Pre-participation Sports Physicalrwjms.umdnj.edu/departments_institutes/pedspweb/residency/documents/...S h i lp a P a i , M D F A P A s si t a n t C l i n c al r o f e s s o r o f

Pre-participation

Sports Physical

Shilpa Pai, MD FAAP

Assistant Clinical Professor of Pediatrics

Robert Wood Johnson Medical School

Learning Objectives

Review the guidelines for preReview the guidelines for pre--participation participation sports physicalsports physical

Understand the key things to identify in a Understand the key things to identify in a medical history for a patient planning to medical history for a patient planning to participate in athleticsparticipate in athletics

History of the PPE

Initially suggested by Teddy Roosevelt in 1905 Initially suggested by Teddy Roosevelt in 1905

Created 30 years ago, primarily to look at Created 30 years ago, primarily to look at congenital heart diseasecongenital heart disease

American Heart Association first developed American Heart Association first developed screening guidelines in 2007screening guidelines in 2007

Most recent guideline from 2010 PPE 4Most recent guideline from 2010 PPE 4thth edition edition monographmonograph

Benefits of the PPE

>7.6 million athletes participated in high school >7.6 million athletes participated in high school sports in 2010sports in 2010--2011 academic year2011 academic year

medical homemedical home

updating of immunizations updating of immunizations

identification and management of chronic health identification and management of chronic health conditionsconditions

provision of anticipatory guidance related to sportsprovision of anticipatory guidance related to sports

Benefits

facilitate and encourage safe participation, not facilitate and encourage safe participation, not to disqualifyto disqualify

<2% of 2700 athletes screened disqualified <2% of 2700 athletes screened disqualified

12% athletes required follow up12% athletes required follow up

Athletics are good for teensAthletics are good for teens

less likely to be truantless likely to be truant

less likely to get pregnantless likely to get pregnant

Limitations of PPE

Not necessarily effective screening toolNot necessarily effective screening tool

•• 310 studies of the PPE 310 studies of the PPE ““the evaluation likely does the evaluation likely does little to prevent morbidity and mortality in screened little to prevent morbidity and mortality in screened athletes; ineffective for identifying athletes at risk for athletes; ineffective for identifying athletes at risk for sudden cardiac death or orthopedic injuries and at sudden cardiac death or orthopedic injuries and at detecting exercisedetecting exercise--induced bronchospasminduced bronchospasm””

Inconsistencies between states (no standard)Inconsistencies between states (no standard)

AHA guidelines are often not followedAHA guidelines are often not followed

It’s the Law

National Federation of State High School National Federation of State High School Associations (NHFS) regards PPE as Associations (NHFS) regards PPE as prerequisite to sports prerequisite to sports

liability issueliability issue

highhigh--school and middleschool and middle--school athletes required school athletes required to obtain signed every 1 to 2 academic yearsto obtain signed every 1 to 2 academic years

Preparticipation Physical Evaluation 4th Edition 2010

Approved by:Approved by:

AAPAAP

AAFPAAFP

American College of Sports MedicineAmerican College of Sports Medicine

American Medical Society for Sports MedicineAmerican Medical Society for Sports Medicine

American Orthopedic Society for Sports MedicineAmerican Orthopedic Society for Sports Medicine

American Osteopathic Academy of Sports MedicineAmerican Osteopathic Academy of Sports Medicine

PPE 4th Edition 2010

Primary objectives:Primary objectives:

Screen for conditions that may be lifeScreen for conditions that may be life--threatening or threatening or disablingdisabling

Screen for conditions that may predispose to injury or Screen for conditions that may predispose to injury or illness (e.g. recurrent ankle/shoulder illness (e.g. recurrent ankle/shoulder injuryinjury, obesity), obesity)

Secondary objectives:Secondary objectives:

Determine general health Determine general health

entry point to health care systementry point to health care system

opportunity to initiate discussion of healthopportunity to initiate discussion of health--related topicsrelated topics

Recommendations for the PPE

Who does it?Who does it?

Preferably primary MD/DO with review of previous Preferably primary MD/DO with review of previous medical recordsmedical records

Some states allow nonSome states allow non--physician healthcare physician healthcare providers to perform PPEproviders to perform PPE

Recommendations for the PPE

When should you do it?When should you do it?

At least 6 weeks prior to preseason practiceAt least 6 weeks prior to preseason practice

Allows for strengthening/conditioning and Allows for strengthening/conditioning and identification of injury patterns and rehabilitationidentification of injury patterns and rehabilitation

Periodicity is determined by state lawPeriodicity is determined by state law

AHA recommend q 2 years with annual updates to AHA recommend q 2 years with annual updates to include history, height, weight, BP and a probleminclude history, height, weight, BP and a problem--focused examfocused exam

Recommendations for the PPE – Where?

Individual exam/office settingIndividual exam/office setting

privacy and continuity of careprivacy and continuity of care

costlycostly

Station approachStation approach

Can be done for entire athletic team at onceCan be done for entire athletic team at once

Time efficientTime efficient

Utilizes primary care providers and specialistsUtilizes primary care providers and specialists

InexpensiveInexpensive

How should you do it?

History alone detects >75% of problemsHistory alone detects >75% of problems

Should be conducted with both athlete and Should be conducted with both athlete and parentparent

Only 19Only 19--39% of athlete39% of athlete’’s response match info from s response match info from parentparent

Include confidential information (HEADSS)Include confidential information (HEADSS)

History form for preparticipation evaluation.

Peterson A R , Bernhardt D T Pediatrics in Review 2011;32:e53-e65

©2011 by American Academy of Pediatrics

History - Cardiovascular

Annual incidence of sudden cardiac death = Annual incidence of sudden cardiac death = 1/100,000 1/100,000 –– 1/200,000 high school aged teens1/200,000 high school aged teens

previously asymptomaticpreviously asymptomatic

Structural cardiac problems Structural cardiac problems fatal arrhythmias: fatal arrhythmias: >90% sudden death in young athletes >90% sudden death in young athletes

36% from hypertrophic cardiomyopathy36% from hypertrophic cardiomyopathy

8% from idiopathic LVH8% from idiopathic LVH

17% from coronary artery anomalies17% from coronary artery anomalies

History - Cardiovascular

PCP evaluation:

•• SyncopeSyncope

•• NearNear--syncopesyncope

•• Chest painChest pain

•• PalpitationsPalpitations

•• Excessive shortness of Excessive shortness of breathbreath

Cardiology referral:

known congenital heart known congenital heart diseasedisease

Cardiac channelopathies Cardiac channelopathies

History of myocarditisHistory of myocarditis

Coronary anomalies Coronary anomalies

AHA Recommendations –History (8 points)•• Exertional chest Exertional chest

pain/discomfortpain/discomfort

•• Exertional syncope or Exertional syncope or nearnear--syncopesyncope

•• Excessive exertional and Excessive exertional and unexplained fatigueunexplained fatigue

•• Prior Prior recognitionrecognition of heart of heart murmurmurmur

•• Elevated SBPElevated SBP

•• Premature death Premature death (sudden) <50 y.o.(sudden) <50 y.o.

•• Disability from heart Disability from heart disease in close relative disease in close relative <50 y.o.<50 y.o.

•• Family cardiac historyFamily cardiac history

AHA Recommendations –Physical Exam (4 points)1.1. Heart murmur Heart murmur

2.2. Femoral pulses Femoral pulses

3.3. Physical stigmata of Marfan syndromePhysical stigmata of Marfan syndrome

4.4. Brachial artery BPBrachial artery BP

Screening EKG not recommendedScreening EKG not recommended

1 or more positive responses may be enough to 1 or more positive responses may be enough to trigger a cardiology referraltrigger a cardiology referral

History -Musculoskeletal

history is very sensitive for identifying history is very sensitive for identifying abnormalities abnormalities –– 92%92%

Ask about current injuriesAsk about current injuries

History of injuries that needed further evaluationHistory of injuries that needed further evaluation

Medications

Current and past medicationsCurrent and past medications

Therapeutic use exemption (TUE)Therapeutic use exemption (TUE)

Screen for illicit drugsScreen for illicit drugs

Banned substances Banned substances –– college levelcollege level

World AntiWorld Anti--Doping AgencyDoping Agency

NCAANCAA

History - Dermatologic

Open wounds Open wounds –– cleaned and coveredcleaned and covered

Sunblock usageSunblock usage

InfectiousInfectious

MRSA infectionsMRSA infections

ImpetigoImpetigo

Molluscum contagiosumMolluscum contagiosum

Tinea corporisTinea corporis

Herpes simplex Herpes simplex

History - Neurologic

Personal history of concussionPersonal history of concussion

PostPost--concussion symptomsconcussion symptoms

Symptomatic athlete should NEVER be allowed to Symptomatic athlete should NEVER be allowed to return to playreturn to play

Neurocognitive testing (NCT) Neurocognitive testing (NCT) –– controversialcontroversial

History - Neurologic

Cervical cord neuralgia Cervical cord neuralgia ––> transient quadriplegia> transient quadriplegia

transient compression of cervical spinal cord from transient compression of cervical spinal cord from forced hyperextension, hyperflexion, or axial loadingforced hyperextension, hyperflexion, or axial loading

Common in athletes with cervical spinal stenosisCommon in athletes with cervical spinal stenosis

Transient Transient -- <15 minutes<15 minutes

Controversial if should be allowed to play contact Controversial if should be allowed to play contact sportssports

History – Heat Illness

Kills 1000 people each year in the U.S.Kills 1000 people each year in the U.S.

Proper hydrationProper hydration

Avoid stimulants and antihistaminesAvoid stimulants and antihistamines

History - Ophthalmologic20/40 best corrected vision 20/40 best corrected vision –– ““functionally onefunctionally one--eyedeyed

Eye protection recommended for all athletes by AAP Eye protection recommended for all athletes by AAP and AAOand AAO

Some sports do not allow eyewear, so need contact Some sports do not allow eyewear, so need contact lenseslenses

Ultraviolet blocking eyewear for sun or snow sportsUltraviolet blocking eyewear for sun or snow sports

History - Pulmonary

History of exerciseHistory of exercise--induced bronchospasm (EIB)induced bronchospasm (EIB)

Asthma is the most chronic illness in adolescentsAsthma is the most chronic illness in adolescents

1010--79% of athletes (high school, college, Olympics) 79% of athletes (high school, college, Olympics) have EIBhave EIB

Athletes should have active prescription for Athletes should have active prescription for bronchodilatorbronchodilator

History – Infectious Diseases

Mononucleosis and monoMononucleosis and mono--like infectionlike infection

Disqualified from participation any sport where Disqualified from participation any sport where risk for abdominal traumarisk for abdominal trauma

33--4 week symptom free4 week symptom free

Universal precautionsUniversal precautions

History - Genitourinary

Solitary/horseshoe kidney Solitary/horseshoe kidney –– individual assessmentindividual assessment

Inguinal hernia Inguinal hernia –– worsen with sports requiring high worsen with sports requiring high static demand static demand

Menstrual history: female athlete triadMenstrual history: female athlete triad

eating disordereating disorder

Menstrual dysfunctionMenstrual dysfunction

OsteoporosisOsteoporosis

Physical Exam

HeightHeight

WeightWeight

BMIBMI

can be inaccuratecan be inaccurate

Heart rateHeart rate

BradycardiaBradycardia

Wide pulse pressureWide pulse pressure

Physical Exam – Vital Signs

Blood pressureBlood pressure

9090--94% or 120/80 = pre94% or 120/80 = pre--hypertensionhypertension

>95% measured on 3 occasions = mild/moderate >95% measured on 3 occasions = mild/moderate hypertension hypertension

>99% + 5mm Hg = severe hypertension>99% + 5mm Hg = severe hypertension

Higher risk for a catastrophic event, worse end organ Higher risk for a catastrophic event, worse end organ damagedamage

Physical Exam - HEENT

Vision: better than 20/40 correctedVision: better than 20/40 corrected

Auricular cartilage damage Auricular cartilage damage ear protectionear protection

Nasal septum damageNasal septum damage

Dental cariesDental caries

Physical Exam

Neurologic examNeurologic exam

Cardiovascular:Cardiovascular:

Not benign Not benign cardiology referralcardiology referral

Genitourinary (males only)Genitourinary (males only)

Undescended/absent testicle Undescended/absent testicle

Only one functional testicle Only one functional testicle

History of groin painHistory of groin pain

Physical Exam

Dermatologic lesionsDermatologic lesions

Physical Exam

Musculoskeletal examMusculoskeletal exam

Low yield in asymptomatic athletesLow yield in asymptomatic athletes

History 92% sensitive in detecting significant History 92% sensitive in detecting significant musculoskeletal injuriesmusculoskeletal injuries

Refer if recurrent injury, joint instability, locking of Refer if recurrent injury, joint instability, locking of joints, weakness, muscular atrophyjoints, weakness, muscular atrophy

Classification of sports

Contact Contact –– based on potential for injury from based on potential for injury from collisioncollision

Strenuous/dynamic Strenuous/dynamic –– put a larger load on LVput a larger load on LV

Static exercise Static exercise –– dangerous for dangerous for

those with htn, L. heart obstruction,those with htn, L. heart obstruction,

risk of aortic dissectionrisk of aortic dissection

Contact/CollisionContact/Collision Limited contactLimited contact NonNon--contact contact BoxingBoxing BaseballBaseball ArcheryArchery

BasketballBasketball BicyclingBicycling BadmintonBadminton

CheerleadingCheerleading Canoeing/kayak Canoeing/kayak (whitewater)(whitewater)

Body building & wt liftingBody building & wt lifting

DivingDiving FencingFencing BowlingBowling

Field HockeyField Hockey Field EventsField Events Canoe/kayak (flat water)Canoe/kayak (flat water)

FootballFootball Floor hockeyFloor hockey Crew/RowingCrew/Rowing

Ice HockeyIce Hockey Flag footballFlag football CurlingCurling

LacrosseLacrosse GymnasticsGymnastics DancingDancing

Martial ArtsMartial Arts Horseback RidingHorseback Riding Field eventsField events

RodeoRodeo RaquetballRaquetball GolfGolf

RugbyRugby Skating (in line, ice, roller)Skating (in line, ice, roller) OrienteeringOrienteering

Skiing/jumping/snowboardSkiing/jumping/snowboard SkateboardingSkateboarding Race walking Race walking

SoccerSoccer SoftballSoftball RifleryRiflery

HandballHandball SquashSquash Rope jumpingRope jumping

Water poloWater polo VolleyballVolleyball Running (track, xRunning (track, x--country)country)

WrestlingWrestling Windsurfing/SurfingWindsurfing/Surfing Sailing Sailing

Ultimate Ultimate frisbeefrisbee Scuba divingScuba diving

SwimmingSwimming

Tennis, table tennisTennis, table tennis

CONTACT/COLLISION - LIMITED CONTACT - NON-CONTACT

Determining Clearance

Must maintain confidentialityMust maintain confidentiality

1.1. Cleared without restrictions Cleared without restrictions

2.2. Cleared with recommendations Cleared with recommendations

3.3. Not cleared, reconsider after further eval or Not cleared, reconsider after further eval or treatment treatment

4.4. Not cleared for certain or all sportsNot cleared for certain or all sports

Determining Clearance –Special Situations

SeizuresSeizures

Risk of seizure very low during competitionRisk of seizure very low during competition

Refer to stateRefer to state’’s legal seizures legal seizure--free interval to return to driving: 3free interval to return to driving: 3--6 6 monthsmonths

Athletes with poorly controlled epilepsy benefit from exerciseAthletes with poorly controlled epilepsy benefit from exercise

Avoid:Avoid:

ArcheryArchery --weigh weigh liftinglifting

Power liftingPower lifting --weight trainingweight training

RifleryRiflery --sports involving heightssports involving heights

swimmingswimming

Determining Clearance –Special Situations

Down SyndromeDown Syndrome

Cervical spine instability Cervical spine instability –– 30%30%

Special Olympics requires CSpecial Olympics requires C--spine filmsspine films

Prohibited from collision sports regardlessProhibited from collision sports regardless

If instability, no If instability, no ““neckneck--stressingstressing”” sportssports

Diving Diving

GymnasticsGymnastics

soccersoccer

Determining Clearance –Special Situations

Acute febrile illnessAcute febrile illness

Fever puts them at risk for acute heat illnessFever puts them at risk for acute heat illness

Reduces maximal exercise capacityReduces maximal exercise capacity

Type 1 Diabetes MellitusType 1 Diabetes Mellitus

Monitor glucose: q 30 min during continuous exercise, Monitor glucose: q 30 min during continuous exercise, 15 min after completion of exercise and at bedtime15 min after completion of exercise and at bedtime

Permitted to participate in any sportPermitted to participate in any sport

When to Disqualify an Athlete from Sports Participation

Pulmonary vascular disease with Pulmonary vascular disease with cyanosis or a hemodynamically cyanosis or a hemodynamically significant rightsignificant right--toto--left shuntleft shunt

Severe pulmonary stenosis Severe pulmonary stenosis (untreated)(untreated)

Severe aortic stenosis or Severe aortic stenosis or regurgitation (untreated)regurgitation (untreated)

Severe mitral stenosis or Severe mitral stenosis or regurgitation (untreated)regurgitation (untreated)

Any cardiomyopathyAny cardiomyopathy

Vascular EhlersVascular Ehlers--Danlos syndromeDanlos syndrome

Coronary anomalies (especially Coronary anomalies (especially anomalous coronary origins)anomalous coronary origins)

Catecholaminergic polymorphic Catecholaminergic polymorphic ventricular tachycardiaventricular tachycardia

Acute pericarditisAcute pericarditis

Acute myocarditisAcute myocarditis

Acute Kawasaki diseaseAcute Kawasaki disease

Recommendations for vitamins and hydration

VitaminsVitamins

1300 mg calcium1300 mg calcium

400400--600 IU Vitamin D600 IU Vitamin D

HydrationHydration

Fluids 2Fluids 2--4 hr prior to activity (until urine is clear)4 hr prior to activity (until urine is clear)

Every 15Every 15--20 minutes during activity20 minutes during activity

1616--24 hours after activity24 hours after activity

<1 hour of exercise: water only<1 hour of exercise: water only

>1 hour of exercise: sports drinks >1 hour of exercise: sports drinks

Sports Injury Prevention

Time offTime off

Strengthen musclesStrengthen muscles

Increase flexibilityIncrease flexibility

Use proper techniqueUse proper technique

Take breaksTake breaks

Stop activity if there is painStop activity if there is pain

Sports injury prevention

Play safePlay safe

Baseball/softball: avoid headfirst slidingBaseball/softball: avoid headfirst sliding

Football: no spearingFootball: no spearing

Hockey: no body checkingHockey: no body checking

Sports injury prevention

Wear the right gear Wear the right gear

Properly fit equipmentProperly fit equipment

Athletes should not assume they can do more Athletes should not assume they can do more dangerous activitiesdangerous activities

ReferencesPeterson, A, Peterson, A, ““PrePre--participation Sports Physical,participation Sports Physical,”” Pediatrics in Review, May 2011Pediatrics in Review, May 2011

Loutit, Carrie, Loutit, Carrie, ““PrePre--participation Sports Physical participation Sports Physical –– Continuity Clinic Curriculum,Continuity Clinic Curriculum,”” 20112011

The Preparticipation Evaluation Monograph. Forth Edition, McGrawThe Preparticipation Evaluation Monograph. Forth Edition, McGraw--Hill 2010 Hill 2010

AAP History / Physical Exam / Clearance Forms: http://www.amssmAAP History / Physical Exam / Clearance Forms: http://www.amssm.org/Content/pdf%20files/PPE2010RevisedForm.pdf .org/Content/pdf%20files/PPE2010RevisedForm.pdf

““Contact Sports for Young Athletes.Contact Sports for Young Athletes.”” Pediatric Annals May 2010 vol 39, no 5 Pediatric Annals May 2010 vol 39, no 5

Metzl JD Metzl JD ““Sports Medicine in the Pediatric OfficeSports Medicine in the Pediatric Office””. Multimedia Case. Multimedia Case--Based Text With Video AAP 2008 Based Text With Video AAP 2008

American Academy of Pediatrics. Medical Conditions Affecting SpoAmerican Academy of Pediatrics. Medical Conditions Affecting Sports Participation. Pediatrics 2008;121:841rts Participation. Pediatrics 2008;121:841--8 8

http://pediatrics.aappublications.org.laneproxy.stanford.edu/conhttp://pediatrics.aappublications.org.laneproxy.stanford.edu/content/121/4/8tent/121/4/8 41.long 41.long

Metzl JD: Preparticipation examinations of the adolescent athletMetzl JD: Preparticipation examinations of the adolescent athlete: part 1 Pediatric Rev June 2001;22 (6):199e: part 1 Pediatric Rev June 2001;22 (6):199--204 http://pedsinreview.aappublications.org.laneproxy.stanford.e204 http://pedsinreview.aappublications.org.laneproxy.stanford.edu/cgi/content/fu du/cgi/content/fu ll/22/6/199 ll/22/6/199

Metzl JD: Preparticipation examinations of the adolescent athletMetzl JD: Preparticipation examinations of the adolescent athlete: part 2 Pediatric Rev July 2001;22 (7):227e: part 2 Pediatric Rev July 2001;22 (7):227--235 235 http://pedsinreview.aappublications.org.laneproxy.stanford.edu/chttp://pedsinreview.aappublications.org.laneproxy.stanford.edu/cgi/content/fugi/content/fu/22/7/227 /22/7/227

Peds in Review 2011 the Preparticipation Sports EvaluationPeds in Review 2011 the Preparticipation Sports Evaluation

http://pedsinreview.aappublications.org.laneproxy.stanford.edu/http://pedsinreview.aappublications.org.laneproxy.stanford.edu/cgi/content/fu ll/32/5/e53?maxtoshow=&hits=10&RESULTFORMAT=&fullcgi/content/fu ll/32/5/e53?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=sports+medici text=sports+medici