The Preparticipation Physical Evaluation

Preparticipation Physical Evaluation (PPPE)

  • History and physical examination, with additional testing as indicated, is performed before participation in sport that meets several objectives and is one of the most important functions provided by the sports medicine physician.

    • Addition of a 12-lead echocardiography (ECG) examination as part of the standardized screening process is controversial.

  • Often, this is the first interaction between the physician and the athlete; for many young adults, it may be the first exposure to the healthcare system.

  • It does not replace regular physical examinations, although many athletes think that it covers all healthcare needs.

  • It encompasses clearance for participation in the sport and provides education and information to athletes regarding issues such as nutrition, supplementation, training and conditioning, injury prevention, and rehabilitation.

  • Special considerations of PPPE include age specificity, sex specificity (special concerns for female vs. male athletes), sport specificity (specific demands of each sport should be considered), athletes with special needs, and athletes with physical or intellectual disabilities.

Objectives of the PPPE

  • Emphasize cardiovascular, neurologic, and musculoskeletal issues

  • Identify any life-threatening or disabling conditions (e.g., underlying cardiovascular or neurologic abnormalities)

  • Identify any conditions that may put an athlete at risk of injury or illness (e.g., underlying ligamentous instability, musculoskeletal abnormalities, organomegaly, or acute medical illness)

  • Assess an injury that has not been appropriately rehabilitated

  • Assess medical conditions and strength and flexibility deficits that put an athlete at risk of injury

  • Assess general health status (e.g., immunizations), fitness, and maturity

  • Meet insurance or legal requirements

  • Screen for menstrual dysfunction, stress fractures, or disordered eating (female athlete triad, disordered eating in male athletes)

  • Introduce athletes to the healthcare system and concepts of preventive medicine

  • Offer an opportunity to address issues such as recreational and performance-enhancing substance use and abuse, sexuality issues, depression and emotional issues, and health promotional activities (alcohol and drug abuse, seat belts, helmets, and self-breast or self-testicular examination)


  • The PPPE should be performed at least 6 weeks before the beginning of the sport season to allow adequate time for further evaluation of identified problems and treatment or rehabilitation of any conditions or injuries.

  • If athletes are unavailable 4–6 weeks before the beginning of an early fall season, examinations performed at the end of the previous school year may be considered. Athletes should report any interval injuries, illnesses, and new medications between their examinations and the beginning of the fall season.

  • A detailed medical history may be completed by athletes and/or parents in advance, which may improve the accuracy of the information (e.g., immunization records) and examination efficiency. Internet resources can facilitate the history and interval injury reporting process. An electronic format (ideally a national database) has several benefits, including communication and administration of the PPPE.


  • Variable recommendations depend on individual athletes (i.e., age, gender, sport [single or multiple]; their health [underlying medical conditions or injury history], and cost); availability of records from past PPPEs (continuity of care); and requirements of state, city, or athletic governing body.

  • General guidelines (no consensus about optimal frequency)

    • Comprehensive baseline PPPE before initiating a new sport or attaining a new level (e.g., entry into high school, college, or professional level), every 2 years in younger athletes (e.g., middle and high school students), and every 2–3 years in older athletes

    • Subsequent annual PPPEs may be limited to injuries or illnesses disclosed by an interim health questionnaire; yearly evaluation of the cardiopulmonary system may be appropriate.

    • If an athlete is participating in multiple sports during the year, consider more frequent evaluations.

    • Several states require an annual full screening examination (no standard requirements).

    • The National Collegiate Athletics Association (NCAA) requires an initial comprehensive PPPE on entrance, followed by interim history in intervening years; limited additional examinations focusing only on new problems.

    • The American Heart Association (AHA) recommends initial comprehensive PPPE on entrance for high school and college athletes. The AHA recommends another comprehensive PPPE after 2 years for high school athletes and follow-up interim history and blood pressure measurements annually, along with focused additional examinations for new problems for college student athletes.



  • Potential advantages: patient-centered, physician–patient familiarity, privacy, and continuity of care

  • Potential disadvantages: greater cost, limited appointment time, limited physician interest/experience, and lack of communication of pertinent information to school athletic staff

Coordinated Medical Team-Based ( Table 3.1 )

  • Potential advantages: specialized personnel, time and cost efficiency, and good communication with school athletic staff

  • Potential disadvantages: rushed examinations, lack of privacy, and inadequate follow-up of identified problems

  • Two types of group PPPEs: multistation (multiple physicians, each at a specialized station) and “locker room” (single or multiple physicians performing complete examinations individually, each in their own area [e.g., locker room]).



Required Stations Personnel
Sign-in, height and weight (BMI * ), blood pressure, and vision Ancillary personnel (coach, nurse, and community volunteer)
History review, physical examination , and clearance Physician
Optional Stations Personnel
Nutrition Dietitian
Dental Dentist
Injury evaluation Physician
Flexibility Trainer or therapist
Body composition Physiologist
Strength Trainer, coach, therapist, and physiologist
Speed, agility, power, balance, and endurance Trainer, coach, and physiologist

* Body mass index (BMI) can be calculated from height and weight (for specific age- and gender-adjusted categories, see ).

Physical examination can be subdivided if more than one physician is present.

A musculoskeletal injury evaluation station may be used to provide a more complete evaluation when a musculoskeletal injury is detected during the required musculoskeletal screening examination.


  • At the final station of a station-based examination, an experienced team physician should be available to review all data and to determine clearance or provide appropriate recommendations.

  • Communication between other primary or consulting physicians, athletic trainers, coaches, and parents may be enhanced by carefully documenting the problems and specific recommendations in the clearance section of the PPPE form.

  • Cases of special concern may warrant a telephone conversation between the team physician and other involved healthcare providers.

  • The 2010 Preparticipation Physical Evaluation monograph (see “ Recommended Readings ”) considers “gymnasium examination” to be inadequate to achieve the goals and objectives of the PPPE process.



  • PPPEs should be performed by an MD/DO physician, nurse practitioner, or physician assistant, with final clearance by an MD or DO physician.

  • Regulations by certain states at the high school level allow other practitioners (e.g., chiropractors or naturopathic clinicians) to perform PPPEs.

  • Primary care physicians perform a majority of PPPEs because of their ability to evaluate all organ (i.e., cardiopulmonary, musculoskeletal, neurologic, ophthalmologic, gastrointestinal, genitourinary, and dermatologic) systems.

  • Specialists such as orthopedic surgeons, cardiologists, and ophthalmologists or optometrists are key consultants and may be present on site during the screening-station format examination.


  • Medical staff, including athletic trainers, physical therapists, nurses, exercise scientists, dietitians, and sports psychologists, may be involved, particularly during the screening-station format PPPE.

  • Nonmedical staff, including coaches, school administrators, and community volunteers, are particularly helpful during the screening-station format PPPE.

Medical History

  • There is emphasis on screening for cardiovascular and musculoskeletal problems, prior head injuries and other neurologic problems, and significant recent illnesses. In addition, prior heat illness, pulmonary problems, medication problems, inadequate immunizations, allergic reactions, skin problems, and menstruation abnormalities and disordered eating disorders in female athletes should be addressed (PPPE: History Form available at , accessed March 2016). Medical history is an essential component of the PPPE that detects abnormalities in a majority of athletes.

  • Joint completion of history forms by athletes and parents/guardians is recommended when possible, particularly if the athlete is unclear about family or personal history. In addition, parent/guardian should be present or available during PPPE for additional questions that may arise.

  • Cardiovascular history ( Table 3.2 ):

    • Screen for causes of sudden cardiac death (SCD; Fig. 3.1 ). The most common cause in people aged <35 years is hypertrophic cardiomyopathy (HCM; Fig. 3.2 ); in people aged ≥35 years, the most common cause is coronary artery disease (CAD). The PPPE is scrutinized by certain physicians for its ability to detect underlying causes of SCD, particularly in younger patients. However, the AHA states that a certain form of preparticipation screening for high school and college athletes is justifiable and compelling based on ethical, legal, and medical grounds.

      Figure 3.1

      Sudden cardiac death.

      Figure 3.2

      Hypertrophic cardiomyopathy.

    TABLE 3.2


    Personal Medical History Family History Physical Examination
    Chest pain/discomfort/tightness/pressure related to exertion
    Unexplained syncope/near-syncope *
    Excessive and unexplained dyspnea/fatigue or palpitations, associated with exercise
    Prior recognition of a heart murmur
    Elevated systemic blood pressure
    Prior restriction from participation in sports
    Prior heart testing ordered by a physician
    Premature death (sudden and unexpected or otherwise) in ≥1 relative aged <50 y attributable to heart disease
    Disability from heart disease in a close relative aged <50 y
    Hypertrophic or dilated cardiomyopathy, long-QT syndrome, or other ion channelopathies or Marfan syndrome or clinically significant arrhythmias; specific knowledge of genetic cardiac conditions in family members
    Heart murmur
    Femoral pulses to exclude aortic coarctation
    Physical stigmata of Marfan syndrome
    Brachial artery blood pressure (sitting position)

    From Assessment of the 12-lead ECG as a screening test for detection of cardiovascular disease in healthy general populations of young people (12-25 years of age): a scientific statement from the American Heart Association and the American College of Cardiology.

    * Judged not to be neurocardiogenic (vasovagal) in origin; is of particular concern when occurs during or after physical exertion.

    Refers to heart murmurs judged likely to be organic and unlikely to be innocent; auscultation should be performed in both supine and standing positions (or with Valsalva maneuver), specifically to identify murmurs of dynamic left ventricular outflow tract obstruction.

    Preferably taken in both arms.

  • Personal history is important.

    • History of exertional chest pain, tightness, or chest pressure, any unexplained syncope or near-syncope, and excessive and unexplained dyspnea/fatigue or palpitations associated with exercise are all significant.

    • Prior recognition of a heart murmur

    • Determine past history of invasive or noninvasive cardiac tests ordered by a physician.

    • Prior history of hypertension or prehypertension noted during examinations

  • Family history is important.

    • Twenty-five percent of first-degree relatives of patients with HCM exhibit morphologic evidence of HCM in ECG.

    • Other known genetic cardiac conditions associated with SCD (e.g., long QT syndrome, other ion channelopathies, Marfan syndrome, clinically or significant arrhythmias)

    • Premature death (sudden and unexpected or otherwise) before 50 years of age attributable to heart disease in ≥1 relative

    • Disability from heart disease in close relatives aged <50 years

    • Hypertension

Neurologic Concerns

  • It is important to ask questions about previous head or neck injury, concussion, neurologic symptoms, exercise-related syncope, stingers/burners, and seizure disorder.

  • The NCAA has recommended symptom score, cognitive examination, and balance assessment as “best practices” for every athlete as part of his or her baseline physical examination.

  • Concussion history including the number, symptoms, and time out of activity as well as a history for “modifiers” for concussion (e.g., migraine history, learning disability history, or history of depression/anxiety) should be considered as part of the baseline PPE.

  • Any positive response mandates more thorough history, physical examination, and evaluation.

Musculoskeletal Concerns

  • Complete history is essential.

  • History of previous ligamentous injuries, documentation of surgery, rehabilitation, and time out of play

  • History of prior advanced imaging (e.g., radiographs, MRI, CT, or bone scan) for a musculoskeletal problem

  • Any positive response mandates careful attention during physical examination, including assessment of ligamentous instability, strength and flexibility deficits/mismatches, and completeness of rehabilitation, as well as consideration for obtaining medical records related to the evaluation.

  • If an athlete has had prior surgery, obtain medical records related to the evaluation and a documentation that the operating surgeon has cleared the athlete to return to competition and/or determine the athlete’s rehabilitation status.

Previous Medical Illnesses (Examples)

  • Heat exhaustion/illness

  • Infectious mononucleosis

  • Hepatitis

  • HIV disease

  • Diabetes

  • Sickle cell disease/hemoglobinopathy

  • Asthma

  • Allergic reactions

Female Athlete Triad

  • Screening questions:

  • Age of menarche and history of amenorrhea or oligomenorrhea

  • History of stress fractures, bone injury, or risk factors for osteoporosis

  • History and risk factors for disordered eating patterns: questions that ascertain ideal versus current body weight, body image concerns, and pathogenic eating behaviors

Additional Concerns

Additional concerns not always included on the PPPE form may be addressed on an individual basis. If you do not ask, you might never find out.

  • Nutritional issues: fluids, game-day nutrition, and general nutrition

  • Supplements and performance-enhancing agents

  • Sexuality concerns: pregnancy, sexually transmitted diseases, and sexual orientation (best addressed in a private setting)

  • Recreational drugs and alcohol use

  • Preventive medicine (e.g., seat belts, helmets, self-breast or self-testicular examination, cholesterol screening, and gynecologic examinations/Pap smear)

  • Psychosocial issues: stress management, anxiety, depression, suicide (consider including screening questionnaires such as the Patient Health Questionnaire-9 [PHQ-9] or Generalized Anxiety Disorder-7 [GAD-7] for depression and anxiety, respectively)

Physical Examination ( Box 3.1 )

  • The physical examination should be comprehensive. It should focus on areas of greatest importance in sports participation and address any problems uncovered while recording an athlete’s history.

  • Adequate exposure during the examination is important.

  • The physical examination form (PPPE: Physical Examination Form available at , Accessed March 2016) is generally comprehensive and covers the scope of such examination, but it should not limit the clinician if additional examination is deemed pertinent.

Box 3.1

Standard Components of the Preparticipation Physical Evaluation

  • Height

  • Weight

  • Eyes: visual acuity and pupil size

  • Oral cavity

  • Ears

  • Nose

  • Lungs

  • Cardiovascular system: blood pressure, femoral and radial pulses, and heart rate, rhythm, and murmurs

  • Abdomen: masses, tenderness, and organomegaly

  • Skin: rashes and lesions (infectious)

  • Musculoskeletal system: contour, range of motion, and symmetry of neck, back, shoulder/arm, elbow/forearm, wrist/hand, hip/thigh, knee, leg/ankle, and foot

Modified from Preparticipation Physical Evaluation, 4 th ed. Elk Grove Village, Ill.: American Academy of Pediatrics; 2010.

Height and Weight

  • In athletes with excessive weight change, explore the possibility of eating disorders or steroid abuse.

  • Body mass index (BMI) should be calculated (gender and age specific; see ). Understand the indications and limitations of using BMI.

    • Underweight (<5 th percentile)

    • Overweight (85 th –94 th percentile)

    • Obese (≥95 th percentile)

Head, Eyes, Ears, Nose, and Throat (HEENT)

  • Optical examination is important: check visual acuity in all athletes, pupils for anisocoria, conjunctiva for anemia.

  • Certain athletes may have predilection for ear issues (e.g., swimmers [otitis externa], scuba divers [otic barotrauma], and wrestlers [auricular hematoma]).

  • Allergy sufferers and athletes with history of nose trauma need nasopharyngeal examinations.

  • Smokeless tobacco users need oropharyngeal examinations.

Cardiovascular Assessment

Cardiovascular assessment is essential for both initial PPPE and annual reevaluations (see Box 3.1 ).

Jul 19, 2019 | Posted by in SPORT MEDICINE | Comments Off on The Preparticipation Physical Evaluation

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