2006 Pre-participation Physical Evaluations

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					                 Pre-participation Physical
                    Evaluations - 2012

Clark H. Cobb, MD, FAAFP
Family Medicine / Sports Medicine
Martin Army Community Hospital
Fort Benning, GA
         Your Best Source

Only source endorsed by AAFP, AAP, ACSM, AMSSM,
4th Edition 2010
National Endorsements 2010
National Athletic Trainers’ Association
Sports Physical Therapy Section of the
American Physical Therapy Association
Special Olympics Medical Committee
American Heart Association
The overall goal of performing a PPE is to
promote the health and safety of athletes
in training or competition
The purpose of the PPE is to facilitate and
encourage safe participation, NOT to
exclude athletes unnecessarily
The PPE is a tool to screen athletes for
injuries, illness, or factors that might put
them or others at risk
Effective screening tool is one that can
easily identify disease, be sensitive and
accurate and be practical and affordable
Currently, data on the ability of the PPE to
meet these criteria are lacking
   Almost all states require PPEs
   The NHFS (National Federation of State High School Associations)
   considers the PPE a prerequisite for
   participation *
   The NCAA requires a PPE, at least, on entrance
   to a program
   The Special Olympics also requires a PPE

* NFHS has neither the authority to require PPSE or ability to standardize exam
       Primary Objectives
Screen for any condition that may be life-
threatening or disabling
Screen for any condition that predisposes
an athlete to injury during practice or
Meet legal and insurance requirements for
the school or the athlete (2005 objective)
        Secondary Objectives
Determine the general health of the athlete
Serve as an entry point to the healthcare
system for adolescents
Provide an opportunity to initiate
discussion on health topics
Assess physical maturity (2005 objective)
Evaluate fitness and assess performance
(2005 objective)
           Future Goals
Develop sport-specific evaluation profiles
Develop standards and norms for age-
related groups
Conduct epidemiologic studies on sports
injury prevention
Refine the disposition and clearance
Administrative, Ethical, and
     Legal Concerns
Administrative and Legal Issues
Right to participate
– Clearance issues
– Exculpatory waivers
Sexual Harassment Issues
“Good Samaritan” statutes
– Charitable Immunity Provision
– O.C.G.A. 51-1-45 Georgia Law
HIPAA and FERPA regulations
HIPAA protects the privacy of health information through
applicable federal privacy and confidentiality
requirements in health care settings that use electronic

HIPAA rules allow release of medical information without
the individuals authorization in certain circumstances
– “Cleared” or “Not cleared” decision CAN be relayed to coaches
  and school administrators if done so without other medical
Applicable law when information is part of an
educational record

FERPA documents are specifically excluded
from HIPAA
– Such as training room records (and often PPE’s)

Whether HIPAA or FERPA regulations apply can
be a complex legal issue
    Administrative Concerns
Confidentiality and PPSE forms
Restriction from participation
Sharing emergency and public health
Electronic transmission
Restricting information
           Ethical Concerns
Breaches of conduct
– Sexual improprieties
– False accusations

Ethical decision-making
– Ethically right versus legally prudent
– First, do no harm
              Legal Concerns
“A team physician and an institution have
the legal right to restrict an individual from
participating in athletics as long as the
decision is individualized, reasonably
made and based on competent medical
– St Johns Law Review 2002; 76(1):; 100-182
                  Legal Concerns
Informed consent (hand-written, signed, video-taped ?)
Limiting legal risk
– 36th Bethesda Guidelines
– http://www.scribd.com/doc2353746/36th-BETHESDA-CONFERENCE-

Ramifications of the exam setting
Good Samaritan statutes and Charitable
Immunity provisions
– www.volunteersinhealthcare.org/manuals/charit.imm/man.12.02.pdf
          Georgia Law 51-1-45
Any person licensed to practice medicine and surgery pursuant to Article 2
of Chapter 34 of Title 43 and including ANY PERSON LICENSED to render
services ancillary thereto who in good faith renders VOLUNTARY service
without compensation as an athletic team physician, either as the team
doctor during or in conjunction with athletic practice activities or athletic
contests or in conducting preseason physicals for athletes, SHALL NOT BE
LIABLE for any civil damages as a result of any act or omission by such
person in rendering such voluntary service or in conducting such physicals
or as a result of any act or failure to act to provide or arrange for further
medical treatment or care for the amateur or nonprofessional athlete.
Liability for civil damages shall attach to any willful or wanton act or
omission by such person committed in rendering such voluntary service or
in conducting such physicals or as a result of any act or failure to act to
provide or arrange for further medical treatment or care for the athlete.
Timing, Setting, and
Qualifications of the Examiners
“Physicians who have earned an MD or
DO and have training and an unrestricted
medical license that allows them to deal
with the broad range of problems that may
be encountered during the PPE”

What kind of docs do this well?
 – AAP and AAFP now endorse the “medical home” as
   the ideal standard
      Timing the Evaluation
Ideally, the PPSE
should be conducted
at least 6 weeks
before training and
practice begin in
order to allow time to
address, and
hopefully correct,
identified problems
How frequently is a PPSE needed?
 Varies by state
 Varies by school
 Usually upon entering
 high school or
 beginning a new sport
 Often done annually
35 states require yearly examinations
11 states require exams every other year
3 states have every third year
Several states have NO standardized
forms or schedules
Institute for Clinical Systems
     Improvement - 2004

Periodic Health
Exams advised for
children at ages:

– 5,7,9,12,15 and 18
General Health of Adolescents
Many adolescents don’t see their PCM regularly but
most express desire for more health information
CDC recommends annual exams for teens (along with
– J Adolesc Health 1997; 21 (3): 203-214
Annual exams of adolescents not useful or cost-effective
– AFP 1998; 57 (9): 2181-2190
5-10% of adolescents have a chronic medical problem
– J Fam Pract 2005; 54 (7): 628-632
50% of adolescents have less serious medical concerns
– Society for Adolescent Medicine, 2005
    Consensus Opinion - 2006
** NO outcomes-based research indicates that
   more frequent PPEs lessen the risk of injury or
   death in student athletes
   A comprehensive PPE should be performed
   every 2 years in younger athletes and every 2-3
   in older athletes
   A comprehensive PPE should be performed at
   entry to middle school or high school or upon
   school transfer
   Annual updates should include a history, HT,
   WT, BP and problem-focused exam
  – Careful cardiac auscultation advised every other to every third
Methods of evaluation
   2010 Consensus Opinion
“PPE writing group considers gymnasium/locker
room-based examinations as inappropriate to
accomplish the goals of the PPSE process”
– However, when needed, the H&P should be done by a single
  physician rather than splitting the exam into “body systems”

Ideally, the PPSE is performed in the PCM’s
office in the patient-centered medical home
Tips to Coordinate Group PPEs
Provide advanced        Include as many local
information about the   PCMs as possible
examination             Establish a clear
Request appropriate     protocol for referral
attire                  Enlist the aid of
Separate males and      coaches and athletic
females                 directors to maintain
Allow for some          order
Know your plan
Know your “customers”
Administrative Summary 2010
Final responsibility lies with coordinating
Group PPSE’s are NOT equivalent to
recommended preventive health
PPSE’s should be used to encourage
routine health care
Standardized PPSE forms recommended
Administrative Summary 2010
A single provider should perform the entire
exam and determine clearance
Adolescents should be seen apart from
their parents
Defined sections of the PPSE are PHI
Athletes/parents are responsible for timely
scheduling of the PPSE and completing
the history honestly
The Process
            Medical History
General PMHx                Asthma
Medications and             Paired Organs
Supplements                 Eyes and Vision
Nutrition                   Viral Illnesses
Allergies and Anaphylaxis   Dermatologic
Sickle Cell                 Neurologic
Cardiovascular              Heat Injuries
Surgical                    Menstrual History
Musculoskeletal             Immunizations
           Medical History
Most important part of the PPSE
76-90% of diagnoses based on history
– 88% of medical and 67% of M-S conditions
Only 19-39% of athletes’ responses agree
with those of parents or guardians
Any positive response should prompt
further questions
– Youth Risk Behavior Surveillance System
– MMWR Surveillance Summary 2002
         General Medical
                Key Points 1

Obesity, DM, HIV, Hepatitis
– Only 1-2% of screened athletes are
  completely disqualified from participation
– Obesity is an increasing problem among
  youth and young athletes
– The risk of transmitting blood-borne
  pathogens is not zero, but it has not been
           General Medical
                   Key Points 2

Meds and supplements
– Medications may reveal medical problems
– OTC meds can affect performance
– Some meds may be “banned”
Allergic disease
– Allergic reactions range from mild rhinitis to
– Injectable epinephrine should be on-site for those with
  a history of anaphylaxis
           General Medical
                   Key Points 3

– Full recovery with no long-term impact is required for
  full clearance after surgery
– The surgeon must clear the athlete
Paired organs
– The absence of a paired organ does NOT limit
  athletic competition
– Protective equipment may be advised
          General Medical
                 Key Points 4
– Fatigue may prevent full activity for weeks or
– Splenomegaly is almost universally present
– Splenic rupture is rare beyond 28 days of
– Most athletes are restricted from play for a
             General Medical
                      Key Points 5
Heat Illness
–   Exertional heat stroke can be fatal
–   Most often seen in preseason football
–   Maintaining hydration may slow the onset of EHS
–   Risk factors include:
      Hot, humid conditions
      Poor fitness
      Football equipment
      Inadequate acclimatization
          General Medical
                Key Points 6

Sickle cell trait or disease
– SC trait has been associated with sudden
  death in athletes during strenuous activity
– Greater risk seen at altitude and in the heat
– Universal screening has not been
         General Medical
               Key Points 7

Eye disorders and vision
– Eye protection should be worn in moderate- to
  high-risk sports
– Eye injuries increase the risk of subsequent
  glaucoma and need further monitoring
The PPE Physical Exam
Dental Screening
Vision Screening
Visual acuity of 20/40 or better in at least
one eye is considered to provide good
Athletes with best corrected vision in one
eye of less than 20/40 should be
considered functionally one-eyed
AAO and AAP recommend mandatory
protective eyewear for all functionally one-
eyed athletes regardless of sport
Medical Stations
    Special Considerations *
While the most pages
of the guide have
been devoted to
examination in the
past, cardiovascular
screening is the focus
of most of the recent
controversy and
    Cardiovascular Disease
Leading cause of death in young athletes
75% of all causes of sudden death
Current estimates of SCD 1:75,000
– Up from original estimates of 1:200,000
– 80% occur in high school or college ages
Male:female ratio from 5:1 to 9:1
Highest in football and basketball
> 40% occur in AA athletes
    Cardiovascular Deaths
About 100 cases occur annually across all
levels of sports participation
Most of these abnormalities have no
symptoms or signs
Only a fraction of athletes with serious
cardiac anomalies are diagnosed before
sudden death
Causes of Sudden Cardiac Death
Structural / Functional          Electrical
–   HOCM                         –   Long QT syndrome
–   Idiopathic LVH               –   Polymorphic VT
–   Coronary anomalies           –   WPW
–   Myocarditis                  –   Brugada syndrome
–   Arrhythmogenic RV            –   Short QT syndrome
–   Dilated cardiomyopathy
–   Aortic stenosis
–   Marfan’s syndrome            Other
–   CAD                          – Drugs/stimulants
–   Complex vent ectopy          – PPH
–   Post op congenital disease   – Commotio cordis
Cardiovascular Screening Questions

Have you ever passed out or nearly passed out
during exercise?
Have you ever had discomfort, pain or pressure
in your chest during exercise?
Does your heart race or skip beats during
Has a doctor ever told you that you have heart
problems (high blood pressure, high cholesterol,
a heart murmur or a heart infection)?
Cardiovascular Screening Questions

Has a doctor ever ordered a test for your heart?
Do you get lightheaded or feel more short of
breath than expected with exercise?
Have you ever had an unexplained seizure?
Do you get more tired or short of breath than
your friends during exercise?
Cardiovascular Screening Questions

Has anyone in your family died of heart
problems or had an unexpected or unexplained
sudden death before age 50?
Does anyone in your family have a heart
problem, pacemaker or implanted defibrillator?
Does anyone in your family have Marfan’s
Has anyone in your family had unexplained
fainting, seizures or near drowning?
             Red flags
Family history of premature sudden death
Exertional syncope or pre-syncope
Exertional chest pain
Exertional dyspnea
   Cardiovascular Physical Exam

Blood pressure
Palpation of radial
and femoral pulses
Dynamic cardiac
Evaluation for
Marfan’s syndrome
      Worrisome exam findings

Hypertension above 99th percentile for
sex, age and height
Murmurs that are:
– Diastolic
– Louder that grade III
– Of long duration
– Louder with Valsalva or squat-to-stand
– Radiate to axilla or carotids
– Associated with arrhythmia or abnormal pulse
What about EKG’s?
      University of Padua Study
                 JAMA 2006
Studied athletes and non-athletes 1979-2004,
ages 12-35...PPE required by law for last 25+
Among athletes rate of sudden deaths fell by
89% after screening and restriction.
Rate among non-athletes did not change
Two important findings:
– PPE is effective at recognizing unsuspected heart
  disease (the first time this was documented)
– Recognition reduces sudden cardiac deaths among
                    The Italian Experience

    33,735 athletes screened over 17 years
    1,058 disqualified for medical reasons
    621 related to cardiovascular diseases
     – 38% dysrhythmias, 27% HTN, 21% MV disease

    3,016 referred for echocardiography
    22 diagnosed with HOCM and disqualified
     – 18 had abnormal EKG, 5 had abnormal history and/or physical

    0 died during 8 years of follow up
Corrado D; Basso C; Schiavon M; Thiene G N Engl J Med 1998 Aug 6;339(6):364-9.
       Padua Study-JAMA 2006

JAMA editorial
– EKG’s are effective screening tool
     The lowest annual death rate found in the study after
     screening was similar to the US rate among HS and college
     athletes between 1983-1993.
     The rate of sudden cardiac death before screening was
     higher than that of prior studies.

   *Over 25 years of data needed to reach this conclusion (but
     results currently endorsed by the IOC)
   *Not a controlled comparison study, but observational
   American Family Physician
                            April 1, 2007

The Athletic Pre-participation Evaluation:
Cardiovascular Assessment
SORT: Key Recommendations for Practice

A careful personal and family history and
physical examination designed to identify
cardiovascular conditions in young athletes
should be included in pre-participation
Athletes with a murmur that becomes softer with
squatting or louder or longer with standing or
during a Valsalva maneuver should be
evaluated for hypertrophic cardiomyopathy and
mitral valve prolapse
SORT: Key Recommendations for Practice

Routine screening with noninvasive tests, such
as echocardiography, exercise stress testing,
and electrocardiography, is not recommended
Athletes with suspicious cardiovascular
examination findings or a history of unexplained
exercise-related symptoms (e.g., syncope, pre-
syncope, chest pain) after initial testing should
be restricted from athletic participation pending
further cardiologic evaluation.
SORT: Key Recommendations for Practice

Athletes with stage 2 hypertension (i.e., blood
pressure above the 99th percentile [based on
age, sex, and height] plus 5 mm Hg; or blood
pressure more than 160/100 mm Hg for athletes
older than 18 years) should be restricted from
participation until hypertension is controlled
          British Medical Journal
                 29 SEP 2008

PPSE using health questionnaires and physical
examination has poor sensitivity in detecting
athletes at risk for sudden death
While not cost effective in most countries,
screening with a 12 lead EKG prevents sudden
cardiac death from channel-opathies and
cardiomyopathies, but not from coronary artery
                 BMJ Sep 2008
      Criteria for a Positive 12 lead EKG
P wave
–   LAE or RAE

QRS complex
–   RAD > 120 or LAD -30 to -90 degrees
–   Increased voltage
–   Pathological Q waves
–   RBBB or LBBB

ST segment, T waves, QT interval
–   ST segment depression, T wave flattening or inversion in 2 or more leads
–   QT > 0.44 sec in males or > 0.46 sec in females

Rhythm and conduction
–   PVCs, SVT, A fib or flutter
–   Short PR interval with or without a “delta” wave
–   Sinus bradycardia with HR < 40
–   First, second or third degree AV block
                 BMJ Sep 2008
Regular exercise is beneficial
Only a small number of athletes with silent CVS disease
are at increased risk of sudden death with exercise
PPSE H&P’s have poor sensitivity
Elaborate programs are cost prohibitive
EKG screening prevents sudden death from
dysrhythmias and cardiomyopathy, but not from coronary
artery disease
False positive testing is common
Extensive screening not cost effective in most countries
Key Points – 2010 Consensus
SCD is caused by a diverse etiology of
structural and electrical diseases
A detailed personal and FHX may identify
those at risk
CP, syncope or near-syncope, seizures,
DOE, fatigue or palpitations may require a
cardiac work-up before clearance
Key Points – 2010 Consensus
Fam Hx of sudden or unexplained death
before age 50, SIDS, unexplained
drowning, near-drowning or unexplained
seizures may indicate increased risk
PE should focus on pathological murmur
detection and signs of Marfan’s
Any suspicion should prompt a cardiology
Investigation of Athletes with CV Symptoms
               PPE 4th Edition 2010

 Stress EKG
 Advanced Imaging
 Holter / Event monitoring
 Cardiology Consultation
EKG Interpretation in athletes > 12 years of age

Abnormal                             Normal
 –   ST depression > 2 leads         –   Sinus bradycardia
 –   T wave inversion > 2 leads      –   Sinus arrhythmia
 –   LVH with ST depression          –   Prolonged PR or First degree
 –   Pathological Q waves            –   Junctional arrhythmia
 –   Complete RBBB or LBBB           –   Early repolarization
 –   Prolonged QT                    –   Tall T waves
 –   Epsilon wave                    –   Incomplete RBBB
 –   Ventricular pre-excitation      –   Voltage criteria for LVH
 –   LAE/RAE                         Possibly abnormal
 –   LAD/RAD                         –   Borderline QTc
 –   3rd degree block or Mobitz II   –   Wenckebach block
 –   SVT/AF/A flutter                –   QRS > 0.11 sec, LAFB
                                     –   > 3 PVCs per tracing
2010 CV Screening Limitations
No outcomes-based study exists that
demonstrates that the PPE is effective in
preventing or detecting athletes at risk for
sudden death
Warning symptoms and/or concerning family
history are often present
Appropriate questions must be asked
Standardized questionnaire forms are
  Noninvasive CV Screening
AHA recommends against it
– Cost per life saved is highly disputed:
     $44K if used in high school athletes (Fuller, 2000)
     $3.4 million according to AHA (Circulation, 2007)
     Differences based on baseline statistics and false positive rates

European Society of Cardiology, IOC and
several US and international sports leagues
support routine use of EKG
Who pays? What is the long term result of
disqualifications that result?
Clearance Recommendations
36th Bethesda Conference sponsored by the
ACC provides eligibility recommendations
Withdrawal from training and competition can
reduce a portion of sudden deaths in those
predisposed to SCA
Early detection, in some cases, permit timely
therapeutic interventions that may alter the clinic
course and prolong life
Most common CV disorder in athletes (6.4%)
HPI should include FHX, stimulants, steroids
Diagnostic requirements in athletes under 18:
– At least 3 BP readings required
– Age, gender and height-based norms
– 90-95% (pre-HTN), 95-99% (stage I) and >99% (stage II)
Those diagnosed may require CHEM, CBC, UA, EKG,
renal US, ECHO, retinal exam
Stage II athletes are disqualified until BP controlled
Central Nervous System
     Central Nervous System

Concussions are common, under-recognized
and under-reported
Concussions usually do not involve LOC
No one should return to a contact or collision
sport after sustaining a concussion
Once asymptomatic, a graded return to exercise
is advised
      Central Nervous System
Athletes younger than 18 take longer to recover
than older athletes
Sequelae of concussion include:
– Second Impact Syndrome
– Post-concussion Syndrome
– Permanent Neurologic Deficits
Computerized neuropsychological testing most
helpful when a baseline is available
Return to play decisions must be individualized
     American Family Physician
      Jan 15, 2012 - Key Recommendations
             (Scorza, Raleigh, O’Connor)

PE and concussion assessment tool use
Imaging studies NOT usually indicated
Complete cognitive and physical rest
Postural stability testing
Graded return-to-play
Complete recovery and return to play
Symptom management
The role of protective gear
     Central Nervous System
HA’s can be triggered or worsened by exercise
Migraine triggers should be identified and
Cough headache (benign exertional headache)
occurs with frequent valsalva
Primary exertional HA (effort HA) occurs with
aerobic exercise
SAH can present as exertional HA
      Central Nervous System
 – Should not preclude athletes from participation
Stingers and Burners
 – Always unilateral
 – May return to play when asymptomatic
Central Cord Neuropraxia
 – Presents with motor and/or sensory changes in more
   than one extremity
 – Should be evaluated for spinal stenosis
 – Return to play is controversial
Pulmonary System
        Pulmonary System
Most people with asthma will develop symptoms
with an appropriate exercise challenge
Many athletes with EIB may have undiagnosed,
underlying chronic asthma
Athletes with environmental allergies (atopy) are
at increased risk for EIB
Vocal cord dysfunction should be considered if
EIB does not respond to therapy
GI and GU Systems
        GI and GU Systems
A solitary kidney may not limit participation in
sports, but clearance should be individualized
A solitary testicle does not limit participation, but
a protective cup should be worn for high-risk
An abdominal hernia is not a reason to limit
HSM must be evaluated before clearance
Dermatological Conditions
  Dermatological Conditions
Skin infections are common reasons to
temporarily restrict participation
MRSA, HSV, molluscum and tinea are very
common in athletes
Contact, collision and shared-equipment sports
are of most concern
Proper diagnosis, documentation and treatment
are critical in determining return to play
Orthopedic Stations
           Athletes with unresolved M-S
           pain require further evaluation
           before clearance
           Stress fractures and recurrent
           soft tissue injuries can be
           associated with nutritional
           A general screening exam is
           reasonable for asymptomatic
           athletes with no previous injury
  Clearance for Participation
Must look at long term risks and benefits
Based on degree and type of prior injury
Requires an ability to compete safely
Considers requirements of a given sport
May designate protective padding, taping
or bracing
May require consultation with specialists
The Female Athlete
        The Female Athlete
Eating disorders and energy imbalance may be
associated with persistent injury, recurrent injury
or stress fractures
Those with M-S injuries and menstrual
dysfunction have longer interruptions of training
than those with regular cycles
Vitamin D deficiency is becoming increasingly
The PPE provides an opportunity for nutritional
  The Female Athlete Triad
Disordered eating, amenorrhea,
osteopenia / osteoporosis
Clearance may be withheld pending
extensive medical, psychiatric and/or
nutritional assessment
Hospitalization criteria:
– Temp < 97 F or 36.1 C
– HR < 40 adults or
– HR < 50 children and teens
The Athlete with Special Needs
Benefits of sports participation
Focused PPE screening
Physically impaired athletes
 – Paralympics
Cognitively impaired athletes
 – Special Olympics
Diagnostic imaging
Determining clearance
     Routine Screening Tests
PPE working group concurs that NO
routine screening tests are required
Cardiac Screening
– “considerable controversy surrounds mass ECG screening”
– Curr Sports Med Rep, Mar 2011; 10(2): 90-8

Asthma Screening
– “resting spirometry is not reliable enough to justify cost”

– Only based on findings from H&P

Drug Screening and HIV testing
     Determining Clearance
Cleared without restrictions
Cleared with recommendations for further
evaluation and treatment
Not cleared
Not cleared for certain types of sports
            The Questions
Does the problem place the athlete at increased
risk for injury or illness?
Is another participant at risk for injury or illness
because of the problem?
Can the athlete safely participate with
Can limited participation be allowed while
evaluation and treatment is ongoing?
If clearance is denied, in what activities can the
athlete safely participate?
        Future Considerations
– Common form
– Optimal frequency
– Measuring PPE effectiveness
Electronic Opportunities
–   PPE Pilot Project
–   Security
–   Tracking tools
–   Financing
–   Data management
                 Question #1
A 14-year old boy presents for a PPSE. A heart
murmur is noted during the cardiovascular
assessment. Which one of the following murmur
characteristics suggests a pathological cause?
–   A. Becomes louder during Valsalva
–   B. Early to midsystolic
–   C. Crescendo-decrescendo murmur
–   D. Musical, vibratory or buzzing quality
             Question #2
Which one of the following should
physicians routinely perform during a
– A. Electrocardiography
– B. Echocardiography
– C. Palpation of the radial and femoral pulses
– D. Exercise stress testing
            Question #3
Which of the following is/are
manifestations of Marfan’s syndrome?
– A. Kyphosis
– B. High-arched palate
– C. Pectus excavatum
– D. Myopia
Questions ?

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