A thorough pre-participation evaluation (PPE) is critical to determining the health status of any athlete. The PPE screens for injuries or medical conditions that may place an athlete at risk of further injury [2]. In contrast to the 1–3% incidence of sport-significant abnormalities found in able-bodied athletes, in Special Olympians the incidence is closer to 40% [3]. The standard recommendation is that the evaluation be performed at least 6 weeks in advance of competition to allow adequate opportunity for any identified health concerns to be addressed, and lead time is particularly critical in athletes with disabilities where complex equipment and widely diverse medical issues are more likely to be present. In addition to the standard aspects of the PPE for able-bodied athletes, there are additional considerations for the sports medicine physician when evaluating adaptive athletes. The current PPE monograph endorsed by the 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 includes a supplemental history form for the adaptive athlete in addition to the recommended history and physical examination form for able-bodied athletes [4]. A similar PPE monograph recently proposed by a team of sports medicine specialists in Canada is based on the International Olympic Committee consensus statement and includes a more comprehensive format for the adaptive athlete. Some of these additional recommendations include assessment of functional daily activities and evaluation of orthoses and other adaptive devices [2]. Current recommendations are that a PPE be performed upon entry into sports and should be repeated at least every 2–3 years, depending on the age and participation issues of the athlete. An interim evaluation (often just a brief history and blood pressure) prior to each sport season may be necessary to determine if the athlete’s health condition has changed [5].

The medical team involved in the longitudinal care of the adaptive athlete should perform the PPE, since as knowledge of baseline functioning is critical to proper recommendations and protections for the athlete. Physicians should complete the PPE in a systematic and comprehensive fashion and should avoid the common mistake of becoming overly focused on the athlete’s impairment/disability and overlooking other medical and pre-participation issues. The evaluation of an adaptive athlete often requires a multispecialty team approach. For example, a physician specializing in sports medicine and a spinal cord injury specialist may work together to jointly assess an individual with spinal cord injury (SCI) and safely clear them for participation.

The sport, level of participation, athletic organization, clinical indications, and medical conditions of the athlete determine the required elements of the PPE. The PPE should provide information to guide the athletic organizer, athlete, trainer, coach, and team physician toward safe participation for the athlete [5].

Cardiovascular and pulmonary evaluations seek to identify conditions that may lead to disease progression or sudden cardiopulmonary collapse. Suggested guidelines for cardiovascular screening of the athlete are available from the 36th Bethesda Conference: Eligibility Recommendations for Competitive Athletes With Cardiovascular Abnormalities [4, 6].

Additional elements of the PPE for adaptive athletes should include an assessment of pre-disability health, present level of training, current medications and supplements used, presence of impairments, level of functional independence for mobility and self-care, history of prior sports participation, and anticipated needs for adaptive equipment. Assessment of sensory deficits, neurologic impairment, and joint stability, range of motion (ROM), muscle strength, and skin integrity are even more important in the population of adaptive athletes compared to able-bodied athletes. An evaluation of the athlete-equipment interface is critical to a proper PPE. For instance, during the musculoskeletal examination of an athlete who uses a wheelchair, the physician should evaluate the stability, flexibility, and strength of the commonly injured body sites (e.g., shoulder, hand and wrist, and lower extremities) as well as the trunk. Special attention should be made during the PPE for skin breakdown on insensate pressure areas (e.g., buttocks and back) as well as sites that come in contact with orthotics/prosthetics. A careful history of heat/cold injuries and changes in neurologic function should also be solicited [5].

Additional musculoskeletal testing is recommended for limb-deficient athletes due to amputations or congenital deformity. The musculoskeletal examination of an individual, who has had a lower extremity (LE) limb deficiency, should assess the stability, flexibility, and strength of the trunk, as well as the hip girdle and the unaffected and affected LE with and without the prosthesis. For individuals with upper extremity (UE) limb deficiency, the stability, flexibility, and strength of the shoulder girdle must be assessed in the unaffected and affected extremity with and without prosthesis, in addition to a trunk and LE evaluation [5].

Careful evaluation of the athlete’s wheelchair, prosthetics, orthotics, and assistive/adaptive devices should also be performed prior to competition. This is usually facilitated by consultation with the individual’s orthotist, prosthetist, or other healthcare specialists with experience in this area [5].

In summary, pre-participation evaluation of the adaptive athlete should encompass all the aspects of the able-bodied clearance exam but with additional attention paid to key areas of unique concern to that individual athlete. A comprehensive, systematic, and multidisciplinary team approach is critical to identifying and managing both disability-related and non-disability-related conditions in the adaptive athlete.

Physicians covering adaptive sporting events experience a high volume of visits to the medical treatment area and significant acuity of medical conditions. For instance, 82% of participating athletes at a recent Paralympic Games utilized provided medical services most for prior existing medical conditions [7]. The general medical conditions and category-related injuries that adaptive athletes experience are covered here in this chapter, while sport-specific considerations and injury patterns are covered separately and in greater depth in the following chapters.

Most wheelchair athletes have spinal cord injuries; however, athletes with a deficiency of multiple limbs due to amputations or congenital deformity, cerebral palsy, polio, or other neurologic disorders are eligible to compete in this category. The conditions experienced by athletes with spinal cord injuries may be applicable to other wheelchair athletes, depending on the extent of trunk and upper extremity function, level of sensation, and preservation of bowel and bladder function [8].