The Pre-participation Physical Exam

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The Pre-participation Physical Exam What you
Need to Know

• David L. Marshall, MD
• Medical Director
• Sports Medicine Program
• Children's Healthcare of Atlanta

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The Form

• Developed in 1997, revised 2001, 2004, 2011
• AAP, AAFP, ACSM, AMSSM, AOSSM, AOASM
• AHA

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National Data from Glover, Maron, 1998

• Eight of the 51 states (including DC) do not have
  a recommended form to serve as a guideline for
  examiners (CA, GA, ME, MS, NH, NJ, OR, RI)
• Of the states that do have a form, it varies from
  a simple clearance statement to a detailed multi
  page questionnaire

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National Data cont.

• The AHA consensus panel met in 1996 and
  recommended 13 specific items be included in the
  PPSPE

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AHA Recommendations

• exertional syncope
• exertional chest pain
• exertional SOB
• heart murmur on exam
• femoral pulses
• Marfan stigmata
• BP measurement (resting)
• Parental verification

• family history of premature or sudden death
• heart disease in surviving relatives
• heart murmur
• high blood pressure
• excessive fatigue

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National Data cont.

• AHAs findings
• 17 (40) of the states forms contained at least
  9 of the 13 recs
• 14 (32) of the forms contained 5-8 of the recs
• 12 (28) of the forms contained 0-4 of the recs

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National Data cont.

• 23 states had updated or revised their form in
  the past 5 years
• 16 states had not updated their form in the last
  5 years
• 6 states had not updated their forms in the past
  10 years

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Who Performs the PPSPE?

• 44 of the 50 states requiring screening recommend
  that it be done by a medical or osteopathic
  physician
• Nurse practitioners or physician assistants can
  perform screenings in 22 states
• Chiropractors can perform screenings in 11
  states!!!!
• Orthopedic surgeons?

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Georgia Data from Wiser, Stevens, unpublished

• 373 schools in the GHSA contacted to request
  forms used in the PPSPE
• 301 (81) of the schools returned forms
• 89 different forms

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Georgia Data from Wiser, Stevens, unpublished

• Results
• 12 addressed all issues recommended by the AHA
• 17 addressed six or less of the recommended
  issuess
• 11 addressed four or less
• 72 addressed two or less
• 34 of the forms did not ask any questions
  regarding cardiac history

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The Results
March 31, 2003, the GHSA Executive Committee,
after being presented this information, voted
unanimously to adopt the form for statewide use.
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Why the Need for a Standardized Form

• gt75 of cardiac and orthopedic problems affecting
  athletes can be picked up by history alone
• Two of the leading causes of sudden death in
  young athletes are hereditary (HCM, Marfans)
• Two-thirds of adolescent athletes view the sports
  physical as their yearly health maintenance exam

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How a state-wide form helps

• Decrease variability in the process
• Provide guidelines for practitioners with low
  interest in sports
• Streamline data collection, updates
• Recognition of a state high school medical
  advisory committee

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www.gaaap.org www.ghsa.net www.choa.org/sportsm
edicine
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Objectives of the Exam

• Primary
• Life-threatening conditions
• Conditions that pre-dispose to injury
• Conditions that interfere with optimal
  performance
• Secondary Objectives
• Determine general health
• Serve as entry point to the adolescent healthcare
  system
• Provide opportunity to initiate discussion on
  health-related topics

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Timing and Frequency

• Should be performed 6-8 weeks prior to the start
  of a season
• Frequency requirements vary
• Yearly
• Level of competition
• Interim history with each sport and PE based on
  the history

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Timing and Frequency

• Should be performed 6-8 weeks prior to the start
  of a season
• Frequency requirements vary
• Yearly
• Level of competition
• Interim history with each sport and PE based on
  the history

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Setting

• Office based exam
• Multi-station exam
• Locker room exam
• Immediate Care Center exam
• CVS, Walgreens, Publix, Little Clinic

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Office Based Exam

• Disadvantages
• Cost
• Time consuming
• Varying knowledge in sports medicine
• Hard to communicate with athletic staff

• Advantages
• Dr-pt familiarity
• Parent, records available
• Continuity
• Privacy to discuss sensitive issues

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Multi Station Exam

• Disadvantages
• No records, parent available
• Hard to address sensitive issues
• Dishonesty with someone they dont know or trust

• Advantages
• Cost effective
• Can have multi subspecialists
• Coach and trainer available
• Can be sports-specific

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Legal Ramifications

• Right to participate
• Rehabilitation Act of 1973
• Americans with Disabilities Act of 1990
• Sexual harassment claims
• Good Samaritan statutes
• HIPPA and FERPA
• Confidentiality with forms (who needs to know?)

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History

• Cornerstone of any medical evaluation
• Athlete and parent fill out together and both
  sign
• Conditions most likely to be reported
• Joint injuries, cardiac problems, asthma,
  allergies
• Concussions

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History

• Conditions not reported
• Hypertension, shoulder instability, tight
  hamstrings, scoliosis, pronation, supplement use
• Concussions

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History

• Demographics
• Personal physician
• Emergency contact info

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History cont

• Primary questions (on form)
• 1. Has a doctor ever denied or restricted you
  participation in sports for any reason?
• 2. Do you have an ongoing medical condition
  (like diabetes or asthma)?
• Secondary questions (not on form)
• When and why were you disqualified?
• Have you seen a doctor for this condition?
• What has changed since you were disqualified?

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History

• 3. Medications and supplements
• Truthfulness?
• 4. Allergies and anaphylaxis
• Medications?
• Hospitalizations?
• Intubated?
• Epi-pen?

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Questions 5-14 Cardiac

• Very difficult to detect a life-threatening
  cardiovascular condition in an asymptomatic
  individual
• Life-threatening cardiac conditions are rare
• Sudden death occurs 1100,000 to 1300,000 high
  school athletes

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Cardiac

• Structural defects leading to fatal arrhythmias
  account for 95 of all sudden deaths in athletes
  lt 30
• 36 HCM
• 13 anomalous coronaries
• Basketball, football, track, soccer

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Anomalous coronary
abnormal
normal
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Cardiac questions 5-14

• Syncope? (with exercise vs after)
• Chest pain or pressure?
• Dyspnea on exertion?
• Heart racing or skipping beats?
• Hypertension, cholesterol, murmur, or heart
  infection?
• Marfan syndrome?

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Cardiac

• Family history of unexplained death or sudden
  cardiac death before age 50
• HCM, Marfans, lipid abnormalities may be familial
• Consider cardiology referral for positives

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Questions 15-16Surgical

• T A
• Appy
• Paired organ
• Orthopedic
• Rehab?
• Brace?

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Questions 17-22Musculoskeletal

• Very common injuries in sports
• Fractures or dislocations are more serious
• Stress fractures may indicate eating disorders
• X-ray, MRI, CT, PT, casting, etc may indicate
  more severe injury

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Questions 23-26Asthma

• EIA has a prevalence in adolescents of 10-50
• Secondary questions
• Where do you keep you inhaler?
• Missed practices or games?
• Gone to hospital?
• Intubated?
• Who is your asthma doctor?

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Questions

• 27. paired organs
• 28. mono
• splenomegaly
• 29-30. Dermatologic conditions
• Herpes gladatorum
• Tinea
• MRSA
• 31-36. Neuro
• Concussions
• Burners or stingers

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Questions

• 37. Heat illness
• ADD, antihistamines, obese, umacclimated, Sickle
  trait
• 38. Sickle cell
• 39-41. Eyes and vision
• 42-45. Nutrition and weight
• 46. General concerns
• 47. Menstrual history

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Physical Exam

• Attire
• Height and weight
• Wrestlers, gymnasts, dancers
• May need questioning about recent weight loss,
  eating habits, body image
• Eyes
• Visual acuity (20/40 or better corrected)
• Protective lenses
• anisocoria

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PE cont

• Ears
• Perforations important for swimmers
• Dentition
• Mouth guards for orthodontia
• Caries
• Lymph nodes

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PE cont

• Cardiac
• Marfan stigmata
• Blood pressure (note cuff size)
• Radial and femoral pulses
• Auscultation supine and standing or sitting
• Innocent murmurs are common
• Murmurs that increase with standing or valsalva
  may indicate hypertrophic cardiomyopathy (due to
  decreased venous return and decreased LV size)

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PE cont

• Refer to cardiology
• Positive cardiac history
• Grade III or IV hypertension
• Murmur grade III or higher or diastolic
• PVC not extinguished with exercise
• Murmur that increases with standing or valsalva
• Known structural heart disease
• When in doubt

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PE cont

• Abdomen / GU
• Organomegaly
• Presence of both testicles, protection
• Hernia exam not necessary if asymptomatic
• Neuro
• Covered in musculoskeletal exam
• Additional exam needed for recurrent concussions,
  burners/stingers

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Musculoskeletal Exam

• Yield is low in asymptomatic athletes
• History alone is 92 sensitive in detecting
  significant musculoskeletal injuries
• General screening exam
• 2 minute orthopedic exam
• Asymptomatic with no previous injury
• Joint-specific exam

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Musculoskeletal Exam

• Joint-specific exam
• History of previous injury
• Pain, locking, instability, weakness or other
  signs suggested by history or general screening
  exam
• May need to be referred to specialist for
  evaluation/clearance

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Musculoskeletal Exam

• Sport-specific exam
• Focus on areas under increased stress
• Shoulder in pitchers, swimmers
• Low back flexibility in tumblers
• Hamstrings, core stability, patello-femoral
  alignment, feet in runners

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Musculoskeletal Exam

• Neck
• Flexion, extension, rotation, lateral bending
• History or cervical injury with neurologic
  symptoms warrant cervical x-rays, and/or MRI
• Down syndrome (atlantoaxial subluxation)

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Musculoskeletal Exam

• Back
• Kyphosis
• Scoliosis
• Consider spondylolysis if pain in extension
• Suspect neoplasm with unexplained back pain, or
  night pain

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Musculoskeletal Exam

• Shoulder
• Look for symmetry
• Shrug
• Abduction, adduction, flexion, extension,
  internal rotation, external rotation
• Advise on pre-season conditioning for overhead
  athletes

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Musculoskeletal Exam

• Elbow
• Flexion, extension, pronation, supination
• Pitch counts, curveballs in LL pitchers
• Hands and wrists
• Clench fist, spread fingers
• Old injury
• Gymnasts wrists

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Musculoskeletal Exam

• Hips
• Flexion, extension
• Internal and external rotation
• Knee
• Effusion, swelling
• Flexion, extension
• Ligament stability / laxity

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Musculoskeletal Exam

• Quadricep, hamstring, calf flexibility
• Ankle and feet
• Swelling, pain, instability
• Advise pre-season strengthening
• Brace for recurrent sprains
• Calf symmetry
• Pronation

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Labs

• Not recommended as part of the PPSPE
• If exam is part of routine adolescent health
  maintenance labs may be indicated (CBC, UA, lipid
  panel, ferritin, sickle trait)

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Clearance

• Unrestricted
• Approved after coach, trainer, team physician
  notified about a particular problem
• Not cleared pending further evaluation
• Not cleared

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Liability and Assumption of Risk

• Courts have ruled that young people have the
  right to accept medical risks despite
  disqualification by medical team
• Consult physician with specific expertise in the
  identified problem
• With the consultant, fully inform the athlete and
  family of the risk of participation
• Document carefully

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Current Hot Issues

• AEDs
• EKG and Echocardiograms as part of the PPSPE
• Chest protectors for youth baseball
• Head protection for soccer
• Neurocognitive testing for concussions

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Room to Improve

• National standardization of the PPSPE
• Universal endorsement of the examination form by
  all states
• Site-specific forms for office or station-based
  exams
• Recommendation that only appropriately trained
  personnel perform the exam
• Provide handouts, video, etc. for education at
  the multi-station exam

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Summary

• Get involved with this healthy population
• PPSPE is a valuable tool to counsel adolescents
  in many areas
• Sudden death in a young athlete is an extremely
  rare event

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Annual Causes of Teenage Death
Cause of Death
Deaths/year
Motor vehicle accidents 14,700
Drowning 1500
Firearm accidents 500
Fires 400
Inhaled poisonous gases 250
Falls at home 100
Lightning 100
Sports 25
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Thanks
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dgkmarshall_at_comcast.net