1. Preparticipation Exam- “Sports Physical”
Crystal Sturgis, PA-C, MSPAS
ThedaCare Orthopedic Care

2. Financial Disclosures
I do not have any financial relationships or interests to disclose with relation to any information provided in this talk

3. WIAA Requirements
A preparticipation physical fitness form attesting to current physical fitness to participate in sports as determined by a licensed physician, Physician Assistant (PA) or Advanced Practice Nurse Prescriber (APNP) no less than every other school year with April 1 the earliest date of examination (chiropractors are not accepted).

4. Athletic Disqualifications
There are two major considerations for restricting persons from participation in athletics:
1. Is there a disease or condition which prevents the individual from competing fairly with others?
2. Is there a disease or condition which might be aggravated by athletic competition?
Both of these are relative and circumstances alter decisions. It is the examining provider’s responsibility to determine qualification or disqualification for athletic participation.

5. Disqualifying conditions from Wisconsin Interscholastic Athletic Association's Medical Policies and Procedures
Maturity
The state of maturity varies greatly in adolescents of the same age. Almost all boys/girls have reached the same stage of maturity by the junior year in high school, but many freshmen and some sophomores are not mature and should be withheld from competing with boys/girls who are. At earlier levels, seventh and eighth grades, it is important to identify the boy/girl who is mature and prevent him from injuring his classmates in athletic activities.

6. Disqualifying conditions from Wisconsin Interscholastic Athletic Association's Medical Policies and Procedures
Absence or Severe Disease of One of a Paired Organ
Most commonly involved organs are the kidneys, the eye and the testicles.
The American Academy of Pediatrics, the American Academy of Family Practice and the American Medical Association all feel that if there is only one of a paired organ left, then collision and contact sports should be restricted. These athletes should be directed into the noncollision, noncontact sports. If they are to be allowed to participate, every safeguard must be taken to protect the uninjured paired organ that is left.
Ultimately, may be a legal decision

7. Disqualifying conditions from Wisconsin Interscholastic Athletic Association's Medical Policies and Procedures
Hernia and Hydrocele
Considered disqualifying until repaired.
Hydrocele is usually associated with a hernia.
The danger of hemorrhage into or around the hydrocele as the result of a blow is great. This can result in irreparable damage to the cord and the testicle.
Repair should be done as soon as possible.
Once repaired, the athlete can return to full competition.

8. Disqualifying conditions from Wisconsin Interscholastic Athletic Association's Medical Policies and Procedures
Head Injury
No athlete shall return to play or practice on the same day of being diagnosed with a concussion or rendered unconscious.
Any athlete suspected of having a concussion must be evaluated by an appropriate health-care professional that day.
Any athlete with a concussion must be medically cleared by an appropriate health-care professional prior to resuming participation in any practice or competition. Return to play must follow a step-wise protocol which includes provisions for delaying return to play based upon the return of any signs or symptoms.
Wisconsin state law requires concussion information sheets to be distributed and acknowledged for coaches, parents, and athletes before practice may be allowed.

9. Disqualifying conditions from Wisconsin Interscholastic Athletic Association's Medical Policies and Procedures
Orthopedic Conditions
Epiphyseal conditions (Osgood-Schlatter, Legg-Perthes, etc.) determined on case-by-case basis dependent on symptoms
Back pain- Any student who has persistent back pain should be x-rayed and closely evaluated for some congenital abnormality or early rheumatoid spondylitis. Spondylolysis and Scheuermann’s disease (osteochondrosis of the vertebra) are examples of causes of back pain that should be considered as possible temporary disqualification for contact/collision sports.
Other orthopedic conditions should be evaluated on basis of symptoms and severity

10. Disqualifying conditions from Wisconsin Interscholastic Athletic Association's Medical Policies and Procedures
Epilepsy and Diabetes
When under control are not necessarily causes for restriction from athletics

11. Disqualifying conditions from Wisconsin Interscholastic Athletic Association's Medical Policies and Procedures
Skin Diseases
At least temporary disqualification when infections- bacterial, viral or fungal- are present.
Herpes infections are extremely contagious, especially in wrestlers. The student with this infection should be restricted until the infection is controlled.

12. Disqualifying conditions from Wisconsin Interscholastic Athletic Association's Medical Policies and Procedures
Asthma and Other Respiratory Conditions
If controlled, not disqualifying. Appropriate consultations are recommended.

13. Disqualifying conditions from Wisconsin Interscholastic Athletic Association's Medical Policies and Procedures
Disease of the Cardiovascular System
Area of uncertainty and controversy
Murmurs- not automatically disqualifying, but should have further workup.
Organic heart disease, especially rheumatic or congenital heart disease, may be a reason for disqualification . Those who have mitral stenosis or aortic stenosis may be seriously harmed by severe exertion.
Cardiac arrhythmia not associated with organic heart disease is not disqualifying
Hypertension should be evaluated by repeated examinations. It is not unusual to find high school athletes with elevated blood pressure on an emotional basis. If it remains elevated, further evaluation is necessary to rule out coarctation of aorta, unilateral kidney disease, or some other congenital abnormality.

14. Sudden Cardiac Arrest/Death in Athletes
Annual incidence is 1 in 80,000 high school athletes and 1 in 50,000 college athletes
Most SCA/D events (50-61%) occur in males in football and basketball
56-80% of SCA/D in athletes occurs during exercise, remainder nonexertional
Limited evidence that athletes have higher risk of SCA than general population of similar age

15. Sudden Cardiac Arrest/Death in Athletes
Prevalence of cardiac conditions associated with SCA/D in athletes is approximately 0.3%
Most common causes of SCA/D: Hypertrophic cardiomyopathy, anomalous coronary arteries, idiopathic left ventricular hypertrophy, arrthymogenic right ventricular cardiomyopathy, dilated cardiomyopathy, myocarditis, long QT syndrome, WPW, aortic dissection, and CAD
Up to 44% of athletes with SCA/D have no structural cardiac abnormalities on autopsy
HCM prevalence in young athletic population is 1 in 800 to 1 in 2600, in general adult population is 1 in 500

16. History and PE for Cardiovascular Screening
Personal history of CV symptoms (i.e. exertional syncope) and/or family history of juvenile/young adult SCA/D or inheritable cardiac conditions
PE findings of HTN, pathologic murmur, physical stigmata of Marfan’s and other connective tissue disorders
Significant variance in providers’ diagnostic abilities
Only detects about 20% of cardiac disorders with elevated risk for SCA/D

17. EKG for Cardiovascular Screening
Estimated 60% of cardiac disorders at risk for SCA/D have detectable EKG abnormalities
Risks: increased cost, false positives, false negative
Risk-stratified screening may provide more benefit- males, older age, African Americans, high risk sports, level of play
Current recommendation from American Medical Society for Sport Medicine: No conclusive evidence to make universal recommendation for or against addition of EKG during pre-participation evaluation

18. Real Risks to Athletes
SCA/D incidence remains very rare- 35 of the 7 million adolescents in sports at risk
15-18,000 annual adolescent deaths from automobile injuries, many involving alcohol/drugs
6,000 annual young adult homicide victims
Suicide deaths over 5,000/year, with 50 to 200 attempts for every death
1 million pregnancies per year among American women age 19 or younger
Up to 6 million cases annually of STIs in adolescents
Teenagers account for nearly 50% of reported cases of child abuse
Crucial for providers to address risk-taking behaviors and other age-appropriate preventative topics

19. Sports Physical vs Well Child Exam
Goldberg et al surveyed over 700 high school athletes
For 78% of them, the sports physical was the only annual health assessment.
Best practice is to incorporate sports specific requirements into regular health maintenance visit
Multi-station screening sports physical not recommended
Noisy
Rushed
Lack of privacy
Minimal parental communication

20. References
Wisconsin Interscholastic Athletic Association Medical Procedures Guide
Cavanaugh Jr. R, Miller M, Henneberger K. The Preparticipation Sports Physical: Are We Dropping the Ball? Pediatrics 1995; 96;1151
Drezner J et al, AMSSM Position Statement on Cardiovascular Preparticipation Screening in Athletes: Current Evidence, Knowledge Gaps, Recommendations and Future Directions. Clinical Journal of Sport Medicine September 2016; Vol. 26, Issue 5, p

21. Thank you
Crystal Sturgis, PA-C, MSPAS
ThedaCare Orthopedic Care