Overview of the Sports Preparticipation Physical Jose Yasul, MDCCRMCMartinez, CA

ObjectivesReview why we do a PPEDetermine your responsibilityDescribe the major features of the PPEFamiliarize you with the comprehensive musculoskeletal exam

Preparticipation Physical Evaluation:Third Edition (2005)Editorial Board: American Academy of Family Physicians American Academy of Pediatrics American College of Sports Medicine American Medical Society for Sports Medicine American Orthopaedic Society for Sports Medicine American Osteopathic Academy of Sports Medicine

PerceptionViewed in different ways among: Athletes Coaches Parents Athletic Trainers Administrators Physicians

My Goalis to ensure the student-athlete is healthy to participate in sports If a problem is identified, then it can be addressed Im not looking for a reason to disqualify or exclude students from participating

Objectives of the PPEPrimary Screen for conditions that may be life-threatening or disablingScreen for conditions that may predispose to injury or illnessMeet administrative requirements

Objectives of the PPESecondaryDetermine general healthServe as an entry point to the healthcare system for adolescentsProvide an opportunity to initiate discussion on health-related topics

Timing of evaluationTo allow time to treat or rehabilitate any identified problem (>6 weeks prior)Preferably with their PERSONAL PHYSICIAN with access to medical recordsGood option is midsummer or the end of the previous school year

Setting of evaluation

Physicians office versus coordinated team approachIn either setting it is preferred that the history and PE be done by the same physician

Setting of EvaluationStagePurposeWaiting AreaSign in and review instructions about filling out formsVitals stationHeight, weight, BP, visionExam AreaReview history, perform physical, sign out to preceptor OptionalEducational/Rehab areas

Tips for coordinated approachInform athletes in advance about the detailed nature of the exam and the appropriate attire -Sports bras for girls-Shorts for boysSeparate areas for examining boys and girlsPrivate counseling room for sensitive issues

Tips for coordinated approachClear protocols for referralsTeam physicians or athletic trainers should have a list of disqualified athletes or those who require further evaluation before final clearanceIf the athlete is not cleared for their desired sport, the evaluating physician should be prepared to counsel on alternative activities

PPE Medical History The most crucial componentWill identify approximately 75% of problems affecting athletes

PPE Medical HistoryMedical History (1-4)Meds & supplements (5-6)Allergies (7)Cardiovascular problems (8-18)Viral illness (17)Dermatological conditions (19)Neurological conditions (20-25)Heat Illness (26)Asthma/allergic rhinitis (27-29)

Eyes & Vision (31-32)Anaphylaxis (33)Musculoskeletal injury (34-35)Nutritional concerns (36-37)General concerns (38-39)Menstrual history (4-44)

Questions I askDid you have any injuries last season did you miss any games or practices because of an injury?Have you ever passed out while exercising?Has anyone in your family died unexpectedly under the age of 50?Do you find it hard to catch your breath when you exercise?When exercising, do you get tired more quickly than your friends?Do you cramp up easily?Are you taking any supplements?

PPE Medical HistoryYOUTH RISK BEHAVIORQuestions to be asked in the exam roomDo you feel stressed out or under a lot of pressure?Do you feel so sad or hopeless that you stop your usual routine for more than a few days?Do you feel safe?Have you ever tried cigarette smoking, even 1 or 2 puffs?During the past 30 days have you used smokeless tobacco?During the past 30 days have you had at least 1 drink of alcohol?Have you ever taken steroid pills or shots without a doctors rx?Are you taking anything to lose weight or improve your performance?Questions about guns, seatbelts, unprotected sex, D. V., drugs, etc.(Youth Risk Behavior Survey)

Physical ExaminationVitals, height, weightEyes Visual acuity (Snellen) PupilsOral cavity/Ears/NoseCardiovascular exam >Blood Pressure >Pulses (radial, femoral) >Heart (rate, rhythm, murmur)LungsAbdomenGenitalia (males only) Cryptorchidism Testicular massesSkinMusculoskeletal exam

Blood PressureNORMAL VALUES FOR KIDS DIFFER FROM ADULTSSBP & DBP are compared by sex, age and heightBP is 95th percentile, child may be hypertensive repeated measurements are indicated

http://www.cc.nih.gov/ccc/pedweb/pedsstaff/bp.html

AHA Recommended Elements of Preparticipation Cardiovascular Screening in Young Athletes Medical historyFamilyDeath from heart disease in one or more relatives younger than 50 yearsDisability from heart disease in a close relative younger than 50 yearsHypertrophic or dilated cardiomyopathy, long QT syndrome or other ion channelopathies, Marfan syndrome, or clinically important arrhythmias in any family memberPersonalElevated systemic blood pressureExcessive exertional and unexplained dyspnea or fatigue associated with exerciseExertional chest pain or discomfortHistory of heart murmurUnexplained syncope or near-syncopePhysical examinationBrachial artery blood pressure (measured while seated)Femoral pulses to exclude coarctation of the aortaHeart murmurPhysical stigmata of Marfan syndrome

Incidence of sudden death in athletesAuto accidents 30/100,000Homicide12/100,000Suicide10/100,000

Sports 0.5/100,000

Cause of sudden death in young athletes

Hypertrophic cardiomyopathyUsually AD, variable penetrance and expression Murmur systolic and increases with standing and valsalva and decreases with squatting and isometric handgrip

Marfans syndrome - stigmata ArachnodactylyTall staturepectus excavatumKyphoscoliosisLenticular dislocation Murmur of mitral valve prolapse and/or aortic regurgitation

Musculoskeletal System

Determining ClearanceImportant & occasionally difficult decision3.1 to 13.9% of student athletes require further evaluation before a final clearance status can be given

Determining ClearanceInitial Clearance has 4 categoriesCleared without restrictionCleared, with recommendations for further evaluation or treatment (i. e. check BP in 1 month)Not cleared, reconsideration after completion of further evaluation, treatment, or rehabilitationNot cleared for certain types of sports or all sports

Determining ClearanceAMERICAN ACADEMY OF PEDIATRICS: Medical Conditions Affecting Sports Participation PEDIATRICS Vol. 121 No. 4 April 2008, pp. 841-848 (doi:10.1542/peds.2008-0080) Classification of Sports by Contact Classification of Sports by Strenuousness Medical Conditions and Sports Participation http://www.pediatrics.org/cgi/content/full/107/5/1205

Summary Single examinerIn addition to reviewing the history, ask pertinent questions to the athlete directlyGoal is to assure safe student-athlete participation in a sport

My doctor told me I shouldnt work out until Im in better shape.I told him, All right, dont send me a bill until I pay you.

Steven Wright

*AHA differences vs AAFPFamily history of heart diseaseMarfans family history or stigmataSpecific item for heart murmur

note: A positive response to any item listed may be sufficient evidence to provide a referral for a cardiovascular examination.Adapted with permission from Maron BJ, Thompson PD, Ackerman MJ, Balady G, Berger S, Cohen D, et al. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update. Circulation 2007;115:1646.

*Hypertrophic cardiomyopathy36%Coronary artery anomalies23%Idiopathic LVH10% The other third include mostly CV isuues: Marfans, myocarditis, aortic stenosis, arrhythmogenic RVdysplasia, dysrhythmias, WPW, long QT, cocaine, steroids, alcohol