The P'P'E'

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The P.P.E.

• J. Bryan Mann, MD, FAAP
• [phone]
• Mann_at_chp.twsu.edu

• Preparticipation Physical evaluation (PPE)
• Preparticipation Athletic Examination
• Sports physical

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Sports Participation AAP Committee on
Sports Medicine and Fitness and Committee on
School Health. Organized Sports for Children and
Preadolescents. Pediatrics. 2001. 10761459-1462

• There is no consensus as to the overall value of
  organized sports for preadolescents.
• The younger the participant, the greater the
  concern about safety and benefits.
• Basic motor skills do not develop sooner simply
  as a result of introducing them to children at an
  earlier age.
• The shift from child-oriented goals to
  adult-oriented goals can further negate positive
  aspects of organized sports.

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Intensive Training AAP Committee on Sports
Medicine and Fitness. Intensive Training and
Sports Specialization in Young Athletes.
Pediatrics. 2000. Volume 106 pp 154-157

• Research supports the recommendation that child
  athletes avoid early sports specialization.
• Those who participate in a variety of sports and
  specialize only after reaching the age of puberty
  tend to be more consistent performers, have fewer
  injuries, and adhere to sports play longer than
  those who specialize early.

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Preparticipation Physical Evaluation (PPE)

• Recommendations for PPE exist and are based on
  consensus of the literature (AAP, AAFP, AAOSSM)
• Primary Goals of PPE
• Detect conditions that may cause injury
• Detect conditions that may be life-threatening
• Meet legal/insurance requirements

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PPE Goals

• Identify conditions that may interfere with
  participation
• Identify conditions that may be exacerbated by
  participation
• Help select an appropriate sport or the childs
  particular abilities and physical maturity

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PPE Goals

• Poorly conditioned children
• Children with muscle or joint weakness (usually
  related to recent injury)
• Immature children (physically)
• Previously unsuspected disease

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PPE

• 1 of children undergoing PPEs have conditions
  that might limit sports participation and are
  generally discovered through the history.

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Sports - The Numbers

• 30 million American children annually participate
  in sports (7 million adolescents)
• Majority of sports examinations are ineffective
  in determining potential health problems
• 80 of pediatric population will have no other
  health care during the year
• Majority of adolescents and their parents regard
  the PPE as sufficient annual health examination.

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PPE - Utility

• Value of PPE remains unproven
• Screening of a healthy population is somewhat
  dubious
• 35 of 7 million adolescents participants are at
  risk of sudden death
• 4,537.00/athlete identified with any significant
  medical condition
• Only proven utility is the recognition of at
  risk participants from poorly rehabilitated or
  recent orthopedic injuries
• Ideally, incorporate health maintenance exam,
  anticipatory guidance, with the PPE

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Morbidity and Mortality

• 6,000,000 cases of adolescent STDs/year
• 1,000,000 pregnancies/year to lt 19 yrs
• 500,000 live births
• 15,000- 18,000 adolescent MVA deaths/year
• 6,000 young adult homicides/year
• 5,000 adolescent suicides/year

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PPE

• Locker room method
• Station method
• Individual office-based method

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PPE-History

• 1. Significant underlying health conditions
• Surgical
• Hospitalization
• Duration gt one week
• 2. Sustained a significant injury
• 3. Use of medication(s)
• Ergogenic aids, substance abuse
• 4. Medical allergies/Anaphylaxis
• 5. Tetanus/Immunizations

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PPE-History

• 6.Cardiovascular disease?
• Syncope, dizziness, or chest pain with exercise
• Hear murmur or hypertension?
• Sudden cardiac death before age 35 yrs
• 7. Concussion?
• 8. Exercise tolerance
• 9. Corrective lenses/dental appliances
• 10. Missing a paired organ?
• 11. Menstrual history
• 12. Heat-related illness

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Taken from Contemporary Pediatrics (2000)
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Px Whats Important?

• Musculoskeletal exam
• 10 of males examined will have an orthopedic
  abnormality, usually minor
• 92 will be detected by history alone
• Two minute orthopedic examination

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PPE Laboratory?

• Generally thought to be unnecessary as screening
  tools
• Hematocrit
• UA
• Body fat measurement
• Aerobic capacity

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Physical Exam

• Ht
• Wt
• BP
• Visual acuity
• CV exam
• Palpation of the abdomen
• GU exam (males)
• Screening musculoskeletal exam

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Obesity

• Obesity - excess of body fat relative to lean
  body mass
• Third National Health and Nutrition Examination
  Survey (NTHANES III)
• 33 of adult Americans are obese
• 25 of children and adolescents are either
  overweight or highly at risk

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Expert Committee on Obesity

• Obesity
• gt 95tile BMI for age and sex
• At risk for obesity
• 85-95tile or age and sex
• BMI tables are available from the CDC
  http//www.cdc.gov/growthcharts/

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Expert Committee on Obesity - Recommendations

• Weight maintenance (slowing of excessive weight
  gain) for
• Children 2-7 years with at risk BMI
• BMI gt 95 and no complications of obesity
• gt 7 yrs lt 95 and no complications
• Weight Loss
• gt 2 yrs and BMI gt 95 and complications of
  obesity
• gt 7 yrs with a BMI gt 85 and a secondary health
  complication

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PPE - CV Exam

• Evaluate peripheral pulses, murmurs, BP
• BP gt 135/85 (in adolescence) should prompt
  concern and repeat exams
• 3/6 systolic and all diastolic murmurs should be
  referred
• IHSS apical murmur that increases with Valsalva
  maneuver and intensifies with standing
• Femoral pulses in coarctation
• Marfans syndrome habitus

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HypertensionAAP Athletic Participation by
Children and Adolescents Who Have Systemic
Hypertension. Pediatrics. 1997.994637-638.

• Youth who have severe hypertension need to be
  restricted from competitive sports and highly
  static (isometric) activities until their
  hypertension is under adequate control and they
  have no evidence of target organ damage.

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Sudden Death - Cardiac

• Cardiomyopathy
• Hypertropic cardiomyopathy
• Congenital heart disease
• Anomalous left or hypoplastic coronary artery
• Aortic rupture
• Cardiac Arryhthmias
• Prolonged QT syndrome (Romano-Ward)
• WPW

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Marfan syndrome

• Tall and skinny
• Long, narrow face
• High arched palate
• Pectus deformity
• Long fingers and toes
• Hyperflexible
• Myopia/lentis ectopia
• Family hx of early, sudden death

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Abdomen and Genitalia

• Hepatomegaly
• Splenomegaly
• IM return to play one month after onset of
  illness and no splenic enlargement

• Absence or atrophy of testicles
• Tanner staging
• Inguinal hernia
• Varicolcele
• Testicular mass

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Varicolcele

• Taken from Adelman and Joffe. Contempory
  Pediatics. 1999.

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Varicocele

• Most common scrotal mass
• 15 of teenagers have a varicoceles
• Usually asymptomatic
• Bag of worms
• Controversy as to therapy

• Surgical repair
• Large varicocele and testicle not growing
  normally
• Left testis 3 ml smaller than right
• - 2 SD for testicular size
• Bilateral or symptomatic varicoles
• Pain

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Sexual Maturity

• Preadolescents and adolescents should avoid
  competitive weight lifting, power lifting, body
  building, and maximal lifts until they reach
  physical and skeletal maturity.
• - AAPStrength Training by Children and
  Adolescents. Pediatrics. 2001.10761470-1472

• Caution with Tanner stage lt 3 in collision sports.

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Skin

• Active impetigo
• Tinea corporis
• Scabies
• Molluscum contagiosum
• Herpes simplex

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PPE - Musculoskeletal

• Majority of all abnormalities identified
• two-minute musculoskeletal examination
• Garrick 1977
• 14 screening positions
• Specificity of 97.5

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Orthopedic Screening Exam (Garrick)

• 1. Acromioclavicular joint/general habitus
• 2. Cervical spine motion
• 3. Trapezius strength
• 4. Deltoid strength
• 5. Shoulder motion
• 6. Elbow motion
• 7. Elbow and wrist motion

• 8. Hand/finger deformity
• 9. Symmetry/effusion
• 10/12. LE symmetry/strength
• 11. Lower back
• 12. Scoliosis
• 13. Knee effusion
• 14. Calf symmetry/strength

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Adolescent Scoliosis

• Lateral curvature of the spine
• Usually not painful
• Most common spinal deformity in the 10-16 year
• 30 will have a family history

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Scolisosis - Adams Forward Bend Test

• Knees fully extended
• Hands to side
• Bends forward to a horizontal position
• Document asymmetry with a scoliometer
• 7 degrees on
• scoliometer 20 degrees on x-ray

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Adolescent PPE - Anticipatory Guidance

• Immunizations
• Tetanus
• Varicella
• Hepatitis B
• Meningococcemia
• Behavioral/
• Psychosocial screen

• Testicular/Breast self-exam
• Discussion of
• Androgenic agents
• Natural agents
• DHEA
• Creatine
• Female athlete triad

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Participation - Medical Conditions AAP
Committee on Sports Medicine and Fitness. Medical
Conditions Affecting Sports Participation
(RE0046). Pediatrics. 2001. 10751205-1209.

• Who should and should not participate in a
  particular sport?
• What, if any, modifications are necessary?
• Risk of injury related to any conditions present

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Participation - Medical Conditions AAP
Committee on Sports Medicine and Fitness. Medical
Conditions Affecting Sports Participation
(RE0046). Pediatrics. 2001. 10751205-1209.

• Sports are categorized into three categories by
  degree of contact
• Collision
• Limited Contact
• Noncontact
• Assessment of various medical conditions
• Risk of injury
• Risk of adversely affecting the medical condition

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• Sports Classifi

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• When an athlete's family disregards medical
  advice against participation, the physician
  should ask all parents or guardians to sign a
  written informed consent statement indicating
  that they have been advised of the potential
  dangers of participation and that they understand
  them. The physician should also document, with
  the child's signature, that the child athlete
  also understands the risks of participation.
• - AAP Committee on Sports Medicine and
  Fitness. Medical Conditions Affecting Sports
  Participation (RE0046). Pediatrics. 2001.
  10751205-1209.

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Adolescent Female - Sports

• 1972 127
• 2000 13
• Injury rates are similar between male and female
  adolescents in the same sport except
• Female Athlete Triad
• Stress fractures
• ACL injuries

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Female Athlete Triad

• Eating disorder or
• Disordered eating
• Less severe and more subtle than true eating
  disorders
• fasting
• vomiting
• food restriction
• diet pills/laxatives
• Amenorrhea
• Osteoporosis

• Risk factors
• Highly structured life
• Social isolation
• Lack of support system
• Family hx of eating disorders

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Amenorrhea - Definitions

• Primary amenorrhea
• No menses by age 16 years
• No menses 4.5 years after onset of breast
  development
• Secondary amenorrhea
• Absence of at least 3-6 menstrual cycles in a
  female that has begun menstruation

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Female Athlete Triad AAP Committee on Sports
Medicine and Fitness. Medical Concerns in the
Female Athlete. Pediatrics.2000. 1063610-613

• 3-60 will have amenorrhea vs. 2-5 in adult
  women
• Normal weight athletes usually dont have
  menstrual problems
• Disordered eating may occur in 15-65 of all
  female athletes
• Disordered eating should be considered in
  adolescent amenorrhea

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Disordered Eating - Amenorrhea
Decreased calories
Energy drain
Hypothalamic dysfunction
Decreased estrogen production
Amenorrhea
Decreased BMD
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Female Athlete - Amenorrhea

• Athletes with amenorrhea have lower bone mineral
  density (BMD)
• Bone mass maybe unrecoverable after resumption of
  menses
• Complete exam is necessary for any adolescent
  with primary or secondary amenorrhea

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Amenorrhea - Treatment

• Decrease training
• Attempt to increase weight/height to 10
• Calcium intake
• Addressing any eating disorders
• Premarin/OCT?

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Stress Fractures

• 3.5X more common in female athletes (vs. male
  athletes)
• Load exceeds bodies attempts at skeletal repair
• More common in tibia, femur and pelvis
• Pain with activity initially, later pain at rest

• Risk factors
• Smoker
• Asian
• Corticosteroids
• Female Athlete
• Amenorrhea
• Family history

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Stress Fracture

• Plain radiographs may miss a stress fracture
• Bone scan is the gold standard
• Conservative treatment for 6-12 weeks

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References

• Callahan, L.R. The Evolution of the Female
  Athlete Progress and Problems. Pediatric Annals.
  2000. 29149-155.
• Berul, C. Cardiac Evaluation of the Young
  Athlete. Pediatric Annals. 2000. 29162-165.
• AAP and AAOS. Care of the Young Athlete. 2000.
  ISBN 1-58110-050-7
• Menses and the Pediatrician The Pediatricians
  Role in the Development of Adolescent Girls.
  Pediatric Annals. 1997. Volume 26, Number 2,
  Supplement.
• Metzel, J. ed., Sports Medicine in the Pediatric
  Office. Pediatric Annals. 2000. 29139-188.
• Killiam, J.T., et. al. Current Concepts in
  Adolescent Scoliosis. Pediatric Annals. 1999.
  28755-761.
• American Academy of Pediatrics. Preparticipation
  Physcial Evaluation. 2nd Ed. 1997
• Sarah E. Barlow and William H. Dietz. Obesity
  Evaluation and Treatment Expert Committee
  Recommendations. Pediatrics. 1998 102 e29.

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References

• AAPCommittee on Sports Medicine and Fitness.
  Medical Concerns in the Female Athlete.
  Pediatrics. 2000. 1063 610-613
• American Academy of Pediatrics Committee on
  Sports Medicine and Fitness. Medical Conditions
  Affecting Sports Participation (RE0046).
  Pediatrics. 2001. Volume 1075 pp 1205-1209.
• American Academy of Pediatrics Committee on
  Sports Medicine and Fitness and Committee on
  School Health. Organized Sports for Children and
  Preadolescents (RE0052). Pediatrics. Volume 107,
  Number 6 pp 1459-1462
• Krowchuk, D.P. The Preparticipation Athletic
  Examination A Closer Look. Pediatric Annals.
  26137-47
• AAP Committee on Sports Medicine and Fitness.
  Medical Concerns in the Female Athlete.
  Pediatrics.2000. 1063610-613.
• Adelman an Joffe. The Adolescent Male Genital
  examination Whats Normal and Whats Not.
  Contemporary Pediatrics. 1999.
• AAPStrength Training by Children and
  Adolescents. Pediatrics.2001. 10761470-1472
• Perriello,V. ajd Barth, J. Sports Concussion
  Coming to the Right Conclusion. Contemporary
  Pediatrics. 2000.

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