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? CAD Premature CAD Myocarditis HCM Rupture of the aorta

Q2 Which of the following is a contraindication to participation in contact sports? Sickle cell trait HIV Solitary testicle Fever of 102F Convulsive disorder, well controlled

Q3 Which of the following tests is recommended for routine screening of athletes during the preparticipatation evaluation (PPE)? Echo ECG Exercise stress test Vision screen UA

Can’t play any contact sports Can’t play until BP is under control 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 Can’t play any contact sports Can’t play until BP is under control He is cleared to play, but must have his BP measured twice during next month If he begins BP med immediately, then he is cleared 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? Herpes simplex Hep C Inguinal hernia Diabetes mellitus

Q6 Which of the following statement concerning PPE is true? About 10% of athletes are denied clearance during PPE The PPE ideally should be performed 6 month prior to present practice A primary objective of the PPE is to detect conditions that may predispose an athlete to injury 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 2009 Facts 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 findings Aortic 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 higher Brugada 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 anomalies Personal 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 treatment Personal 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 death Personal history of palpitations or recurrent syncope 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 normal Palpable or auscultated extra systoles, third or fourth heart sound gallops, and other clinical signs of heart failure should be considered suspicious Arrhythmogenic right ventricular cardiomyopathy Family history of premature sudden death; more common in persons of Mediterranean descent

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 Exertional CP or discomfort, or SOB? Exertional syncope or near-syncope, or unexpected fatigue? Hx of cardiac murmur or systemic HTN? FH of HCM, long QT syndrome, Marfan syndrome, significant dysrhythmias? 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 Syndrome The 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 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 Exam VS: GA: Marfan syndrome (Arachnodactyly, arm span>ht, Pectus excavatum) EYE: vision defect. Lens subluxation, severe myopia, retinal detachment, strabismus. CV: PMI, murmur RESP: wheezing ABD: liver or spleen GU: hernia, varicoceles, testicular mass MS: spine and extremity SKIN: molluscum contagiosum, HSV, impetigo, tinea corporis, scabies International Pediatric Hypertension Association (2006) www.pediatrichypertension.org

Blood pressure (mm Hg) Girls Boys Age (yr) 50th % 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

Hypertension classification Definition* Follow-up 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 Sports Active myocarditis or pericarditis HCM Severe HTN until controlled by therapy 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) Long QT interval syndrome History of recent concussion and symptoms of post concussion syndrome (no contact or collision sports) Poorly controlled convulsive disorder 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) Sickle cell disease Eating disorder Acute enlargement of spleen or liver Information 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