Preparticipation Physical Evaluation

Aka: Preparticipation Physical Evaluation, Sports Physical, Adolescent Athlete

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II. Epidemiology

  1. Sports participation among children and teens in U.S.
    1. Prevalence Overall: 60 Million
    2. Prevalence High School: 7.9 Million
  2. Sports participation declines steadily ages 10-18 years
    1. Fun is most important
    2. Winning not a major benefit

III. Background: Pre-participation Exam

  1. Perform 6-12 weeks before start of practice
  2. Early exam allows for further evaluation if necessary
  3. Frequency (varies among states and grade level)
    1. College: yearly exam
    2. Middle and High School: Exam at entry of each school
  4. Use standard Pre-participation Physical forms (e.g. Minnesota State High Schoo Leaguel)
    1. http://www.mshsl.org/mshsl/publications/code/forms/physicalExam.pdf

IV. Efficacy

  1. Preparticipation Physical guidelines are a consensus among all major related U.S. professional organizations
    1. General organizations include AAFP, AAP
    2. Sports medicine associations include ACSM, AMSSM, AOSSM, AOASM
    3. Preparticipation Exam is in 5th edition as of 2021 (PPE5)
  2. Sports Physical helps prevent sudden death
    1. Retrospectively studied young athletes from 1979-2004
    2. Sports Physicals became mandatory in 1982
    3. Sudden Cardiac Death dropped 89% in screened athletes
    4. Corrado (2006) JAMA 296:1593-601 [PubMed]
  3. Required by most high school and college athletic programs (NFHS, NCAA)
    1. Preparticipation Physical guidelines recommend before participation and every 2-3 years
      1. Annual updates needed only for specific concerns
    2. Guidelines vary by state, and many high schools require annual Sports Physicals despite national guidelines
  4. However, Choosing Wisely Campaign discourages preparticipation physicals
    1. Sudden Cardiac Death is devastating but rare (1 in 150,000 teen athletes per year, <100 in U.S. per year)
      1. Preparticipation physical misses many of these cases
      2. Malhotra (2018) N Engl J Med 379(6): 524-34 [PubMed]
    2. High False Positive Rate that excludes children from Physical Activity
      1. Rowin (2012) Am J Cardiol 110(7): 1027-32 [PubMed]
    3. High False Negative Rate for Hypertrophic Cardiomyopathy
      1. Halkin (2012) J Am Coll Cardiol 60(22):2271-6 [PubMed]
    4. May be a barrier to participation in socioeconomically or medically disadvantaged communities
      1. May not be covered by insurance (may be combined with preventive Health Maintenance)
    5. References
      1. Schefft (2019) Am Fam Physician 99(6): 376-82 [PubMed]
  5. Electrocardiogram (EKG)
    1. Some countries (e.g. Israel) have instituted universal EKGs with the Sports Physical
      1. Goal is to prevent Sudden Cardiac Death (some present with Exertional Syncope)
    2. Current U.S. guidelines recommend EKG only when indicated by history or exam findings
      1. See Sports Physical Exam
      2. See Sports Physical Special Circumstances
      3. Petek (2020) Curr Emerg Hosp Med Rep 8(3): 77-89 +PMID:33552703 [PubMed]
        1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7863976/
    3. EKG does increase Test Sensitivity of preparticipation evaluation (from Test Sensitivity 30% to 50%)
      1. However EKG has False Positive Rate (up to 40%) and False Negative Rate (10% for Hypertrophic Cardiomyopathy)
      2. NNT to prevent one cardiac death is 33,000 to 192,000
    4. EKG False Positive Rate often arises from normal physiologic cardiac remodeling in response to regular intensive Exercise
      1. See Normal Electrocardiogram Changes in Athletes (Athletic Heart Syndrome)
      2. See Arrhythmias in Athletes
    5. References
      1. Estes (2012) Prog Cardiovasc Dis 54(5):451-4 +PMID:22386297 [PubMed]
      2. O'Connor (2010) J Athl Train 45(3): 265-72 +PMID:20446840 [PubMed]
      3. Schefft (2022) Am Fam Physician 105(3): 302-6 [PubMed]

V. History

  1. See Pre-participation History
  2. Most important part of the Sports Physical (detects 88% of general, and up to 75% of musculoskeletal conditions)

VI. Exam

  1. See Pre-participation Exam
  2. Station Divided Sports Physical

VII. Evaluation

  1. See Pre-participation Special Circumstances
  2. See Sports Participation Disqualifiers
  3. See Sports Contact Levels (Contact Sport or Collision Sport)
  4. See Sports Intensity Levels (Dynamic Sports, Static Sports)

VIII. Associated Conditions

  1. See Sports Related Trauma
  2. Cardiovascular Conditions in Athletes
    1. Athletic Heart Syndrome
    2. Arrhythmias in Athletes
    3. Sudden Death in Athletes
    4. Syncope in Athletes
  3. Psychiatric Illness in Athletes
    1. Depression in Athletes
    2. Drug Abuse in Athletes
    3. Female Athlete Triad (Anorexia or Bulimia)
    4. Exercise addiction
    5. Overtraining

IX. Resources

  1. Preparticipation History
    1. https://www.aap.org/en-us/Documents/PPE-History-Form-%28English%29.pdf
  2. Preparticipation History Addendum for Athletes with Disability
    1. https://www.aap.org/en-us/Documents/PPE-Athletes-with-Disabilities-Form.pdf
  3. Preparticipation Exam
    1. https://www.aap.org/en-us/Documents/PPE-Physical-Examination-Form.pdf
  4. Preparticipation Medical Eligibility
    1. https://www.aap.org/en-us/Documents/PPE-Medical-Eligibility-Form.pdf

X. Prevention

  1. See Nutrition for Athletes
  2. See Sports Eye Protection

XI. References

  1. MacDonald (2021) Am Fam Physician 103(9): 539-46 [PubMed]

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