Tweet
1 of 1 DOCUMENT
Copyright 2003 Gale Group, Inc.
ASAP
Copyright 2003 Dowden Health Media, Inc.
Journal of Family Practice
February 1, 2003
SECTION: No. 2, Vol. 52; Pg. 127; ISSN: 0094-3509
IAC-ACC-NO: 97724146
LENGTH: 4678 words
HEADLINE: A thorough yet efficient exam identifies most problems in school
athletes; Applied evidence: research findings that are changing clinical
practice.
BYLINE: Carek, Peter J.; Mainous, Arch G., III
BODY:
Practice recommendations
* A complete medical history, preferably from the student and a parent, will
reveal approximately 75% of problems affecting initial athletic participation
(D).
* For asymptomatic athletes with no previous injuries, a 90-second screening
musculoskeletal test will detect 90% of significant musculoskeletal injuries
(A).
* A routine screening need not include noninvasive cardiac testing or
laboratory tests such as urinalysis, blood count, chemistry profile, lipid
profile, ferritin level, or spirometry (B).
Is the preparticipation physical examination the best way to determine
whether a student athlete can participate fully in his or her chosen sport? This
examination has become the standard of care for the over 6 million high school
and college students. While most athletes pass the exam without significant
medical or orthopedic abnormalities being noted, it often detects conditions
that may predispose an athlete to injury or limit full participation in certain
activities. We describe an efficient approach to the
preparticipation examination.
Although many organizations have adopted the preparticipation exam there has
been considerable debate on its content and usefulness. (l-4) Nevertheless,
sponsoring institutions continue to require the medical evaluation prior to
competition in organized athletics, so family physicians should be knowledgeable
about the objectives and limitations of the exam.
The American Academy of Family Physicians, the American Academy of
Pediatrics, the American Medical Society for Sports Medicine, the American
Orthopedic Society for Sports Medicine, and the American Osteopathic Academy of
Sports Medicine established the Preparticipation Physical Examination Task
Force. The recommendations of this task force serve as a guide for the physician
conducting these examinations for high school and collegiate athletes. (5,6)
* ASSESSING RISKS OF MORTALITY AND MORBIDITY
The mortality associated with athletic participation is most often the
result of sudden cardiac death, which occurs in about 0.5 per 100,000 high
school athletes per academic year and is most commonly due to hypertrophic
cardiomyopathy. (7,8) Screening for predisposing conditions is limited by the
low prevalence of relevant cardiovascular lesions in the general youth
population, the low risk of sudden death even among persons with an unsuspected
abnormality, and the large number of school athletes. (7-9)
An estimated 200,000 children and adolescents would have to be screened to
detect the 500 athletes who are at risk for sudden cardiac death and the 1
person who would actually experience it. (10) Even when cardiac abnormalities
are detected, the findings leading to disqualification are most often rhythm and
conduction abnormalities, valvular abnormalities, and systemic hypertension,
which are not the cardiac abnormalities usually associated with sudden cardiac
death in athletes. (11,12)
The majority of sudden deaths are associated with 4 sports: football,
basketball, track, and soccer. Approximately 90% of athletic-field deaths have
occurred in males, mostly high school athletes. (7,13)
More frequently than mortality, athletic participation places the individual
at risk for acute injury or worsening of an underlying medical condition. These
conditions are most commonly musculoskeletal, cardiovascular, or ophthalmologic
(Table 1). (5,9,21)
Nine studies of the preparticipation exam done between 1980 and 1999 show
general agreement on the rates at which it qualifies (84.8% to 96.6%), qualifies
with conditions (3.1% to 13.9%), and disqualifies students for sports
participation (0.2% to 2.6%). (14-22)
* WHAT SHOULD THE MEDICAL HISTORY INCLUDE?
The examining physician should obtain a medical history from each
participant (strength of recommendation [SOR]: D). A complete medical history
will identify approximately 75% of problems that will affect initial athletic
participation and serves as the cornerstone of the exam. (14,19) Most conditions
requiring further evaluation or restriction will be identified from the medical
history. Rifat and colleagues (21) noted that a complete medical history
accounted for 88% of the abnormal findings and 57% of the reasons cited for
activity restriction. The Preparticipation Physical Evaluation Task Force has
developed a history form that emphasizes the areas of greatest concern. (5)
In particular, examining physicians should ask regarding risk factors and
symptoms of cardiovascular disease (Table 2). You should confirm a positive
response to any of these questions, and conduct further evaluation if necessary.
Unfortunately, most athletes with hypertrophic cardiomyopathy do not report a
history of syncope with exercise or a family history of premature sudden cardiac
death due to the disease.
Musculoskeletal injury is a common cause for disqualification of an athlete.
(14,19,21) The most common injury to restrict participation is a knee injury,
with an ankle injury the next most common. (23) The strongest independent
predictor of sports injuries is a previous injury (odds ratio [OR]=9.4) and
exposure time (OR=6.9). (24) DuRant and colleagues (23) found that a previous
knee injury or knee surgery was significantly associated with further knee
injuries during the subsequent sports season when compared with individuals who
did not report previous knee injury or surgery (30.6% vs. 7.2%, P=.0001).
Additional historical information has been recommended for inclusion (SOR:
D). For example, the examining physician should question the athlete about
wheezing during exercise. Due to the high rate of recurrence and potential for
long-term adverse effects, he or she should also obtain a history of previous
concussions. Other issues to be addressed include presence of a single bilateral
organ and use of performance-enhancing medication. Finally, physicians should
question female athletes regarding their menstrual history and other symptoms or
signs of the female athletic triad (eating disorder, amenorrhea, and
osteoporosis).
Always carefully review the information provided by the athlete and his or
her parents. In 2 separate studies, minimal agreement was found between
histories obtained from athletes and parents independently. (19,25) We do not
know which source provides the most accurate history; therefore, both the
parents and student athlete should be questioned.
* WHAT SHOULD THE PHYSICAL EXAMINATION INCLUDE?
A complete physical examination is not necessary (SOR: D). (5) The screening
physical examination should include vital signs (ie, height, weight, and blood
pressure) and visual acuity testing as well as a cardiovascular, pulmonary,
abdominal, skin, genital (for males), and musculoskeletal examination. Further
examination should be based on issues elicited during the history.
Cardiovascular examination
The cardiovascular examination requires an additional level of detail.
Perform auscultation of the heart initially with the patient in both standing
and supine position, and during various maneuvers (squat-to-stand, deep
inspiration, or Valsalva's maneuver), as these maneuvers can clarify the type of
murmur.
Any systolic murmur grade III/VI or louder, any murmur that disrupts normal
heart sounds, any diastolic murmur, or any murmur that intensifies with the
previously described maneuvers should be evaluated further through diagnostic
studies (echocardiography) or consultation prior to participation. Sinus
bradycardia and systolic murmurs are commonly found, occurring in over 50% and
between 30% and 50% of athletes, respectively; they do not warrant further
evaluation in the asymptomatic athlete. (26) Third and fourth heart sounds are
also commonly found in asymptomatic athletes without underlying heart disease.
(26,27)
Noninvasive cardiac testing (eg, electrocardiography, echocardiography, or
exercise stress testing) should not be a routine part of the screening
preparticipation exam (SOR: B). (7) These tests are not cost-effective in a
population at relatively low risk for cardiac abnormalities and cannot
consistently identify athletes at actual risk. (28-32) For example, a
substantial minority of subjects (11%) were found to have a clinically
significant increased ventricular wall thickness, which made clinical
interpretation of the echocardiographic findings difficult in individual
athletes. (28) Furthermore, some patients with hypertrophic cardiomyopathy are
able to tolerate particularly intense athletic training and competition for many
years, and even maintain high levels of achievement without incurring symptoms,
disease progression, or sudden death. (29)
Echocardiography and stress testing are the most commonly recommended
diagnostic tests for patients with an abnormal cardiovascular history or
examination. With the assistance of clinical information, echocardiography is
able to distinguish the nonobstructive hypertrophic cardiomyopathy from the
athletic heart syndrome. (33)
Musculoskeletal examination
A screening musculoskeletal history and examination in combination can be
used for asymptomatic athletes with no previous injuries (Table 3) (SOR: A).
(34) An accurate history is able to detect over 90% of significant
musculoskeletal injuries. The screening physical examination is 51% sensitive
and 97% specific. (34) If the athlete has either a previous injury or other
signs or symptoms (ie, pain; tenderness; asymmetries in muscle bulk, strength,
or range of motion; any obvious deformity) detected by the general screening
examination or history, the general screening should be supplemented with
relevant elements of a site-specific examination.
Additional forms of musculoskeletal evaluation are often performed for
athletes to determine their general state of flexibility and muscular strength.
While various degrees of hyperlaxity, muscular tightness, weakness, asymmetry of
strength or flexibility, poor endurance, and abnormal foot configuration may
predispose an athlete to increased risk of injury during sports competition,
studies have failed to demonstrate conclusively that injuries are prevented by
interventions aimed at correcting such abnormalities. (35-37)
Role for lab tests?
Studies do not support the use of routine laboratory or other screening
tests such as urinalysis, complete blood count, chemistry profile, lipid
profile, ferritin level, or spirometry as part of the exam (SOR: B). (38-41)
* DETERMINING CLEARANCE
Occasionally, an abnormality or condition is found that may limit an
athlete's participation or predispose him or her to further injury. In these
cases, the examining physician should review the following questions: (5)
1. Does the problem place the athlete at increased risk for injury?
2. Is another participant at risk for injury because of the problem?
3. Can the athlete safely participate with treatment (ie, medication,
rehabilitation, bracing, or padding)?
4. Can limited participation be allowed while treatment is being completed?
5. If clearance is denied only for certain sports or sport categories, in
what activities can the athlete safely participate?
Physicians should base clearance to participate in a particular sport on
previously published guidelines, such as the recommendations by the American
Academy of Pediatrics, the 26th Bethesda Conference, and the American Heart
Association. (7,43,44) Participation recommendations are based on the specific
diagnosis, though multiple factors such as the classification of the sport and
the specific health status of the athlete affect the decision. (44)
* APPROACH TO THE PATIENT
While current research demonstrates that the preparticipation physical
examination has no effect on the overall morbidity and mortality rates in
athletes, these exams may fulfill other objectives. Furthermore, no harmful
effects of these examinations have been reported, and the exam has become
institutionalized in the athletic and sports medicine community. As such,
physicians should base their evaluation on the best available evidence using the
standard form shown in "Preparticipation physical evaluation for athletics." (6)
(A copy of the Preparticipation Physical Evaluation form can be found at
www.jfponline.com.) This may require that the physician work with local school
systems to assure that they understand what constitutes an appropriate
examination.
To assist future patient care decisions and research efforts, a standardized
preparticipation physical examination with an associated form similar to the
evaluation recommended by the Preparticipation Physical Evaluation Task Force
should be uniformly implemented throughout the country. The use of consistent
clearance criteria as recommended by the Preparticipation Physical Evaluation
Task Force or the American Academy of Pediatrics ("Medical conditions and sports
participation," also available at www.jfponline.com) should be used, studied,
and revised as needed. (5,44)
In addition to the exam, physicians should consider exploring other aspects
of sports participation to assist athletes in reducing the risk of injury.
Rules, equipment, or other factors may have a greater effect on decreasing the
mortality and morbidity associated with athletic participation. A marked
decrease in cervical spine injuries occurred following the rule change in
football banning deliberate "spearing"--the use of the top of the helmet as the
initial point of contact in making a tackle. (41)
TABLE 1
Medical and orthopedic conditions
resulting in additional evaluations
Lively,
Rifat, 1995 * 1999
([dagger])
n=2,574 n=596
Pass with Follow-up
follow-up Fail with or
and/or follow-up restriction
restriction (2.6%) (14.1%)
(12.6%)
Medical (% of overall total) 76.6 74.1 55.4
Cardiovascular 18.3 35.0 63.0
Dermatologic 6.8
Endocrinologic 0.4
Ear, nose, and throat 9.6 2.5
Gastrointestinal 0.9 2.2
Genitourinary 9.6 12.5 8.7
Gynecologic 4.4
Infectious 0.4 6.5
Neurologic 6.5
Ophthalmologic 26.0 25.0 6.5
Psychological 2.2
Pulmonary 14.2 2.5
Other ([double dagger]) 13.7 22.5
Total medical (%) 100.0 100.0 100.0
Orthopedic (% of overall total) 23.4 25.9 44.6
Ankle/Foot 14.9 7.7 2.7
Back/Neck 22.4 14.3 5.4
Elbow 5.4
Hand/Wrist 1.5 10.9
Knee 41.8 7.1 43.2
Leg 5.4
Shoulder 27.0
Nonspecific pain/injury 19.4 71.4
Total orthopedic (%) 100.0 100.0 100.0
* Studied junior high and high school students. Two individuals
failed (nonspecific pain/injury).
([dagger]) Studied college-aged students. One individual
failed (complicated pregnancy).
([double dagger]) "Other" includes abdominal pain, allergy,
bruising, chest pain, chronic/recurrent illness, dizziness/
syncope with exercise, surgery (recent).
TABLE 2
Questions to help discern cardiovascular risk
Have you ever passed out during or after exercise?
Have you ever been dizzy during or after exercise?
Have you ever had chest pain during or after exercise?
Do you get tired more quickly than your friends during exercise?
Have you ever had racing of your heart or skipped heartbeats?
Have you ever had high blood pressure or high cholesterol?
Have you been told you have a heart murmur?
Has any family member or relative died of heart problems or of
sudden death before age 50?
Have you had a severe viral infection (for example, myocarditis or
mononucleosis) within the last month?
Has a physician ever denied or restricted your participation in sports
for any heart problem?
TABLE 3
The "90-second" musculoskeletal screening examination
Instruction Observations
Stand facing examiner Acromiclavicular joints: general
habitus
Look at ceiling, floor, over both Cervical spine motion
shoulders, touch ears to
shoulder
Shrug shoulders (resistance) Trapezius strength
Abduct shoulders to 90[degrees] Deltoid strength
(resistance at 90[degrees])
Full external rotation of arms Shoulder motion
Flex and extend elbows Elbow motion
Arms at sides, elbows at Elbow and wrist motion
90[degrees] flexed; pronate and
supinate wrists
Spread fingers; make fist Hand and finger motion, strength,
and deformities
Tighten (contract) quadriceps; Symmetry and knee effusions, ankle
quadriceps effusion relax
"Duck walk" away and towards Hip, knee, and ankle motions
examiner
Back to examiner Shoulder symmetry; scoliosis
Knees straight, touch toes Scoliosis, hip motion, hamstring
tightness
Raise up on toes, heels Calf symmetry, leg strength
REFERENCES
(1.) MacAuley D. Does the preseason screening for cardiac disease really
work?: the British perspective. Med Sci Sports Exerc 1998; 30(Suppl):S345-S350.
(2.) Glover DW, Maron BJ. Profile of preparticipation cardiovascular
screening for high school athletes. JAMA 1998; 279:1817-9.
(3.) Pfister GC, Puffer JC, Maron BJ. Preparticipation cardiovascular
screening for US collegiate student-athletes. JAMA 2000; 283:1597-9.
(4.) Reich JD. It won't be me next time: an opinion on
preparticipation sports physicals. Am Fam Physician 2000;61:2618, 2620, 2625,
2629.
(5.) Smith DM, Kovan JR, Rich BSE, Tanner SM. Preparticipation Physical
Evaluation. 2nd ed. Minneapolis, Minn: McGraw-Hill Co; 1997:1-46.
(6.) Lombardo JA, Robinson JB, Smith DM, et al. Preparticipation physical
examination. 1st ed. Kansas City, Mo: American Academy of Family Physicians,
American Academy of Pediatrics, American Medical Society for Sports Medicine,
American Orthopedic Society for Sports Medicine, American Osteopathic Academy of
Sports Medicine; 1992.
(7.) Maron BJ, Thompson PD, Puffer JC, et al. Cardiovascular
preparticipation screening of competitive athletes. A statement for health
professionals from the Sudden Death Committee (clinical cardiology) and
Congenital Cardiac Defects Committee (cardiovascular disease in the young),
American Heart Association. Circulation 1996; 94:850-6.
(8.) Maron BJ, Gohman TE, Aeppli D. Prevalence of sudden cardiac death
during competitive sports activities in Minnesota high school athletes. J Am
Coll Cardiol 1998; 32:1881-4.
(9.) American Medical Association Board of Trustees, Group on Science and
Technology. Athletic participation examinations for adolescents. Arch Pediatr
Adolesc Med 1994; 148:93-8.
(10.) Epstein SE, Maron BJ. Sudden death and the competitive athlete:
perspectives on preparticipation screening studies. J Am Coll Cardiol 1986;
7:220-30.
(11.) Pelliccia A, Maron BJ. Preparticipation cardiovascular evaluation of
the competitive athlete: Perspectives from the 30-year Italian experience. Am J
Cardiol 1995; 75:827-9.
(12.) Corrado D, Basso C, Schiavon M, Thiene G. Screening for hypertrophic
cardiomyopathy in young athletes. N Engl J Med 1998; 339:364-9.
(13.) Cantu RC, Mueller FO. Fatalities and catastrophic injuries in high
school and college sports, 1982-1997. Phys Sportsmed 1999; 27:35-48.
(14.) Goldberg B, Saraniti A, Witman P, et al. Pre-participation sports
assessment: an objective evaluation. Pediatrics 1980; 66:736-45.
(15.) Linder CW, DuRant RH, Seklecki RM, Strong WB. Preparticipation health
screening of young athletes: results of 1268 examinations. Am J Sports Med 1981;
9:187-93.
(16.) Tennant FS Jr, Sorenson K, Day CM. Benefits of preparticipation sports
examinations. J Fam Pract 1981; 13:287-8.
(17.) Thompson TR, Andrish JT, Bergfeld JA. A prospective study of
preparticipation sports examinations of 2670 young athletes: method and results.
Cleve Clin Q 1982; 49:225-33.
(18.) DuRant R, Seymore C, Linder CW, Jay S. The
preparticipation examination of athletes. Comparison of single and multiple
examiners. Am J Dis Child 1985; 139:657-61.
(19.) Risser WL, Hoffman HM, Bellah GG Jr. Frequency of
preparticipation sports examinations in secondary school athletes: are the
University Interscholastic League guidelines appropriate? Tex Med 1985; 81:35-9.
(20.) Magnes SA, Henderson JM, Hunter SC. What limits sports participation:
experience with 10,540 athletes. Phys Sportsmed 1992; 20:143-60.
(21.) Rifat SF, Ruffin MT, Gorenflo DW. Disqualifying criteria in
preparticipation sports evaluation. J Fam Pract 1995; 41:42-50.
(22.) Lively MW. Preparticipation physical examinations: a collegiate
experience. Clin J Sports Med 1999; 9:38.
(23.) DuRant RH, Pendergrast RA, Seymore C, Gaillard G, Donner J. Findings
from the preparticipation athletic examination and athletic injuries. Am J Dis
Child 1992; 146:85-91.
(24.) Van Mechelen W, Twisk J, Molendijk A, Blom B, Snel J, Kemper HC.
Subject-related risk factors for sports injuries: a 1-yr prospective study in
young adults. Med Sci Sports Exerc 1996; 28:1171-9.
(25.) Carek PJ, Futrell MA. Athlete's view of the preparticipation physical
examination: Attitudes toward certain health screening questions. Arch Fam Med
1999; 8:307-12.
(26.) Huston TP, Puffer JC, Rodney WM. The athletic heart syndrome. N Engl J
Med 1985; 313:24-32.
(27.) Crawford MH, 0'Rourke RA. The athlete's heart. Adv Intern Med 1979;
24:311-29.
(28.) Lewis JF, Maron BJ, Diggs JA, Spencer JE, Mehrotra PP, Curry CL.
Preparticipation echocardiographic screening for cardiovascular disease in a
large, predominately black population of collegiate athletes. Am J Cardiol 1989;
64:1029-33.
(29.) Maron BJ, Klues HG. Surviving competitive athletes with hypertrophic
cardiomyopathy. Am J Cardiol 1994; 73:1098-104.
(30.) Fuller CM, McNulty CM, Spring DA, et al. Prospective screening of
5,615 high school athletes for risk of sudden death. Med Sci Sports Exer 1997;
29:1131-8.
(31.) Fuller CM. Cost effectiveness of analysis of high school athletes for
risks of sudden cardiac death. Med Sci Sports Exer 2000; 32:887-90.
(32.) Pelliccia A, Maron BJ, Culasso F, et al. Clinical significance of
abnormal electrocardiographic patterns in trained athletes. Circulation 2000;
102:278-84.
(33.) Maron BJ, Pelliccia A, Spirito P. Cardiac disease in young trained
athletes: insights into methods for distinguishing athlete's heart from
structural heart disease with particular emphasis on hypertrophic
cardiomyopathy. Circulation 1995; 91:1596-1601.
(34.) Gomez JE, Landry GL, Bernhardt DT. Critical evaluation of the 2-minute
orthopedic screening examination. Am J Dis Child 1993; 147:1109-13.
(35.) Abbott HG, Kress JB. Preconditioning in the prevention of knee
injuries. Arch Phys Med Rehabil 1969; 50:326-33.
(36.) Jackson DW, Jarrett H, Bailey D, Kausek J, Swanson J, Powell JW.
Injury prediction in the young athlete: a preliminary report. Am J Sports Med
1978; 6:6-14.
(37.) Nicholas JA. Injuries in knee ligaments: Relationship to looseness and
tightness in football players. JAMA 1970; 212:2236-9.
(38.) Dodge WF, West EF, Smith EH, Harvey B 3rd. Proteinuria and hematuria
in schoolchildren: epidemiolegy and early natural history. J Pediatr 1976;
88:327-47.
(39.) Peggs JF, Reinhardt RW, O'Brien JM. Proteinuria in adolescent sports
physical examinations. J Fam Pract 1986; 22:80-1.
(40.) Rupp NT, Brudno DS, Guill MF. The value of screening for risk of
exercise induced asthma in high school athletes. Ann Allergy 1993; 70;339-42.
(41.) Feinstein RA, LaRussa J, Wang-Dohlman A, Bartolucci AA. Screening
adolescent athletes for exercise-induced asthma. Clin J Sports Med 1996;
6:119-23.
(42.) Torg JS, Vegso JJ, Sennett B, Das M. The National Football Head and
Neck Injury Registry. 14-year report on cervical quadriplegia, 1971 through
1984. JAMA 1985; 254:3439-43.
(43.) 26th Bethesda Conference: Recommendations for determining eligibility
for competition in athletes with cardiovascular abnormalities. Med Sci Sports
Exerc 1994; 26(Suppl):S223-S283.
(44.) American Academy of Pediatrics. Medical conditions affecting sports
participation. Pediatrics 2001; 107:1206-7.
Corresponding author: Peter J. Carek, MD, MS, Associate Professor,
Department of Family Medicine, Medical University of South Carolina, 9298
Medical Plaza Drive, Charleston, SC 29406. E-mail: [email protected].
Copyright 2003 Gale Group, Inc.
ASAP
Copyright 2003 Dowden Health Media, Inc.
Journal of Family Practice
February 1, 2003
SECTION: No. 2, Vol. 52; Pg. 127; ISSN: 0094-3509
IAC-ACC-NO: 97724146
LENGTH: 4678 words
HEADLINE: A thorough yet efficient exam identifies most problems in school
athletes; Applied evidence: research findings that are changing clinical
practice.
BYLINE: Carek, Peter J.; Mainous, Arch G., III
BODY:
Practice recommendations
* A complete medical history, preferably from the student and a parent, will
reveal approximately 75% of problems affecting initial athletic participation
(D).
* For asymptomatic athletes with no previous injuries, a 90-second screening
musculoskeletal test will detect 90% of significant musculoskeletal injuries
(A).
* A routine screening need not include noninvasive cardiac testing or
laboratory tests such as urinalysis, blood count, chemistry profile, lipid
profile, ferritin level, or spirometry (B).
Is the preparticipation physical examination the best way to determine
whether a student athlete can participate fully in his or her chosen sport? This
examination has become the standard of care for the over 6 million high school
and college students. While most athletes pass the exam without significant
medical or orthopedic abnormalities being noted, it often detects conditions
that may predispose an athlete to injury or limit full participation in certain
activities. We describe an efficient approach to the
preparticipation examination.
Although many organizations have adopted the preparticipation exam there has
been considerable debate on its content and usefulness. (l-4) Nevertheless,
sponsoring institutions continue to require the medical evaluation prior to
competition in organized athletics, so family physicians should be knowledgeable
about the objectives and limitations of the exam.
The American Academy of Family Physicians, the American Academy of
Pediatrics, the American Medical Society for Sports Medicine, the American
Orthopedic Society for Sports Medicine, and the American Osteopathic Academy of
Sports Medicine established the Preparticipation Physical Examination Task
Force. The recommendations of this task force serve as a guide for the physician
conducting these examinations for high school and collegiate athletes. (5,6)
* ASSESSING RISKS OF MORTALITY AND MORBIDITY
The mortality associated with athletic participation is most often the
result of sudden cardiac death, which occurs in about 0.5 per 100,000 high
school athletes per academic year and is most commonly due to hypertrophic
cardiomyopathy. (7,8) Screening for predisposing conditions is limited by the
low prevalence of relevant cardiovascular lesions in the general youth
population, the low risk of sudden death even among persons with an unsuspected
abnormality, and the large number of school athletes. (7-9)
An estimated 200,000 children and adolescents would have to be screened to
detect the 500 athletes who are at risk for sudden cardiac death and the 1
person who would actually experience it. (10) Even when cardiac abnormalities
are detected, the findings leading to disqualification are most often rhythm and
conduction abnormalities, valvular abnormalities, and systemic hypertension,
which are not the cardiac abnormalities usually associated with sudden cardiac
death in athletes. (11,12)
The majority of sudden deaths are associated with 4 sports: football,
basketball, track, and soccer. Approximately 90% of athletic-field deaths have
occurred in males, mostly high school athletes. (7,13)
More frequently than mortality, athletic participation places the individual
at risk for acute injury or worsening of an underlying medical condition. These
conditions are most commonly musculoskeletal, cardiovascular, or ophthalmologic
(Table 1). (5,9,21)
Nine studies of the preparticipation exam done between 1980 and 1999 show
general agreement on the rates at which it qualifies (84.8% to 96.6%), qualifies
with conditions (3.1% to 13.9%), and disqualifies students for sports
participation (0.2% to 2.6%). (14-22)
* WHAT SHOULD THE MEDICAL HISTORY INCLUDE?
The examining physician should obtain a medical history from each
participant (strength of recommendation [SOR]: D). A complete medical history
will identify approximately 75% of problems that will affect initial athletic
participation and serves as the cornerstone of the exam. (14,19) Most conditions
requiring further evaluation or restriction will be identified from the medical
history. Rifat and colleagues (21) noted that a complete medical history
accounted for 88% of the abnormal findings and 57% of the reasons cited for
activity restriction. The Preparticipation Physical Evaluation Task Force has
developed a history form that emphasizes the areas of greatest concern. (5)
In particular, examining physicians should ask regarding risk factors and
symptoms of cardiovascular disease (Table 2). You should confirm a positive
response to any of these questions, and conduct further evaluation if necessary.
Unfortunately, most athletes with hypertrophic cardiomyopathy do not report a
history of syncope with exercise or a family history of premature sudden cardiac
death due to the disease.
Musculoskeletal injury is a common cause for disqualification of an athlete.
(14,19,21) The most common injury to restrict participation is a knee injury,
with an ankle injury the next most common. (23) The strongest independent
predictor of sports injuries is a previous injury (odds ratio [OR]=9.4) and
exposure time (OR=6.9). (24) DuRant and colleagues (23) found that a previous
knee injury or knee surgery was significantly associated with further knee
injuries during the subsequent sports season when compared with individuals who
did not report previous knee injury or surgery (30.6% vs. 7.2%, P=.0001).
Additional historical information has been recommended for inclusion (SOR:
D). For example, the examining physician should question the athlete about
wheezing during exercise. Due to the high rate of recurrence and potential for
long-term adverse effects, he or she should also obtain a history of previous
concussions. Other issues to be addressed include presence of a single bilateral
organ and use of performance-enhancing medication. Finally, physicians should
question female athletes regarding their menstrual history and other symptoms or
signs of the female athletic triad (eating disorder, amenorrhea, and
osteoporosis).
Always carefully review the information provided by the athlete and his or
her parents. In 2 separate studies, minimal agreement was found between
histories obtained from athletes and parents independently. (19,25) We do not
know which source provides the most accurate history; therefore, both the
parents and student athlete should be questioned.
* WHAT SHOULD THE PHYSICAL EXAMINATION INCLUDE?
A complete physical examination is not necessary (SOR: D). (5) The screening
physical examination should include vital signs (ie, height, weight, and blood
pressure) and visual acuity testing as well as a cardiovascular, pulmonary,
abdominal, skin, genital (for males), and musculoskeletal examination. Further
examination should be based on issues elicited during the history.
Cardiovascular examination
The cardiovascular examination requires an additional level of detail.
Perform auscultation of the heart initially with the patient in both standing
and supine position, and during various maneuvers (squat-to-stand, deep
inspiration, or Valsalva's maneuver), as these maneuvers can clarify the type of
murmur.
Any systolic murmur grade III/VI or louder, any murmur that disrupts normal
heart sounds, any diastolic murmur, or any murmur that intensifies with the
previously described maneuvers should be evaluated further through diagnostic
studies (echocardiography) or consultation prior to participation. Sinus
bradycardia and systolic murmurs are commonly found, occurring in over 50% and
between 30% and 50% of athletes, respectively; they do not warrant further
evaluation in the asymptomatic athlete. (26) Third and fourth heart sounds are
also commonly found in asymptomatic athletes without underlying heart disease.
(26,27)
Noninvasive cardiac testing (eg, electrocardiography, echocardiography, or
exercise stress testing) should not be a routine part of the screening
preparticipation exam (SOR: B). (7) These tests are not cost-effective in a
population at relatively low risk for cardiac abnormalities and cannot
consistently identify athletes at actual risk. (28-32) For example, a
substantial minority of subjects (11%) were found to have a clinically
significant increased ventricular wall thickness, which made clinical
interpretation of the echocardiographic findings difficult in individual
athletes. (28) Furthermore, some patients with hypertrophic cardiomyopathy are
able to tolerate particularly intense athletic training and competition for many
years, and even maintain high levels of achievement without incurring symptoms,
disease progression, or sudden death. (29)
Echocardiography and stress testing are the most commonly recommended
diagnostic tests for patients with an abnormal cardiovascular history or
examination. With the assistance of clinical information, echocardiography is
able to distinguish the nonobstructive hypertrophic cardiomyopathy from the
athletic heart syndrome. (33)
Musculoskeletal examination
A screening musculoskeletal history and examination in combination can be
used for asymptomatic athletes with no previous injuries (Table 3) (SOR: A).
(34) An accurate history is able to detect over 90% of significant
musculoskeletal injuries. The screening physical examination is 51% sensitive
and 97% specific. (34) If the athlete has either a previous injury or other
signs or symptoms (ie, pain; tenderness; asymmetries in muscle bulk, strength,
or range of motion; any obvious deformity) detected by the general screening
examination or history, the general screening should be supplemented with
relevant elements of a site-specific examination.
Additional forms of musculoskeletal evaluation are often performed for
athletes to determine their general state of flexibility and muscular strength.
While various degrees of hyperlaxity, muscular tightness, weakness, asymmetry of
strength or flexibility, poor endurance, and abnormal foot configuration may
predispose an athlete to increased risk of injury during sports competition,
studies have failed to demonstrate conclusively that injuries are prevented by
interventions aimed at correcting such abnormalities. (35-37)
Role for lab tests?
Studies do not support the use of routine laboratory or other screening
tests such as urinalysis, complete blood count, chemistry profile, lipid
profile, ferritin level, or spirometry as part of the exam (SOR: B). (38-41)
* DETERMINING CLEARANCE
Occasionally, an abnormality or condition is found that may limit an
athlete's participation or predispose him or her to further injury. In these
cases, the examining physician should review the following questions: (5)
1. Does the problem place the athlete at increased risk for injury?
2. Is another participant at risk for injury because of the problem?
3. Can the athlete safely participate with treatment (ie, medication,
rehabilitation, bracing, or padding)?
4. Can limited participation be allowed while treatment is being completed?
5. If clearance is denied only for certain sports or sport categories, in
what activities can the athlete safely participate?
Physicians should base clearance to participate in a particular sport on
previously published guidelines, such as the recommendations by the American
Academy of Pediatrics, the 26th Bethesda Conference, and the American Heart
Association. (7,43,44) Participation recommendations are based on the specific
diagnosis, though multiple factors such as the classification of the sport and
the specific health status of the athlete affect the decision. (44)
* APPROACH TO THE PATIENT
While current research demonstrates that the preparticipation physical
examination has no effect on the overall morbidity and mortality rates in
athletes, these exams may fulfill other objectives. Furthermore, no harmful
effects of these examinations have been reported, and the exam has become
institutionalized in the athletic and sports medicine community. As such,
physicians should base their evaluation on the best available evidence using the
standard form shown in "Preparticipation physical evaluation for athletics." (6)
(A copy of the Preparticipation Physical Evaluation form can be found at
www.jfponline.com.) This may require that the physician work with local school
systems to assure that they understand what constitutes an appropriate
examination.
To assist future patient care decisions and research efforts, a standardized
preparticipation physical examination with an associated form similar to the
evaluation recommended by the Preparticipation Physical Evaluation Task Force
should be uniformly implemented throughout the country. The use of consistent
clearance criteria as recommended by the Preparticipation Physical Evaluation
Task Force or the American Academy of Pediatrics ("Medical conditions and sports
participation," also available at www.jfponline.com) should be used, studied,
and revised as needed. (5,44)
In addition to the exam, physicians should consider exploring other aspects
of sports participation to assist athletes in reducing the risk of injury.
Rules, equipment, or other factors may have a greater effect on decreasing the
mortality and morbidity associated with athletic participation. A marked
decrease in cervical spine injuries occurred following the rule change in
football banning deliberate "spearing"--the use of the top of the helmet as the
initial point of contact in making a tackle. (41)
TABLE 1
Medical and orthopedic conditions
resulting in additional evaluations
Lively,
Rifat, 1995 * 1999
([dagger])
n=2,574 n=596
Pass with Follow-up
follow-up Fail with or
and/or follow-up restriction
restriction (2.6%) (14.1%)
(12.6%)
Medical (% of overall total) 76.6 74.1 55.4
Cardiovascular 18.3 35.0 63.0
Dermatologic 6.8
Endocrinologic 0.4
Ear, nose, and throat 9.6 2.5
Gastrointestinal 0.9 2.2
Genitourinary 9.6 12.5 8.7
Gynecologic 4.4
Infectious 0.4 6.5
Neurologic 6.5
Ophthalmologic 26.0 25.0 6.5
Psychological 2.2
Pulmonary 14.2 2.5
Other ([double dagger]) 13.7 22.5
Total medical (%) 100.0 100.0 100.0
Orthopedic (% of overall total) 23.4 25.9 44.6
Ankle/Foot 14.9 7.7 2.7
Back/Neck 22.4 14.3 5.4
Elbow 5.4
Hand/Wrist 1.5 10.9
Knee 41.8 7.1 43.2
Leg 5.4
Shoulder 27.0
Nonspecific pain/injury 19.4 71.4
Total orthopedic (%) 100.0 100.0 100.0
* Studied junior high and high school students. Two individuals
failed (nonspecific pain/injury).
([dagger]) Studied college-aged students. One individual
failed (complicated pregnancy).
([double dagger]) "Other" includes abdominal pain, allergy,
bruising, chest pain, chronic/recurrent illness, dizziness/
syncope with exercise, surgery (recent).
TABLE 2
Questions to help discern cardiovascular risk
Have you ever passed out during or after exercise?
Have you ever been dizzy during or after exercise?
Have you ever had chest pain during or after exercise?
Do you get tired more quickly than your friends during exercise?
Have you ever had racing of your heart or skipped heartbeats?
Have you ever had high blood pressure or high cholesterol?
Have you been told you have a heart murmur?
Has any family member or relative died of heart problems or of
sudden death before age 50?
Have you had a severe viral infection (for example, myocarditis or
mononucleosis) within the last month?
Has a physician ever denied or restricted your participation in sports
for any heart problem?
TABLE 3
The "90-second" musculoskeletal screening examination
Instruction Observations
Stand facing examiner Acromiclavicular joints: general
habitus
Look at ceiling, floor, over both Cervical spine motion
shoulders, touch ears to
shoulder
Shrug shoulders (resistance) Trapezius strength
Abduct shoulders to 90[degrees] Deltoid strength
(resistance at 90[degrees])
Full external rotation of arms Shoulder motion
Flex and extend elbows Elbow motion
Arms at sides, elbows at Elbow and wrist motion
90[degrees] flexed; pronate and
supinate wrists
Spread fingers; make fist Hand and finger motion, strength,
and deformities
Tighten (contract) quadriceps; Symmetry and knee effusions, ankle
quadriceps effusion relax
"Duck walk" away and towards Hip, knee, and ankle motions
examiner
Back to examiner Shoulder symmetry; scoliosis
Knees straight, touch toes Scoliosis, hip motion, hamstring
tightness
Raise up on toes, heels Calf symmetry, leg strength
REFERENCES
(1.) MacAuley D. Does the preseason screening for cardiac disease really
work?: the British perspective. Med Sci Sports Exerc 1998; 30(Suppl):S345-S350.
(2.) Glover DW, Maron BJ. Profile of preparticipation cardiovascular
screening for high school athletes. JAMA 1998; 279:1817-9.
(3.) Pfister GC, Puffer JC, Maron BJ. Preparticipation cardiovascular
screening for US collegiate student-athletes. JAMA 2000; 283:1597-9.
(4.) Reich JD. It won't be me next time: an opinion on
preparticipation sports physicals. Am Fam Physician 2000;61:2618, 2620, 2625,
2629.
(5.) Smith DM, Kovan JR, Rich BSE, Tanner SM. Preparticipation Physical
Evaluation. 2nd ed. Minneapolis, Minn: McGraw-Hill Co; 1997:1-46.
(6.) Lombardo JA, Robinson JB, Smith DM, et al. Preparticipation physical
examination. 1st ed. Kansas City, Mo: American Academy of Family Physicians,
American Academy of Pediatrics, American Medical Society for Sports Medicine,
American Orthopedic Society for Sports Medicine, American Osteopathic Academy of
Sports Medicine; 1992.
(7.) Maron BJ, Thompson PD, Puffer JC, et al. Cardiovascular
preparticipation screening of competitive athletes. A statement for health
professionals from the Sudden Death Committee (clinical cardiology) and
Congenital Cardiac Defects Committee (cardiovascular disease in the young),
American Heart Association. Circulation 1996; 94:850-6.
(8.) Maron BJ, Gohman TE, Aeppli D. Prevalence of sudden cardiac death
during competitive sports activities in Minnesota high school athletes. J Am
Coll Cardiol 1998; 32:1881-4.
(9.) American Medical Association Board of Trustees, Group on Science and
Technology. Athletic participation examinations for adolescents. Arch Pediatr
Adolesc Med 1994; 148:93-8.
(10.) Epstein SE, Maron BJ. Sudden death and the competitive athlete:
perspectives on preparticipation screening studies. J Am Coll Cardiol 1986;
7:220-30.
(11.) Pelliccia A, Maron BJ. Preparticipation cardiovascular evaluation of
the competitive athlete: Perspectives from the 30-year Italian experience. Am J
Cardiol 1995; 75:827-9.
(12.) Corrado D, Basso C, Schiavon M, Thiene G. Screening for hypertrophic
cardiomyopathy in young athletes. N Engl J Med 1998; 339:364-9.
(13.) Cantu RC, Mueller FO. Fatalities and catastrophic injuries in high
school and college sports, 1982-1997. Phys Sportsmed 1999; 27:35-48.
(14.) Goldberg B, Saraniti A, Witman P, et al. Pre-participation sports
assessment: an objective evaluation. Pediatrics 1980; 66:736-45.
(15.) Linder CW, DuRant RH, Seklecki RM, Strong WB. Preparticipation health
screening of young athletes: results of 1268 examinations. Am J Sports Med 1981;
9:187-93.
(16.) Tennant FS Jr, Sorenson K, Day CM. Benefits of preparticipation sports
examinations. J Fam Pract 1981; 13:287-8.
(17.) Thompson TR, Andrish JT, Bergfeld JA. A prospective study of
preparticipation sports examinations of 2670 young athletes: method and results.
Cleve Clin Q 1982; 49:225-33.
(18.) DuRant R, Seymore C, Linder CW, Jay S. The
preparticipation examination of athletes. Comparison of single and multiple
examiners. Am J Dis Child 1985; 139:657-61.
(19.) Risser WL, Hoffman HM, Bellah GG Jr. Frequency of
preparticipation sports examinations in secondary school athletes: are the
University Interscholastic League guidelines appropriate? Tex Med 1985; 81:35-9.
(20.) Magnes SA, Henderson JM, Hunter SC. What limits sports participation:
experience with 10,540 athletes. Phys Sportsmed 1992; 20:143-60.
(21.) Rifat SF, Ruffin MT, Gorenflo DW. Disqualifying criteria in
preparticipation sports evaluation. J Fam Pract 1995; 41:42-50.
(22.) Lively MW. Preparticipation physical examinations: a collegiate
experience. Clin J Sports Med 1999; 9:38.
(23.) DuRant RH, Pendergrast RA, Seymore C, Gaillard G, Donner J. Findings
from the preparticipation athletic examination and athletic injuries. Am J Dis
Child 1992; 146:85-91.
(24.) Van Mechelen W, Twisk J, Molendijk A, Blom B, Snel J, Kemper HC.
Subject-related risk factors for sports injuries: a 1-yr prospective study in
young adults. Med Sci Sports Exerc 1996; 28:1171-9.
(25.) Carek PJ, Futrell MA. Athlete's view of the preparticipation physical
examination: Attitudes toward certain health screening questions. Arch Fam Med
1999; 8:307-12.
(26.) Huston TP, Puffer JC, Rodney WM. The athletic heart syndrome. N Engl J
Med 1985; 313:24-32.
(27.) Crawford MH, 0'Rourke RA. The athlete's heart. Adv Intern Med 1979;
24:311-29.
(28.) Lewis JF, Maron BJ, Diggs JA, Spencer JE, Mehrotra PP, Curry CL.
Preparticipation echocardiographic screening for cardiovascular disease in a
large, predominately black population of collegiate athletes. Am J Cardiol 1989;
64:1029-33.
(29.) Maron BJ, Klues HG. Surviving competitive athletes with hypertrophic
cardiomyopathy. Am J Cardiol 1994; 73:1098-104.
(30.) Fuller CM, McNulty CM, Spring DA, et al. Prospective screening of
5,615 high school athletes for risk of sudden death. Med Sci Sports Exer 1997;
29:1131-8.
(31.) Fuller CM. Cost effectiveness of analysis of high school athletes for
risks of sudden cardiac death. Med Sci Sports Exer 2000; 32:887-90.
(32.) Pelliccia A, Maron BJ, Culasso F, et al. Clinical significance of
abnormal electrocardiographic patterns in trained athletes. Circulation 2000;
102:278-84.
(33.) Maron BJ, Pelliccia A, Spirito P. Cardiac disease in young trained
athletes: insights into methods for distinguishing athlete's heart from
structural heart disease with particular emphasis on hypertrophic
cardiomyopathy. Circulation 1995; 91:1596-1601.
(34.) Gomez JE, Landry GL, Bernhardt DT. Critical evaluation of the 2-minute
orthopedic screening examination. Am J Dis Child 1993; 147:1109-13.
(35.) Abbott HG, Kress JB. Preconditioning in the prevention of knee
injuries. Arch Phys Med Rehabil 1969; 50:326-33.
(36.) Jackson DW, Jarrett H, Bailey D, Kausek J, Swanson J, Powell JW.
Injury prediction in the young athlete: a preliminary report. Am J Sports Med
1978; 6:6-14.
(37.) Nicholas JA. Injuries in knee ligaments: Relationship to looseness and
tightness in football players. JAMA 1970; 212:2236-9.
(38.) Dodge WF, West EF, Smith EH, Harvey B 3rd. Proteinuria and hematuria
in schoolchildren: epidemiolegy and early natural history. J Pediatr 1976;
88:327-47.
(39.) Peggs JF, Reinhardt RW, O'Brien JM. Proteinuria in adolescent sports
physical examinations. J Fam Pract 1986; 22:80-1.
(40.) Rupp NT, Brudno DS, Guill MF. The value of screening for risk of
exercise induced asthma in high school athletes. Ann Allergy 1993; 70;339-42.
(41.) Feinstein RA, LaRussa J, Wang-Dohlman A, Bartolucci AA. Screening
adolescent athletes for exercise-induced asthma. Clin J Sports Med 1996;
6:119-23.
(42.) Torg JS, Vegso JJ, Sennett B, Das M. The National Football Head and
Neck Injury Registry. 14-year report on cervical quadriplegia, 1971 through
1984. JAMA 1985; 254:3439-43.
(43.) 26th Bethesda Conference: Recommendations for determining eligibility
for competition in athletes with cardiovascular abnormalities. Med Sci Sports
Exerc 1994; 26(Suppl):S223-S283.
(44.) American Academy of Pediatrics. Medical conditions affecting sports
participation. Pediatrics 2001; 107:1206-7.
Corresponding author: Peter J. Carek, MD, MS, Associate Professor,
Department of Family Medicine, Medical University of South Carolina, 9298
Medical Plaza Drive, Charleston, SC 29406. E-mail: [email protected].
I thought one of the first things you stopped with HCM was competitive sports.
2 
Comment