NCC Pediatrics Continuity Clinic Curriculum: Sports Physical I

Transcription

NCC Pediatrics Continuity Clinic Curriculum:
Sports Physical I: Overview
Faculty Guide
Goals & Objectives: To understand the importance of the pre-participation exam and to
gain the skills necessary to perform an adequate exam and recognize common problems.
• Demonstrate knowledge and understanding of the components of the sports exam,
including history and physical, including simple maneuvers to screen potential athletes.
• Demonstrate knowledge of risk factors that may limit the type of or extent of sports
participation, or disqualify the athlete entirely. Also to be cognizant of the psychosocial
aspects of not being able to participate in sports.
Sports Physical II (Summer Module) details CV Screening & Concussions
Pre-Meeting Preparation:
Please read the following enclosures:
• “The Pre-Participation Sports Evaluation” (PIR, 2011)
o “The 2-minute Orthopedic Exam”
• Skim 2 excerpts from “Medical Conditions Affecting Sports Participation”
o Table 1: Classification of Sports According to Contact
o Table 2: Medical Conditions & Sports Participation
Conference Agenda:
•
•
•
•
Review Sports Physical I Quiz
Complete Sports Physical I Case
Hands-on Exercise 1: Choose a partner. Perform 2-min Orthopedic
Exam. Time yourselves! Simulate abnormal results & discuss differential.
Hands-on Exercise 2: Compare & Contrast local PPE forms.
Post-Conference: Board Review Q&A
Extra-Credit:
•
•
•
•
•
NCAA 2016-2017 Banned Drugs List: comprehensive list, referred to in article
Eating Attitudes Test (EAT): referred to in article as screen for disordered eating
Epilepsy & Driving Laws: seizure-free interval in MD is 3mo (links to other states)
AAP PPE Form: includes supplemental history of children with special needs
2016 Sports Injury Prevention Tip Sheet: anticipatory guidance for injury prevention
© 2016 Developed- MAJ Rachael Paz.
Edited- MAJ Jennifer Hepps, MAJ Patricia Kapunan, LT Jack McDonnell
Article
sports medicine
The Preparticipation Sports Evaluation
Andrew R. Peterson, MD,
MSPH,* David T.
Bernhardt, MD†
Author Disclosure
Drs Peterson and
Bernhardt have
disclosed no financial
relationships relevant
to this article. This
commentary does not
contain a discussion
of an unapproved/
Objectives
After completing this article, readers should be able to:
1. Perform a preparticipation history and physical examination and identify children and
adolescents who may be at increased risk of morbidity or mortality from sports
participation.
2. Recognize that many adolescents make infrequent contact with the medical system
and that the mandatory preparticipation evaluation serves as an opportunity to address
medical issues not necessarily associated with sports participation.
3. Know the conditions that should be evaluated by a cardiologist before sports
participation.
4. Discuss the importance of assessing and documenting neurocognitive function in a
preparticipation sports examination.
5. Understand that disqualification from one sport does not imply disqualification from
all sports.
investigative use of a
commercial
product/device.
Introduction
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
Abbreviations
go play with their friends. The clinician should coordinate and
address the goals of parents, athletes, and organizations while
ADHD: attention-deficit/hyperactivity disorder
promoting safe participation in physical activity.
AHA: American Heart Association
The utility of the sports preparticipation evaluation (PPE) has
DM1: type 1 diabetes mellitus
been
questioned in recent years. Very few athletes are disqualified
EIB:
exercise-induced bronchospasm
from
sports on the basis of findings from the PPE. In the largest
NCT: neurocognitive testing
evaluation
of the PPE, only 1.9% of 2,729 high school athletes
PPE: preparticipation evaluation
were
disqualified
from sports participation and only 11.9% required
TUE: therapeutic use exemption
any
type
of
follow-up
evaluation. (3) A recent systematic review of
VCD: vocal cord dysfunction
the literature identified 310 studies of the PPE and concluded that
*Department of Pediatrics, University of Iowa, Iowa City, IA.
†
Departments of Pediatrics and Orthopedics and Rehabilitation, University of Wisconsin, Madison, WI.
Pediatrics in Review Vol.32 No.5 May 2011 e53
Downloaded from http://pedsinreview.aappublications.org/ by John McDonnell on July 1, 2016
sports medicine
preparticipation sports evaluation
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.
Structure of the Evaluation
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 middleschool 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.
Obtaining the Medical History
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
e54 Pediatrics in Review Vol.32 No.5 May 2011
sports medicine
Figure 1. History form for preparticipation evaluation.
sports medicine
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.
Cardiovascular
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 AHArecommended 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.
Musculoskeletal
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.
Medications
A review of the athlete’s list of current and past medications may provide clues to chronic or recurring medical
conditions that may affect sports participation. In addition, the athlete’s institution or governing sports federation may ban some medications and substances. A comprehensive review of banned substances is beyond the
scope of this article. In general, the athlete is responsible
for knowing what medications may be banned in his or
her sport. The clinician may assist athletes by directing
them to their governing body’s website and banned
substance list. Physicians who frequently care for
college-, national-, and international-level athletes
should be aware of the substances that are banned by the
National Collegiate Athletic Association (15) and the
World Anti-Doping Agency. (16) Comprehensive lists of
banned substances can be found at: http://www.
ncaa.org/wps /wcm/connect/public/ncaa/studentathlete⫹experience/ncaa⫹banned⫹drugs⫹list and
http://www.wada-ama.org/en/World-Anti-DopingProgram/.
Some medications can be taken if the athlete has a
therapeutic use exemption (TUE) on file. In some cases,
special testing may need to be obtained to meet the
requirements of the TUE. TUEs should be filed well
before the start of the season to avoid the possibility of
miscommunication or a gap in treatment of chronic
medical conditions. Often, a permitted medication can
be substituted for a banned substance.
Use of alcohol, tobacco, and other recreational drugs
is common among teenagers, including athletes. It is
useful to discuss these substances when discussing medications, vitamins, and supplements that the athlete may
be taking.
sports medicine
Dermatologic
The 12-element American Heart
Association Recommendations for
Preparticipation Cardiovascular Screening
of Competitive Athletes
Athletes in certain sports are at addiTable.
tional risk for dermatologic conditions
associated with their environment or
contact with other athletes. Open
wounds should be cleaned and covered for practice and play to reduce the
risk of blood-borne pathogen transMedical History
mission. Methicillin-resistant Staphylo• Personal history
coccus aureus infections have received
–Exertional chest pain/discomfort
–Unexplained syncope/near-syncope
considerable attention because they
–Excessive exertional and unexplained dyspnea/fatigue associated with
can result in necrotizing fasciitis, sepexercise
sis, and even amputation. Skin infec–Prior recognition of a heart murmur
tions such as impetigo, molluscum
–Elevated systemic blood pressure
contagiosum, tinea, and herpes sim• Family history
–Premature death (sudden and unexpected, or otherwise) before age 50
plex infection are common in sports
years due to heart disease in first-degree relative
that involve close skin-to-skin contact,
–Disability from heart disease in a close relative younger than 50 years of
such as wrestling and rugby. Each of
age
these conditions requires treatment to
–Specific knowledge of certain cardiac conditions in family members:
minimize the risk of transmission.
hypertrophic or dilated cardiomyopathy, long QT syndrome and other ion
channelopathies, Marfan syndrome, and clinically important arrhythmias
Many sport federations have specific regulations for how skin infecPhysical Examination
tions should be treated and how long
• Heart murmur
athletes should be asymptomatic or
• Femoral pulses to exclude aortic coarctation
under treatment before returning to
• Physical stigmata of Marfan syndrome
• Brachial artery blood pressure (sitting position)
practice and competition. Some athletes and teams use prophylactic doses
Data from American Heart Association, Inc.
of antiviral medications, such as acyclovir, for prevention of herpes outically, the clinician should ask about any type of head
breaks during the season. This practice has not been
injury, feeling “dazed” or “foggy,” memory loss, headsystematically evaluated but anecdotally does seem effecaches following a hit to the head, difficulty playing or
tive for decreasing herpes gladiatorum transmission
practicing following a hit to the head, and any type of
among wrestlers.
injury that resulted in a loss of consciousness. The cliniAthletes who practice and compete in the sun should
cian should be attuned to the fact that the presenting
use a sun block lotion to minimize their risk of sun
signs and symptoms of concussion can be subtle.
damage and skin cancer. Controversy surrounds the apIf the athlete does provide a history of concussion,
propriate sun protection factor for outdoor athletes. In
more detailed questioning is required to determine the
general, any over-the-counter sun block applied liberally
presence or absence of frequent concussions, prolonged
and frequently provides sufficient protection. Athletes
postconcussion symptoms, and concussions that ocwho have already had significant sun exposure require a
curred with seemingly trivial trauma. Athletes who have
careful examination of the sun-exposed skin to monitor
had rare, mild concussions that resolved spontaneously
for skin cancer and precancerous lesions.
do not need additional evaluation. For athletes who have
had frequent concussions, are more easily concussed, or
Neurologic
have had prolonged postconcussive symptoms, careful
Although sports-related concussions are most common
discussion with the athlete and family is necessary to
in contact and collision sports, all athletes should be
understand the risks of repeated concussions. A sympasked about a personal history of concussion or other
tomatic athlete should never be allowed to return to play,
head injury. Often, directed questions about head injuand a graduated, stepwise approach should be used for
ries are required to elicit a history of concussion because
returning to physical activity. (17)
many athletes do not consider an injury in which there
Obtaining baseline computer-based neurocognitive
was no loss of consciousness to be a concussion. SpecifPediatrics in Review Vol.32 No.5 May 2011 e57
sports medicine
testing (NCT) before the start of the season is controversial. Although clinical assessment should be the mainstay of concussion evaluation, NCT increases the sensitivity for detecting residual concussion symptoms. (18)
Specifically, if baseline NCT is available when a concussed athlete clinically appears ready to return to play,
repeat NCT can provide an objective measurement of his
or her recovery. However, NCT has poor specificity for
concussion, and the utility of postinjury NCT in an
athlete who does not have a baseline study is controversial.
“Stingers,” also called “burners,” are injuries to the
brachial plexus caused either by direct trauma or a traction injury. Symptoms are typically brief. Athletes who
have had stingers with persistent symptoms of arm pain,
paresthesia, or weakness may have more significant injuries to the brachial plexus or cervical nerve root injury.
No athlete should be permitted to return to practice or
play who has persistent symptoms.
Cervical cord neurapraxia, also called transient quadriplegia, is a frightening condition characterized by temporary loss of motor control, with or without loss of
sensation or paresthesia, caused by transient compression
of the cervical spinal cord due to forced hyperextension,
hyperflexion, or axial loading. The condition is more
common in athletes who have cervical spinal stenosis.
(19) Episodes are transient and typically last less than
15 minutes. It is very rare for symptoms to last longer
than 48 hours. There is no increased risk of permanent
spinal cord injury following a single episode, (19)(20)
but athletes who have multiple episodes or persistent
symptoms require additional evaluation. Those who are
found to have instability, fractures, or degenerative
changes in the cervical spine should not be allowed to
return to contact or collision sports. Although athletes
who have cervical spinal stenosis are at increased risk of
cervical cord neurapraxia, it is unknown if they are at
increased risk for permanent spinal cord injury. Whether
athletes who have spinal stenosis should be allowed to
play contact sports is controversial and should be evaluated on a case-by-case basis by a qualified physician.
Heat Illness
Heat illness kills more than 1,000 people in the United
States every year. (21) Athletes who have had a history of
heat illness are at risk for future heat illness, including
heat stroke. Once identified, the athlete can take measures to assure proper hydration and acclimatization to
minimize their risk. In addition, stimulants and antihistamines increase the risk of heat illness and should be
avoided, if possible, during training and competition in
warmer weather.
Ophthalmologic
Athletes who require corrective lenses for sports participation may need to work with an optometrist or ophthalmologist to ensure that they have appropriate lenses for
sport. Some sports, such as wrestling, boxing, and rugby,
do not allow eyewear, so athletes in need of corrective
lenses must use contact lenses. Athletes whose bestcorrected vision is worse than 20/40 in one eye (also
referred to as “functionally one-eyed”) must wear American Society for Testing and Materials-approved protective eyewear. (22)
Athletes who practice and compete in the sun or on
the snow should wear ultraviolet-blocking eyewear to
prevent acute photoretinitis and possibly decrease the
chance of developing cataracts. In addition, any baseline
ocular abnormality or normal variant should be documented. Being aware of baseline anisocoria or abnormally shaped pupils can help to prevent an unnecessary
evaluation if the athlete presents later with a head or eye
injury.
Pulmonary
Athletes who have baseline lung disease may require
additional evaluation or a change in their treatment
regimen before the season. Athletes who have known
EIB should have an active prescription for a bronchodilator such as albuterol. Such athletes may benefit from
having multiple inhalers to keep in multiple settings,
such as at home, at school, and with their coach or
athletic trainer. In general, athletes who have isolated
EIB do not benefit from inhaled corticosteroids. However, there is significant overlap between asthma and
EIB. In general, if an athlete has symptoms in other
settings and the EIB is poorly controlled with bronchodilator monotherapy, adding a controller medication,
such as an inhaled corticosteroid, may be beneficial. (23)
Some athletes compete in sports or under federation
rules that require them to obtain a TUE before using
bronchodilators. As mentioned, it is important to obtain
appropriate pulmonary function tests and to complete
the TUE paperwork well in advance of the season.
Vocal cord dysfunction (VCD) is another common
respiratory complaint among athletes. Triggers or associated risk factors for VCD include allergic rhinitis, gastroesophageal reflux disease, anxiety, and poorly controlled asthma. The diagnosis can be made with a history
of isolated inspiratory stridor (typically worse in competition situations) or with laryngoscopy. Most athletes can
sports medicine
control their symptoms with special breathing techniques that require intensive teaching and are best taught
by speech therapists or other professionals who are familiar with VCD. Like other chronic medical conditions,
gaining control of VCD symptoms before the start of the
sports season is important for increasing the likelihood of
success.
A history of other chronic pulmonary diseases, such as
cystic fibrosis or chronic lung disease due to bronchopulmonary dysplasia, should not automatically disqualify a
child or adolescent from sports participation. Careful
partnership and close follow-up with a pulmonologist or
other clinician who is familiar with the specific disorder is
essential. It may be reasonable to dissuade children and
adolescents who have severe lung disease from participating in sports that impose a high cardiovascular demand
and steer them toward sports in which they are more
likely to find success.
Gastrointestinal
Although gastrointestinal complaints are common
among children and adolescents, very few require disqualification or modified sports participation. Diarrhea
may put the athlete at increased risk of dehydration, but
dehydration usually can be prevented with increased fluid
intake. Gastroesophageal reflux disease can worsen with
increased physical activity but usually can be controlled
with diet modification. Gastric acid-suppressing medications (histamine-2 receptor blockers and proton pump
inhibitors) may be necessary in some patients. Because
inflammatory bowel disease can cause a profound anemia
that can make physical activity more difficult and impair
performance, close follow-up with a gastroenterologist
to help ensure good control of symptoms is essential.
Infectious Disease
Mononucleosis and mononucleosis-like infection caused
by viral infections (typically Ebstein-Barr virus, but occasionally cytomegalovirus) can cause splenomegaly and
put the athlete at increased risk for splenic rupture. Any
athlete who has mononucleosis should be disqualified
from practice and competition in any sport in which
there is a risk of abdominal trauma. Most athletes are safe
to return to sport by 3 to 4 weeks after the start of
symptoms. (24)
Blood-borne pathogens, including human immunodeficiency virus and infectious hepatitis, should not
prompt disqualification from sports. (25) The athlete
may participate in any sport that his or her health allows.
Universal precautions should be used for all athletes, and
skin lesions should always be covered properly, regardless
of any known or suspected infectious disease.
Genitourinary
Few components of the genitourinary history should
disqualify an athlete or require modified participation.
Athletes who have a solitary or horseshoe kidney require
individual assessment for contact and collision sports.
(26) Protective equipment may be necessary to protect
the remaining kidney, and the risks of injury should be
weighed carefully against the benefits of contact or collision sport participation. Inguinal hernias may worsen
with increased physical exertion, especially in sports such
as weightlifting that impose a high static demand (increased muscle tension with relatively no change in muscle length or joint mobility). Females who experience
amenorrhea or oligomenorrhea should be assessed for
eating disorders and impaired bone health. Female adolescents who exercise intensively or play sports (especially
those sports that emphasize leanness) are at risk for
developing the “female athlete triad” of disordered eating, amenorrhea, and osteoporosis that is associated with
significant health problems later in life.
Psychological
Eating disorders are common among athletes in weightrestricted and esthetic sports. Many athletes do not meet
diagnostic criteria for anorexia nervosa or bulimia nervosa but clearly have disordered eating patterns. They
can be diagnosed as having eating disorder not otherwise
specified, which has been included in the most recent
version of the Diagnostic and Statistical Manual of Mental Disorders. (27) Screening for disordered eating
should be performed as part of every PPE. Several validated screening instruments are available, but the most
commonly used is the 26-item Eating Attitudes Test.
(28) Screening tools for disordered eating generally assess the patient’s body image and screen for abnormal
eating behaviors, such as irrational avoidance of certain
foods, ritualistic approaches to meals (eg, very slow eating, cutting food into very small pieces, extraordinary
calorie counting), vomiting, or engaging in excessive
exercise after meals.
Disordered eating is one of the three elements of the
female athlete triad, along with amenorrhea and decreased bone mineral density. The presence of any one of
these conditions should prompt the clinician to evaluate
for the other two. The female athlete triad puts the
athlete at risk for stress fractures. Although not an absolute contraindication to sports participation, complications of an eating disorder (including electrolyte abnorPediatrics in Review Vol.32 No.5 May 2011 e59
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malities and cardiac rhythm disturbances) need to be
monitored. A multidisciplinary team, including physicians, dietitians, and mental health professionals, is essential for the necessary care of an athlete who has an eating
disorder.
Depression and anxiety are common mental health
problems that can appear in athletes. Unless severe, these
conditions should not disqualify the athlete from sports
participation. Mental health professionals may help the
athlete to cope better with his or her psychological
symptoms. Often, athletes can be persuaded to use mental health services by discussing the possible performance
improvements that might come from controlling their
depression or anxiety.
The prevalence of attention-deficit/hyperactivity disorder (ADHD) among athletes is similar to the prevalence among other children and adolescents of the same
age. Stimulant medications are a common treatment but
may require a TUE or documentation of ADHD testing
before the start of the sports season.
Immunization
The PPE provides an opportunity to review the immunization history and provide catch-up immunizations.
Although missing immunizations should not be criteria
for sports disqualification, athletes and clinicians should
be aware that some immunizations are required by
schools and colleges for enrollment. In addition, athletes
who are competing internationally may need documentation of specific immunizations to gain entry into certain
countries.
have mild-to-moderate hypertension (⬎95th percentile
for age, sex, and height) require evaluation but should be
encouraged, rather than prohibited, from participating in
sports. Athletes who have severe hypertension (characterized as ⬎5 mm Hg over the 99th percentile for age,
sex, and height) should be disqualified from sports characterized by a high static demand and avoid heavy weight
training and powerlifting. (29)(30)
Head and Neck
Corrected visual acuity should be better than 20/40 in
both eyes. If not, protective lenses are required for contact sports participation. (22) Auricular cartilage damage
should prompt the clinician to remind the athlete to use
ear protection for sports such as wrestling and rugby.
Nasal septum damage should prompt referral to an otolaryngologist. Dental carries may indicate overuse of
sports drinks or eating disorders such as bulimia.
Cardiovascular
The AHA-recommended elements of the cardiovascular
evaluation are listed in the Table. In general, any cardiac
abnormality that is not clearly benign should be fully
evaluated before sports participation. A pediatric cardiologist who is familiar with the demands of sport participation should perform the follow-up evaluation. It is best
to avoid ordering echocardiography and other advanced
cardiac testing from facilities that are unfamiliar with
congenital heart disease and sport participation in children.
Genitourinary
The Physical Examination
The PPE physical examination varies little from the standard health supervision evaluation, although a few components require additional attention in the athlete.
Vital Signs
The vital signs of an athlete may be different from what a
clinician is used to seeing in nonathletes. A child or
adolescent who has a high degree of cardiovascular fitness may have bradycardia and a wide pulse pressure.
Respiratory rate may be lower than expected when resting but may be elevated for several hours after exercise.
Body mass index may be an inaccurate method of screening for overweight and obesity in some athletes who are
very muscular. The blood pressure should be normal.
Elevated blood pressure in children and adolescents,
regardless of sports participation, requires evaluation and
treatment. For idiopathic or “essential” hypertension,
one of the first-line treatments is exercise. Athletes who
The female genitourinary examination is not a standard
part of the PPE. However, any concerns raised by findings on the patient’s history should be evaluated appropriately. Males should have two descended testicles. Any
male who has an undescended or absent testicle should
be evaluated by a urologist. Athletes who have only one
functional testicle may participate in all sports but should
be encouraged to use a protective cup to decrease the risk
of injury in contact or collision sports. The PPE allows
the clinician an opportunity to discuss testicular selfexamination with the older adolescent. Males who have a
history of groin pain should be evaluated for an inguinal
hernia with a digital examination of the inguinal ring.
Asymptomatic athletes do not need to be screened for
hernias. (5)
Dermatologic
Any infectious skin condition should be treated before
the athlete’s return to sport. Any skin lesions that are
sports medicine
suspicious for malignancy should be removed and evaluated by a pathologist.
Neurologic
Any history of neurologic injury, including concussions
and stingers, should prompt a detailed neurologic evaluation. The assessment should include cognitive function, cranial nerves, sensation, strength, tone, reflexes,
and cerebellar function. Any abnormality should be evaluated thoroughly before sports participation.
Musculoskeletal
Clinicians often feel compelled to perform a detailed
musculoskeletal examination on athletes who present for
a PPE. However, as discussed, the physical examination
adds little diagnostic value to the orthopedic history.
(14) A cursory evaluation of strength and range of motion is sufficient for athletes who have no musculoskeletal
complaints. Focused, detailed examinations of specific
joints can be reserved for evaluating previous injuries or
current complaints.
The Laboratory Evaluation
No screening laboratory or imaging tests are required as
part of a routine PPE. Significant controversy surrounds
the use of screening echocardiography and electrocardiography to detect occult congenital heart disease. (13) In
addition, the utility of testing for hemoglobinopathies,
anemia, bleeding disorders, infectious diseases, cardiovascular risk factors (such as hypercholesterolemia), and
other chronic diseases that may affect athletic performance or general health is unclear.
and uncommon medical conditions affect sports participation should see the American Academy of Pediatrics
Council on Sports Medicine and Fitness’s report on
“Medical Conditions Affecting Sports Participation.”
(26)
Seizures
The child or adolescent who has a well-controlled seizure
disorder should not be disqualified from sports participation. (26) In these athletes, the risk of having a seizure
during practice or competition is very low, partially due
to their already low seizure frequency but also due to the
antiepileptic effects of exercise. It is sometimes surprising
to officials and policy makers that athletes who have
known seizure histories can be allowed to participate in
contact and collision sports and in sports where they
would seem to be at increased risk of injury should they
have a seizure. The clinician may need to advocate for the
athlete in such situations. A useful point of reference is
the individual state’s legal seizure-free interval before
individuals who have epilepsy are allowed to return to
driving. In most states, it is 3 to 6 months.
Children and adolescents who have poorly controlled
epilepsy also benefit from physical exercise, but more care
must be taken to ensure the safety of these athletes and
those around them. An individual assessment should be
made to determine the athlete’s suitability for contact
and collision sports. The following sports should be
avoided:
●
●
●
Special Situations
●
Fewer than 2% of PPEs result in disqualification of the
athlete from sport. However, many medical conditions
require adaptation or close monitoring for complications
related to sports participation. In addition, sporting activities are heterogeneous in their physical and cardiovascular demands as well as in their level of contact. Certain
medical conditions may be incompatible with particular
static or dynamic (changes in muscle length or joint
mobility with relatively small change in muscle tension)
demands or with the risks associated with contact or
collision sports. A comprehensive review of the medical
conditions affecting sports participation is beyond the
scope of this article, but several conditions that frequently come to clinical attention during the PPE are
discussed. This list is far from exhaustive, and the reader
who is interested in learning more about the specific
demands of sports participation and how many common
●
●
●
Archery
Power lifting
Riflery
Swimming
Weight lifting
Weight training
Sports involving heights (eg, parachuting, hanggliding)
Down Syndrome
Down syndrome, also known as trisomy 21, is a genetic
syndrome involving multiple congenital anomalies. Children born with Down syndrome often require interdisciplinary care to maximize their health outcomes and
quality of life, regardless of sports participation. Of note,
instability of the cervical spine (primarily atlantoaxial
instability, but also occipitoatlantal instability) has been
reported in up to 30% of patients who have Down
syndrome. (31) The Special Olympics® organization
requires radiographic evaluation of the cervical spine
before sports participation. It is common for patients
sports medicine
who have had normal cervical spine radiographs to acquire cervical instability. For this reason, patients who
have Down syndrome should be prohibited from participating in collision sports regardless of the radiographic
appearance of their spines. However, no other limitations need be imposed for patients who have normal
cervical spine radiographs. Patients who have radiographic evidence of cervical instability but no neurologic
signs or symptoms should be disqualified from “neckstressing” sports. Special Olympics considers diving,
gymnastics, butterfly stroke, high jumping, soccer, and
pentathlon to be “neck-stressing.” Athletes who have
Down syndrome and cervical instability may use a cervical collar, but this practice does not change their sport
restriction.
Down syndrome is associated with other abnormalities that may influence sports participation, such as cardiac abnormalities (septum defects in particular), cataracts, diabetes, thyroid disease, hip and patellar
instability, and foot abnormalities. Each of these conditions, if present, requires evaluation before sports participation. However, no other special precautions need to
be taken for these children.
Acute Febrile Illness
Athletes who have a fever should be prohibited from
practice and competition. (26) Fever puts the athlete at
risk for acute heat illness (due to increased heat storage),
reduced maximal exercise capacity, and hypotension
(due to decreased peripheral vascular tone and possibly
dehydration).
Type 1 Diabetes Mellitus
Athletes who have type 1 diabetes mellitus (DM1) are
permitted to participate in any sport without restriction.
(26) However, DM1 monitoring and treatment often
becomes more complex with the varying demands of
organized sports. Careful evaluation and monitoring of
blood glucose, diet, insulin types and doses, and hydration status are essential. Blood glucose should be
checked more frequently than usual. At a minimum,
athletes who have DM1 should measure their blood
glucose every 30 minutes during continuous exercise,
15 minutes after completion of exercise, and at bedtime.
For optimum control and performance, many athletes
who have DM1 find that they need to measure their
blood glucose and modulate their insulin and carbohydrate intake frequently. Insulin pumps and rapid-acting
insulins have allowed athletes to fine-tune their glycemic
control much more effectively than in the past. It is not
uncommon for athletes who have DM1 to develop com-
plex treatment plans involving both pump and injectable
insulin therapy.
The Disabled Athlete
Disabled athletes may face special challenges, but the
clinician should encourage exercise and sports participation for the same reasons they are encouraged in ablebodied athletes. (5) Good communication among athletes, coaches, parents, and clinicians is essential for
ensuring safe and successful sports participation. The
supplemental history form from the 2010 PPE monograph (Fig. 2) can help to facilitate this communication.
When to Disqualify an Athlete From Sports
Participation
Although most complaints and abnormalities identified
during the PPE are not absolute contraindications to
sports participation, several conditions should prompt
disqualification from sport. Most of these are cardiovascular conditions and have been outlined in the 36th
Bethesda Conference guidelines: (32)
●
●
●
●
●
●
●
●
●
●
●
Pulmonary vascular disease with cyanosis or a hemodynamically significant right-to-left shunt
Severe pulmonary stenosis (untreated)
Severe aortic stenosis or regurgitation (untreated)
Severe mitral stenosis or regurgitation (untreated)
Any cardiomyopathy
Vascular Ehlers-Danlos syndrome
Coronary anomalies (especially anomalous coronary
origins)
Catecholaminergic polymorphic ventricular tachycardia
Acute pericarditis
Acute myocarditis
Acute Kawasaki disease
Although the guidelines from the 36th Bethesda conference only comment on disqualification for these
specific conditions, any cardiovascular disease should
be thoroughly evaluated and treated by a pediatric
cardiologist to ensure the athlete’s safe participation in
sports.
In addition to cardiac abnormalities, any condition
that cannot be well controlled and puts the athlete at risk
of significant injury or death or endangers the health of
teammates or competitors requires further evaluation or
disqualification from sport. For example, a musculoskeletal injury that impairs the athlete’s ability to protect
him- or herself during practice and competition should
prompt disqualification until the athlete is safely able to
return to play. For a discussion of the evaluation and
sports medicine
Figure 2. Supplemental history form for athletes who have special needs.
sports medicine
6. Herbert DL. Legal Aspects of Sports Medicine. 2nd ed. Canton,
Summary
OH: PRC Publishers; 1995
7. Gallup EM. Law and the Team Physician. Champaign, IL:
• In general, the evidence base for the PPE is limited.
(5)
• The clinician should coordinate and address the
goals of parents, athletes, and organizations while
promoting safe participation in physical activity.
• Based on at least fair evidence, the PPE does little to
prevent morbidity and mortality in athletes. (4)
• Based on expert opinion, the PPE is best performed
well in advance of the competitive season. (5)
• Based on expert opinion, the office-based PPE is
preferable to the station-based approach. (5)
• Based on at least fair evidence, clinicians should
focus on the medical and musculoskeletal history
because most conditions that affect participation are
elicited from that history. (5)(13)(14)
• Based on expert opinion, athletes who have suffered
a concussion should not be allowed to return to play
while symptomatic and should follow a stepwise
progression of graduated return to full activity. (17)
• Based on expert opinion, screening echocardiography
and electrocardiography should not be routine parts
of the PPE. (13)
• Based on expert opinion, athletes who have lost a
paired organ may compete in any sport with proper
protective equipment. (22)(26)
• Based on expert opinion, most athletes who have
chronic medical conditions can compete safely in
most sports. (26)
management of specific sports-related injuries, please see
the recent Pediatrics in Review article, “Managing Sports
Injuries in the Pediatric Office.” (33)
In performing the PPE, the clinician’s first responsibility is to ensure the health and safety of the patient.
However, the physical and psychological benefits of exercise and sport participation should weigh heavily on
decisions to disqualify an athlete from sport.
References
1. Garrick JG. Preparticipation orthopedic screening evaluation.
Clin J Sport Med. 2004;14:123–126
2. Garrick JG, Requa RK. Injuries in high school sports. Pediatrics.
1978;61:465– 469
3. Smith J, Laskowski ER. The preparticipation physical examination: Mayo Clinic experience with 2,739 examinations. Mayo Clin
Proc. 1998;73:419 – 429
4. Hulkower S, Fagan B, Watts J, Ketterman E, Fox BA. Clinical
inquiries: do preparticipation clinical exams reduce morbidity and
mortality for athletes? J Fam Pract. 2005;54:628 – 632
5. Bernhardt DT, Roberts WO, American Academy of Family
Physicians, American Academy of Pediatrics. PPE: Preparticipation
Physical Evaluation. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2010
Human Kinetics Publishers; 1995
8. Murphy v Blum, 160 AD 2d 914: NY, Apellate Div, (1990)
9. Risser WL, Hoffman HM, Bellah GG Jr. Frequency of preparticipation sports examinations in secondary school athletes: are the
University Interscholastic League guidelines appropriate? Tex Med.
1985;81:35–39
10. Carek PJ, Futrell M, Hueston WJ. The preparticipation physical examination history: who has the correct answers? Clin J Sport
Med. 1999;9:124 –128
11. Singh A, Silberbach M. Consultation with the specialist: cardiovascular preparticipation sports screening. Pediatr Rev.
2006;27:418 – 424
12. Vitiello R. Commentary: the value of the ECG in the preparticipation sports physical examination: the Italian experience. Pediatr Rev. 2006;27:e75– e76
13. Maron BJ, Thompson PD, Ackerman MJ, et al. Recommendations and considerations related to preparticipation screening for
cardiovascular abnormalities in competitive athletes: 2007 update: a
scientific statement from the American Heart Association Council
on Nutrition, Physical Activity, and Metabolism: endorsed by the
American College of Cardiology Foundation. Circulation. 2007;
115:1643–1455
14. Gomez JE, Landry GL, Bernhardt DT. Critical evaluation of
the 2-minute orthopedic screening examination. Am J Dis Child.
1993;147:1109 –1113
15. NCAA Drug Testing Program. Accessed February 2011 at:
http://www.ncaa.org/wps/wcm/connect/public/ncaa/studentathlete⫹experience/ncaa⫹banned⫹drugs⫹list
16. World Anti-Doping Agency. Accessed February 2011 at:
http://www.wada-ama.org/
17. McCrory P, Meeuwisse W, Johnston K, et al. Consensus
statement on concussion in sport: the 3rd International Conference
on Concussion in Sport held in Zurich, November 2008. Br J Sports
Med. 2009;43(suppl 1):i76 –i90
18. Van Kampen DA, Lovell MR, Pardini JE, Collins MW, Fu FH.
The “value added” of neurocognitive testing after sports-related
concussion. Am J Sports Med. 2006;34:1630 –1635
19. Pavlov H, Torg JS, Robie B, Jahre C. Cervical spinal stenosis:
determination with vertebral body ratio method. Radiology. 1987;
164:771–775
20. Torg JS, Pavlov H, Genuario SE, et al. Neurapraxia of the
cervical spinal cord with transient quadriplegia. J Bone Joint Surg
Am. 1986;68:1354 –1370
21. Centers for Disease Control and Prevention. Heat-related
Deaths — United States, 1999 –2003. MMWR Morb Mortal Wkly
Rep. 2006;55:796 –798
22. Protective eyewear for young athletes. Pediatrics. 2004;113:
619 – 622
23. Expert Panel Report 3 (EPR-3): guidelines for the diagnosis
and management of asthma-summary report 2007. J Allergy Clin
Immunol. 2007;120(5 suppl):S94 –S138
24. Putukian M, O’Connor FG, Stricker P, et al. Mononucleosis
and athletic participation: an evidence-based subject review. Clin
J Sport Med. 2008;18:309 –315
25. Committee on Sports Medicine and Fitness. American Academy of Pediatrics. Human immunodeficiency virus and other
blood-borne viral pathogens in the athletic setting. Pediatrics.
1999;104:1400 –1403
sports medicine
26. Rice SG. Medical conditions affecting sports participation.
Pediatrics. 2008;121:841– 848
27. American Psychiatric Association Task Force on DSM-IV. Diagnostic and Statistical Manual of Mental Disorders. DSM-IV-TR. 4th
ed. Washington, DC: American Psychiatric Association; 2000
28. Garner DM, Olmsted MP, Bohr Y, Garfinkel PE. The Eating
Attitudes Test: psychometric features and clinical correlates. Psychol
Med. 1982;12:871– 878
29. McCambridge TM, Benjamin HJ, Brenner JS, et al. Athletic
participation by children and adolescents who have systemic hypertension. Pediatrics. 2010;125:1287–1294
30. The fourth report on the diagnosis, evaluation, and treatment
of high blood pressure in children and adolescents. Pediatrics.
2004;114(2 suppl):555–576
31. Winell J, Burke SW. Sports participation of children with
Down syndrome. Orthop Clin North Am. 2003;34:439 – 443
32. Pelliccia A, Zipes DP, Maron BJ. Bethesda Conference
#36 and the European Society of Cardiology consensus recommendations revisited: a comparison of U.S. and European criteria for eligibility and disqualification of competitive athletes with
cardiovascular abnormalities. J Am Coll Cardiol. 2008;52:
1990 –1996
33. Metzl JD. Managing sports injuries in the pediatric office.
Pediatr Rev. 2008;29:75– 84
HealthyChildren.org Parent Resources from AAP
The reader is likely to find material to share with parents that is relevant to this article by
going to this link: http://www.healthychildren.org/English/healthy-living/sports/
Pages/default.aspx
2-Minute Orthopedic Exam
1
STEP 1: Patient stands straight with arms at
sides, facing examiner.
3
Normal findings: symmetry of upper and
lower extremities and trunk.
Common abnormalities: Enlarged AC joint,
enlarged sterno-clavicular joint, asymmetric
waist (leg-length difference or scoliosis),
swollen knee and swollen ankle.
STEP 2: Patient looks at the ceiling, looks
at the floor, touches right/ left ear to
shoulder and looks over right/ left shoulder.
Normal findings: patients should be able to
touch chin to chest, ears to shoulders and
look equally over the shoulders.
Common abnormalities: loss of flexion, loss
of lateral bending and loss of rotation— may
indicate previous neck injury.
2
STEP 3: Patient stands in front of
examiner with arms at side. Examiner
tries to hold shoulder down while
patient tries to shrug.
Common abnormalities include
atrophy or weakness of muscles
indicating shoulder, neck or trapezius
nerve abnormalities.
STEP 4: Patient holds arms
out from sides horizontally
and tries to lift them (while
examiner holds arms down).
Normal findings: strength
should be equal in both arms,
and deltoid muscles should
be equal in size.
Common abnormalities: loss
of strength and wasting of
the deltoid muscle.
4
STEP 5: Patient holds arms out from
sides with elbows bent at 90 degrees;
patient raises hands vertically as far as
they will go.
6
Normal findings: Hands go back
equally and at least to upright vertical
position.
Common abnormalities: loss of
external rotation, which may indicate
shoulder problem or old dislocation.
STEP 6: Patient holds arms out from sides, palms
up, and completely straightens and bends elbows.
Normal findings: motion should be equal on left
and right sides.
Common abnormalities, which include loss of
extension and loss of flexion, may indicate old
elbow injury, dislocation, fractures, etc.
5
STEP 7: Patient holds arms down at sides with elbows bent
at 90 degrees, then twists palms up and down.
8
Normal findings: palms should go from facing the ceiling to
facing the floor.
Common abnormalities, which include lack of full supination
and full pronation, may indicate an old injury of the forearm,
wrist or elbow.
STEP 8: Patient makes a fist, opens the hand
and spreads the fingers.
Normal findings: fist should be tight and
fingers straight when spread.
Common abnormalities, which include a
knuckle protruding from the fist and a
swollen or crooked finger, may indicate old
finger fractures or sprains.
7
10
9
STEP 10: Patient stands up straight
with arms at sides (with back to the
examiner).
Normal findings: symmetry of
shoulders, waist, thighs and calves.
STEP 9: Patient squats on heels,
duck-walks four steps and stands up.
Common abnormalities include high
shoulder (scoliosis) or low shoulder
(muscle loss), prominent rib cage
(scoliosis), high hip or asymmetric
waist (leg-length difference or
scoliosis), and small calf or thigh
(weakness from an old injury).
Normal findings: maneuver is
painless, heel-to-buttock distance is
equal on left and right sides and knee
flexion is equal during the walk.
inability to fully flex one knee and
inability to stand up without twisting
or bending to one side.
STEP 11: Patient bends forward
slowly with knees straight and
touches the toes.
11
12
STEP 12: Patient stands on the heels
and then rises up on the toes.
Normal findings: patient bends
forward straightly and smoothly.
Normal findings: equal elevation on
right and left sides, symmetry of calf
muscles.
patient twisting to one side (low back
pain) and asymmetric back (scoliosis).
wasting of calf muscles (Achilles
injury or old ankle injury).
Classification of Sports According to Contact
(Compare to Table 3—Classification According to Type of Exercise— in Sports Physical II)
Sports Physical I Quiz
1. Which of the following is/are the goal(s) of the Sports PPE? Are these goals actually met?
A.
B.
C.
D.
E.
Fulfill a school or league’s legal and liability requirements
Provide some assurance to coaches that athletes are healthy and fit
Provide an opportunity to discover treatable conditions
Predict and prevent future injuries
All of the above
*B, C, & D may not be met: A literature review concluded that the PPE 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.
2. When is the ideal time for a Sports PPE to be done? At least 6 wks prior to start of practice.
3. How often should the PPE be performed? At least every 2 years, most states require it yearly.
4. What percentage of PPEs results in disqualification for a sport? Fewer than 2%.
5. Review the NCAA List of Banned Substances. Which of the following is/are prohibited? Is
there any “work-around”?
A. Adderall
* Some medications can be taken if the athlete has a
B. Anastrazole
therapeutic use exemption (TUE). Often, a permitted
C. Furosemide
medication can be substituted for a banned substance.
D. Salbutamol
E. All of the above
6. Rate the following conditions based on ability to participate in sports:
Yes, Qualified Yes, Qualified No, No
a. Atlantoaxial Instability: Qual’d Yes
b. Infectious Diarrhea: Qualified No
c. Diabetes Mellitus:
Yes
d. Functionally one-eyed: Qual’d Yes*
e. Fever: No
* May require proper protective equipment
f.
g.
h.
i.
j.
HIV Infection: Yes
Malignant Neoplasm: Qualified Yes
Absent Kidney: Qualified Yes
Obesity: Yes
Absence of ovary/testicle: Yes*
7. What counseling would you give a patient with seizures who wishes to participate in sports?
• Determine type & severity of seizures? Is patient is well-controlled or not?
• Which sports? Patients with uncontrolled seizures may not participate in archery,
power-lifting, riflery, swimming, weight lifting/training, sports involving heights.
• What sort of special protective equipment might they need to participate? (e.g. helmets)
8. What are the requirements for athletes with Down Syndrome? (see Module for further info)
The Special Olympics requires XR of the cervical spine before sports participation to r/o atlantoaxial instability. Regardless of the XR results, T21 athletes should avoid collision sports. If XR
shows cervical instability without neurologic s/s, T21 athletes should avoid “neck stressing”
sports (e.g. diving, gymnastics, high jumping, soccer, pentatholon). Of note, the AAP no longer
recommends screening all children with Down Syndrome prior to sports participation.
Sports Physical I Case
Rebecca is a 14 year-old female coming to see you with her mother for you to fill out her sports
clearance forms for the new school year. She reports that she has always been active in sports in
primary school and summer leagues, but has never played on a truly competitive team before.
She is excited to try out for her new high school’s Volleyball and Track & Field teams.
What further history would you like to know? Every person at the table should list 1 item:
•
•
•
•
•
•
•
•
Past medical, surgical, family, social, developmental histories
Past history of CV symptoms: e.g. syncope, near-syncope, dizziness, exercise intolerance, chest
pain, palpitations, SOB or fatigue with exertion, or any symptoms with exercise (see Table: 12element AHA Recommendations for Pre-participation CV Screening)
Past history of or current MSK injuries (especially those involving medical evaluation, casting,
bracing, surgery, or missing practice/play)
Medications, supplements, substances. History of eating disorder.
Personal history of skin conditions: impetigo, molluscum, tinea, HSV, MRSA
Personal history of concussion or head injury, including frequency, number, circumstances, postconcussive symptoms, and any current or persistent symptoms
History of heat illness/injury. Use of corrective lenses
Past history of Pulm symptoms: asthma, symptoms of exercise-induced bronchospasm
What family history is particularly important to elicit?
Cardiovascular history, especially history of sudden or unexpected death before age 50 (e.g. drowning,
unexplained MV crash, seizures), congenital heart disease, arrhythmias or pro-arrhythmic diseases (Long
QT, WPW, Brugada), cardiomyopathy, Marfan Syndrome.
Her vital signs are all normal for age. Her height is 66 in and her weight is 100 lbs. What is her
BMI and the percentile? Is this normal for her age? Are you concerned? Why or why not?
•
•
16.1 kg/m2, 6th %ile (See Growth Chart, HERE)
BMI is low, <10%ile for age. Concerned for possible eating disorder in this female athlete. Look
at past growth trends, discuss her current eating habits and exercise regimen. Think femaleathlete triad: disordered eating, amenorrhea, and osteoporosis.
What is especially important to include as part of your physical exam of this athlete?
•
•
Good cardiovascular exam, listening both supine and sitting, and possibly squatting.. Make sure
BP is part of your vitals.
Orthopedic exam and ROM of major joints. 2-minute orthopedic exam is good general screening.
Can then do specific joint maneuvers if history of injury or any abnormalities.
Will you order any screening laboratory or imaging tests on this athlete?
In general, no lab or imaging tests are required as part of a routine PPE. Because we identified possible
F.A.T., would consider further evaluation with CBC, CMP, U/A, TFTs. If amenorrhea, would consider
LH, FSH, E2, PRL, hCG, and DEXA (see Nutrition III).
Would you clear her to participate in sports?
It depends. . . If patient’s weight is normal and stable, and she is not participating in dangerous
compensatory behaviors (e.g. purging, laxative abuse), it is reasonable to clear her to participate with
close monitoring. In contrast, if clear ED, then should be excluded from all activities. Ability to
participate in sports may be a good motivator for behavior change.
Sports Physical I Board Review
1. You are seeing a 15-year-old girl for her annual health supervision visit. Her menarche occurred at age
12 years, and she had normal monthly menses over the first 2 years. In the last year, however, her periods
became progressively more irregular and stopped 4 months ago. Her mother notes that the girl has been
very health-conscious since she entered puberty. She has gained no weight over the last 3 years and is on
the cross-country team at school. On physical examination, her body mass index is 17 kg/m2, her heart
rate is 55, she has no acne or hirsutism, and she is at SMR 5 genital development. The remainder of the
physical exam is normal.
Of the following, the MOST likely cause of this girl's amenorrhea is
A. ergogenic agents
B. exercise regimen
C. heart disease
D. physiologic anovulation
E. school stress
The American College of Sports Medicine coined the term "the female athlete triad" in 1992. It comprises
three interrelated components: disordered eating, amenorrhea, and osteoporosis. The risk of the disorder is
greatest among those participating in endurance sports. Athletes are distributed along a spectrum between
health and disease, and those at the pathologic end may not exhibit all of the components simultaneously.
The girl described in the vignette has amenorrhea that is related to her exercise and inadequate nutrition.
Nutrition issues underlie most of the pathophysiology of the female athlete triad. Energy availability is
defined as dietary energy intake minus exercise energy expenditure. Exercise-induced amenorrhea can be
an indicator of decreased energy availability that may be inadvertent, intentional, or psychopathological.
Bone density loss results from the low estrogen environment and is concerning because 50% of adult
skeletal mass is laid down during adolescence, with peak bone mass attained between 18 and 25 years.
The first aim of treatment for any triad component is to increase energy availability by increasing energy
intake, reducing exercise energy expenditure, or both. Nutrition counseling and monitoring are sufficient
for many athletes, but significantly disordered eating warrants more intensive intervention. Education of
athletes, parents, coaches, trainers, judges of competitions, and administrators is a priority for prevention
and early intervention. Athletes should be assessed for the triad during pre-participation physical
examination or the annual health screening examination and whenever an athlete presents with any of the
triad's symptoms or signs. Sports administrators should consider rule changes to discourage unhealthy
weight loss practices. Athletes who have eating disorders should be required to meet established weight
criteria to continue exercising, and their training and competition may need to be modified.
Ergogenic aids are dietary supplements used to enhance athletic performance. The most commonly used
are those that have supposed anabolic effects because they mimic the effects of steroids and are legal for
use. Creatine is the most widely used such supplement taken by both professional and recreational
athletes. It causes weight gain from muscle hypertrophy and fluid retention. It does not alter vital signs or
cause menstrual changes. The girl described in the vignette has no symptoms referable to the
cardiovascular system; her low heart rate likely is a result of her inadequate nutrition and exercise. In the
first 2 years following menarche, irregular menses may be the result of immaturity of the hypothalamic
pituitary axis (physiologic anovulation). However, this girl's regular menses in the first 2 years make
physiologic anovulation a less likely cause of the amenorrhea. Psychological stress in an adolescent may
cause amenorrhea, but the history and exam are most consistent with amenorrhea resulting from exercise.
2. As the sports physician for the local high school football team, you are asked to give a lecture to
coaches about medical conditions and safe sports participation. You tell them that some conditions are
relative or absolute contraindications to playing football because of increased risk to the athlete's health.
Of the following, the condition that is a CONTRAINDICATION to playing football is
A. diabetes mellitus
B. febrile illness
C. human immunodeficiency virus infection
D. seizure disorder
E. sickle cell disease
Sports participation can help children and adolescents learn physical fitness and team-building skills.
However, some medical conditions warrant special consideration with regard to participation, and both
the type of sport and nature of the medical condition should be considered when making decisions. Sports
are classified according to contact and intensity, and specific guidelines for participation in each sport
have been outlined in the 36th Bethesda conference.
Absolute contraindications to participation in any sport include carditis, which may result in sudden death
with exertion, and febrile illness, which can result in decreased heat tolerance, increased risk of heat
illness, and dehydration. In addition, fever may be the heralding sign of an underlying condition that may
put the athlete at additional risk during exercise, such as myocarditis, pulmonary infection, or infectious
mononucleosis with splenomegaly. Athletes should avoid sports until the febrile illness has resolved.
Children and adolescents who have diabetes mellitus and sickle cell disease may participate in sports, but
special care should be taken to avoid dehydration and overheating, and blood glucose should be
monitored frequently for those who have diabetes mellitus. Because the risk of transmitting HIV to others
during sports is very low, those who have the infection should be encouraged to participate in sports. Skin
lesions should be covered fully, and sports requiring high skin contact, including wrestling and boxing,
should be avoided if the viral load is elevated. Children who have seizure disorders may participate in
sports, but if seizures are not well controlled, they should avoid sports such as swimming, weightlifting,
riflery, and archery because of risk of harm to themselves or others.
3. A 14-year-old boy presents for a pre-participation sports evaluation for baseball. He plays shortstop.
His mother is very concerned about his playing because of the injuries she has heard about in professional
and collegiate athletes. You explain to her that appropriate equipment, including a batting helmet, is
needed to provide protection for her son.
Of the following, the LARGEST percentage of baseball injuries can be prevented by using
A. a mouth guard
B. a protective cup
C. elbow pads
D. knee pads
E. polycarbonate goggles
More than 50% of all high school students participate in athletics, and injury prevention should be a
mainstay of sports participation for youth. Both parents and coaches should provide and insist on the use
of equipment and safety rules to prevent injury in young athletes. Mouth injuries, along with other head
injuries, account for the majority of injuries (48%) sustained by youth in baseball. Injuries generally are
caused by contact with sports equipment. Most serious injuries result from being struck by a batted ball
and are more common among infield players. Other injuries include those to the leg and groin as well as
the chest. Use of a protective cup in all sports is recommended to prevent testicular injury
Dental and facial injuries may be prevented best by using a mouth guard both in the field and at the plate
in baseball to avoid injury by pitched and batted balls. Plastic and metal helmets with face protection have
been available for batters for several years but are used uncommonly in high school athletics. Clearly, use
of a helmet with face protection is important to prevent cranial injuries for the catcher. Even with the use
of a helmet, mouth guards protect further against injuries of teeth and from teeth to the oral mucosa. The
American Association of Orthodontists recommends that mouth guards be used for the following sports:
baseball, football, soccer, basketball, wrestling, softball, ice and field hockey, volleyball, and lacrosse.
Elbow and knee pads may be helpful in prevention of abrasions and other minor injuries, but they are
unlikely to prevent serious injury. Polycarbonate goggles are recommended for batting, but evidence for
their routine use in fielding is lacking. Eye protection is afforded by most helmets with face protection.
4. A 16-year-old football player presents for evaluation of a 1-week history of fever, progressively
worsening fatigue, and a sore throat. Physical examination shows a tired-appearing teenager who has a
temperature of 38.9°C, moderate tonsillar enlargement with exudates, a liver edge that is palpable 3 cm
below the right costal margin, and a spleen tip that is easily palpable 2 cm below the L costal margin.
Results of the spot test for infectious mononucleosis are positive.
Of the following, the MOST appropriate management for this patient includes
A. avoidance of contact sports
B. bed rest for 1 week
C. oral acyclovir
D. oral amoxicillin
E. oral steroids
The patient described in the vignette has acute infectious mononucleosis (IM), the most common cause of
which is Epstein-Barr virus (EBV), a herpesvirus. Humans are the only source of EBV, and close
personal contact is needed for transmission. The spectrum of disease manifestations is wide, ranging from
asymptomatic to fatal infection. Infections frequently are unrecognized in infants and young children.
Classic IM is an acute illness characterized by the clinical findings of exudative tonsillopharyngitis, fever,
lymphadenopathy, and hepatosplenomegaly. Anorexia, malaise, myalgias, and fatigue are common.
Nonspecific tests for heterophile antibodies frequently are used for diagnosis. The heterophile antibody
response is a transient immunoglobulin M response that is present in about 85% to 90% of cases of EBV
IM in adolescents and adults. The antibody appears during the first 2 weeks of illness and gradually
disappears over a 6-month period. The results of heterophile antibody tests are often negative in children
4 years of age and younger. Serologic testing is used routinely for the detection and diagnosis of EBV.
Treatment of IM is primarily supportive. The patient’s level of activity is tailored to what he or she can
tolerate comfortably. Bed rest may be needed, but there is no specific recommendation for its use and
little evidence to support that this shortens the course of disease or prevents complications. Contact sports
should be avoided until the patient is fully recovered and the spleen no longer is palpable. Neither
ampicillin nor amoxicillin should be given to patients who have suspected mononucleosis because their
use is associated with the development of a nonallergic morbilliform rash in a large proportion of patients,
leading to an incorrect suspicion of allergy. Most importantly, antibiotics do not treat the infection.
The routine use of corticosteroids in patients who have IM is not recommended. A short course of
corticosteroids may be considered only for those who have marked tonsillar inflammation with impending
airway obstruction, massive splenomegaly, myocarditis, hemolytic anemia, or hemophagocytic syndrome.
Even though acyclovir has in vitro against EBV, this agent has no proven value in the treatment of IM.

NCC Pediatrics Continuity Clinic Curriculum: Sports Physical I

Transcription

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