Second of two parts

Making the preparticipation athletic evaluation more than just a "sports physical"

Part 2: Performing a focused physical exam

By Michael C. Koester, MD, ATC

The physical examination for a patient seeking clearance to participate in a sport should focus on areas likely to yield significant findings—notably, the cardiovascular and musculoskeletal systems.

The first installment of this two-part review of the preparticipation athletic evaluation (PAE) detailed the history. Here, I review the physical examination component. Even though many significant findings will be apparent by history, a screening process should be established to ensure that important areas are assessed by physical exam. Employing this strategy not only enables you to evaluate any problem identified on history but also safeguards against missing a condition that the athlete is either unaware of or has given an untruthful answer about for fear of disqualification.

The exam should focus on areas likely to yield significant findings—namely, the cardiovascular and musculoskeletal systems. Few clinicians advocate a routine HEENT (head, eyes, ears, nose, and throat) examination during the PAE, as it is unlikely to yield positive findings. In addition, an abdominal examination is optional unless the athlete has recently had mononucleosis. A skin examination is indicated for wrestlers—tinea corporis, impetigo, and cutaneous herpes simplex virus infection all must be treated prior to practice or competition.

Opinion varies as to the value of a routine genital examination in young males. An inguinal hernia is not a contraindication to sports participation and most young men who have a single testicle already know it. In my opinion, the great anxiety induced by the genital exam, particularly in younger males, outweighs its low diagnostic yield.

The following areas should be assessed in all athletes seeking preparticipation clearance.

Blood pressure

Obtain BP with the athlete in a seated position, using an appropriate size cuff on the right arm. If the reading is elevated, perform additional measurements over the next several weeks. If hypertension persists, an appropriate evaluation should be initiated. Only athletes with severe hypertension, or moderate hypertension with evidence of end-organ damage, should be held out of sports while an evaluation is completed (Table 1). [Editor's note: For more on hypertension in the pediatric population, see "Recognizing and managing the hypertensive child," in the August 2003 issue.]

TABLE 1
Classification of hypertension in teenagers

Eyesight

Screen vision in each eye. Consider any athlete with a best-corrected vision of less than 20/40 in one eye to be functionally one-eyed. (Please refer to the discussion in Part 1 about protective eyewear.) An athlete with an overall vision of less than 20/40 who has no correction may be held from sports pending the prescription of appropriate eyewear. When deciding whether to allow activity while awaiting further evaluation, consider the athlete's particular sport. Certainly, a distance runner is at much less risk of potential injury due to poor vision than a baseball player.

Cardiovascular exam

As detailed in the American Heart Association guidelines on cardiovascular preparticipation screening of competitive athletes,¹ examination of the cardiovascular system includes auscultation of the heart in both the upright and supine positions, palpation of the femoral pulses (to rule out aortic coarctation), and assessment for the stigmata of Marfan syndrome (Table 2), in addition to measurement of brachial artery BP. The hallmark physical examination finding in hypertrophic cardiomyopathy (HCM) is a systolic murmur that decreases in intensity with the athlete in the supine position (increased ventricular filling, decreased obstruction). This contrasts with functional outflow murmurs common in athletes that increase in intensity upon lying down. The intensity of the HCM murmur increases with the Valsalva maneuver (decreased ventricular filling, increased obstruction). Any athlete who has a systolic murmur with an intensity of 3/6 or greater; a diastolic, holosystolic, or continuous murmur; or any other murmur that the examining physician finds suspicious should be held from participation and referred to a cardiologist for evaluation (Table 3).

TABLE 2
History and physical exam findings that suggest Marfan syndrome

TABLE 3
Heart murmurs that require further work-up

Musculoskeletal exam

Many authorities recommend using the "two-minute" orthopedic examination as a screen for musculoskeletal abnormalities.^2,3 One study of this exam as a screening instrument found it to be effective, but the authors provided suggestions for improvement.⁴ Because most significant injuries occur in or around the knee-thigh, ankle-leg, and shoulder regions, these areas should be of high importance when screening. The musculoskeletal screening exam that I conduct (described in the text that follows) is a modified version of the two-minute orthopedic exam, based on the modifications proposed by Gomez and colleagues⁴ and on my clinical experience.

Begin the exam with the athlete standing upright, thigh muscles tightened. Observe overall limb and musculature symmetry, including acromioclavicular joints, knees, and quadriceps. (This step and those that follow are depicted in the illustrations.) Next, have the athlete look at the ceiling and floor and over each shoulder successively, then touch each ear to each shoulder, while you assess neck range of motion.

PLEASE NOTE: If you are using Internet Explorer version 6 or higher, after clicking to enlarge each graphic in the article, click the picture icon that appears in the lower right-hand corner of the graphic.

Test deltoid strength next: With the athlete's arms abducted to 90°, have him (or her) resist as you apply downward force to the distal portion of the forearms. Assess the supraspinatus muscle (one of the rotator cuff muscles) by again applying downward force as the athlete resists, but this time with the athlete's arms abducted and forward-flexed 45° with the thumbs pointed toward the floor. Then, assess shoulder internal rotation by asking the athlete to place each arm behind his or her back.

Next, have the athlete again abduct the arms to 90° (with palms up) and flex and extend the elbow joints; assess elbow extension and flexion. As the arms are then lowered to the sides with the elbows flexed, observe supination and pronation of the forearms. With the arms still flexed at the sides, ask the athlete to make a fist with each hand and then spread the fingers. Assess for finger and hand deformities.

Have the athlete turn his back to you, and observe for any back or hip asymmetry. While the athlete bends over with knees straight, check for scoliosis, kyphosis, and hamstring tightness. Ask the athlete to arch the back upon returning to a neutral position. Pain with arching may signal lower back pathology such as spondylolysis. Last, have the athlete balance on each foot and then hop three or four times (still on each foot) as a brief test of proprioception and function.

The inability to fully perform any of these movements, pain upon any of the movements, or obvious deformities or weaknesses must be further assessed before clearance for sports participation. Athletes with a history of injury should have the injured joint or limb further assessed for strength and function. Compare strength of the injured and uninjured limbs, and assess for point tenderness, swelling, and ligamentous laxity, if applicable.

Any athlete with a history of lower extremity injury must be put through a variety of functional ability drills. If possible, conduct a series of short running and cutting drills in an open space outside the office. Such testing takes only a short time and provides useful information. The drills should emphasize speed, quick changes in direction (agility), and sport-specific movements. After a short warm-up period, testing begins with straight-ahead running and progresses through more complex movements: sprinting, figure-8 running, side-stepping, back-pedaling, etc. The athlete can be safely cleared for participation if he or she is able to progress through the drills at full speed, without pain or limping during or after activity. Any athlete who is unable to complete the drills due to pain or weakness requires further evaluation or referral to a sports medicine specialist, physical therapist, or certified athletic trainer (ATC) (more about ATCs later).

Evaluating functional ability in upper-extremity injuries (such as a swimmer with past shoulder injuries or a baseball pitcher with a history of elbow pain) can be difficult. Simple dynamic tests such as push-ups or "clap" push-ups may be performed, but they are not specific to the movement of the sport. In these circumstances, it is best to seek feedback from coaches and parents once practice begins.

Laboratory tests

Routine lab testing as part of the PAE is not indicated. In the past, urinalysis was routinely performed to check for the presence of glucose, blood, or protein, but such testing is no longer recommended. Some authorities recommend a screening hematocrit for females. Although anemia is common in this age group, it is not a contraindication to sports activity.

Disqualifying conditions and referral

The American Academy of Pediatrics has provided guidelines on sports participation for patients with any of a variety of medical conditions (see Table 4 in the print edition: Medical conditions and sports participation: Who should you clear? Adapted from American Academy of Pediatrics Committee on Sports Medicine and Fitness: Medical Conditions Affecting Sports Particiation. Pediatrics 2001;107:1205. Used with permission of Pediatrics).⁵ They have also classified sports by contact risk and strenuousness.⁵ Only about 1% of athletes who undergo a PAE are disqualified from athletic activity.⁶ In fact, few absolute contraindications to athletic activity exist. With many athletes, however, clearance may be contingent upon further evaluation or upon rehabilitation. Athletes with poor vision, a suspicious heart murmur, or previously undiagnosed injury, among other conditions, should be referred for further evaluation and management. The athlete should be reassessed after such services have been provided.

Athletes with a functional deficit such as weakness around a previously injured joint must be properly rehabilitated before being cleared. This is one of many instances in which a certified athletic trainer can be a valuable ally to the clinician. ATCs are medical professionals who specialize in the prevention, assessment, treatment, and rehabilitation of injuries and illnesses in athletes and other physically active individuals. (More information on ATCs is available at the Web site of the National Athletic Trainers' Association, www.nata.org .) If the athlete's school employs an ATC, that person can work with the athlete to regain the previous level of strength and function, as well as put strategies into place to avoid further injuries. If an ATC is not available, referral to a physical therapist experienced in sports medicine is appropriate.

Sports safety and injury prevention

Despite the extensive set of potential problems discussed, most young athletes are quite healthy and many have no previous injuries. Even after a thorough review of the history and a focused examination, the examiner should reserve time during the encounter to review some simple issues that may limit the athlete's injury risk in the future. A handout to give to young athletes and their parents appears below.

An important topic to cover with both athletes and parents is when they should be seen following an injury. Many athletes are weaned on such expressions as "no pain, no gain," and parents are uncertain about the difference between simple soreness and injury. In general, any injury in a young athlete that keeps him or her out of practice for two days or longer needs to be evaluated. Persistent pain during activity, even if it is not affecting performance, should also be investigated.

Adolescents are at particular risk of overuse injury for a variety of anatomic reasons. The overall training load and the progression toward more intense training early in the course of the season are major determinants in the development of overuse injuries. In addition to placing increased stress on the muscles and joints, the body is more likely to fatigue, thereby compromising form and technique. This further increases the risk of injury. An increase in total training volume or intensity of no more than 10% per week has been suggested to limit injury risk. For example, a young distance runner who begins the week running 3 miles per day would increase that to no more than 3.3 miles per day the next week. The same principle can be applied to young pitchers, swimmers, or gymnasts in regard to overall length or volume of training sessions.

A PAE that scores

Obtaining clearance to participate in a sport is among the most common reasons for an otherwise healthy adolescent to come to your office. As presented in Part 1 of this review, Metzl outlined three clear objectives the physician should have in conducting a PAE⁷:

• Identify medical and musculoskeletal conditions that could make participation in sports unsafe, with specific consideration of the sport for which the athlete is being cleared

• Screen for underlying illness through a medical and family history, review of systems, and physical examination

• Recognize preexisting injury patterns from a previous sports season(s) and devise rehabilitation programs to prevent recurrence

To achieve these goals, you do not need an extensive background in sports medicine—only the knowledge and desire to make the PAE more than just a "sports physical."

REFERENCES

1. Maron BJ, Thompson PD, Puffer JC, et al: Cardiovascular preparticipation screening of competitive athletes. Circulation 1996;94:850

2. Smith DM, Kovan JR, Rich BSE, et al: Preparticipation Physical Evaluation, ed 2. Minneapolis, McGraw-Hill, 1997

3. Krowchuk DP: The preparticipation athletic examination: A closer look. Ped Annals 1997;26:37

4. Gomez JE, Landry GL, Bernhardt DT: Critical evaluation of the 2-minute orthopedic screening examination. AJDC 1993;147:1109

5. American Academy of Pediatrics, Committee on Sports Medicine and Fitness: Medical conditions affecting sports participation. Pediatrics 2001;107:1205

6. Smith J, Laskowski ER: The preparticipation physical examination: Mayo clinic experience with 2,739 examinations. Mayo Clin Proc 1998;73:419

7. Metzl JD: Preparticipation examination of the adolescent athlete: Part 1. Peds Rev 2001;22:199

DR. KOESTER is a pediatrician at Good Shepherd Medical Center, Hermiston, Ore. He has nothing to disclose in regard to affiliation with, or financial interests in, any organization that may have an interest in any part of this article.

GUIDE FOR PATIENTS

Preventing sports injuries

Many injuries caused by participation in a sport happen at the start of the season. This is often the result of doing "too much, too soon" or not being properly prepared. The following guidelines can help prevent injuries throughout the year.

The three keys

1. Practice "prehabilitation." Instead of rehabilitating injuries—restoring injured parts to normal function—prevent injuries from occurring in the first place by strengthening at-risk muscle groups. If you participate in a sport that demands the same upper body movement over and over (such as swimming, tennis, or, if you'rea pitcher, baseball and softball), contact a certified athletic trainer or physical therapist several months before your sports season begins to devise ashoulder-and-elbow strengthening program.

2. Follow the 10% rule. Slowly increase your training load at the start of the season. Inflammation of the tendons (tendonitis), stress fractures, and other injuries may result from a sudden increase in training load.Do not increase the intensity or volume of your training by more than 10% per week. For example, runners who run an average of 20 miles a week should increase that to no more than 22 miles the following week. Then to about 24.2 miles the following week. And so on.

3. Stay active. Even if you participate in only one sport, you should engage in a variety of physical activities throughout the year. Running, biking, swimming, basketball, and many other activities are excellent ways to maintain conditioning and avoid the need to play "catch-up" to get in shape when your sport season begins.

Warm up, cool down

Prevent pulled muscles by jogging for five minutes and then stretching for 10 to 15 minutes before practices and games. Following the same jogging and stretching routine after activity can decrease muscle soreness.

Prevent dehydration

Dehydration—loss of water from the body—can result from sweating during athletic activities, especiallyin hot weather. It can lead to dangerous heat illness.To prevent dehydration, drink water before, during, and after all practices and games. Cool water (50° to 70° F) is preferred to warm water (like that in a bottle that sits outside while you work out) because it is more rapidly absorbed from the stomach. A good guide isas follows:

• Drink 16 oz of water 30 to 60 minutes before activity

• Drink 4 to 8 oz of water every 15 to 30 minutes during activity

• Drink 16 oz of water for every 1 lb of weight lost after activity

Sports drinks such as Gatorade and Powerade are only really needed if activity is very intense and lasts longer than 90 minutes.

Nutrition tips

A good diet is essential to peak athletic performance. It helps maintain strong bones, avoid anemia, and build muscle.

Vitamins. If you are eating a good variety of foods, vitamin supplements are usually unnecessary. Here's how much calcium, iron, and protein you should be getting:

Calcium: Adolescents require between 1,200 and 1,500 mg/day. Foods high in calcium include dairy products, fortified juices, broccoli, shrimp, and spinach. Soda (caffeine and phosphorous), alcohol, cigarette smoking, and low-estrogen levels (absent periods) can interfere with calcium absorption.

Iron: Females 11 to 24 years old need 15 to 18 mg/day; males 11 to 18 years old need 12 mg/day, and males 19 to 24 years old need 10 mg/day. Foods high in iron include all meats, especially beef and liver; refried beans; spinach; and most cereals.

Protein. About 1.5 gram per kilogram (g/kg) of body weight per day is a good guideline for adolescent athletes. The recommended daily allowance for nonathletes is 0.8 g/kg/day. All athletes need protein in their diets; those trying to build muscle through weight training require even more (up to 2 g/kg/day). Adequate protein intake can be easily obtained through the diet, without resorting to expensive protein powders and shakes. Foods high in protein include meat, fish, poultry, eggs, dairy products, grains, breads, beans, and peanut butter.

Pre-game meals. How long before an event a meal should be eaten, and what should be eaten, varies from person to person. Typically, a meal should be eaten three or four hours before the event and consist of easily digested foods. This is no time to try something new!

This guide may be photocopied and distributed without permission to give to your patients and their parents. Reproduction for any other purpose requires express permission of the publisher.