Preparticipation Physical Examination Deb Jacobson, M.D.

Goals and objectives n Eval general health status n Determine fitness for competition n Foster injury prevention n Discover diseases/injuries n Counsel on health-related issues

Goals and objectives n Detect conditions that may be life- threatening or disabling n Determine sports specific skill level and conditioning n Meet legal and insurance requirements

PPE is NOT n Barrier to athlete participation n Purpose not to exclude but promote safety n Only % denied clearance n Only % require further evaluation n Not intended to substitute for regular health maintenance

Problems with PPE n Previously consisted of three H’s n Now has multiple objectives n No clear purpose n No standardization

Problems with PPE n Is PPE a good screening tool? n NO! Rarity of serious medical conditions found in millions of athletes screened n Does serve a purpose n Best guideline is PPE monograph published by Physician and Sportmed

Timing of PPE n Ideally should be 6-8 wks prior to preseason practice n Allows sufficient time to rehab injuries n Allows time for evaluation or correction of identified medical problems

Frequency of PPE n Most advocate full examination annually n Some say prior to every sports season n Some say prior to entering new school level with interim evaluation

Structure of PPE n Office-based vs... station-based n Advantages and disadvantages of each

History n Most important element of PPE n 75% of conditions evident from history n Only 39% of history given by athlete agreed with that of parent n Get parents involved!!!

History n Start w/ general medical questions n Hospitalizations and surgeries n Medications (including supplements, OTC, etc) n CV- 95% of sudden death in athletes under age 30 due to structural cardiac problems –history should include h/o syncope, chest pain, palpitations, dizziness w/exercise

History n Respiratory- wheeze, RAD, EIA, cystic fibrosis n Infectious disease- respiratory, skin, GI n Organs- paired, enlarged n Metabolic- DM, eating disorders, female triad, obesity, heat illness, steroid use, sickle cell n Neurologic- repeated concussions, seizure d/o, CP n Musculoskeletal- prior trauma or injury, rehab n Psych/soc- stress, depression, anxiety, pressure n Social- tobacco, alcohol, drugs, STD prevention

Exam n Vital signs, height and weight n Eyes- Visual acuity, pupils (document physiologic anisocoria) n ENT- general well-being n CV- BP, radial/femoral pulses, auscultation in supine and standing position for rate, rhythm, and murmurs. Further eval w/ maneuvers as needed. –AHA guidelines

Exam n Be aware of ranges of normal w/ the “athlete’s heart” –bradycardia –functional murmur –physiologic gallop –ECG abnormalities

Exam n Lungs- breath sounds, wheezing, ask about tobacco n Abdomen- masses, HSM n Genitalia –males- testicular presence/masses, hernia exam ONLY if indicated –females- not part of PPE n Skin- rashes, lesions, infections

Exam n Musculoskeletal- 90 second screening exam n see handout –Caveats n top to bottom n watch ROM n look for symmetry n focused joint exam if abnormality discovered or history suggests n can tailor exam for sports specific

Determining clearance n You picked up something abnormal on history or physical –What now? n Two good resources –“Contraindications to Athletic Participation”. Physician and Sportsmedicine, vol 24, no. 8 & 9 –26th Bethesda Conference: Recommendations for Determining Eligibility for Competition in Athletes with CV Abnormalities. Medicine and Science in Sports and Exercise, 26(10), Supp, Oct ‘94

Medicolegal considerations n Failure to diagnose/improper clearance –Reggie Lewis, Hank Gathers –each state has own regulations, no universally accepted standard n Right to participate –Team M.D. often lose, courts rule with athlete under the Americans with Disabilities Act n Knapp v. Northwestern n Pahulu v. University of Kansas

Medicolegal considerations n Sexual harassment claims –have chaperone, document n Good Samaritan Status –does not apply in all states –must not accept any form of payment to be protected

Conclusion n Done correctly PPE can enhance safety of sports participation n Also provides teachable moment n Need standardization n Get involved- IT’S FUN

References n Glover, D.W. et al. The Preparticipation Physical Examination: Steps Toward Consensus and Uniformity. The Physician and Sportsmedicine, 27(8). n Herbert, D.L. Practice Guidelines Take Center Court. The Physician and Sportsmedicine, 24(3). n Mitchell, J.H. et al, editor, ACSM, ACC 26th Bethesda Conference: Recommendations for Determining Eligibility for Competition in Athletes with Cardiovascular Abnormalities. Medicine and Science in Sports and Exercise, 26(10). n Moeller, J.L. Contraindications to Athletic Participation: Respiratory and Central Nervous System Conditions. Physician and Sportsmedicine, 24(8):

References n Moeller, J.L. Contraindications to Athletic Participation: Spinal, Systemic, Dermatologic, Paired Organ and Other Issues. Physician and Sportsmedicine, 24(9): n Preparticipation Physical Evaluation Monograph, second edition. Joint publication of AAFP,AAP, AMSSM, AOSSM, AOASM. Physician and Sportsmedicine, publisher, 1996.