Athletics is a “culture” that is flourishing worldwide. The roots of peak athletic performance and success, especially during close contests, are embedded in the optimal health of athletes. Most universities have a sports medicine team—“the team that takes care of the teams”—and it is the assumed responsibility of every team member to provide consistent, thorough, evidence-based, comprehensive care for each athlete. Team medical coverage has evolved rapidly and has become a pivotal component of athletics at all levels of competition. The ultimate responsibility for medical decisions regarding both prevention and cure rests with the team of medical professionals, which includes the medical director, other team physicians, athletic trainers, and allied health care providers. The minimum qualifications for the medical director and other team physicians include :
Having a Doctor of Medicine (MD) or a Doctor of Osteopathy (DO) degree in good standing, with an unrestricted license to practice medicine.
Possessing a fundamental knowledge of emergency care with regard to sporting events.
Being trained in cardiopulmonary resuscitation (CPR) and the use of an automated external defibrillator (AED).
Having a working knowledge of trauma, musculoskeletal injuries, and medical conditions affecting athletes.
Duties of the medical team are numerous but primarily include (1) effectively coordinating preparticipation evaluations, (2) managing on-field emergencies, and (3) navigating the ethical and medicolegal issues unique to sports medicine. These topics are discussed in detail in this chapter.
Preparticipation Physical Evaluation
A mainstay of modern medicine is the idea of preventative health care. In the realm of organized athletics, the preparticipation physical evaluation (PPE) has historically served as the cornerstone of the prevention of unnecessary morbidity and mortality on the playing field. In May 2010, recommendations for the PPE were updated and published in the fourth edition of the PPE (PPE-4). Based on expert opinion and a comprehensive review of the medical literature, the PPE-4 was developed with input from six medical societies and is endorsed as the gold standard for PPE. Historically, however, PPE screening standards in the United States have been determined by individual state and local legislative authorities, with varying medical and legal standards and community medical resources. As a result, the implementation of the PPE nationally has been heterogeneous, with variable compliance by educational institutions and athletic associations. The lack of uniform application of the PPE has made it difficult to interpret outcome data for the few studies that exist. A recent review found no medium- or better-quality evidence that the PPE reduces morbidity or mortality. With this in mind, the author societies advocate for comprehensive and uniformly applied PPEs. Despite variation in the format and use of PPEs, it is held that, at the very least, the PPE allows for establishment of a “medical home,” an immunization record, identification and management of acquired and congenital medical conditions, and proactive counseling related to medical conditions in sports and lifestyle risk factors.
Goals and Objectives
Many sports governing bodies mandate a PPE not only to ensure the health and well-being of the participant but also to minimize legal liability for conditions that may occur or worsen with participation in sports. The principal goal of the author societies who formulated the PPE-4 is the promotion of the health and safety of athletes.
Primary objectives of the PPE include :
Screening for potential life-threatening or disabling conditions.
Screening for conditions that may predispose to injury or illness.
Secondary objectives that address general health care and prevention include:
Determining general health.
Serving as an entry point to the health care system.
Providing an opportunity to initiate a discussion on health-related topics.
The PPE may be the only annual medical appointment that underinsured athletes have. It is thus important to take advantage of this valuable time to initiate a discussion on drug use, seat belt and helmet usage, and safe sexual practices. Failure to limit risk-taking behaviors is more likely to cause harm in adolescents than is participation in sports.
Timing, Setting, and Organization
Ideally, the PPE should take place at least 6 weeks before the start of organized practices. A small percentage of athletes may be conditionally withheld from participation pending further workup or consultation with a specialist, or they may have ongoing medical issues that need to be resolved. In general, more frequent evaluation is recommended for younger athletes because cardiac abnormalities may manifest during dynamic growth periods, despite normal results of earlier evaluations. At the secondary school level, comprehensive examinations should occur every 2 to 3 years, interspersed with problem-focused evaluations annually. For the collegiate age group, it is recommended that a comprehensive evaluation be performed prior to the first season and that shorter, more focused evaluations be performed annually thereafter. A new recommendation by PPE-4 is for children (>6 years) and adolescents to undergo a PPE as part of their annual health maintenance examination. The authors of the PPE-4 reason that all children should be encouraged to be active, given the recent trends in obesity and inactivity. Children who plan to be active in nonstructured sports settings are equally susceptible to injury and illness and thus should be offered a PPE.
The two typical main approaches to the PPEs are (1) a primary care physician’s office visit and (2) coordinated team examinations. A comparison of the two settings is outlined in Table 14-1 . The PPE-4 recommends examinations at the primary care physician’s office. During team examinations, the ultimate responsibility to clear athletes is incumbent upon a physician with an unrestricted MD or DO license. A standardized history questionnaire should be filled out by the athlete prior to arrival, and parental guidance is advocated for minors. The PPE-4 consistently reinforces the adage that the history is the most important diagnostic tool. It has been shown that 75% or more medical and orthopaedic conditions are detected by history alone.
|Office Based||Coordinated Team|
History and Physical Examination
Head, Ears, Eyes, Nose, and Throat
A detailed history of eye disorders, injuries, and the need for corrective or protective eyewear should be obtained. Visual acuity should be assessed via a standard Snellen eye chart. Poor visual acuity is one of the most frequently reported findings on PPEs, and appropriate consultation with a specialist should be facilitated. Athletes whose visual acuity in the poorer eye is less than 20/40 with optical correction should be classified as being “functionally one-eyed,” and akin to persons missing an eye, they should wear protective eyewear when participating in sports with a high risk for eye injury. Furthermore, they should be restricted from participating in sports that feature intentional harm, such as full-contact martial arts, boxing, and wrestling. A pupillary examination to document baseline anisocoria should be performed for reference in the event of a head injury. Odontogenic pathology such as oral ulcers, gingival atrophy, and decreased enamel may be a sign of occult eating disorders.
Athletes represent the pinnacle of health, and their death provokes a sense of vulnerability in persons who idolize their exploits. Sudden cardiac death (SCD) is the most feared complication of sports participation. Box 14-1 outlines the most common causes of sudden death in young athletes in the United States. To reduce the cardiovascular risk for SCD during sports participation, the PPE-4 endorses the recommendations made by the 2007 American Heart Association (AHA) consensus statement on preparticipation cardiovascular screening. The author societies of PPE-4 admit that no outcome-based studies have demonstrated that the PPE is effective in preventing or detecting athletes at risk for SCD. The PPE-4 questions used to evaluate cardiac history (personal and family) are listed in Box 14-2 . These questions have been expanded in the PPE-4 to help identify ion channelopathies such as long QT and Wolff-Parkinson-White syndromes.
Left ventricular hypertrophy of indeterminate causation
Ruptured aortic aneurysm
Arrhythmogenic right ventricular cardiomyopathy
Have you ever passed out or nearly passed out DURING or AFTER exercise?
Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?
Does your heart ever race or skip beats during exercise?
Has a doctor ever told you that you have any heart problems?
Has a doctor ever ordered a test for your heart?
Do you get lightheaded or feel more short of breath than expected during exercise?
Have you ever had an unexplained seizure?
Do you get more tired or get short of breath more quickly than your friends do during exercise?
Has any family member or relative died of heart problems or had any unexpected or unexplained sudden death before the age of 50 years?
Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia?
Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator?
Has anyone in your family experienced unexplained fainting, unexplained seizures, or near drowning?
The physical examination recommended by the AHA includes (1) auscultation for heart murmurs, (2) palpation of radial and femoral pulses to exclude aortic coarctation, (3) examination for physical stigmata of Marfan syndrome (MFS), and (4) brachial artery blood pressure taken in the sitting position. Auscultation should be performed with athletes seated and with Valsalva or squatting maneuvers to accentuate potentially pathologic murmurs related to aortic stenosis or hypertrophic cardiomyopathy. Soft early systolic murmurs are common in athletes and represent hyperdynamic flow rather than anatomic pathology. Blood pressure measurements should be made with an appropriately sized cuff. All athletes with hypertension require further workup and monitoring. Athletes with stage I hypertension (i.e., the 95th to 99th percentile plus 5 mm Hg in children and 140/90 to 160/100 in adults) who do not have heart disease, end organ damage, or left ventricular hypertrophy should not be restricted, except from static sports such as weightlifting. Athletes with stage II hypertension (i.e., >99th percentile plus 5 mm Hg in children and >160/100 in adults) should initially be restricted from all participation pending a thorough workup and control of blood pressure.
Special attention should be directed at excluding MFS (and related disorders, such as Ehlers-Danlos and Loeys-Dietz syndromes), which all manifest genetic deficiencies of connective tissue proteins and thereby increase risk of dissection of the aorta and other smaller arteries. Clinical manifestations of MFS may also include the ocular, musculoskeletal, respiratory, central nervous, and integumentary (skin) systems ( Box 14-3 ). For the diagnosis of MFS, revised Ghent criteria were published in 2010 and consequently are not referenced in the PPE-4. The revised criteria have placed more weight on the two cardinal features of MFS: (1) aortic root enlargement/dissection, and (2) ectopia lentis. In the absence of family history, the presence of both findings is sufficient to make the diagnosis. However, these two features are not easily assessed in the PPE setting, and thus clinicians should be vigilant to identify any possible physical stigmata of MFS, particularly in male athletes taller than 6 feet and female athletes taller than 5 feet, 10 inches. Athletes with a family history of MFS or two or more physical examination findings should be referred for a cardiology consultation to comprehensively assess aortic morphology. Given the greater emphasis on ectopia lentis in the revised criteria, a referral to ophthalmology for slit-lamp testing is also prudent.
Aortic root dilation
Mitral valve prolapse
Tall stature (males taller than 6 feet and females taller than 5 feet, 10 inches) *
* Not formally considered criteria of the revised Ghent nosology.
Increased upper segment to lower segment ratio; increased arm span relative to height
Arachnodactyly (wrist and thumb sign)
Hindfoot deformity, plain pes planus
Reduced elbow extension
Downslanting palpebral fissures
Malar hypoplasia, retrognathia
Other Systemic Features
Debate is boundless regarding noninvasive cardiac screening during the PPE, and although this subject is beyond the scope of this chapter, related controversies are discussed in detail elsewhere in this book. The 2007 AHA guidelines do not endorse the routine use of a screening electrocardiogram (ECG) or a transthoracic echocardiogram and are thus in contradistinction with recommendations of both the International Olympic Committee and the European Society of Cardiology, which recommend the use of a screening ECG during PPEs. The dispute is largely based on studies performed in Italy by Corrado et al., who demonstrated that an ECG had a 77% greater power to detect hypertrophic cardiomyopathy than did a history and physical examination alone. Furthermore, studies completed in the Veneto region of Italy over a 25-year period showed a decrease in sudden death rates from 3.6 SCD/100,000 athlete-years to 0.4 SCD/100,000 athlete-years after implementation of the use of an ECG during the PPE. However, more recent studies in the United States and Israel have not duplicated these results. The inability to effectively extrapolate the Italian data may be rooted in the low baseline prevalence of SCD in the United States (0.4 SCD/100,000 athlete-years).
Reducing the incidence of SCD is a noble goal, but clinicians should be aware of the high false-positive rates associated with PPE ECGs, along with high costs, increased use of medical resources (including expensive studies), baseless disqualification of athletes from participation, and the potential for lost “life-years” following needless, sedentary lifestyle recommendations. Furthermore, athlete ECGs and transthoracic echocardiograms can be difficult to assess because of inherent overlapping features induced by pathologic conditions and the normal-adaptive physiologic response to training (i.e., athlete heart syndrome). Conversely, detecting a potentially life-threatening abnormality in even one athlete is obviously noteworthy. Undoubtedly, debate will continue, and team physicians should stay abreast of cardiac screening guidelines that may change in the future.
It is imperative that athletes be questioned regarding a personal or family history of asthma or exercise-induced bronchoconstriction (affecting 50% to 90% of athletes), asthmalike symptoms and severity, use of bronchodilators, degree of asthma control, and the use of tobacco or exposure to secondhand smoke. A thorough auscultation of the lung fields should be performed during the PPE. Proper diagnosis may require provocative pulmonary function testing, and because an athlete’s symptoms may be related to the environment, these tests may need to be performed in comparable environmental conditions that stimulate symptoms. Vocal cord dysfunction should be considered as a potential diagnosis in athletes with asthmalike symptoms who fail to respond to usual bronchodilator therapy. Athletes with stable asthma or exercise-induced bronchoconstriction can usually be cleared to participate in sports, unless they are recovering from a recent asthma exacerbation.
All four quadrants of the abdomen should be thoroughly examined for masses, tenderness, rigidity, or enlargement of the liver or spleen. In male athletes, a detailed genitourinary examination should be performed to assess for masses, testicular descent, tenderness, and hernias. Liver or spleen enlargement is a contraindication to participation in sports. The athlete with a solitary kidney or testicle may be cleared to participate in contact sports; however, each athlete should be counseled on an individual basis about the harmful consequences of injury, and appropriate protective gear should be mandated during practice and competition. Acute diarrheal illness is a contraindication to participation in sports unless symptoms are mild and the athlete remains well hydrated.
The musculoskeletal history has a very high sensitivity (92%), and thus the physician should inquire about current injuries and a history of injuries requiring evaluation, casting, bracing, surgery, or missed participation. Given the high sensitivity of the history, a screening musculoskeletal examination is sufficient but should be supplemented with a more in-depth joint-specific examination when pathology is suspected. Box 14-4 reviews the 14-step general musculoskeletal screening examination. Clearance is determined on the basis of the degree and type of injury, the ability of the injured athlete to compete safely, and the necessities of a given sport. Use of protective padding, taping, or bracing may enable the athlete to participate in sports safely.
Inspection of the athlete standing facing forward
Neck range of motion
Resisted shoulder shrug
Resisted shoulder abduction
Internal and external rotation of the shoulder
Extension and flexion of the elbow
Pronation and supination of the forearm/wrist
Clench fist and then spread fingers
Inspection of the athlete facing away from the examiner
Inspection of lower extremities
Duck walk four steps
Stand on toes and then heels
Physicians should inquire about prior concussions or head injuries, seizure disorders, frequent or exertional headaches, problems with recurrent burners or stingers (transient brachial plexopathy), or a prior transient quadriparesis or cervical cord neuropraxia. A positive history demands a thorough neurologic examination, including assessment of cognition, cranial nerves, motor-sensory function, muscle tone, reflexes, and cerebellar function. Athletes who have a history of multiple concussions or who have prolonged postconcussive symptoms should be counseled about risks and encouraged to discuss with their families the potential for significant harm resulting from repeated concussions. Formal neuropsychological testing may increase the sensitivity of detecting residual concussion symptoms. Athletes with persistent symptoms should be disqualified and cleared for participation only after they have successfully completed a graded return-to-physical-activity protocol. Likewise, after sustaining a single stinger, athletes must be asymptomatic prior to medical clearance, yet further diagnostics may be necessary for persistent symptoms or recurrent injury, particularly after minimal trauma. Athletes who have had transient quadriparesis should have an MRI scan to rule out spinal stenosis. For atypical, exercise-related headaches, advanced intracranial imaging may be necessary to rule out occult causes of “secondary headaches.” Although a history of seizures does not preclude athletic participation, sports-specific modifications may be needed, particularly for persons involved in water sports to decrease risk of drowning.
Hematologic and Infectious Disease
The risks of transmission of human immunodeficiency virus, hepatitis B, and hepatitis C are considered minimal, and the presence of these infections is not considered a contraindication to sports participation. Conversely, a diagnosis of infectious mononucleosis should preclude all sports participation for the first 3 weeks because of the risk of splenic rupture. Light, noncontact activity may be recommended 21 days after diagnosis if the athlete is asymptomatic without complications. Participation in full-contact sports should be deferred for at least 28 days from the start of symptoms or from clinical diagnosis if the symptom onset date is imprecise. Febrile illness is also a contraindication to participation in sports because of increased susceptibility to heat illness and because it may occasionally accompany conditions such as myocarditis that make sports participation unsafe.
Athletes should be questioned about a personal or family history of sickle cell trait (SCT) or disease. Phenotypic expression is varied, and thus medical clearance or exercise modifications should be made on an individual basis. To prevent exertional sickling collapse, athletes with SCT should avoid strenuous activity in extreme heat and high-altitude environments, especially when they are poorly acclimated. In recognition of these risks, the National Collegiate Athletic Association has mandated that all Division I and II athletes be screened for SCT. Although the National Collegiate Athletic Association does not currently mandate routine screening for SCT at lower divisions of competition, we recommend that all active individuals be screened for SCT with a one-time hemoglobin electrophoresis test.
Persons with type I and II diabetes can participate in sports without restriction but are encouraged to monitor blood glucose more frequently, maintain a balanced diet, adjust medications appropriately, and hydrate suitably. Education regarding activities with relatively higher risk of cutaneous foot injury such as hiking, rock climbing, or surfing is also recommended. Obese patients should not be discouraged from participating in sports but should receive counseling on lifestyle changes such as dietary and activity modifications, as well as prevention of heat-related illness. Other endocrine issues in the PPE-4 are addressed in a new section on the female athlete triad (i.e., amenorrhea, decreased bone mineral density, and disordered eating). A history of stress fractures with prolonged healing in a female athlete should increase clinical suspicion for this treatable yet potentially deadly medical condition. Medical clearance should be defined on an individual basis, and disqualification is prudent when athletic performance or the athlete’s health is compromised.
Athletes should be asked about a history of dermatologic pathology, with particular attention to highly communicable infections such as herpes or methicillin-resistant Staphylococcus aureus . The athlete should be inspected for common infections such as herpes gladiatorum, tinea gladiatorum, impetigo, molluscum contagiosum, warts, and community-acquired methicillin-resistant S. aureus . Prevention of transmission is critical and may be achieved by covering the infected site, using prophylactic medications as indicated, refraining from sharing personal items, cleaning athletic equipment, or ultimately restricting the athlete from participation for a specific period based on the characteristics of the sport, the type of microorganism involved, and league guidelines.
Lack of immunizations does not inherently affect sports participation, but many states require them for school enrollment, and thus the PPE provides a good opportunity and time to discuss elective vaccinations. Athletes traveling internationally for competition should be aware of local immunization guidelines recommended by the Centers for Disease Control and Prevention.
Medications and Allergies
It is imperative that medical personnel be familiar with regulations established by drug-enforcing agencies such as the World Anti-doping Agency. Some medications are strictly prohibited, whereas others, such as albuterol, may be used with a therapeutic use exemption. Over-the-counter drugs and supplements may contain banned substances and should also be thoroughly reviewed. The PPE provides a good opportunity to address the detrimental effects of illicit drug and alcohol use, particularly in the adolescent population. Medication and environmental allergies should be documented in detail. Specifications should include the name of the allergen, the type of reaction, and whether athletes require an epinephrine autoinjector (commonly referred to as an EpiPen). Four recommendations for persons with a history of anaphylaxis include:
All medical personnel and athletes with allergies who may potentially require treatment with an EpiPen should be trained in how to use an EpiPen.
All medical kits should be stocked with an EpiPen and over-the-counter diphenhydramine.
Athletes should carry an EpiPen in their backpacks, have an additional EpiPen in their homes or dormitory rooms, and have over-the-counter diphenhydramine readily available at all times.
An emergency action plan (EAP) should be detailed for athletes during the PPE.
Athletes with a history of heat illness are at enhanced risk for recurrent heat illness. Such athletes should be educated about preventive measures, including adequate hydration and gradual acclimatization over a period of 10 to 14 days. If possible, use of stimulant and antihistamine medications should be avoided during warm-weather activities. Athletes who use stimulant medications (e.g., for attention deficit/hyperactivity disorder) and team health care professionals (e.g., athletic trainers) should be informed about the possible deleterious effects of using these medications in the heat. Athletes who have recently experienced heat exhaustion should be restricted from participating for no fewer than 48 hours after the event, and athletes who have recently experienced heat stroke should follow a gradual, graded return to participation lasting a period no shorter than 2 weeks.
Athletes with Special Needs
The PPE-4 includes a chapter that discusses athletes with special needs and a separate form to aid the provider with unique issues affecting this patient population. The history and physical should be similar to that used with athletes who do not have special needs but may need to focus on more common disease processes such as seizures, hearing loss, vision loss, congenital heart disease, and renal disease. Athletes with Down syndrome should always be questioned about a history of atlantoaxial instability (AAI), and athletes with spinal cord injuries should be asked about difficulties with thermoregulation, autonomic dysreflexia, pressure ulcers, and use of urinary catheterization. The physical examination should focus on the visual, cardiovascular, musculoskeletal, neurologic, and dermatologic systems. Congenital heart disease is present in up to half of all athletes with Down syndrome and may require a cardiology referral for further testing prior to participation in sports.
The neurologic examination in athletes with Down syndrome should include evaluation for symptomatic AAI, which may present with upper motor neuron signs such as spasticity, hyperreflexia, clonus, and clumsiness. Persons with symptomatic AAI should undergo lateral cervical spine flexion and extension views to assess stability. Wheelchair athletes should be evaluated for nerve entrapments, pressures ulcers, and overuse injuries of the shoulders, hands, and wrists.
The PPE has continued to evolve, with updated recommendations to perform a PPE for all active children in an office-based setting. Despite these broad recommendations, evidence showing that the PPE reduces morbidity and mortality is scarce. The PPE-4 emphasizes that history, rather than physical examination, is most sensitive for gleaning information relevant to medical clearance for sports participation. It is hoped that in the future a homogeneous and electronically based PPE will be implemented across various states, which will undoubtedly foster meaningful research and outcomes to help keep athletes safe during physical activity.