Preparticipation Examination of the Adolescent Athlete: Part 1

Objectives After completing this article, readers should be able to: This series of two articles for Pediatrics in Reviewaddresses the preparticipation examination (PPE) as a method of screening adolescents for athletic participation. The first article addresses implementing the PPE as a screening tool and the important issues in the medical and family history portion of the examination. The second article, to be published next month, covers the medical and orthopedic examination portions of the PPE. Together, these two articles delineate a comprehensive approach to the safe and effective screening of the adolescent athlete. A sample PPE form is included at the end of the second article.The number of adolescent athletes participating in organized sports continues to increase yearly in the United States, now totaling more than 14 million. Sports involvement is important for teenagers, teaching lessons such as leadership skills and group dynamics that are important for success in later life. Sports participation also encourages a dedication to physical fitness, which is especially important in the United States, where the incidence of pediatric and adolescent obesity has more than doubled over the past 30 years. Pediatricians, concerned with the healthy development of their teenage patients, should view the trend toward increasing sports involvement extremely favorably.The pediatrician traditionally has provided medical clearance for young athletes involved in organized sports prior to the beginning of each sports season. In past years, this process was limited in scope and effectiveness, often addressing issues of general health such as cardiac and pulmonary disease, but offering minimal input about musculoskeletal pathology. Pediatric training programs, most of which offer fewer than 6 hours of sports medicine or orthopedic training to residents during the entire postgraduate education program,historically have contributed to this limited role by not emphasizing the importance of musculoskeletal evaluation skills.Increasingly, the families of young athletes, who are involved in high-level sports as early as 6 years of age, are demanding more of their health-care practitioners. Pediatricians are being asked to evaluate sports-related injury more frequently and to provide helpful injury prevention strategies. The age-old, previously accepted mantra of “just stay off it until it feels better” no longer is accepted by patients and their families, who are eager for a safe and quick return to athletic competition.For young and otherwise healthy adolescent athletes, many of whom do not see their physicians for annual health supervision visits, the preparticipation examination (PPE) is the most frequent interaction with a clinician during the teenage years. Used fully, the PPE offers an important opportunity to provide preventive care for young athletes.The PPE was created approximately 25 years ago to provide medical clearance for athletes, screening primarily for congenital heart disease in an attempt to “hold” athletes who might be at risk for significant morbidity from increased exertion. Initially required by several states, the PPE has grown in both scope and popularity and now is mandated in 49 of 50 states. In most areas, the present-day PPE investigates family and medical history and includes a screening medical and musculoskeletal examination.As the number of adolescent athletes increases, so does the number of PPEs being performed each year. In high school alone, the number of athletes being screened has increased by almost 50% in the past 10 years, due mostly to the increasing number of female athletes playing on school-sponsored sports teams. The trends in high school sports participation are shown in the FigureF1.Unfortunately, the quality of the examination varies tremendously. In 21 of 50 states, nurses or physician assistants can complete the PPE;11 states allow chiropractors to clear young athletes for competition. Most importantly, there is no standardized form for the PPE. Because of this lack of standardization, the content of the PPE varies considerably from state to state and even from school district to school district. Certain schools and districts have incomplete forms that offer little opportunity for meaningful prevention; other schools and districts have extensive forms that frustrate the pediatrician in a busy pediatric office.Some have argued that the PPE is a waste of time and money because of the lack of “positives” that result in disqualification from sports. A recent study found that only 1.9% of 2,729 high school athletes screened during the PPE were disqualified from sports participation. Seizing on this and similar data, insurance companies are increasingly hesitant to reimburse for the PPE, citing it as a superfluous procedure. For pediatricians, this often means completing multiple PPE forms, with a low chance of finding significant pathology,and receiving poor monetary reimbursement.The overwhelming merits of the PPE, however, outweigh the limitations. The PPE remains the most common reason for healthy adolescents to visit their pediatricians and, therefore, should be viewed as an excellent and rare opportunity for health prevention in teenage patients. It can facilitate dialogue between adolescent patient and clinician and is an important method of preventing sports-related injury, much of which recurrs from season to season.The PPE often discloses issues that require additional medical attention. In the study cited previously, although only 1.9% of athletes were disqualified from sports participation, 11.9% required follow-up, including physical therapy, nutritional counseling, and referral for previously undiagnosed hypertension. In many cases,positive findings on the PPE represent previous injuries and injury patterns that can be prevented in the future with effective preventive conditioning programs.Making the PPE rewarding relies on the examiner’s ability to focus the examination on the sport for which the athlete is being screened through a directed review of the medical and family history before starting the physical examination.The PPE is performed best 4 to 6 weeks before the start of the sports season, which provides sufficient time for effective implementation of injury prevention programs. Practically, most young athletes receive their PPE forms before the start of the school year. Athletes should be encouraged to schedule screening visits earlier in the summer rather than waiting until the day before practice begins.There are several formats for the screening of young athletes,including the station-based school examination and the traditional examination in the pediatric office. Both venues have merit, and if possible, both should be encouraged. Because healthy adolescents rarely interact with the medical system, the station-based examination at school should not replace the office-based PPE; rather, it should serve as a supplement.The station-based examination at school is an excellent opportunity to compare athletes of similar ages and sports. For example, if a team of 12- to 15-year-old soccer players is screened in unison, comparing the ankle examinations allows for a better assessment of which ankles have significant ligamentous laxity or muscular weakness that would predispose a player to repeated inversion injuries. Comparing athletes of a specific age group and team identifies musculoskeletal pathology more easily. Furthermore, prevention programs implemented during the school-based format more easily can be made sport-specific. For example, the entire swim team can work on a rotator cuff strengthening program that is implemented during the school-based examination.The office-based examination is important for two primary reasons. First, it promotes the physician-patient relationship. It offers an opportunity to address issues related directly to sports, such as developing a preventive ankle strengthening program for an athlete who has a history of ankle injuries, and issues not directly related to sports, such as “at-risk” behaviors (eg, drug and alcohol use,unsafe sexual practice). Second, office-based evaluation facilitates the exploration of more sensitive medical issues, such as the female athlete triad (anorexia, osteoporosis, amenorrhea), which frequently are poorly addressed in larger station-based examinations. The office-based examination allows for sport-specific screening, but more importantly, is an opportunity to implement general preventive health measures for adolescents.A final issue that must be considered is the sport for which the athlete is being screened. Sports are graded, based on the level of contact, as high, moderate, and low (Table 1). Generally, an injury pattern is associated with the contact grade of the sport. Macrotraumatic or acute traumatic injury results from one-time, kinetic energy force applied to the body and is common in high-contact sports such as soccer, football, and lacrosse. Therefore,for these sports, the examiner should focus on the previous history of macrotraumatic injury, such as concussion, fracture, or ligament injury. Microtraumatic or overuse injury is seen frequently in repetitive use sports, such as running or swimming, and is more common in the moderate- and low-contact sport categories. For example, a history of “terrible shin splints” should raise the suspicion of an undiagnosed tibial stress fracture during the previous year. In this scenario, the examiner should pay careful attention to the potential causes of stress fracture, including activity patterns, foot biomechanics, and potential medical problems that might cause osteopenia and increase the risk of stress fracture, such as hypoestrogenism or poor dietary calcium intake.As a screening tool, the PPE should identify medical and musculoskeletal conditions that might affect the adolescent, both from a general health perspective and with sports-specific considerations. The examination, at minimum, should meet the following objectives: The PPE should start with a review of the medical history. The following considerations are important and should be considered based on the sport(s) in which the athlete is competing:The report of syncope or alteration of consciousness during exercise is a “red flag” in the PPE. These concerns are especially noteworthy because cardiac deaths comprise the majority of sport-related fatalities in the United States (roughly 5 to 15 children per 1,000,000 participants). Asthma, hypoglycemia, and seizures can cause similar symptoms. Because the purpose of the examination is to screen for conditions that might require further evaluation, athletes who have symptoms of syncope or near-syncope should be evaluated by a pediatric cardiologist prior to participating in sports.Asthma is the most common chronic illness among adolescents. Of those affected, 85% have exercise-induced bronchospasm (EIB). The overall incidence of EIB is believed to be 10% to 35% of athletes and probably is underdiagnosed. The diagnosis of EIB should be entertained in any athlete who has a history of wheezing during sports. Peak flow meter testing for baseline peak flow values is a valuable tool to establish baseline pulmonary function in affected athletes that is obtained easily during the PPE. Baseline values can be compared with initial readings later in the season if necessary. A decrease of 10% to 15% from baseline values is suggestive of EIB.Recent data suggesting the long-term implications of concussion continue to raise awareness about the importance of identifying athletes who are predisposed to concussion. At present, there are no specific recommendations regarding the number of concussions suffered by an athlete and referral to a neurologist. In the adolescent athlete,however, a more conservative approach is warranted. Most sports medicine specialists consider a history of two or three concussions without the loss of consciousness (grade I) or one to two concussions with the loss of consciousness (grade II or III) as grounds for referral to a neurologist. Increasingly, this type of referral consists of neuropsychologic testing to establish a baseline level of neurologic function in addition to imaging studies. A history of concussion is especially important to consider when clearing an athlete for high- or moderate-contact sports.At least 23 scales currently are used to assess the severity of concussion. Examiners should be familiar with at least one grading scale to assist with evaluation and treatment of the concussed athlete. The Cantu scale (Table 2) tends to be the most user-friendly.Mononucleosis-induced splenomegaly can predispose an athlete involved in high- and moderate-contact sports to splenic rupture. Any adolescent who has had mononucleosis within 1 month of the onset of contact sports should be considered at risk for splenomegaly because spleen size peaks within 3 to 4 weeks of the onset of systemic signs of illness. Splenic rupture is the leading cause of death from mononucleosis and usually occurs within the first 3 weeks of illness. If physical examination findings are at all suspicious for a palpable spleen,ultrasonography or computed tomography can be used to assist in the evaluation of splenic size.Athletes who have unilateral organs, including kidneys and testicles, warrant special consideration prior to clearance for athletics. A single kidney is a contraindication to high-contact sports based on the recommendation of the American Academy of Pediatrics (AAP), and athletes wishing to play moderate-contact sports require a protective “flak” jacket. An athlete who has a single testicle requires mandatory protective cup use for all sports.Prescription drugs such as beta-agonists (albuterol),methylxanthines (theophylline), tricyclic antidepressants(imipramine), macrolide antibiotics (erythromycin),nonprescription drugs such as decongestants(pseudoephrine), and illicit drugs (eg, cocaine, amphetamines)have been linked to arrrhythmias. Therefore, it is important to document current drug use in the PPE.Female athletes should be screened for amenorrhea during the medical history portion of the PPE. Primary amenorrhea (absence of menses by age 16) or secondary amenorrhea (absence of menses for more than three cycles) should prompt further consideration of the female athlete triad (anorexia, amenorrhea, osteoporosis). If all three entities are present, bone density studies via dual-energy radiograph absorptiometry (DEXA) are being used increasingly to evaluate baseline bone density values. DEXA can be used to obtain baseline bone density measurements that can be compared with values obtained in subsequent years to assess bone health.The history of a seizure disorder is not a direct contraindication to sports participation if the seizures are well controlled. However, athletes who experience ongoing epileptic activity, particularly if they are involved in aquatic sports, warrant careful review before clearance. The history of a seizure within the past 6 months should raise concern prior to clearance, particularly in those engaging in water sports.Included in this category are injuries that have caused a loss of playing time during the prior athletic season. Attempts should be made to devise rehabilitation protocols to prevent injuries such as chronic ankle sprains from recurring in the ensuing season.Unlike college or professional athletes, who are tested routinely, there currently is no authorized testing policy for ergogenic aid use in high school athletes. With an anabolic steroid user rate of 9% reported in high school athletes and 3% in junior high athletes, the issues of steroid use are addressed best in the medical history section of the PPE.The issue of nutritional supplement use is also of concern to adolescent athletes. None of the so-called“nutritional supplements” such as creatine or androstenedione ever has been tested in adolescents. Although the exact user rate of these substances in adolescents remains unknown, the incidence appears to be increasing.The best method of approaching the subject of ergogenic aid use is with the question, “Have you ever taken a substance to enhance your athletic performance?”A positive family history of these items in particular should prompt further consideration:As the most common cause of sudden death in athletes,cardiac-related death deserves primary attention and consideration. This is especially important in young athletes because 90% of cardiac deaths in school-age athletes occur between the hours of 3 and 9 PM, during or just after sports participation. Congenital heart disease,arrhythmia, prolonged QT syndromes, hypertrophic cardiomyopathy, and Marfan syndrome are all inheritable cardiac diseases that should prompt suspicion if present in a first-degree relative.Asthma, diabetes, epilepsy, and bleeding disorders are only several of the inherited chronic diseases commonly seen in childhood and adolescence. In many pediatric patients, these illnesses do not manifest until adolescence. A family history of any of these chronic diseases should alert the examiner for additional signs of chronic illness.