1. Preparticipation Physical Exam
Qiuyang Li, PGY3

2. 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.

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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.

9. 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.

10. 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

11. To detect underlying CV abnormality that may predispose an athletes to sudden death

12. To disclosure defects that may limit participation

13. 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

14. 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

15. 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

16. Quiz
The most common abnormalities leading to disqualification are _____________
The most common cause of sudden death in age older than 35?

17. Major Questions to ask in Medical History Screening?

18. 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.)

19. Physical Finding of Marfan Syndrome?

20. 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

21. Physical Finding of HCM?

22. 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

23. 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

24. 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?

25. 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.

26. 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

27. 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.

28. Female Athletic Triad
Anorexia nervosa
Osteoporosis
Amenorrhea

29. 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)

30. Blood pressure (mm Hg) Girls Boys Age (yr) 50th % for height6
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

32. 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

33. 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

34. 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

35. 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.

36. 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

37. Required stations on PPE
Sign in, ht, wt, vital signs, vision
History review
PE (medical and orthopedic)
Medical clearance

38. 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

39. 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