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 ur inalysis, 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.1-4 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
TABLE 1
Medical and orthopedic conditions resulting in additional evaluations
| Rifat, 1995* | Lively, 1999† | ||
|---|---|---|---|
| n=2,574 | n=596 | ||
| Pass with follow-up and/or restriction (12.6%) | Fail with follow-up (2.6%) | Follow-up or restriction (14.1%) | |
| 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‡ | 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 individual s failed (nonspecific pain/injury). | |||
| †Studied college-aged students. One individual failed (complicated pregnancy). | |||
| ‡“Other ” includes abdominal pain, allergy, bruising, chest pain, chronic/recurrent illness, dizziness/syncope with exercise, surgery (recent). | |||
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 colleagues21 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.