The athletic pre-participation examination (PPE) is a standard sports medicine practice with the primary goal of providing medical clearance for sports participation and promoting the health and safety of athletes in training and competition. The aims of the PPE include identifying medical conditions and musculoskeletal injuries that require treatment or that may be associated with an increased risk of morbidity or mortality during sports participation. Please see Figs. 26–1 and 26–2 for examples of a preparticipation physical examination and a clearance form.
Figure 26–1
Example of a preparticipation examination form.2 (©2010 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, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.)
Figure 26–2
Sample clearance form.2 (©2010 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, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.)
The PPE timing, frequency, and protocol are determined by individual sport governing bodies. Generally, it is advised that the PPE is performed prior to initial participation in organized sports teams, with interim medical history updates and physician follow-up as indicated, usually annually.
Most PPEs occur during individual medical office visits or in a station-based mass athlete screening setting. There are advantages and disadvantages to both methods, including differences in cost, privacy, efficiency, continuity of care, and ease of education and counseling.1
The PPE should include taking a general medical history of prior and existing medical conditions and musculoskeletal injuries, exercise history, prior hospitalizations or surgeries, family and social history, medications, supplements, and medication and environmental allergies. Critical elements of the physical examination include general appearance; vital signs; vision screening; examination of the cardiac, pulmonary, abdominal, musculoskeletal, and dermatological systems; and genitourinary examination in males. A comprehensive PPE form has been created through the collaboration of the American College of Sports Medicine (ACSM), American Academy of Family Physicians, American Academy of Pediatrics (AAP), American Medical Society for Sports Medicine, American Orthopedic Society for Sports Medicine, and American Osteopathic Academy of Sports and is available through the AAP and shown in Figures 26–1 and 26–2.2 Routine laboratory testing and imaging tests are not recommended as a part of the standard PPE but may be ordered if required by the sport governing body protocol or clinical indication.
The PPE was initially recommended by the American Heart Association (AHA) to help identify athletes who may be at risk for sudden cardiac death (SCD).3 SCD in individuals under the age of 35 are primarily due to congenital cardiac abnormalities, most commonly hypertrophic cardiomyopathy or coronary artery abnormalities.3 In athletes over the age of 35 years, it is important to screen for cardiac risk factors such as hypertension, coronary atherosclerotic disease, or diabetes, given the increased risk of myocardial infarction during exercise (see Table 26–1). Other possible causes of SCD include aortic dissection associated with aortic root dilation in Marfan’s syndrome, severe aortic stenosis, arrhythmogenic right ventricular cardiomyopathy, and cardiac conduction abnormalities such as idiopathic long QT syndrome, Wolff-Parkinson-White syndrome, Brugada’s syndrome, or catecholaminergic polymorphic ventricular tachycardia.4,5
| Risk Factor | Criteria |
| Age | Males: 45 years and above Females: 55 years and above |
| Family History | History of premature coronary heart event (myocardial infarction, coronary revascularization, sudden cardiac death) in: Male first-degree relative: below 55 years old Female first-degree relative: below 65 years old |
| Smoking | Current or passive smoker |
| Hypertension | BP ≥140/90 mm Hg or on antihypertensive therapy |
| Dyslipidemia | LDL ≥130 mg/dL (3.37 mmol/L) or HDL <40 mg/dL (1.04 mmol/L) or on lipid-lowering therapy Total cholesterol ≥200 mg/dL (5.18 mmol/L), in the absence of other cholesterol measurements, is considered high. |
| Inadequate physical activity | Less than 150 min/week of moderate-intensity activity, or 75 min/week of vigorous intensity, or an equivalent mixture of the two (see footnote in Table 26–3). |
| Obesity | BMI ≥30 Waist circumference: Male: ≥102 cm (40 in.) Females: ≥88 cm (35 in.) |
| Prediabetes | Impaired fasting glucose: fasting plasma glucose 100–125 mg/dL (5.55–6.94 mmol/L) Impaired glucose tolerance: 2-hr plasma glucose levels in a 75-g oral glucose tolerance test (OGTT) 140–199 mg/dL (7.77–11.04 mmol/L) |
| High HDL levels (negative risk factor) | ≥60 mg/dL (1.55 mmol/L) |
The cardiovascular history should include the 14-point AHA cardiovascular screening questions as described in Table 26–2.6 The presence of cardiac risk factors warrants further evaluation, and the athlete may require an echocardiogram (ECG), echo, or exercise stress testing, based on clinical indication, prior to clearance for sports participation.66 Internationally, there are different guidelines from sports governing bodies and professional medical societies such as the European Society of Cardiology (ESC), American Heart Association, and the International Olympic Committee (IOC) regarding the necessity of a 12-lead ECG as part of the standard PPE.7,8 The recommendations for sports participation clearance for athletes with specific cardiovascular conditions are detailed in the 36th Bethesda Conference report.4
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The presence of HIV or viral hepatitis alone does not mandate exclusion from sports participation. Decisions regarding medical clearance should take into consideration the nature of the sport and the athlete’s disease status.9 While sports that involve direct contact or collision with other athletes presumably have a higher risk of blood and bodily fluid exposure, the risk of bloodborne disease transmission of HIV and hepatitis B virus (HBV) is very low.10–12 Hepatitis A and E are spread through the fecal-oral route, and transmission risk depends on environmental factors.13
Dermatologic infections require special attention in sports with collision, contact, or limited contact such as wrestling or martial arts or mat-based gymnastics.14 If an athlete has any of the following active infections with skin lesions, they require appropriate treatment and covering of lesions prior to sports participation as mandated by the individual sport governing body: tinea corporis, impetigo, furuncles, herpes simplex type 1, scabies, and molluscum contagiosum.15–17
The prevalence of sickle cell trait varies by racial and ethnic group, and guidelines regarding sickle cell trait screening are controversial.17–19,71 While sickle cell trait is not a contraindication to sports participation, individuals with sickle cell trait should be educated on how to recognize and prevent exertional sickling episodes or rhabdomyolysis. Individuals with sickle cell trait should be counseled on the importance of hydrating well; acclimatizing to heat, humidity, and altitude changes; and avoiding intense exercise during febrile illnesses.18,20
The female athlete triad consists of three interrelated clinical entities: low energy availability, menstrual dysfunction, and low bone mineral density.21,22 A fourth component of vascular endothelial dysfunction has been identified in this population, making it a tetrad.23
Screening for the female athlete tetrad during the PPE is advised. The Female Athlete Triad Coalition developed a 12-question screening assessment with questions about disordered eating, menstrual dysfunction, and bone health that can be included in the PPE.24 Any individual with one component of the tetrad should be evaluated in more detail for other risk factors and referred for further evaluation if indicated. Athletes with the female athlete tetrad or eating disorders may warrant restriction from training and competition on a case-by-case basis.22
In 2014, the IOC published a consensus statement entitled “Beyond the Female Athlete Triad: Relative Energy Deficiency in Sport (RED-S).” The syndrome of RED-S refers to “impaired physiological functioning caused by relative energy deficiency and includes, but is not limited to, impairments of metabolic rate, menstrual function, bone health, immunity, protein synthesis and cardiovascular health.” The aetiological factor of this syndrome is low energy availability (LEA) and can affect males or females.24a
Exercise-induced seizures in individuals with epilepsy are rare.25 Physical activity has been shown to decrease seizure frequency for most varieties of seizures, as well as to improve cardiovascular and mental health.25 Individuals with epilepsy can participate in most sports safely with adequate seizure control with medications, as well as appropriate risk management strategies. Contact or collision sports such as American football, hockey, or soccer are not associated with an increased risk of seizures.26 Water sports, swimming, and diving are safe if the seizures are well controlled and the activity is supervised. Sports such as scuba diving, free climbing, skydiving, or hang gliding are contraindicated due to the risk of severe injury or death if a seizure were to occur during the activity.27
In contact sports with a risk of cervical spine injury, such as American football, ice hockey, or rugby, it is important to screen for a history of burners, stingers, or transient quadriparesis. Burner or stinger symptoms are usually sensory with radiating burning pain or numbness, most frequently affecting the C5 and C6 dermatomes, and with possible upper limb weakness in the corresponding myotomes.28 If the athlete has a history of burners or stingers, he or she should have full, pain-free cervical range of motion (ROM) and a normal neurologic examination prior to clearance for sports participation.28 Athletes with three burners in the same season should have further neurologic evaluation and be considered for restriction from contact sports.29
Controversy exists regarding the return to play of athletes with a prior episode of transient quadriparesis. The absolute contraindications for sports participation after an episode of transient quadriparesis include persistent neurologic findings; magnetic resonance imaging (MRI) evidence of spinal cord injury, acute cervical fracture, or ligamentous disruption; cervical spine segmental instability; Arnold-Chiari malformation; basilar invagination; os odontoideum; atlanto-occipital fusion or instability; Klippel-Feil fusion greater than two levels; or history of multilevel cervical spinal fusion.28
During the PPE, it is important to determine whether the athlete has a history of concussions (number, severity, and recovery) and any associated attention, mood, learning, sleep, or headache symptoms.2 Various concussion assessment tools can be used, such as baseline symptom scales, balance testing (Balance Error Scoring System [BESS] or modified BESS), Sideline Concussion Assessment Tool (SCAT3), or computerized neuropsychological testing.30,31
The athlete should be free of concussion symptoms at rest and during and after exertion, and should have a normal neurologic exam compared to baseline before clearance for graded progression back to sports practice and competition.31 Although there are no standard guidelines, restricting an athlete from sports has been recommended when the following are present: structural abnormality on neuroimaging, multiple lifetime concussions, persistent postconcussive symptoms, or prolonged recovery time following concussion.32–34
The PPE should include screening for the presence of any single or abnormal paired organs such as the eyes and kidney and in males for the testes. Congenital or traumatic absence of one kidney does not preclude sports participation.35 There is no evidence that body protectors or vests reduce the risk of injury.36
Sports associated with a high risk for eye injuries are those involving the use of a bat, puck, stick, racquet, or close body contact.37 Individuals with a history of eye injury, infection, surgery, or retinal detachment should be referred to an ophthalmologist for clearance for high-risk sports participation.1 An athlete is considered functionally one-eyed if corrected visual acuity is less than 20/40 in one eye. These athletes should be restricted from high-risk sports such as boxing, wrestling, or contact martial arts in which no eye protectors can be worn. For other high-risk sports, they should be advised to wear sports eye protectors that meet ASTM racquet sports standards.37
Congenital or traumatic absence of a testicle does not preclude sports participation, although these athletes should be counseled on risks of infertility in the event of injury and educated on protective cup use when participating in contact, collision, or projectile sports.1
Down’s syndrome is associated with ligamentous laxity, hypotonia, and an increased risk of atlantoaxial instability. The incidence of radiographic atlantoaxial instability in individuals with Down’s syndrome under the age of 21 is 10% to 20%, and the prevalence of symptomatic atlantoaxial instability is 1% to 2%.38–40 Due to the increased risk of cervical spinal injury associated with atlantoaxial instability, individuals with this condition should be restricted from participation in sports with an increased risk of cervical spine trauma such as rugby, soccer, football, basketball, gymnastics, and diving.39 Routine radiographic screening for atlantoaxial instability in Down’s syndrome is controversial. Radiographic atlantodens interval >4.5 mm or neural canal width <14 mm are considered abnormal and warrant MRI imaging and further neurologic evaluation.41
The incidence of cardiac malformations is approximately 50% in persons with Down’s syndrome and most commonly includes ventricular or atrial septal defects or patent ductus arteriosus.42 Cardiac medical and surgical history should be elicited during the PPE. Individuals with Down’s syndrome, with or without cardiac malformations, have a lower cardiorespiratory fitness level due to their lower peak heart rates.43
Athletes participating in competitive sports are subject to guidelines by individual sport governing bodies, as well as the World Anti-Doping Agency (WADA). During the PPE, the athlete should be asked about any medications and supplements that they use. The updated prohibited list of substances by WADA can be found at https://www.wada-ama.org/en/what-we-do/prohibited-list. In addition, most national anti-doping organizations have online search engines to facilitate the checking of drugs against the prohibited list. If the athlete has to take a prohibited medication, a therapeutic use exemption (TUE) must be submitted by the treating physician in advance for approval.
Exercise has benefits both in the prevention and treatment of many common chronic medical conditions. Many individuals can proceed with light to moderate intensity exercise without the need for further medical clearance. The ACSM algorithm for assessing the need for further medical clearance is in Figure 26–3.
Figure 26–3
Preparticipation Health Screening Algorithm for Aerobic Exercise Participation. Modified from: Riebe, D., Franklin, B., Thompson, P., Garber, C., Whitfield, G., Magal, M. and Pescatello, L. (2015). Updating ACSM’s Recommendations for Exercise Preparticipation Health Screening. Medicine & Science in Sports & Exercise, 47(11), pp.2473–2479.
Exercise improves cardiorespiratory fitness and quality of life in individuals with asthma and does not worsen their symptoms.44 Exercise, however, may induce bronchospasm in asthmatics or nonasthmatics with a drop of forced expiratory volume in 1 second (FEV1) by 10% to 15% with exercise.45 Cold or dry air, air pollutants, and prolonged or high-intensity exercise may be provoking factors.46,47 Warm-up exercise and wearing a face mask during exercise in cold or dry environments may help prevent the onset of exercise-induced bronchospasm (EIB).46 Inhalation of a short-acting beta-2 agonist (SABA) 15 minutes prior to exercise is used to prevent and treat symptoms. Inhaled corticosteroids or leukotriene receptor antagonists may be required for further control. Exercise guidelines in specific medical conditions are highlighted in Table 26–3. Exercise should be postponed during acute exacerbations until symptoms have abated.47
| Medical Condition | Aerobic Exercise | Strengthening Exercise | Remarks |
| Asthma/Exercise-Induced Bronchospasm | Frequency: At least two to three times a week Intensity: At least 60% of measured VO2 peak, or 80% of maximal walking speed as measured with a 6-minute walk test Time: At least 20 to 30 minutes per day Type: Swimming (preferably in a nonchlorinated pool) may be less likely than other forms of aerobic exercise to induce symptoms (Reference: American College of Sports Medicine, 2014) | As per national physical activity guidelines | Aerobic exercise can be increased gradually to 5 days a week, 40 minutes per day, at an intensity of 70% of VO2 peak (American College of Sports Medicine, 2014) |
| Diabetes Mellitus | Frequency: At least every 3 days (no more than 72 hours between bouts, which corresponds to the period the acute drop in glucose lasts) Intensity: Moderate- to vigorous-intensity | ||
| Time: At least 150 minutes of moderate-intensity exercise per week or equivalent (see footnote), with each exercise session lasting at least 10 minutes, and no more than 72 hours in between bouts(American College of Sports Medicine, 2010). | Frequency: At least twice, but ideally thrice a week, with rest days in between sessions Intensity: 10- to 15-rep sets to near fatigue and progressing to 8- to 10-rep sets Time: One set of each exercise, aiming to progress slowly to three sets per exercise Type: At least 5 to 10 exercises involving the large muscle groups of the body (American College of Sports Medicine, 2010) | ||
| Hypertension | Frequency: At least three to four times a week (Eckel RH, 2014) Ideally daily, as the acute drop in blood pressure following an exercise bout, which may last up to 22 hours (Brandão Rondon MU, 2002)62, may contribute to the overall benefit exercise has on blood pressure control (Haskell WL, 1994)65 (Thompson PD, 2001)73 Intensity: For blood pressure control: moderate-intensity exercise (Fagard, 2001) (Hagberg JM, 2000)64 Vigorous-intensity exercise may confer other additional health benefits (Eckel RH, 2014) Time: An average of 40 minutes per session (Eckel RH, 2014) | At least two to three times per week targeting major muscle groups, as per national physical activity guidelines (Office of Disease Prevention and Health Promotion)70 | Avoid the Valsalva maneuver during resistance training to prevent sudden surges in blood pressure |
| Dyslipidemia | Frequency: Three to four times a week (Eckel RH, 2014) Intensity: Moderate- to vigorous-intensity Time: An average of 40 minutes per session (Eckel RH, 2014) At least 150 minutes of moderate-intensity aerobic physical activity per week or equivalent (see footnote) (Office of Disease Prevention and Health Promotion) | As per national physical activity guidelines | |
| Obesity and Metabolic Syndrome | For general health benefits: At least 150 minutes of moderate-intensity aerobic physical activity per week or equivalent (see footnote) For significant weight loss: At least 5 days a week, for at least 30 to 60 minutes per day, with each session lasting at least 10 minutes (American College of Sports Medicine, 2009) | As per national physical activity guidelines | Resistance training may provide some health and fitness benefits in these individuals but should be used as an adjunct in the exercise prescription for weight loss (American College of Sports Medicine, 2009) |
| Osteoporosis | Frequency: 3 to 5 days a week Intensity: Primary prevention: Moderate to vigorous intensity Individuals with osteoporosis: Moderate intensity Time: At least 150 minutes of moderate-intensity exercise per week or equivalent (see footnote) Type: Primary prevention: Weight-bearing activity with high bone-loading forces, including jumps, sudden starts and stops (e.g. rope skipping, gymnastics, soccer, basketball, tennis) Individuals with osteoporosis: Weight-bearing activities with slow, controlled movements (e.g., stair climbing) Walking alone may not confer sufficient benefits on improving bone mineral density (Martyn-St James M, 2008)67 but may be associated with fewer fractures due to improved balance and fewer falls (Feskanich D, 2002)63 (American College of Sports Medicine, 2014) | Primary prevention: High-intensity strengthening exercises such as weightlifting, done twice a week (American College of Sports Medicine, 2014) Individuals with osteoporosis: As per national physical activity guidelines | Balance exercises (e.g., Tai Chi, single leg balancing exercises) should also be done as part of fall prevention (American College of Sports Medicine, 2014) |
| Osteoarthritis | Frequency: 3 to 5 days a week Intensity: Low- to moderate-intensity exercises are preferred, as they may be less likely to cause pain and injuries Time: 150 minutes per week, in bouts of at least 10 minutes in duration (American College of Sports Medicine, 2014) Type: Low impact (e.g., walking, cycling, elliptical training, swimming) | Frequency: Two to three times a week Intensity: 40% to 60% 1 Rep Max (lower weight, more repetitions to improve muscle endurance) Time: 10 to 15 repetitions per exercise Type: Involving major muscle groups (American College of Sports Medicine, 2014) | More intense physical activity should be avoided in patients with significant damage to weight-bearing joints, as it may accelerate further joint damage (American College of Sports Medicine, 2014) |
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