The primary objective of the PPE is to screen for life-threatening problems as well as conditions that may predispose an athlete to injury or illness. There is no empirical evidence that the PPE is able to screen for silent but deadly illness; however, the consensus panel does recommend it be performed.⁴

Secondary objectives include that the PPE often meets administrative requirements of a school, college, or governing body. Currently, most states as well as the National Collegiate Athletic Association (NCAA) require some form of a preparticipation examination prior to sports participation. There may be annual or biannual requirements or an entrance physical followed by yearly interval history updates. Frequency, appropriate documentation, as well as who is able to perform the examination vary from state to state and also from high school to college athletics. Referencing appropriate requirements is essential to perform a proper PPE for the individual athlete. In most settings/states, a physician, nurse practitioner (NP), or physician assistant (PA) is generally acceptable for performing the PPE.

In addition the PPE may serve as an access point for health care and allow for the discussion of health care maintenance topics as well as general health. This may be the only entry for an athlete into the health care delivery system prior to an acute issue. It should be stressed, however, in the absence of the athlete’s primary care provider performing the examination, the standard PPE should not supplement a well child or annual physical examination.

The PPE should ideally be performed 6 weeks prior to the start of the athletic season. This allows adequate time to evaluate and treat any conditions requiring further evaluation, testing, or treatment. Unfortunately, most athletes do not present for a PPE until just prior to the commencement of the season. One way to address this is to screen all returning athletes to a team/school who will need a PPE in the spring prior to return to school.

The setting of the preparticipation examination should ideally be in the athlete’s primary care provider’s office. This allows for confidentiality and continuity of care as well as the ability to address nonsports-related medical issues if the athlete is otherwise healthy to participate in sports. The main limitation is the time utilized and cost.

In order to reduce costs and improve efficiency, some schools and teams opt for a mass PPE session utilizing multiple health care providers. When the PPE is performed by a group of physicians, it is often split up into stations. Often one person will review the medical questionnaire, while another performs the physical examination and finally another provides clearance. An advantage of this format is that a multispecialty team is often created (i.e., primary care, orthopaedic, dentist, etc.), which may decrease the need for referral and avoid delay in clearing athletes for participation. It is important to have separate areas for male and female athletes as well as privacy for the examination portion of the physical. Confidentiality should be maintained at all times.

An alternative format for the mass PPE is the “lockerroom” format where the entire examination is performed by one physician, but there are simultaneous examinations performed at the same time in separate examination rooms. This format requires a large number of physicians capable of performing the entire examination but can be an efficient and cost-effective format as well.

The medical history is the most important part of the PPE. It will identify roughly 75% to 90% of all problems affecting the athlete. There are roughly 4 million competitive athletes in high school alone and 30 million athletes under the age of 18 who play organized sports in the United States.⁴ It is important to remember that the PPE screens for conditions that result in unacceptable risk but does not reach a zero-risk circumstance. An excellent resource for the clinician providing preparticipation physicals is the most recent joint consensus monograph Preparticipation Physical Evaluation, 3rd Edition (American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, American Osteopathic Academy of Sports Medicine). The form is composed of standardized history, physical examination, and clearance sections, which allows for efficient and thorough evaluation of the athlete. A copy of this form is shown in Figure 1.1.