical problem or injury since last evaluation (periodic exam) • Immunizations up to date? • Td, Hep B, MMR, Meningitis • Women: 1st menses, last menses, Longest time between menses • Family use of tobacco, alcohol, street drugs • “How about yourself??” Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

30. Most Important Questions • Ever passed out or became significantly dizzy during/after exercise? • Ever have chest pain during/after exercise? • Do you tire more quickly than your peers? • Hx of increased BP, heart murmur? • Hx of heart racing/skipping beats? • FHx of sudden death before age 50? • Hx of concussion (Traumatic Brain Injury) Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

31. Keep in mind: • 90% of sudden death in athletes <30 y/o is cardiovascular • Syncope or near-syncope may be a sign of underlying hypertrophic cardiomyopathy • Chest pain may be atherosclerotic • Dyspnea on exertion may be asthma, valvular disease, or coronary artery disease • Palpitations may be arrhythmia, WPW Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

32. Key Components of the Physical Exam

33. Height & Weight • Compare to growth charts for age/sex • Body fat: male 5-10%, female 12-15% • Very thin: Ask about diet, weight loss, body image (r/o anorexia, bulimia) • Optional: Body composition: • Skin fold calipers easiest • Electronic scales • Total immersion more accurate • Good time to discuss weight in athletes where weight is important • Wrestling, Ice Skating, Gymnastics

34. Eyes • Absence of 1 eye or vision >20/50 in the best eye: AVOID COLLISION SPORTS! • Anisicoria: slight/baseline is normal and should be noted (1-2mm) • Large difference needs neurological workup first! Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

35. Cardiovascular • BP: Use correct size cuff!! • >110/70 for <10 y/o or >120/80* for >10 y/o must be evaluated (*Latest JNC guidelines) • Check pulses: Symmetrical femoral and radial pulse is a good screen for Coarctation of the aorta • Murmurs: deep inspiration, valsalva, squatting • Innocent, Mitral valve prolapse, Hypertrophic cardiomyopathy, Aortic sclerosis • Arrhythmia: EKG to evaluate • 24 hour monitor Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

36. Neurological • Baseline testing: Neuropsych testing • Memory, Cognitive function • Ability to learn • Orientation • VERY useful if athlete receives TBI • Presence of post-concussive symptoms • More accurate for determining return to play • Can demonstrate loss of baseline function Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

37. Practice Recommendation • Anyone with traumatic brain injury and a recorded Glasgow Coma Scale of 13 or less at any stage after the first 30 minutes OR who received a CT scan of the head as part of their initial assessment should be routinely followed up with, as a minimum, a written booklet about managing the effects of traumatic brain injury and a phone call in the first week after the injury • Approved Source: National Guideline Clearinghouse • Website: http://www.guideline.gov/summary/summary.aspx?doc_id=10281&nbr= 005397&string=concussion • Level of Evidence: B - A well-designed, nonrandomized clinical trial. A non-quantitative systematic review with appropriate search strategies and well-substantiated conclusions Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

38. Other • Lungs: look for symmetry of movement, listen for wheezes/rubs • Abdomen: check for organomegaly, tenderness, rigidity • Skin: check for rashes. growths Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

39. Practice Recommendation • In a population of stable asthmatics short acting beta-agonists, mast cell stabilizers, or anti-cholinergics will provide a significant protective effect against exercise-induced broncho-constriction with few adverse effects • Approved source: Cochrane Database • Website: http://www.cochrane.org/reviews/en/ab002307.html • Strength of Evidence: Twenty-four trials (518 participants) conducted in 13 countries between 1976 and 1998 were included. All drugs were effective at attenuating the exercise-induced bronchoconstriction response but to varying degrees even within the same individual. Compared to anti-cholinergic agents, mast cell stabilizers were somewhat more effective at attenuating bronchoconstriction Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

40. Genito-Urinary Male: • Hernia (?) • Testes both descended • Single: should counsel about collision sports Female: • Pelvic not necessary part of basic exam • Do w/ Hx of severe menstrual irregularities, primary or secondary amenorrhea Both: Maturity & development (self rating?) Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

41. Musculo-Skeletal Need to assess major muscle groups and joints via a screening exam Follow up closely on any abnormalities noted -Decreased ROM, function - Hyper-flexibility Refer to Figures 1-10 (pgs 22-27) Pre-participation Physician Evaluation: 2nd Edition 1997 The Physician and Sports Medicine, A Division of McGraw Hill Co. Minneapolis, MN (PDF files on NJAFP website)

42. Laboratory Testing • Traditionally: UA dip for protein/glucose • Non-pathologic proteinuria VERY common • U-glucose NOT reliable & unproven in large studies for DM screening • Same for CBC, Hct, Fe, Ferritin, Sickle trait • Cardiovascular screening (EKG, Echo) under investigation for cost-effectiveness • Screen only those at risk or positive findings Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

43. Determining ClearanceMOST IMPORTANT PART!! • Does the problem put the athlete at greater risk for injury? • Is the athlete a risk to other players? • Can the athlete safely participate with treatment, rehabilitation, medicine, bracing or padding? • Can limited participation be allowed? • If clearance is denied, are there other activities that the athlete can safely participate in? Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

44. Clearance is based on AAP Committee on Sports Medicine Recommendations for Participation in Competitive Sports Based upon the amount of contact/collision and intensity of exercise (Table 7) Pre-participation Physician Evaluation: 2nd Edition 1997 The Physician and Sports Medicine A Division of McGraw Hill Co. Minneapolis, MN

45. Contact Non-Contact Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

46. Some Specifics Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

47. Acute Illness • Individual assessment • Generally accepted to limit activity during fever • URI’s and strenuous activity (re: cycling) can cause significant impact on the immune system Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

48. Cardiovascular Abnormalities • May Dispose to Sudden Death!! • Mild Hypertension: No restrictions • Moderate to Severe: need assessment and possible treatment • Benign functional murmurs: No restriction • Mild Mitral valve prolapse: No restriction Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

49. MVP with: • PMHx of syncope • Chest pain/tightness increased w/ activity • FHx of sudden death • Moderate to Severe regurgitation REASSESS!! HIGH RISK!! Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

50. Hypertrophic Cardiomyopathy(HCM, IHSS) • Most common cause of sudden death in athletes • Usually find: • Marked LVH (***Need to differentiate from normal LVH in conditioned athletes) • Significant L outflow obstruction & Arrhythmia's Both increased by activity • PMHx of syncope or FHx of sudden death in a young relative • May participate in LOW intensity activities Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians