1. Overview of the Sports Preparticipation Physical Jose Yasul, MD CCRMC Martinez, CA

2. Objectives Review why we do a PPE Determine your responsibility Describe the major features of the PPE Familiarize you with the comprehensive musculoskeletal exam

3. Preparticipation Physical Evaluation: Third Edition (2005) Editorial Board: American Academy of Family Physicians American Academy of Pediatrics American College of Sports Medicine American Medical Society for Sports Medicine American Orthopaedic Society for Sports Medicine American Osteopathic Academy of Sports Medicine

4. Perception Viewed in different ways among: Athletes Coaches Parents Athletic Trainers Administrators Physicians

5. My Goal… …is to ensure the student-athlete is healthy to participate in sports If a problem is identified, then it can be addressed I’m not looking for a reason to disqualify or exclude students from participating

6. Objectives of the PPE Primary Screen for conditions that may be life-threatening or disabling Screen for conditions that may predispose to injury or illness Meet administrative requirements

7. Objectives of the PPE Secondary Determine general health Serve as an entry point to the healthcare system for adolescents Provide an opportunity to initiate discussion on health-related topics

8. Timing of evaluation To allow time to treat or rehabilitate any identified problem (>6 weeks prior) Preferably with their PERSONAL PHYSICIAN with access to medical records Good option is midsummer or the end of the previous school year

9. Setting of evaluation Physician’s office versus coordinated team approach In either setting it is preferred that the history and PE be done by the same physician

10. Setting of Evaluation StagePurpose Waiting AreaSign in and review instructions about filling out forms Vitals stationHeight, weight, BP, vision Exam AreaReview history, perform physical, sign out to preceptor OptionalEducational/Rehab areas

11. Tips for coordinated approach Inform athletes in advance about the detailed nature of the exam and the appropriate attire -Sports bras for girls -Shorts for boys Separate areas for examining boys and girls Private counseling room for sensitive issues

12. Tips for coordinated approach Clear protocols for referrals Team physicians or athletic trainers should have a list of disqualified athletes or those who require further evaluation before final clearance If the athlete is not cleared for their desired sport, the evaluating physician should be prepared to counsel on alternative activities

13. PPE Medical History The most crucial component Will identify approximately 75% of problems affecting athletes

14. PPE Medical History Medical History (1-4) Meds & supplements (5-6) Allergies (7) Cardiovascular problems (8-18) Viral illness (17) Dermatological conditions (19) Neurological conditions (20-25) Heat Illness (26) Asthma/allergic rhinitis (27-29) Eyes & Vision (31-32) Anaphylaxis (33) Musculoskeletal injury (34-35) Nutritional concerns (36- 37) General concerns (38-39) Menstrual history (4-44)

15. Questions I ask Did you have any injuries last season – did you miss any games or practices because of an injury? Have you ever passed out while exercising? Has anyone in your family died unexpectedly under the age of 50? Do you find it hard to catch your breath when you exercise? When exercising, do you get tired more quickly than your friends? Do you cramp up easily? Are you taking any supplements?

16. PPE Medical History YOUTH RISK BEHAVIOR Questions to be asked in the exam room Do you feel stressed out or under a lot of pressure? Do you feel so sad or hopeless that you stop your usual routine for more than a few days? Do you feel safe? Have you ever tried cigarette smoking, even 1 or 2 puffs? During the past 30 days have you used smokeless tobacco? During the past 30 days have you had at least 1 drink of alcohol? Have you ever taken steroid pills or shots without a doctor’s rx? Are you taking anything to lose weight or improve your performance? Questions about guns, seatbelts, unprotected sex, D. V., drugs, etc. (Youth Risk Behavior Survey)

18. Physical Examination Vitals, height, weight Eyes Visual acuity (Snellen) Pupils Oral cavity/Ears/Nose Cardiovascular exam >Blood Pressure >Pulses (radial, femoral) >Heart (rate, rhythm, murmur) Lungs Abdomen Genitalia (males only) Cryptorchidism Testicular masses Skin Musculoskeletal exam

19. Blood Pressure NORMAL VALUES FOR KIDS DIFFER FROM ADULTS SBP & DBP are compared by sex, age and height BP is <90 th percentile, child is normotensive BP between 90 th and 95 th percentiles, child is high-normal observe and consider other risk factors BP > 95 th percentile, child may be hypertensive repeated measurements are indicated http://www.cc.nih.gov/ccc/pedweb/pedsstaff/bp.html

20. AHA Recommended Elements of Preparticipation Cardiovascular Screening in Young Athletes Medical history Family Death from heart disease in one or more relatives younger than 50 years Disability from heart disease in a close relative younger than 50 years Hypertrophic or dilated cardiomyopathy, long QT syndrome or other ion channelopathies, Marfan syndrome, or clinically important arrhythmias in any family member Personal Elevated systemic blood pressure Excessive exertional and unexplained dyspnea or fatigue associated with exercise Exertional chest pain or discomfort History of heart murmur Unexplained syncope or near-syncope Physical examination Brachial artery blood pressure (measured while seated) Femoral pulses to exclude coarctation of the aorta Heart murmur Physical stigmata of Marfan syndrome

21. Incidence of sudden death in athletes Auto accidents 30/100,000 Homicide12/100,000 Suicide10/100,000 Sports 0.5/100,000

22. Cause of sudden death in young athletes

23. Hypertrophic cardiomyopathy Usually AD, variable penetrance and expression Murmur – systolic and increases with standing and valsalva and decreases with squatting and isometric handgrip

24. Marfan’s syndrome - stigmata Arachnodactyly Tall stature pectus excavatum Kyphoscoliosis Lenticular dislocation Murmur of mitral valve prolapse and/or aortic regurgitation

25. Musculoskeletal System

27. Determining Clearance Important & occasionally difficult decision 3.1 to 13.9% of student athletes require further evaluation before a final clearance status can be given

29. Determining Clearance Initial Clearance has 4 categories Cleared without restriction Cleared, with recommendations for further evaluation or treatment (i. e. check BP in 1 month) Not cleared, reconsideration after completion of further evaluation, treatment, or rehabilitation Not cleared for certain types of sports or all sports

30. Determining Clearance AMERICAN ACADEMY OF PEDIATRICS: Medical Conditions Affecting Sports Participation PEDIATRICS Vol. 121 No. 4 April 2008, pp. 841-848 (doi:10.1542/peds.2008-0080) Classification of Sports by Contact Classification of Sports by Strenuousness Medical Conditions and Sports Participation http://www.pediatrics.org/cgi/content/full/107/5/1205

31. Summary Single examiner In addition to reviewing the history, ask pertinent questions to the athlete directly Goal is to assure safe student-athlete participation in a sport

32. My doctor told me I shouldn’t work out until I’m in better shape. I told him, “All right, don’t send me a bill until I pay you.” Steven Wright