The P.P.E.
J. Bryan Mann, MD, FAAP Preparticipation
(316) 978-5735 Physical evaluation
Mann@chp.twsu.edu (PPE)
Preparticipation
Athletic
Examination
Sports physical
Sports Participation
AAP: Committee on Sports Medicine and Fitness and Committee on School Health.
Organized Sports for Children and Preadolescents. Pediatrics. 2001. 107;6:1459-
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.
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.
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
PPE Goals
Identify conditions that may interfere with
participation
Identify conditions that may be exacerbated
by participation
Help select an appropriate sport or the
child’s particular abilities and physical
maturity
PPE Goals
Poorly conditioned children
Children with muscle or joint weakness
(usually related to recent injury)
Immature children (physically)
Previously unsuspected disease
PPE
1% of children undergoing PPE’s have
conditions that might limit sports participation
and are generally discovered through the
history.
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.
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
Morbidity and Mortality
6,000,000 cases of adolescent
STD’s/year
1,000,000 pregnancies/year to one week
2. Sustained a significant injury
3. Use of medication(s)
Ergogenic aids, substance abuse
4. Medical allergies/Anaphylaxis
5. Tetanus/Immunizations
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
Taken from:
Contemporary Pediatrics
(2000)
Px – What’s 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
PPE – Laboratory?
Generally thought to be unnecessary as
screening tools
Hematocrit
UA
Body fat measurement
Aerobic capacity
Physical Exam
Ht
Wt
BP
Visual acuity
CV exam
Palpation of the abdomen
GU exam (males)
Screening musculoskeletal exam
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”
Expert Committee on Obesity
Obesity:
> 95%tile BMI for age
and sex
“At risk” for obesity
85-95%tile or age and
sex
BMI tables are available
from the CDC:
http://www.cdc.gov/growth
charts/
Expert Committee on Obesity -
Recommendations
Weight maintenance (slowing of excessive weight
gain) for:
Children 2-7 years with “at risk” BMI
BMI > 95% and no complications of obesity
> 7 yrs 2 yrs and BMI > 95% and complications of obesity
> 7 yrs with a BMI > 85% and a secondary health
complication
PPE - CV Exam
Evaluate peripheral pulses, murmurs, BP
BP > 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
Marfan’s syndrome habitus
Hypertension
AAP: Athletic Participation by Children and Adolescents Who
Have Systemic Hypertension. Pediatrics. 1997.99;4:637-638.
“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.”
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
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
Abdomen and Genitalia
Hepatomegaly Absence or atrophy
Splenomegaly of testicles
IM return to play one Tanner staging
month after onset of Inguinal hernia
illness and no splenic
enlargement Varicolcele
Testicular mass
Varicolcele
Taken from: Adelman and Joffe.
Contempory Pediatics. 1999.
Varicocele
Most common Surgical repair:
scrotal mass Large varicocele and
testicle not growing
15% of teenagers normally
have a varicoceles
Left testis 3 ml smaller
Usually than right
asymptomatic - 2 SD for testicular
“Bag of worms” size
Bilateral or symptomatic
Controversy as to varicoles
therapy Pain
Sexual Maturity
“Preadolescents and
adolescents should Caution with Tanner
avoid competitive stage < 3 in collision
weight lifting, power sports.
lifting, body building,
and maximal lifts
until they reach
physical and skeletal
maturity.”
- AAP:Strength Training by
Children and Adolescents.
Pediatrics. 2001.107;6:1470-1472
Skin
Active impetigo
Tinea corporis
Scabies
Molluscum contagiosum
Herpes simplex
PPE - Musculoskeletal
Majority of all abnormalities identified
“two-minute” musculoskeletal
examination
Garrick – 1977
14 screening positions
Specificity of 97.5%
Orthopedic Screening Exam (Garrick)
1. Acromioclavicular 8. Hand/finger deformity
joint/general habitus 9. Symmetry/effusion
2. Cervical spine motion 10/12. LE symmetry/strength
3. Trapezius strength 11. Lower back
4. Deltoid strength 12. Scoliosis
5. Shoulder motion 13. Knee effusion
6. Elbow motion 14. Calf symmetry/strength
7. Elbow and wrist motion
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
Scolisosis - Adam’s 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
Adolescent PPE - Anticipatory
Guidance
Immunizations Testicular/Breast
Tetanus self-exam
Varicella Discussion of:
Hepatitis B Androgenic agents
Meningococcemia “Natural” agents
Behavioral/ DHEA
Creatine
Psychosocial screen
Female athlete
“triad”
Participation - Medical Conditions
AAP: Committee on Sports Medicine and Fitness. Medical Conditions Affecting
Sports Participation (RE0046). Pediatrics. 2001. 107:5:1205-1209.
Who should and should not participate
in a particular sport?
What, if any, modifications are
necessary?
Risk of injury related to any conditions
present
Participation - Medical Conditions
AAP: Committee on Sports Medicine and Fitness. Medical Conditions
Affecting Sports Participation (RE0046). Pediatrics. 2001.
107:5:1205-1209.
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
Sports Classifi
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. 107:5:1205-1209.
Adolescent Female - Sports
1972 = 1:27
2000 = 1:3
Injury rates are similar between male
and female adolescents in the same
sport except:
“Female Athlete Triad”
Stress fractures
ACL injuries
Female Athlete Triad
Eating disorder or Risk factors:
Disordered eating Highly structured
Less severe and more life
subtle than true eating
disorders Social isolation
fasting Lack of support
vomiting system
food restriction
Family hx of eating
diet pills/laxatives
disorders
Amenorrhea
Osteoporosis
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
Female Athlete Triad
AAP: Committee on Sports Medicine and Fitness. Medical Concerns in
the Female Athlete. Pediatrics.2000. 106;3610-613
3-60% will have amenorrhea vs. 2-5% in adult
women
Normal weight athletes usually don’t have
menstrual problems
Disordered eating may occur in 15-65% of all
female athletes
Disordered eating should be considered in
adolescent amenorrhea
Disordered Eating - Amenorrhea
Decreased calories
“Energy” drain
Hypothalamic dysfunction
Decreased estrogen production
Amenorrhea Decreased BMD
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
Amenorrhea - Treatment
Decrease training
Attempt to increase weight/height to
10%
Calcium intake
Addressing any eating disorders
Premarin/OCT?
Stress Fractures
Risk factors: 3.5X more common in
female athletes (vs.
Smoker male athletes)
Asian “Load” exceeds bodies
attempts at skeletal
Corticosteroids repair
Female Athlete More common in tibia,
Amenorrhea femur and pelvis
Family history Pain with activity initially,
later pain at rest
Stress Fracture
Plain radiographs may miss a stress fracture
Bone scan is the “gold standard”
Conservative treatment for 6-12 weeks
References
Callahan, L.R. The Evolution of the Female Athlete: Progress and
Problems. Pediatric Annals. 2000. 29;149-155.
Berul, C. Cardiac Evaluation of the Young Athlete. Pediatric Annals.
2000. 29;162-165.
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. 29:139-188.
Killiam, J.T., et. al. Current Concepts in Adolescent Scoliosis. Pediatric
Annals. 1999. 28:755-761.
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.
References
AAP:Committee on Sports Medicine and Fitness. Medical Concerns in the Female
Athlete. Pediatrics. 2000. 106;3: 610-613
American Academy of Pediatrics: Committee on Sports Medicine and Fitness.
Medical Conditions Affecting Sports Participation (RE0046). Pediatrics. 2001.
Volume 107;5: 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. 26;1:37-47
AAP: Committee on Sports Medicine and Fitness. Medical Concerns in the Female
Athlete. Pediatrics.2000. 106;3610-613.
Adelman an Joffe. The Adolescent Male Genital examination: What’s Normal and
What’s Not. Contemporary Pediatrics. 1999.
AAP:Strength Training by Children and Adolescents. Pediatrics.2001.
107;6:1470-1472
Perriello,V. ajd Barth, J. Sports Concussion: Coming to the Right
Conclusion. Contemporary Pediatrics. 2000.
www.aap.org