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Robert Sallis, MD

Robert Sallis, MD Has documented that he has no relevant financial relationships to disclose or COIs to resolve. Robert Sallis, MD has documented that his presentation will not involve discussion of unapproved or off-label, experimental or investigational use . .

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Robert Sallis, MD

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  1. Robert Sallis, MD Has documented that he has no relevant financial relationships to disclose or COIs to resolve.

  2. Robert Sallis, MD has documented that his presentation will not involve discussion of unapproved or off-label, experimental or investigational use.

  3. Participation Sports Physical Robert Sallis, MD, FAAFP,FACSM Co-Director; Sports Medicine Fellowship Department of Family Medicine Kaiser Permanente Medical Center Fontana, California, USA

  4. Overview • Review goals and format of the PPE • Discuss content of the exam • Clearance and disqualification • Prevention of exercise related sudden death

  5. Introduction • Estimated that well over 2 million physician-hours are spent yearly examining over 12 million youth athletes in the U.S. • Many have questioned the cost effectiveness of yearly exams.

  6. 2 were disqualified, and 1 had further treatment prior to participating 3 significant problems uncovered, at cost of $4,537 per problem Looked at 763 PPE’s done on adolescent athletes: 16 athletes were not cleared. Risser, et al; 1985

  7. Mayo Clinic; 1998 • 2,739 PPE’s on HS athletes • 1.9% disqualified; 11.9% needed more evaluation • Musculoskeletal problems were most common reason to disqualify (43%), followed by cardiac problems (19%)

  8. Other Studies Have Shown Similar Results • From .3 to 1.3 % being disqualified. • From 3.2 to 13.5 % requiring consultation. PPE Monograph; 2010

  9. Goals of the Pre-Participation Exam • Detect potentially life threatening or disabling conditions. • Detect conditions that require treatment of rehab before participating. • Meet legal or insurance requirements (49 of 50 states require yearly exam).

  10. Goals of the Pre-participation Exam(Continued) • Determine general health of the athlete. • Answer health related questions. • Counsel on high risk behavior. • Assess fitness level and readiness for sport.

  11. 2 Common Formats Used • Private office: • Records available. • Better continuity. • More privacy. • Group exam: • Lower cost. • Better communication with school staff.

  12. Pre-season Mass Screening • This is a screening exam. • Not meant to replace full exam that should be done by athlete’s personal physician (ideally every 4 years). • Quick screen to look for pre-existing or new problems. • Focus on history form completed prior to exam. • Brief heart and lung exam, with focused musculoskeletal exam.

  13. Frequency - most states require yearly exams; Every 3-4 yrs with yearly screening updates probably adequate. Timing - should occur 4-6 wks before season to allow time to evaluate problems. Frequency and Timing

  14. Content • Since exercise primarily stresses the cardiovascular and musculoskeletal systems – these areas need emphasis • Should begin with a detailed history. • Using a pre-printed form given out prior to the exam is helpful. • Parents should complete form for athletes who are minors.

  15. History • Shown to identify up to 80% of problems affecting participation. • Ask about pre-existing medical problems or injuries and current state of health. • Key problems to screen for include cardiac, MSK, asthma, concussions and heat illness.

  16. Cardiovascular Assessment • Critical history questions: • Have you ever passed out nearly passed out while exercising? • Any chest pressure or pain while exercising? • Any family history of cardiac death before age 35 (50 for adult screen)?

  17. Cardiovascular ExamThe Following Need More Evaluation: • Heart murmurs which are diastolic or > grade 3 (listen during Valsalva). • Ectopic beats that worsen with exertion. ? Cocaine use. • Hypertension – re-check with larger cuff. Avoid high static demand sports if severe.

  18. Musculoskeletal Assessment • Keep in mind the demands of the sport in which the athlete will compete. • Evaluate pre-existing or past injuries (knee, shoulder, ankle are high risk to re-injure. • History shown to ID 92% of musculoskeletal problems. • “Two minute” orthopedic exam is a useful screen.

  19. Other Important Areas • Height / weight – eating disorders. • Lungs – wheezing. • Abdomen - organomegaly or masses. • Skin - infectious diseases, acne. • Genitalia - testicular mass or undescended testicle • Tanner staging no longer recommended.

  20. Pre-season Exam • Brett Butler • John Kruk

  21. Case Discussion15 yo Wrestler in for PPE • Rash on neck for few weeks and seems to be spreading. • Diagnosis? Can he play? • TineaCorporis (Gladiatorum) • Okay to play if can cover lesions with gas-permeable dressing and tape • Must treat for 3 days with topical cream or 2 weeks oral if widespread rash

  22. Screening Tests • Routine CBC and UA not recommended. • Routine EKG and echo not recommended. • Not proven cost effective. • Consider only when Hx and PE support. • Europe using screening EKG Q2yrs starting age 12-14.

  23. Screening ECG Controversy • Pros • Relatively cheap and available • Better than H&P alone at diagnosing causes of SCD • Abnormal in ~80% with cardiomyopathy, myocarditis, Long QT • Cons • Athletes Heart changes mimic disease, so expertise needed • Some potentially fatal heart disease may not have ECG changes • High false positives; increase expense and disqualify 2%

  24. Recommended Screeing Tests • Required tests: UA drug screen (elite athletes), HIV (boxers). • Consider CBC in female athletes. • Cholesterol testing if family hx of CAD or hyperlipidemia. • Consider stress EKG in adult with cardiac risk factors prior to stating exercise program. • Screen for sickle cell trait in black athletes.

  25. Case Discussion17 yo Football player in for PPE • Collapsed in practice last year from Heat Stroke. Spent night in hospital; Full recovery. • Can he play? Precautions? • No exercise x 1 week after asymptomatic, then gradual return. • Likely increased risk to suffer another episode. • Close monitoring with cooling measures. • Ice water immersion. • Heat Tolerance Testing?

  26. Sickle Cell Trait • About 1 in 10 blacks have trait, while about 1 in 400 have sickle cell disease. • Usually benign, but can get sickling with strenuous exercise in high heat, humidity or altitude. • Sickled RBC’s can clog coronary arteries causing arrhythmia. Davaughn Darling

  27. Case Discussion15 yo Soccer in for PPE • Suffered head injury in final game last year with 5 min LOC. CT neg and symptoms resolved over few days. • Can she play? Precautions? • Most important issue is resolution of symptoms. • Graduated RTP protocol. • How many are too many? • Increased risk for 2nd concussion. • Neuropsychtesting controversial.

  28. Return to Play After Concussion • No RTP that day and generally not before 6 days. • Stepwise RTP; advance if no symptoms x 24 hrs; Best case scenario: • Day 1; Rest until asymptomatic (physical and mental) • Day 2; Light aerobic activity (stationary bike) • Day 3; Sports specific exercise • Day 4; Non-contact training drills (light wt lifting) • Day 5; Full contact practice (after med clearance) • Day 6; Return to competition (game play)

  29. Clearance • Most important and often most difficult part of the PPE. • Helpful Tools: • AAP’s recommendations for sports participation. • “36th Bethesda Conference” recommendations for athletes with cardiovascular problems. • 4th Edition PPE Monograph. • Need to consider several factors:

  30. Clearance: Factors to Consider • Does the problem place the athlete at increased risk of injury or illness? Al Toon NY Jets

  31. Clearance: Factors to Consider • Is any other participant at risk if the athlete participates? Magic Johnson

  32. Clearance: Factors to Consider • Can the athlete safely participate with treatment? (brace, tape, pad) Carson Palmer

  33. Clearance: Factors to Consider • Can limited participation be allowed while treatment is being initiated?

  34. Clearance: Factors to Consider • If clearance is denied only for certain activities, in what activities can the athlete safely participate?

  35. 5 Categories of Clearance 1. Clearance without restrictions. Cleared, with recommendations for further evaluation or treatment. Not cleared pending further evaluation, treatment or rehab. Not cleared for certain types of sport (contact or strenuous). Not cleared for any sport. Clearance Form can be helpful. HIPPA Allows release of this info.

  36. Classification of Sports

  37. ClearanceThings to Keep in Mind: • Goal should not be to disqualify, but rather to intervene where needed to allow safe participation. • Athlete and/or parents have final decision. • Americans With Disabilities Act and Rehabilitation Act of 73’ prohibit unjustified discrimination. • Exculpatory Waiver (risk release) may not be protective.

  38. Exercise Related Sudden Death • Prevention is the only effective strategy. • The pre-participation exam is the key to prevention. • Major focus of these exams.

  39. Exercise Related Sudden Death • Actual incidence is rare: • .2 - .5 per 100,000 adolescents per year • Cause is usually cardiac: • Under 30 usually Structural heart problem. • Over 30 usually CAD.

  40. Hypertrophic Cardiomyopathy • Autosomal dom. disorder causing asymmetric septal hypertrophy: • Can cause LV outflow obstruction leading to fatal arrhythmia. • Symptoms: sudden death often first symptom (80%). May see palpitations, syncope, chest pain, DOE. • Exam: hi-frequency SEM – louder with Valsalva. S4 common. EKG abnormal in 90%. • Diagnosis: echo (septum > 15mm).

  41. Hypertrophic Cardiomyopathy John Stewart Will Kimble

  42. Congenital Coronary Artery Anomalies • Probably the 2nd most common cause of sudden death in sports. • Symptoms: sudden death is often the first symptom (80%). May see exertional chest pain or syncope. • Diagnosis: angiogram.

  43. Congenital Coronary Artery Anomalies • 4 types: • Origin of L. Coronary artery from R. Sinus of Valsalva. • Single coronary artery. • Origin of coronary artery from pulmonary artery. • Coronary artery hypoplasia.

  44. “Pistol Pete” Maravich

  45. Pete Maravich1947 – 1988

  46. Pete Maravich1947 – 1988

  47. Marfan’s Syndrome • Autosomal dominant disorder of connective tissue. Can lead to weakening of aortic wall. • Need 2 of 4 major features to diagnose: • 1. Family history. • 2. Cardiovascular abnormality. • 3. Musculoskeletal abnormality. • 4. Ocular abnormality. • Get genetic and cardiology consults if suspected. Need echo to evaluate aorta.

  48. Flo Hymen Died From a Ruptured Aorta in March, 1986.

  49. Marfan’s Syndrome Cases • Chris Patton • Chris Weisheit • Vory Billups

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