The Preparticipation Sports Evaluation

After completing this article, readers should be able to: Sports participation among people of all ages has increased steadily over the past 4 decades. This trend generally has been considered to be a positive development, with conventional wisdom asserting that sports participation teaches leadership and cooperative skills that have a lifelong impact. In addition, as the obesity pandemic worsens, organized sports participation and unstructured play or physical exercise can be a source of needed physical activity for children and adolescents. The pediatrician often is asked to evaluate a child's or adolescent's suitability for sports participation. The purpose of this evaluation has remained constant since it was first described in 1978. (1)(2) The goals are to fulfill the institution's legal and liability requirements, provide some assurance to coaches that athletes will start the season at an acceptable level of health and fitness, provide an opportunity to discover treatable conditions, and aid in predicting and preventing future injuries. The evaluation should be practical and applicable to all sports. The specific objectives of the evaluation can vary, depending on viewpoint, which can create a situation in which parents, athletes, clinicians, and sponsoring institutions or organizations have discordant expectations. Parents may want to ensure the health and safety of their child. Clinicians may seek to provide preventive care and anticipatory guidance. Institutions and organizations may want to limit or transfer their liability for injuries or illnesses caused or worsened by sports participation. Finally, the athletes may just want to have their paperwork signed so they can go play with their friends. The clinician should coordinate and address the goals of parents, athletes, and organizations while promoting safe participation in physical activity.The utility of the sports preparticipation evaluation (PPE) has been questioned in recent years. Very few athletes are disqualified from sports on the basis of findings from the PPE. In the largest evaluation of the PPE, only 1.9% of 2,729 high school athletes were disqualified from sports participation and only 11.9% required any type of follow-up evaluation. (3) A recent systematic review of the literature identified 310 studies of the PPE and concluded that the evaluation likely does little to prevent morbidity and mortality in screened athletes and is ineffective for identifying athletes at risk for sudden cardiac death or orthopedic injuries and at detecting exercise-induced bronchospasm (EIB). (4) However, use of the PPE is endorsed by the American Academy of Pediatrics, American Academy of Family Physicians, and American College of Sports Medicine because it allows for establishment of a medical home, updating of immunizations, identification and management of chronic health conditions, and provision of anticipatory guidance related to sports and other lifestyle risk factors.The PPE is required before practice and play by most sporting organizations. The requirement is typically in place to shield the organization from liability and to ensure that the athlete can participate safely in sports. The evaluation is required by law in many states and some countries. Nearly all high-school and middle-school athletes are required to obtain signed documentation of a completed examination every 1 to 2 academic years. Athletes engaged in club- or federation-level sports are also often required to have documentation of an evaluation, but this practice varies regionally and by sport. Rarely, sports competitions not affiliated with institutions or federations (eg, open races or tournaments) require documentation of the athlete's suitability for competition. Generally, open or free play (such as on an open playground) does not require such documentation. However, the 2010 PPE Monograph emphasizes that clinicians should perform a PPE-type evaluation on all patients when promoting physical activity. (5) Most institutions and organizations that require an evaluation strictly prevent participation until proper documentation has been obtained. This practice seems to be due to a sense that protection from liability is not present until there is “proof” that the athlete is safe to participate. (6)(7) Although this concept has not been legally tested, a 1990 New York State Appellate Court decision (Murphy v. Blum) suggests that the issue of transfer of liability depends on the specifics of the relationship between the organization and the physician as well as between the physician and the athlete. (8)The athlete should be encouraged to schedule the PPE well in advance of the season, ideally at least 6 weeks before the start of practice. This timing allows sufficient time for full evaluation of issues that may arise during the initial visit. It also allows implementation of injury prevention programs or rehabilitation of injuries before the start of the season. The clinician should not be pressured into premature clearance of an athlete before appropriate evaluation is completed.The PPE can be completed in any of several formats, each of which has advantages and shortcomings. The most common and ideal format is the office-based PPE in which an athlete visits his or her primary care clinician in the office. The advantages of this strategy include improved continuity of care, access to medical records, time for anticipatory guidance, and ease of arranging follow-up diagnostic tests and treatment. The primary disadvantages are the time burden and cost of an office visit in addition to the possible limited availability of appointments before the start of sports seasons.To alleviate the time and cost burden of the PPE, the other strategy commonly employed is the station-based PPE. With this approach, the athlete cycles through a series of stations at which a single aspect of the evaluation is performed. Separate stations may address vital signs, visual acuity screening, medical history and physical examination, orthopedic history and physical examination, updating immunizations, and finally meeting with a clinician to review all of the accumulated data and make a decision regarding clearance. This approach is very efficient, can be inexpensive, and allows specialty care at each of the stations, limiting the need for a specialist. Entire teams or schools can be evaluated in a single session, reducing the administrative burden of scheduling each athlete privately.However, there are significant disadvantages to the station-based approach. Continuity of care is severely limited, including access to previous medical records. Coordination of care may be difficult for issues requiring follow-up. There is less privacy and time for anticipatory guidance, and the athlete may be less likely to discuss sensitive issues. Finally, athletes who previously have been disqualified from sports participation may attempt to take advantage of unfamiliar clinicians and use the station-based format as a second chance to get cleared.The history portion of the PPE is similar to the history in a typical health supervision visit for a child or adolescent of the same age. Although several efficient screening tools that have been designed specifically for the PPE are endorsed by multiple professional societies, they should not replace more extensive history collection when it is warranted. The history form from the 2010 PPE Monograph is shown in Figure 1.It is important to explore the past medical, surgical, family, social, and developmental histories, much as it would be done for a nonsports-related evaluation. It is also important to interview a parent or guardian, if available, because athlete and parent histories are often inconsistent. (9)(10)Some aspects of the history require additional attention. Although the following list is not comprehensive, it represents some of the most common challenges to the clinician during the PPE.The component of the PPE that receives the most attention from parents, coaches, administrators, the medical literature, and the popular press is the cardiovascular evaluation. Although a comprehensive discussion of the controversy surrounding preparticipation cardiovascular screening is beyond the scope of this article, Pediatrics in Review has published a summary of the topic, (11)(12) and clear guidelines from the American Heart Association (AHA) discuss the controversy surrounding the evaluation and the role of preparticipation electrocardiography and echocardiography. (13) The AHA-recommended components of the preparticipation cardiovascular evaluation are listed in the Table.Several red flags that may appear in the past medical and family history should prompt further investigation. Known congenital heart disease, cardiac channelopathies (such as long QT or Brugada syndrome), any history of myocarditis, and coronary anomalies such as those caused by Kawasaki disease should be evaluated by a cardiologist before sports participation. A personal history of syncope, near-syncope, chest pain, palpitations, or excessive shortness of breath or fatigue with exertion should prompt a more thorough evaluation, either by the primary clinician or a cardiologist. Postexertional syncope is a common occurrence that is frequently elicited in the PPE history. This benign condition should be differentiated from exercise-associated collapse, which occurs during exertion and is an ominous sign of hemodynamically significant cardiovascular disease or ventricular tachyarrhythmias. All patients who experience syncope should undergo electrocardiography, with further testing on a case-by-case basis.A family history of early sudden cardiac death, Marfan syndrome, cardiomyopathy, and arrhythmias (especially long QT syndrome) should prompt further cardiovascular evaluation. Particular attention should be paid to any family history of unexplained or poorly characterized deaths, such as from drowning, unexplained motor vehicle crashes, or seizures. These events may represent unrecognized sudden cardiac death.The musculoskeletal history is a remarkably sensitive method for identifying abnormalities and injuries. Gomez and associates (14) found the sensitivity of a basic musculoskeletal history to be 92%, which compares favorably with the estimated 75% sensitivity of a general medical history. Inquiring about current injuries and a history of injuries requiring evaluation, casting, bracing, surgery, or missed practice or play captures nearly all musculoskeletal abnormalities that require evaluation or treatment before sports participation. A sports medicine specialist may ask about specific orthopedic injuries that are unique or common to the athlete's sport, but this inquiry generally is not necessary for a primary care screening evaluation. A review of the athlete's list of current and past medications may provide clues to chronic or recurring medical conditions that may sports participation. In addition, the athlete's or sports may some medications and A comprehensive review of is beyond the scope of this In the athlete is for medications may be in his or her sport. The clinician may athletes by to their and who frequently care for and athletes should be of the that are by the Association and the of can be found and medications can be if the athlete has a use on In some testing may need to be to the of the should be well before the start of the season to the of or a in treatment of chronic medical a can be for a of and other is common among including It is to discuss when and that the athlete may be in sports are at additional risk for conditions with their or with other should be and for practice and play to the risk of have attention because they can in and such as and are common in sports that such as and of conditions treatment to the risk of federations have specific for should be and long athletes should be or treatment before to practice and competition. athletes and teams use of such as for prevention of during the season. This practice has not been evaluated but does for among who practice and in the should use a to their risk of and the appropriate protection for In any and frequently sufficient Athletes who have significant require a examination of the to for and are most common in and all athletes should be asked about a personal history of or other about injuries are required to a history of because many athletes not an injury in which there was of to be a the clinician should ask about any type of or following a to the or following a to the and any type of injury that in a of The clinician should be to the that the and of can be the athlete does provide a history of more is required to the or of and that with Athletes who have that not need additional evaluation. athletes who have are more or have discussion with the athlete and family is necessary to the of A athlete should be to to and a approach should be for to physical activity. testing before the start of the season is Although should be the of evaluation, the sensitivity for detecting if is when a athlete to to can provide an of his or her However, has for and the utility of in an athlete who does not have a is also are injuries to the caused either by or a are typically Athletes who have with of pain, or may have more significant injuries to the or athlete should be to to practice or play who has also is a condition characterized by of motor with or of or caused by of the due to or The condition is more common in athletes who have are and typically less It is very for to There is increased risk of injury following a single but athletes who have multiple or require additional evaluation. who are found to have or in the should not be to to or sports. Although athletes who have are at increased risk of it is if they are at increased risk for athletes who have should be to play sports is and should be evaluated on a case-by-case basis by a more people in the every Athletes who have a history of are at risk for future including the athlete can take to proper and to their In addition, and the risk of and should be if during and in Athletes who require for sports participation may need to with an or to ensure that they have appropriate for sport. such as and not so athletes in need of use Athletes is in to as American for and Athletes who practice and in the or on the should to prevent and the chance of In addition, any or should be of or can to prevent an evaluation if the athlete with a or who have disease may require additional evaluation or a in their treatment before the season. Athletes who have should have an for a such as athletes may from multiple to in multiple such as at home, at and with their or In athletes who have not from However, there is significant between and In if an athlete has in other and the is poorly with a such as an may be athletes in sports or that require to obtain a before it is important to obtain appropriate tests and to the paperwork well in advance of the is common among or risk for include disease, and poorly The can be with a history of in or with Most athletes can their with that require and are by or other who are with other chronic medical conditions, of before the start of the sports season is important for the of history of other chronic such as or chronic disease due to should not a child or adolescent from sports participation. and follow-up with a or other clinician who is with the specific is It may be to children and who have disease from in sports that a high cardiovascular and sports in which they are more likely to are common among children and very few require or sports participation. may the athlete at increased risk of but can be with increased disease can with increased physical activity but can be with medications and may be necessary in some disease can a that can make physical activity more difficult and follow-up with a to ensure of is and caused by but can and the athlete at increased risk for athlete who has should be disqualified from practice and in any in which there is a risk of Most athletes are safe to to by to 4 weeks the start of including and should not prompt from sports. The athlete may participate in any that his or her health should be for all athletes, and should be of any or components of the history should an athlete or require participation. Athletes who have a or require for and sports. may be necessary to the and the of injury should be the of or participation. may with increased physical in sports such as that a high with in or who experience or should be for and who exercise or play sports (especially those sports that are at risk for the athlete of and that is with significant health in are common among athletes in and sports. athletes not diagnostic for or but have can be as not which has been in the most recent of the and of for should be as of every PPE. screening are available, but the most commonly is the tools for generally the and for such as of to (eg, very into very or in excessive exercise is of the of the athlete with and The of any of conditions should prompt the clinician to evaluate for the other The athlete the athlete at risk for Although not an to sports of an abnormalities and cardiac need to be A including and health is for the necessary care of an athlete who has an and are common health that can appear in conditions should not the athlete from sports participation. health may the athlete to with his or her athletes can be to use health by the possible that from their or of among athletes is similar to the among other children and of the same age. medications are a common treatment but may require a or documentation of testing before the start of the sports PPE an opportunity to review the history and provide Although should not be for sports athletes and clinicians should be that some are required by schools and for In addition, athletes who are may need documentation of specific to into countries. The PPE physical examination varies little from the health supervision evaluation, a few components require additional attention in the athlete. The vital of an athlete may be from a clinician is to in A child or adolescent who has a high of cardiovascular may have and a may be when but may be for several may be an method of screening for and obesity in some athletes who are very The should be in children and of sports evaluation and treatment. or of the is Athletes who have for and require evaluation but should be from in sports. Athletes who have as over the for and should be disqualified from sports characterized by a high and and visual acuity should be in are required for sports participation. should prompt the clinician to the athlete to use protection for sports such as and should prompt to an may of sports or such as The AHA-recommended of the cardiovascular evaluation are listed in the In any cardiac that is not benign should be evaluated before sports participation. A cardiologist who is with the of participation should perform the follow-up evaluation. It is to and other cardiac testing from that are unfamiliar with congenital heart disease and participation in The examination is not a of the PPE. However, any by findings on the history should be evaluated should have who has an or should be evaluated by a Athletes who have only may participate in all sports but should be encouraged to use a to the risk of injury in or sports. The PPE allows the clinician an opportunity to discuss with the who have a history of should be evaluated for an with a examination of the athletes not need to be screened for (5) condition should be before the athlete's to sport. that are for should be and evaluated by a history of including and should prompt a evaluation. The should include and should be evaluated before sports participation. Clinicians often to perform a musculoskeletal examination on athletes who present for a PPE. However, as the physical examination little diagnostic to the orthopedic history. (14) A evaluation of and of is sufficient for athletes who have musculoskeletal of specific can be for previous injuries or current screening or tests are required as of a PPE. controversy the use of screening and electrocardiography to congenital heart (13) In addition, the utility of testing for cardiovascular risk (such as and other chronic that may or general health is of in of the athlete from sport. However, many medical conditions require or for related to sports participation. In addition, sporting are in their physical and cardiovascular as well as in their level of medical conditions may be with or in or with in or with the with or sports. A comprehensive review of the medical conditions sports participation is beyond the scope of this article, but several conditions that frequently to attention during the PPE are This list is from and the who is in more about the specific of sports participation and many common and medical conditions sports participation should the American Academy of Pediatrics on Sports Medicine and on Sports The child or adolescent who has a should not be disqualified from sports participation. In athletes, the risk of a during practice or is very due to their but also due to the of It is to and that athletes who have histories can be to participate in and sports and in sports they would to be at increased risk of injury should they have a The clinician may need to for the athlete in such A of is the legal before who have are to to In most it is to 6 and who have poorly also from physical but more care be to ensure the safety of athletes and those should be to the athlete's suitability for and sports. The following sports should be syndrome, also as is a multiple congenital with often require care to their health and of of sports participation. of the but also has been in to of patients who have The organization evaluation of the before sports participation. It is common for patients who have to this patients who have should be from in sports of the of their However, other need be for patients who have who have of but or should be disqualified from sports. high and to be Athletes who have and may use a but this practice does not their is with other abnormalities that may sports such as cardiac abnormalities in disease, and and of conditions, if evaluation before sports participation. However, other need to be for who have a should be from practice and competition. the athlete at risk for to increased exercise and to and Athletes who have type 1 are to participate in any However, and treatment often more with the of organized sports. evaluation and of and and are should be more frequently a athletes who have should their every during of and at and many athletes who have that they need to their and their and and have athletes to their much more in the It is not for athletes who have to treatment and athletes may but the clinician should exercise and sports participation for the same they are encouraged in (5) among athletes, coaches, parents, and clinicians is for safe and sports participation. The history form from the 2010 PPE can to this most and abnormalities identified during the PPE are not to sports several conditions should prompt from sport. Most of are cardiovascular conditions and have been in the Although the guidelines from the only on for specific conditions, any cardiovascular disease should be evaluated and by a cardiologist to ensure the athlete's safe participation in sports. In addition to cardiac any condition that be well and the athlete at risk of significant injury or death or the health of or further evaluation or from sport. a musculoskeletal injury that the athlete's to or during practice and should prompt until the athlete is safely able to to a discussion of the evaluation and management of specific the recent Pediatrics in Review article, Sports in the the PPE, the first is to ensure the health and safety of the However, the physical and of exercise and participation should on to an athlete from sport.