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 colleagues23 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.
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? |
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
Musculos keletal 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.