Care of the student athlete
Sports participation is on the rise among youth in the United States. As we continue to address childhood obesity, it is encouraging to see that the number of high school students playing sports has continued to increase yearly since 1983.
Reviewed by Andrew Gregory, MD, FAAP
Sports participation is on the rise among youth in the United States. As we continue to address childhood obesity, it is encouraging to see that the number of high school students playing sports has continued to increase yearly since 1983.1 The National Federation of State High School Associations (NFHS) estimates that 55.5% of all high school students play organized interscholastic sports.2 Nearly 7.8 million students participated during the 2013-2014 school year, up over 80,000 from the previous year and up over 1 million from 2002.1
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Sports offer the potential benefits of improving physical fitness, boosting self-esteem, learning about dedication and discipline, and increasing strength and coordination. Interscholastic competition provides an opportunity for teamwork, challenge, and camaraderie.3
With the growing number of young athletes taking to the fields, courts, and gyms, there is an increasing need for medical screening. The preparticipation examination (PPE) is considered a standard of care for children and adolescents across the United States. It is a tool for screening athletes prior to beginning training and competition. The goal is to promote participation in athletics and optimize safety. The main objectives of the PPE are to screen for life-threatening or disabling conditions and to screen for conditions that may predispose children to injury or illness.4 The aim is to help young athletes participate, with modifications if need be, rather than prohibit participation.5
NEXT: How well does the PPE work?
Research has shown that 3% to 13% of athletes require further evaluation based on PPE findings and only 0.3% to 1.3% of athletes with injuries are ultimately denied clearance during PPEs.3,6 These examinations have been used for nearly 40 years; some type of preparticipation physical for student athletes is required in each of the 50 states by the high school level.7 Controversy exists, however, because of a lack of standardization and debatable efficacy. Legislative requirements vary by state for the timing and content of the PPE and qualifications of the examiner.8,9 The NFHS has not adopted/required a standardized PPE.10 The majority of elementary and middle school-aged athletes have little or no required formal screening-other than routine well-child examinations-prior to training/competition. Elements of the PPE can be incorporated into well child-care visits starting as early as age 6 years.8 Overall, there is wide variation in what is covered at different ages and by different providers, how it is addressed, and the consequent continuity of care.
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With that in mind, the PPE Working Group was established as a joint project of the American Academy of Pediatrics, American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and the American Osteopathic Academy of Sports Medicine.11 Their recommendations guide physicians doing the PPE and are published in the Preparticipation Physical Evaluation, 4th edition (PPE-4). The publication is endorsed by the American Heart Association (AHA) and the National Athletic Trainers' Association. The authoring organizations of the PPE-4 agreed that a comprehensive approach offers the best opportunity to screen for risk and determine the general health of the athlete. Efforts continue to improve the effectiveness of the exam, standardize the format, and educate providers and families as to the benefits of formal screening.
NEXT: When should PPE be administered?
The PPE-4 provides the most current comprehensive guidelines as well as suggested screening questions, tools, and forms. (To download sample PPE forms, go to bit.ly/AAP-PPE-forms.) Among its recommendations is use of the 90-second musculoskeletal screening exam, which it cites as the standard of care (Table).12
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Ideally, the PPE should be completed a minimum of 6 weeks prior to the start of training.13 This allows time for any necessary further workup and treatment without interfering with participation. The PPE-4 recommends a comprehensive physical every 2 years with a brief update exam including questionnaire and problem-focused examinations annually.11 Despite the recommendation, there currently is no standard, evidence-based practice. This is illustrated by a 2006 survey of all states by the Minnesota State High School League Sports Medicine Advisory Committee, which found that 35 states require a yearly examination with or without a mandated form; 11 states require every-other-year comprehensive examinations (6 with interval screening, 5 without); 3 states require comprehensive examinations every 3 years with yearly questionnaires; and several states do not require a standardized form. Therefore, no consensus exists on how frequently the evaluation should be done, which is influenced by local standards, state and school district rules, organization or league requirements, and availability of qualified health professionals.
The main focus of the PPE is to serve as a screen to detect potentially life-threatening medical conditions, yet the PPE presents a broader potential benefit for our young athletes and their families. The PPE offers an opportunity for anticipatory guidance and discussion of lifestyle issues (nutrition, weight-control behaviors, training techniques, self-image), and can serve as an entry point to the healthcare system for adolescents. It certainly does not replace the comprehensive well-child visit. Research has shown, however, that it may be the only opportunity for some athletes to have access to medical care.14 In a study of parents’ knowledge of the purposes and content of the PPE, up to one-third indicated the PPE is their student athletes' only contact with the healthcare system, even when up to 90% had an identified primary care provider and insurance-covered yearly health maintenance examinations.15
NEXT: Importance of the medical history
Medical history
A comprehensive medical history is essential to the PPE. Research shows that personal and family histories reveal 64% to 78% of conditions that could disallow sports participation or at least warrant restrictions.16 This is more sensitive than the actual physical examination. Musculoskeletal conditions are the most common reason for disqualification at a sports physical.17 History alone has been shown to identify 92% of musculoskeletal issues affecting an athlete.18 It is critical that the history is obtained from both the athlete and the parent/guardian. Use of a medical interpreter and/or PPE form in other languages is vital to obtaining an accurate history when English is the secondary language. Discrepancies are commonly found between histories obtained from athletes and parents independently, and it is unknown which source is most accurate.12 Follow-up is needed for every positive answer for additional information with the goal of identifying chronic conditions, risk factors, and incompletely rehabilitated injuries.
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The strongest independent predictor of sports injuries is a previous injury and exposure time, so it is important to inquire about the time spent in training each week, including with the school team, independently, and working with personal trainers and travel/specialized teams.19 It is not uncommon in today's sports culture to have a young athlete playing on multiple teams during the same season. For many student athletes, the "off season" has become obsolete, raising the risk of overuse injury and burnout.
NEXT: Cardiovascular and neurological history
Cardiovascular history
Questions dedicated to risk factors and symptoms of cardiovascular disease should be asked as part of the clinical history. Cardiovascular problems (including rhythm and conduction abnormalities, systemic hypertension, valvular heart disease, congenital heart disease) are the second-most common reason for disqualification on a PPE.20
Cardiovascular disorders are the leading cause of sudden death in young athletes, with hypertrophic cardiomyopathy and coronary artery anomalies being the most common. Other cardiac causes include myocarditis, aortic rupture, arrhythmogenic right ventricular dysplasias, idiopathic left ventricular hypertrophy, aortic stenosis, and premature coronary artery disease.21 These conditions often go undetected in otherwise healthy-appearing young athletes. The prevalence of sudden cardiac death is estimated at 1 case for every 100,000 to 200,000 high school-aged athletes.22,23 It is more common in young men.
The AHA Council on Nutrition, Physical Activity, and Metabolism recommends specific questions on exertional chest pain or discomfort; unexplained syncope or near-syncope (particularly occurring during exercise); excessive unexplained exertional shortness of breath or fatigue; history of heart murmur; and history of systemic hypertension.22 Positive answers to any of these warrant further investigation. Additionally, athletes should be asked about history of palpations, current/past drug use, use of performance-enhancing supplements, and history of any other heart conditions or testing (eg, electrocardiogram [ECG], echocardiogram).
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Family history of cardiovascular disease must be assessed as part of the PPE. The AHA recommends detailed questions on premature death before age 50 years because of heart disease, disabling cardiovascular disease in a first- or second-order relative aged younger than 50 years, and family member with cardiac condition known to cause sudden cardiac death, such as hypertrophic cardiomyopathy, Marfan syndrome, long QT syndrome, arrhythmogenic right ventricular dysplasia, other inherited arrhythmias or conduction abnormalities, and premature coronary artery disease.22
Neurologic history
Concussion, seizure disorder, cervical spine stenosis, recurrent stingers or burners, frequent or exertional headaches, and history of spinal cord injury are neurologic conditions that can affect sports participation and/or necessitate further workup.
Athletes should be screened for a history of concussion, but it needs to be understood that not every athlete/family may necessarily label a past injury as concussion. Loss of consciousness is not required to make the diagnosis; 90% of concussions do not include loss of consciousness.24,25 The clinician should ask about any head injury that caused confusion, prolonged headache or irritability, any issues in school performance, or memory problems, and inquire about the length of recovery and any therapeutic interventions (ie, vestibular therapy, school tutoring, medications). Keep in mind that if an athlete has had a concussion, they are more likely to suffer a second concussion, and subsequent concussions can occur with less trauma and may take longer to return to baseline.11
Baseline neuropsychologic testing is becoming increasingly utilized as a tool in the evaluation and management of concussion. Neuropsychologic assessment can objectively assess cognitive functions, such as verbal memory, visual memory, processing speed, and reaction time.26 It is becoming more common for high school, collegiate, and independent athletic teams/organizations to recommend or require baseline (preinjury) testing as part of the PPE, particularly in higher-risk sports such as football, girls' soccer, wrestling, and hockey. If a head injury occurs, postinjury test scores can be compared to preinjury scores and can be used to track recovery.27
NEXT: Other considerations
Musculoskeletal history
Musculoskeletal issues are the most frequently discussed conditions and concerns at preparticipation exams and are the number 1 reason for restricting participation, with knee injury being most common and ankle injury next. All potential athletes should be asked about previous injuries and current and planned levels of physical activity. It is important to ask about history of injury, any injury that caused an athlete to have to sit out from participation, previous imaging, and any use of braces or orthotic devices including shoe inserts. If they use any type of device/orthotic, is its use and fit appropriate? Is it in good condition to serve its purpose? If there is a history of injury, are there any persistent symptoms? Has rehabilitation been completed?
Level of physical activity is important if an athlete has previously been sedentary and is now planning to start a new activity. In an experienced athlete, frequency and intensity of training should be assessed to screen for overuse injury such as apophysitis, shin splints, tendonitis, and stress fracture.
Special attention should be paid to female athletes when asking about musculoskeletal injuries. Persistent and recurrent injury, including but not limited to stress fracture, can be associated with the Female Athlete Triad, which is the combination of disordered eating, menstrual dysfunction, and osteoporosis. Questions regarding impression of body image and any desire to change weight tend to be helpful and can uncover underlying issues. Eating patterns are also important to assess in all growing children, so asking about any restrictive patterns or preferences such as vegan or vegetarian is pertinent.
Diets with insufficient nutrients provide suboptimal fuel for workouts, increase the risk of nutrient deficiencies that can lead to illness or fatigue, and can hinder bone and muscle growth and recovery. Sports nutrition focuses on proper intake of macronutrients (carbohydrates, protein, fat) and micronutrients (calcium, iron, folate, vitamin B6, zinc). Research shows that insufficiencies exist in adolescent diets, particularly in athletes participating in sports with an emphasis on body composition and appearance (gymnastics, cheer, dance, wrestling).28
Other considerations
All medications and supplements should be reviewed at the PPE visit. A complete review includes questions about supplement use, performance-enhancing substances (including caffeine, creatine, protein shakes), vitamins, and alternative medicine treatments. Medication questions should address frequency of use, dosing, and accessibility. Answers to these questions may reveal medical conditions that were not mentioned by the athlete initially or disclosed on an intake form. Athletes with allergies and a history of anaphylaxis should have injectable epinephrine immediately accessible in case of emergency. Asthmatics should be asked about control of their disease, access to an inhaler, and last use of their rescue inhaler.
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Screening for risk of heat-related illness should be done by asking about intrinsic and extrinsic risk factors. Intrinsic risk factors include poor heat acclimatization, recent viral illness, overexertion, dehydration, poor aerobic fitness, excess body fat, large body size, and previous heat-related illness. Extrinsic risk factors include exposure to hot conditions, sports equipment worn, high humidity, medications, and supplements taken.11 The PPE is an excellent opportunity to educate athletes and their families on how to decrease risk of heat-related illness, how to recognize signs of heat-related illness, and what to do if symptoms occur.
Inquiry should also be done regarding psychosocial issues, asking potential athletes about stress, depression, anxiety, and social family pressures. Questions should further include whether or not they use tobacco, alcohol, anabolic steroids, and/or illicit drugs. Any concerning answers should be explored further in the interest of patient safety and well-being.
NEXT: The physical examination
Physical examination
In addition to the comprehensive history, the physical examination is a screening designed to detect potentially disabling or life-threatening conditions and detect musculoskeletal conditions that could predispose to injury during sports participation.
General appearance and vitals
The PPE includes the inspection of general appearance, with attention given to screening for Marfan syndrome features (arachnodactyly, excessive height, arm span > height, pectus excavatum). Vitals should always be reviewed by the physician. Blood pressure must be interpreted based on age, gender, and height. Taller children can have higher readings but still be normotensive.29 Vision screening is crucial for detecting vision defects. If the visual acuity is asymmetric and the eye with worse acuity has corrected vision worse than 20/40, the athlete is considered functionally one-eyed.11 These families should be counseled on injury prevention, including use of eye protection. Baseball has the highest rate of eye injury; therefore, polycarbonate eyewear should be recommended in these patients. If the athlete wears glasses/contacts, the vision screening is a good time to ask whether their prescription is up to date and whether they wear the glasses/contacts as recommended.
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Cardiovascular exam
The AHA recommends 4 key elements of cardiovascular screening. These include listening for heart murmurs, evaluation for Marfan stigmata (mitral valve prolapse, aortic insufficiency murmur), measurement of brachial artery blood pressure in the seated position, and palpation of femoral pulses to exclude aortic coarctation (diminished pulses).22 The point of maximal impulse should be palpated for increased intensity and displacement, suggestive of hypertrophy. Sinus bradycardia and similar dysrhythmias are common in young athletes. In the absence of structural heart disease or symptoms, these athletes typically can be cleared for participation and monitored.30 Atrial fibrillation, paroxysmal supraventricular tachycardia, pre-excitation syndromes, and ventricular tachycardia require that the athlete be asymptomatic with documented control of the rhythm for 6 months before they can be cleared for participation.31 Athletes with any systolic murmur grade 3/4 or louder, any murmur that disrupts normal heart sounds, any diastolic murmur, or any murmur that intensifies with squat-to-stand, deep inspiration, or Valsalva should be referred to cardiology for further evaluation.12
Musculoskeletal exam
Musculoskeletal findings are the most likely reason to keep an athlete from full clearance without restrictions. A complete musculoskeletal screening exam is commonly used and can be completed efficiently in less than 2 minutes (Table).12
If symptoms or other abnormalities are noted on the physical exam or if the athlete has recent or recurrent injury, a more detailed examination should be done on that part of the body. Orthopedic examination includes scoliosis screening and ideally an assessment of flexibility if time allows. Imbalance of flexibility and strength at the posterior versus anterior lower limbs is a common risk factor for lower extremity injury.3
Although not a traditional component of the PPE, performance testing is becoming a popular addition to preseason evaluations. Tests can be general or sports specific. Testing may include agility, speed, balance, and cardiovascular endurance. The Functional Movement Screen (FMS) is an example of a performance assessment tool used by some teams, requested by some coaches, and gaining popularity among sports medicine physical therapists.32-34
Other physical exam components
The PPE includes screening of all body systems. For the respiratory component, the main goal is to screen for signs of asthma or dyspnea. The clinician needs to inspect for accessory muscle use and listen for prolonged expirations or wheezing. The abdominal exam should be done with the patient supine and relaxed, and the clinician should palpate for spleen and liver enlargement. The skin should be examined, particularly in athletes playing sports with direct skin-to-skin contact, such as wrestling and martial arts. Molluscum contagiosum, herpes simplex, impetigo, tinea corporis, and scabies are contagious conditions that temporarily prohibit participation.35 Examination of the mouth and teeth is important to screen for loose teeth, soft tissue lesions consistent with smokeless tobacco use, and enamel erosion and/or caries suggestive of purging behavior.36 It is also a chance to ask about use of a mouth guard. In male athletes, the scrotum should be examined for testicles, testicular masses, inguinal hernia, and varicocele.35 Tanner staging is no longer done for the PPE as there is no evidence linking it to injury reduction.37
NEXT: Additional workups
Testing and additional workup
No additional testing or lab work is universally recommended for the routine PPE. Nothing has been found to be cost effective on a large scale.9,32 This includes ECG, echocardiogram, exercise stress testing, spirometry, DNA testing, and labs such as complete blood count, urinary analysis, and ferritin level.
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Recommendations regarding universal ECG screening are highly debated in sports medicine and pediatric cardiology.11 Controversy stems from data showing low sensitivity, high false-positive rate, poor positive predictive value, poor cost-effectiveness, low prevalence of disease, and lack of practicality because of the large number of young athletes. However, routine use of ECG is supported by the European Society of Cardiology, the International Olympic Committee, and the governing bodies of multiple US and international professional sports organizations. Additional research and medical education is needed in order to better define acceptable versus concerning ECG findings, determine cost-effectiveness of screening, and find consensus between US and European sports medicine authorities.
Electrocardiogram can be used selectively for evaluation of higher-risk athletes with concerning past medical or family history or abnormal exam findings. The PPE-4 provides a list of ECG findings that strongly suggest underlying cardiovascular disease, may suggest cardiovascular disease, or are common in well-conditioned athletes as a guide for physicians using ECG in their overall evaluation.11
Athletic clearance
The majority of potential athletes coming in for PPEs are healthy overall. Only 3% to 13% require further workup, and less than 1% are fully disqualified from sports based on results of their PPE.32,35 There are 4 categories of athletic clearance: cleared without restrictions; cleared with recommendations for further evaluation; not cleared pending further evaluation, treatment, or rehabilitation; and not cleared for certain activities or not cleared for any activity.11 It is essential that the clearance category be personalized for each potential athlete. If an athlete is recovering from an injury, consider whether limited participation can be safely allowed in the interim. Complicated clearance decisions and plans are best done collaboratively involving the athlete, their parent/guardian, coaches, involved health providers, and their school athletic trainer (if applicable).
Conclusion
Athletic participation continues to rise among children and adolescents. More and more children are getting involved in sports at even younger ages, and the intensity of involvement has remarkably increased over the past several decades. As healthcare providers, we have a responsibility to promote physical fitness and health. Equally important, we also have a duty to ensure a safe athletic environment. This requires diligence and attention to detail to recognize conditions that put young athletes and other participants at risk of injury. Unfortunately, there is not yet consistency regarding use of the PPE, neither in examination requirements nor in documentation, or in which types of healthcare providers are allowed to do the screening. Further efforts are necessary to improve efficacy and stress the importance of standardization.
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Dr Frye serves as teaching faculty for the Michigan State University College of Human Medicine, East Lansing. She also is a nonsurgical pediatric orthopedics and sports medicine physician in Grand Blanc, Michigan. The author has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article. Dr Gregory is a physician in the Sports Medicine Division, Department of Orthopedics, assistant professor of orthopedics and pediatrics, and co-director of the Primary Care Sports Medicine Fellowship, Vanderbilt University School of Medicine, Nashville, Tennessee. He reports he has consulted for DJO Global.
