KEY ELEMENTS OF PHYSICAL EXAMINATION

Marfanoid features are particularly important to catch due to the cardiac implications of the syndrome. It is also important to be aware of normal variants seen in certain sports: for example, baseball pitchers routinely have increased external rotation in their throwing arm compared to the contralateral side. This should not be mistaken for instability or acute ligamentous injury, and need not be documented or worked up further. Pain is a fairly reliable indicator for pathology in athletes, who generally tend to minimize their symptoms. If any examination maneuver produces pain or visible discomfort, more focused examination for the affected part should be performed and documented. If there is any uncertainty, referral to the appropriate provider should be done with a specific request for clearance to participate.

Granting clearance for participation assumes responsibility for the athlete’s well-being to a certain degree. Participation in sports involves a certain level of risk that is unavoidable, and it is understood that all adverse events cannot be predicted or prevented. By systematically ruling out any contraindications and identifying factors that need further attention, the physician is attempting to protect the participant as much as can be reasonably expected. An athlete may be granted full clearance without restrictions, conditional clearance pending further evaluation, or not cleared for participation. Conditional clearance requires referral and follow-through with the appropriate health care provider, depending on the medical concern.

Impairment in sports is addressed in a very delicate fashion, as there are many psychosocial factors involved. Physiatrists are attuned to the needs of patients who have suffered loss of function, and are well suited to addressing these issues in athletes. When dealing with single conditions, such as paraplegia or amputation, adjustments are relatively straightforward. Wheelchair sports, for instance, have a systematic method of accounting for various levels of functionality in order to evenly balance opposing teams. Significant challenges arise when dealing with the integration of disabled athletes with their able-bodied counterparts. In 2012, paralympian Oscar Pistorius was the first amputee to participate in the Olympics, raising much controversy about the potential advantage of his bilateral carbon composite flex-foot sprinting prostheses. There are many cases of amputees in wrestling who compete with the same rules as their able-bodied opponents. It is impossible to objectively quantify the mismatch that may be occurring, due to the complexity of both physical and mental interactions between competitors. While the able-bodied athletes have the seemingly obvious advantage, it is reasonable to suggest that there are sport-specific advantages in certain conditions. The low center of mass in a double amputee may serve to his advantage in the wrestling ring. On a separate note, it is theorized that an able-bodied participant may unknowingly attenuate his or her performance out of sympathy for the disabled opponent.

Female athletes must be screened with particular emphasis on three factors affecting their well-being. The “female athlete triad” consists of menstrual disturbances, disordered eating, and impaired bone mineralization, and is found more in participants of sports that favor lower body weight such as gymnastics.

MEDICAL KNOWLEDGE

GOALS

Demonstrate knowledge of established and evolving biomedical, clinical epidemiological, and sociobehavioral sciences pertaining to sports medicine, as well as the application of this knowledge to screening and guiding evaluation of athletes.

OBJECTIVES

In 2007, an extensive review of 16 years’ of injury surveillance data over 15 different National Collegiate Athletic Association sports was done. Sports included baseball, softball, basketball, football, hockey, soccer, lacrosse, and gymnastics in a variety of combinations of men’s and women’s divisions. More than 50% of overall injuries involved the lower extremity, with the ankle ligament sprain being the single most common injury. Football had the highest rate of injury of all sports (1).

While the routine musculoskeletal examination is more or less identical for all sports, certain sport-specific emphasis should be maintained. A commonly overlooked area in football players is the wrist. They are prone to carpal bone fractures and dislocations due to the repetitive falling as well as the grabbing and pulling motions required during play. Boxers are prone to nasal, orbital, and hand fractures to a greater degree than most other sportsmen. Basketball players are at increased risk for eye injuries, in addition to the general ailments involved with running and throwing athletes. All contact sports require deeper inquiry about prior contusions and concussions compared to noncontact sports. These examples only touch the surface of the extensive body of evidence regarding injury mechanisms based on sport type. Prior to evaluating athletes of a particular sport, physicians must do adequate groundwork to familiarize themselves with their particular athletic population.

Evaluating athletes is often very rewarding because one can appreciate the determination and focus that they dedicate to their sport. This, however, can become challenging when an athlete minimizes symptoms in order to achieve clearance to play. Although the physician may sympathize with such concerns, it is unethical to deviate from protocol due to a persuasive athlete. Any findings on evaluation that may impair his or her ability to safely perform his or her functions must be further evaluated without question.

Besides checking routine vital signs, there is no mandatory laboratory work or diagnostic testing required in preparticipation screening. However, when pertinent positives are found on history and physical examination, further evaluation is warranted. Any history of syncope, palpitations, chest pain, or an early cardiac event in the family requires an EKG. It is controversial whether routine screening EKGs should be done even in the absence of risk factors due to the relatively low incidence of cardiac events in athletes. Females showing signs of any of the 3 conditions seen in the female athlete triad should be screened with electrolyte panels, caloric intake assessments, and bone mineral density testing.