Preparticipation Physical Exam Qiuyang Li, PGY3. First year team physicians dilemma This is your 1 st yr as team physician for the local high school.

Preparticipation Physical Exam

Qiuyang Li, PGY3

First year team physician’s dilemma

• This is your 1st yr as team physician for the local high school. All the talk in the community is about the school’s football team, which is expected to win the state championship this season. The coach of the football team “doesn’t like to lose” and was known to put pressure on the previous team physician to give medical clearance to player before games.

Q1• Which of the following is the most common

cause of sudden death in an athlete younger than age 35 years?

A.CADB.Premature CADC.MyocarditisD.HCME.Rupture of the aorta

Q2

• Which of the following is a contraindication to participation in contact sports?

A.Sickle cell traitB.HIVC.Solitary testicleD.Fever of 102FE.Convulsive disorder, well controlled

Q3

• Which of the following tests is recommended for routine screening of athletes during the preparticipatation evaluation (PPE)?

A.EchoB.ECGC.Exercise stress testD.Vision screenE.UA

During PPE, you note that the 17yo boy has a BP of 148/95mmHg. His past medical history is negative, and he has never been told that he had HTN. He is 6 ft2in tall and wt 175 lb. As the team physician, you tell him

A.Can’t play any contact sportsB.Can’t play until BP is under controlC. He is cleared to play, but must have his BP

measured twice during next monthD.If he begins BP med immediately, then he is

clearedE. He must lose 10lb before he will be cleared

Q5

• The school’s wrestling team has had an unusually high amount of injuries this season. Which of the following conditions is reason to disqualify a wrestler from competition?

A.Herpes simplexB.Hep CC.Inguinal herniaD.Diabetes mellitus

Q6• Which of the following statement concerning PPE

is true?A.About 10% of athletes are denied clearance

during PPEB.The PPE ideally should be performed 6 month

prior to present practiceC. A primary objective of the PPE is to detect

conditions that may predispose an athlete to injury

D.A complete hx will identify about 95% of problems affecting athletes.

Introduction

• Each yr , between 17 and 25 million adolescents engage in some type of sports activity.

• >6 million high school athletes at about 20,000 high schools.

• >2 million injuries occur each yr requiring 500,000 doctor visit and 30,000 hospitalization.

• Since 8/08, at least 12 high school football, 2 youth league football and 2 soccer players have died during

or as a result of athletic participation.

N M A A S P O R T S M E D I C I N E A D V I S O R Y C O M M I T T E E 2009

Goal #1: Safe Participation

Goal #2: Meeting Legal Requirements

Goal #3: Preventative Healthcare

To detect underlying CV abnormality that may predispose

an athletes to sudden death

To disclosure defects that may limit participation

N M A A S P O R T S M E D I C I N E

A D V I S O R Y C O M M I T T E E 2009Facts

• A thorough medical history can reveal up to 75% of conditions that would limit or alter sports participation.

• In conjunction with basic musculoskeletal testing highlights the fact that the majority of

athletes are healthy.• Only 3 to 13 percent require further

evaluation

CV causes of sudden death in young athletes• HCM• Coronary artery anomalies• Commontio cordis (i.e, blunt trauma to the chest causing VF)• LVH• Myocarditis• Marfan syndrome• Arrythmogenic Right ventricular cardiomyopathy• Tunneled coronary artery• Dilated CM• AS• Myxomatous MV degeneration• MVP• Drug abuse• Long QT syndrome• Cardiac sarcoidosis• Brugada syndrome (genetic disorder of myocardial sodium ion channels)

AAFP, The athletic PPE: cardiovascular assessment

Table 2. Common Etiologies of Sudden Death in Young Athletes

Condition Historical features Physical examination findingsAortic stenosis Personal history of exercise-induced chest

pain, breathlessness, light-headedness, syncope, or dizziness

Constant apical ejection click; harsh systolic ejection murmur heard best at

the upper right sternal border; crescendo-decrescendo murmur, normally grade 3

murmur or higherBrugada syndrome (a genetic disorder of

myocardial sodium ion channels)Family history of premature sudden

death, particularly in men of Southeast Asian descent

Unremarkable

Coronary artery diseases (congenital or acquired)

Family history of early coronary artery disease, premature sudden death, or

coronary anomaliesPersonal history of exercise-induced chest

pain, syncope, or fatigue

Usually normal

Hypertrophic cardiomyopathy Family history of hypertrophic cardiomyopathy, premature sudden death, recurrent syncope, or lethal

arrhythmias requiring urgent treatmentPersonal history of Exertional chest pain

or syncope

Wide range of ausculatory findings, from normal examination to a harsh

midsystolic murmur that accentuates with standing or the Valsalva maneuver

Long QT syndrome Family history of premature sudden deathPersonal history of palpitations or

recurrent syncope

Unremarkable

Marfan syndrome Family history of Marfan syndrome or premature sudden death

See Table 5

Myocarditis Personal history of fatigue, Exertional dyspnea, syncope, palpitations,

arrhythmias, or acute congestive heart failure

May be normalPalpable or auscultated extra systoles,

third or fourth heart sound gallops, and other clinical signs of heart failure should

be considered suspiciousArrhythmogenic right ventricular

cardiomyopathyFamily history of premature sudden death; more common in persons of

Mediterranean descentPersonal history of palpitations or

recurrent syncope

Unremarkable

Quiz

• The most common abnormalities leading to disqualification are _____________

• The most common cause of sudden death in age older than 35?

Major Questions to ask in Medical History Screening?

• ?

Critical screening questions

1. Exertional CP or discomfort, or SOB?2. Exertional syncope or near-syncope, or

unexpected fatigue?3. Hx of cardiac murmur or systemic HTN?4. FH of HCM, long QT syndrome, Marfan

syndrome, significant dysrhythmias?5. FH of premature death or known CAD in a first-

or second-order relative younger than 50 years? (More concern if younger than 40 years.)

Physical Finding of Marfan Syndrome

• ?

Physical Findings of Marfan Syndrome

• Aortic insufficiency murmur• Arachnodactyly• Arm span that is greater than body height• High arched palate• Kyphosis• Lenticular dislocation• MVP• Pectus excavatum• Myopia• Thumb sign• Wrist sign

Physical Finding of HCM

• ?

Physical Finding in HCM

• Systolic murmur• Louder with standing, decreases with

squatting• 2nd RT ICS or Lt sternal border• Lateral displacement of apical impulse• Holosystolic murmur of mitral regurgitation at

apex with radiation to axilla

Discussion

EKG from a 33-year-old man with HCM. These are voltage criteria for left ventricular hypertrophy. Note the ST-segment elevation (short arrow) in the lateral leads and biphasic T-waves (long arrow) in V1 to V3.

AAFP: The pre-participation Athletic evaluation 2000

Discussion

• 19 y.o. football player come for PPE, he was found to have II/VI systolic murmur at LLSB. He was referred for an Echo. Echo showed mild LVH, EF 60%, mild TR. Can he play football?

Athletic Heart SyndromeThe Merck Manual online library

A constellation of structural and functional changes that occur in the heart of athlete.

→Asymptomatic; →Signs include bradycardia, a systolic murmur, and extra heart

sounds. →ECG abnormalities are common. →Diagnosis is clinical or by echocardiography. →No treatment is necessary. →It must be distinguished from serious cardiac disorders.

http://www.merck.com/mmpe/sec07/ch082/ch082c.html

Features Distinguishing Athletic Heart Syndrome From Cardiomyopathy Feature Athletic Heart Syndrome Cardiomyopathy

Left ventricular hypertrophy*< 13 mm > 15 mm

Left ventricular end-diastolic diameter†

< 60 mm > 70 mm

Diastolic function Normal (E:A ratio > 1) Abnormal (E:A ratio < 1)

Septal hypertrophy Symmetric Asymmetric (in hypertrophic cardiomyopathy)

Family history None May be present

BP response to exercise Normal Normal or reduced systolic BP response

Deconditioning Left ventricular hypertrophy regression

No left ventricular hypertrophy regression

*A value of 13 to 15 mm is indeterminate.

†A value of 60 to 70 mm is indeterminate.

E:A ratio = ratio of early to late atrial transmitral flow velocity.

The Merck Manual online library

Athletic Heart Syndrome Prognosis and Treatment

• Although gross structural changes resemble those in some cardiac disorders, no adverse effects are apparent. In most cases, structural changes and bradycardia regress with detraining, although up to 20% of elite athletes have residual chamber enlargement, raising questions, in the absence of long-term data, about whether the athletic heart syndrome is truly benign.

• No treatment is required, although 3 mo of deconditioning may be needed to monitor LV regression as a way of distinguishing this syndrome from cardiomyopathy. Such deconditioning can greatly interfere with an athlete's life and may meet with resistance.

Female Athletic Triad

• Anorexia nervosa• Osteoporosis• Amenorrhea

Preparticipatation Physical ExamVS:GA: Marfan syndrome (Arachnodactyly, arm span>ht, Pectus

excavatum)EYE: vision defect. Lens subluxation, severe myopia, retinal

detachment, strabismus. CV: PMI, murmur RESP: wheezingABD: liver or spleen GU: hernia, varicoceles, testicular massMS: spine and extremitySKIN: molluscum contagiosum, HSV, impetigo, tinea corporis,

scabies

International Pediatric Hypertension Association (2006) www.pediatrichypertension.org

Blood pressure (mm Hg)

Girls Girls Boys Boys

Age (yr)

50th % for height

75th % for height

50th % for height

75th % for height

6 111/73 112/73 114/74 115/75

12 123/80 124/81 123/81 125/82

17 129/84 130/85 136/87 138/88

AAFP: The pre-participation Athletic evaluation 2000

Table 6. Recommended Follow-up for Hypertension in Children and Adolescents

Hypertension classification Definition* Follow-up Athletic participation

Prehypertension Blood pressure is between the 90th

and 95th percentiles

Recheck blood pressure in six

months

Full participation is appropriate

Stage 1 Blood pressure is between the 95th

and 99th percentiles plus 5

mm Hg

Recheck blood pressure during two additional visits in one to two weeks, or

sooner if patient is symptomatic

Participation is appropriate, although the patient should avoid

power lifting

Stage 2 Blood pressure is above the 99th

percentile plus 5 mm Hg

Refer for immediate

evaluation and treatment

Participation restriction is needed until hypertension is controlled

AAFP: The pre-participation Athletic evaluation 2000

Benign Murmur• Absence of associated symptoms• Absence of family history• Associated with normal, physiologic splitting of S2; absence of

other abnormal heart sounds (e.g., clicks, gallops)• Early to midsystolic• Crescendo-decrescendo murmur• Musical, vibratory, or buzzing quality• Normal blood pressure, pulse contour, electrocardiography,

or precordial examination• Often heard best over pulmonic area or mid-left sternal

border• Soft murmur (grade 1 or 2)

AAFP: The pre-participation Athletic evaluation 2000

Pathologic Murmur• Associated arrhythmia• Associated left ventricular apical or right ventricular parasternal heave• Associated with abnormal jugular venous pulse; wide pulse pressure; or

brisk, rapidly rising pulse or weak, slowly rising pulse• Change in intensity with physiologic maneuvers (especially if murmur

becomes louder with valsalva or squat-to-stand maneuvers)• Diastolic murmur• Family history of sudden death or cardiac disease• Long duration (mid- or late-peak or holosystolic murmur)• Loud murmur (grade 3 or more)• Other abnormal heart sounds (e.g., loud S1, fixed or paradoxically split S2,

midsystolic click)• Presence of associated symptoms (e.g., chest pain, dyspnea on exertion,

syncope)• Radiation to axilla or carotids

AAFP: The pre-participation Athletic evaluation 2000

Contraindications for Sports1. Active myocarditis or pericarditis2. HCM3. Severe HTN until controlled by therapy 4. Suspected coronary artery disease until fully evaluated (patients with impaired

resting left ventricular systolic function <50%, or exercise-induced ventricular dysrhythmias, or exercise-induced ischemia on exercise stress testing are at greatest risk of sudden death)

5. Long QT interval syndrome 6. History of recent concussion and symptoms of post concussion syndrome (no

contact or collision sports)7. Poorly controlled convulsive disorder 8. Recurrent episodes of burning upper-extremity pain or weakness, or episodes

of transient quadriplegia until stability of cervical spine can be assured (no contact or collision sports)

9. Sickle cell disease 10. Eating disorder 11. Acute enlargement of spleen or liverInformation from Smith DM. Preparticipatation physical evaluation. 2d ed. Minneapolis: Physician and Sports medicine, 1997.

Common Questions on PPE• Eye• Fever• Heart murmur• Diabetes mellitus• Diarrhea• Eating disorders • HIV infection• HTN• Convulsive disorder• Asthma• Sickle cell disease

• Sickle cell trait• Enlarged spleen• Testicle• MVP• Enlarge liver• Absence of one kidney• Molluscum contagiosum• HSV• Impetigo• Tinea corporis• Scabies

Required stations on PPE

• Sign in, ht, wt, vital signs, vision• History review• PE (medical and orthopedic)• Medical clearance

Conclusion

The pre-participation physical exam is the single most effective method of addressing the health concerns of the adolescent student-athlete.

◊ Promotes safe participation ◊ Identifies areas of concern◊ Helps satisfies legal requirements ◊ Addresses risk management issues ◊ Increasing the chance that the student athlete

will have the best possible outcome

References:

• “Primary care reports” The practical journal for primary care and family physician. Nov. 13, 2000

• “The athletic preparticipation evaluation: cardiovascular assessment” AFP April 1, 2007.

• “The preparticipation athletic evaluation” AFP May 1, 2000

• NMAA sports medicine advisory committee 2009• The Merck Manual online library