CAPÍTULO DE LIVRO

The Preparticipation Physical Evaluation

Source
Morteza Khodaee; Tatiana Patsimas; Margot Putukian; Christopher C. Madden
Netter's Sports Medicine, 3, 8-22.e2

Preparticipation Physical Evaluation (PPPE)

Close

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

• 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.

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

• 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, exercise-induced bronchospasm, 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, mental health issues, and health promotional activities (alcohol and drug abuse, seat belts, helmets, and self-breast or
self-testicular examination)

Timing
• 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.

Frequency
• 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), and every 2–3 years thereafter.

• Subsequent annual PPPEs may be limited to injuries or illnesses disclosed by an interim health questionnaire, which
focuses on issues associated with heat, head, heart, and mental health; 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 the 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.

• The American Medical Society for Sports Medicine (AMSSM) emphasizes a shared decision-making process involving the
athletes or their legal representatives and clinicians for any potential limitation for initial sports participation or return
to play.

Methodology

Office-Based
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 (https://www.clinicalkey.com/#!/content/book/3-s2.0-B9780323796699000037#t0010) )

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

Table 3.1
Required and Optional Stations and Personnel for Coordinated Preparticipation Physical Evaluation

Required Stations Personnel

Sign-in, height and weight (BMI a (https://www.clinicalkey.com/#!/content/book/3-s2.0- Ancillary personnel (coach, nurse, and
B9780323796699000037#tbl3_1fna) ), blood pressure, and vision community volunteer)

History review, physical examination b (https://www.clinicalkey.com/#!/content/book/3-s2.0- Physician

B9780323796699000037#tbl3_1fnb) , and clearance

Optional Stations Personnel

Nutrition Dietitian
Dental Dentist
 Injury evaluation c (https://www.clinicalkey.com/#!/content/book/3-s2.0-B9780323796699000037#tbl3_1fnc) Physician

Flexibility Trainer or therapist

Body composition Physiologist
Strength Trainer, coach, therapist, and physiologist
Speed, agility, power, balance, and endurance Trainer, coach, and physiologist

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]).

Recommendations
• 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 2019 Preparticipation Physical Evaluation monograph (see “Recommended Readings”) considers “gymnasium
examination” to be inadequate to achieve the goals and objectives of the PPPE process.

Personnel

Physicians
• 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.

Ancillary
• 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 an 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 eating disorders
in female athletes should be addressed (PPPE: History Form in English and in Spanish available at
https://services.aap.org/en/community/aap-councils/council-on-sports-medicine-and-fitness/preparticipation-physical-
evaluation; accessed January 2021). The 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, the parent/guardian should be present or available during the
PPPE for additional questions that may arise. However, athletes should be alone with the provider when questions regarding
high-risk behaviors and mental health are addressed.

• Cardiovascular history ( Box 3.1 (https://www.clinicalkey.com/#!/content/book/3-s2.0-B9780323796699000037#b0010) ):

 • Screen for causes of sudden cardiac death (SCD; Fig. 3.1 (https://www.clinicalkey.com/#!/content/book/3-s2.0-B9780323796699000037#f0010)
). The most common cause in people aged <35 years is hypertrophic cardiomyopathy (HCM; Fig. 3.2
(https://www.clinicalkey.com/#!/content/book/3-s2.0-B9780323796699000037#f0015) ); 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.

Illustrations and E K Gs of hypertrophic cardiomyopathy, Long Q T syndrome, and Brugada syndrome. A composite medical image
with illustrations and E K Gs of cardiac conditions. The top part shows an illustration and E K G of hypertrophic cardiomyopathy. The
bottom part shows diagrams and E K Gs of two channelopathies, Long Q T syndrome and Brugada syndrome. The images are a
conceptual overview of these genetic conditions.

FIGURE 3.1
Sudden cardiac death.

Two illustrations of a heart with subaortic stenosis. Two medical illustrations of a heart with subaortic stenosis. The illustration on
the left shows a cross-section of the heart with a fibrotic ring below the aortic valve, which is labeled as Fibrous subaortic stenosis. The
illustration on the right shows a cross-section of the heart with hypertrophic muscle below the aortic valve, which is labeled as
Idiopathic hypertrophic subaortic stenosis. Both are congenital conditions.

FIGURE 3.2
Hypertrophic cardiomyopathy.

BOX 3.1
The 14-Element American Heart Association Recommendations for Preparticipation Cardiovascular Screening of
Competitive Athletes
 From Maron BJ, Thompson PD, Ackerman MJ, et al. 2007 Update. Circulation 2007;115:1643-1655. 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.

Personal Medical History

• Chest pain/discomfort/tightness/pressure related to exertion

• Unexplained syncope/near-syncope a

• 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

Family History

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

• Disability from heart disease in a close relative aged <50 years

• 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

Physical Examination

• Heart murmur b

• Femoral pulses to exclude aortic coarctation

• Physical stigmata of Marfan syndrome

• Brachial artery blood pressure (sitting position) c

• 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 a 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 PPPE.

• Any positive response mandates a 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, magnetic resonance imaging [MRI], computed tomography [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

• Kawasaki disease

Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S)

Screening Questions
• Menstrual history:

• Age of menarche

• Date of last menstrual period

• Number of periods in the past 12 months

• Bone health history:

 • History of stress fractures

• History of bone injuries

• Risk factors for osteoporosis

• Nutrition history and risk factors for disordered eating:

• Discrepancies between ideal versus current body weight

• Body image concerns

• Pathologic 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)

• Mental health and 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 3.2 (https://www.clinicalkey.com/#!/content/book/3-s2.0-B9780323796699000037#b0015) )

• 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.

BOX 3.2
Standard Components of the Preparticipation Physical Evaluation

Modified from Preparticipation Physical Evaluation, 5th ed. Elk Grove Village, IL: American Academy of Pediatrics;
2019.

• 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
• Adequate exposure during the examination is important.

• The physical examination form (PPPE: Physical Examination Form available at https://downloads.aap.org/AAP/PDF/PPE-
Physical-Examination-Form.pdf (https://downloads.aap.org/AAP/PDF/PPE-Physical-Examination-Form.pdf ) , copyright 2019, accessed January
2021) is generally comprehensive and covers the scope of such examination, but it should not limit the clinician if additional
examination is deemed pertinent.

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 www.cdc.gov/growthcharts
(http://www.cdc.gov/growthcharts) ). Understand the indications and limitations of using BMI.

• Underweight (<5th percentile)

• Overweight (85th–94th percentile)

• Obese (≥95th 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 a 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
A cardiovascular assessment is essential for both the initial PPPE and annual reevaluations (see Box 3.2
(https://www.clinicalkey.com/#!/content/book/3-s2.0-B9780323796699000037#b0015) ).

Brachial artery blood pressure measurement (with appropriate cuff size and ideally in both arms): if elevated, recheck after the
athlete rests quietly for 15 minutes and later, if needed ( Table 3.2 (https://www.clinicalkey.com/#!/content/book/3-s2.0-
B9780323796699000037#t0015) ). The following are blood pressure categorizations for children and adolescents according to the 2017
American Academy of Pediatrics (AAP) guidelines.

Table 3.2
Classification of Hypertension

Age and Phase 90th–94th Percentile b 95th–99th Percentile b >99th Percentile b

(https://www.clinicalkey.com/#!/content/book/3- (https://www.clinicalkey.com/#!/content/book/3- (https://www.clinica
s2.0-B9780323796699000037#tbl3_2fnb) s2.0-B9780323796699000037#tbl3_2fnb) s2.0-B97803237966
High Normal a Significant HTN a Severe HTN a
(https://www.clinicalkey.com/#!/content/book/3- (https://www.clinicalkey.com/#!/content/book/3- (https://www.clinica
s2.0-B9780323796699000037#tbl3_2fna) s2.0-B9780323796699000037#tbl3_2fna) s2.0-B97803237966
Prehypertensive c Stage 1 HTN c Stage 2 HTN c
(https://www.clinicalkey.com/#!/content/book/3- (https://www.clinicalkey.com/#!/content/book/3- (https://www.clinica
s2.0-B9780323796699000037#tbl3_2fnc) s2.0-B9780323796699000037#tbl3_2fnc) s2.0-B97803237966

6–9 yr
Systolic b 104–121 108–129 >115–129
(https://www.clinicalkey.com/#!/content/book/3-
s2.0-B9780323796699000037#tbl3_2fnb)

Diastolic b 68–81 72–89 >83–89

(https://www.clinicalkey.com/#!/content/book/3-
s2.0-B9780323796699000037#tbl3_2fnb)

10–12 yr
 Age and Phase 90th–94th Percentile b 95th–99th Percentile b >99th Percentile b
(https://www.clinicalkey.com/#!/content/book/3- (https://www.clinicalkey.com/#!/content/book/3- (https://www.clinica
s2.0-B9780323796699000037#tbl3_2fnb) s2.0-B9780323796699000037#tbl3_2fnb) s2.0-B97803237966
High Normal a Significant HTN a Severe HTN a
(https://www.clinicalkey.com/#!/content/book/3- (https://www.clinicalkey.com/#!/content/book/3- (https://www.clinica
s2.0-B9780323796699000037#tbl3_2fna) s2.0-B9780323796699000037#tbl3_2fna) s2.0-B97803237966
Prehypertensive c Stage 1 HTN c Stage 2 HTN c
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s2.0-B9780323796699000037#tbl3_2fnc) s2.0-B9780323796699000037#tbl3_2fnc) s2.0-B97803237966

Systolic b 112–127 116–135 >123–135

(https://www.clinicalkey.com/#!/content/book/3-
s2.0-B9780323796699000037#tbl3_2fnb)

Diastolic b 73–83 77–91 >84–91

(https://www.clinicalkey.com/#!/content/book/3-
s2.0-B9780323796699000037#tbl3_2fnb)

13–15 yr
Systolic b 117–135 121–142 >128–142
(https://www.clinicalkey.com/#!/content/book/3-
s2.0-B9780323796699000037#tbl3_2fnb)

Diastolic b 76–85 80–93 >87–93

(https://www.clinicalkey.com/#!/content/book/3-
s2.0-B9780323796699000037#tbl3_2fnb)

16–17 yr
Systolic b 121–140 125–147 >132–147
(https://www.clinicalkey.com/#!/content/book/3-
s2.0-B9780323796699000037#tbl3_2fnb)

Diastolic b 78–89 82–97 >90–97

(https://www.clinicalkey.com/#!/content/book/3-
s2.0-B9780323796699000037#tbl3_2fnb)

≥18 yr
Systolic c 120–139 140–159 ≥160
(https://www.clinicalkey.com/#!/content/book/3-
s2.0-B9780323796699000037#tbl3_2fnc)

Diastolic c 80–89 90–99 ≥100

(https://www.clinicalkey.com/#!/content/book/3-
s2.0-B9780323796699000037#tbl3_2fnc)

HTN, Hypertension.

• Classification categories of hypertension in children aged 1–13 years old:

• Normal (<90th percentile for age, sex, and height)

• Elevated blood pressure (≥90th but <95th percentile for age, sex, and height or 120/80 mmHg to <95th percentile,
whichever is lower)

• Stage 1 hypertension (≥95th percentile for age, sex, and height to <95th percentile + 12 mmHg or 130/80 to 139/89
mmHg, whichever is lower)

• Stage 2 hypertension (≥95th percentile for age, sex, and height + 12 mmHg or ≥140/90 mmHg, whichever is lower)

• Classification categories of hypertension in children aged ≥13 years old:

• Normal (<120/80 mmHg)

• Elevated blood pressure (systolic blood pressure [SBP] between 120 and 129 with diastolic blood pressure [DBP] <80
mmHg)

• Stage 1 hypertension (130/80 to 139/89 mmHg)

• Stage 2 hypertension (blood pressure ≥140/90 mmHg)

Palpate radial and femoral pulses:

 • Decreased or nonpalpable femoral pulses should raise suspicion for coarctation of the aorta.

• Irregular pulse should raise suspicion for arrhythmia and requires ECG evaluation.

Heart auscultation in supine and standing positions: note the presence and character of any murmurs

• HCM murmur: systolic murmur heard best at lower left sternal border in the standing position; increases with
maneuvers that decrease venous return to the heart

• Provocative maneuvers help differentiate functional murmurs from pathologic murmurs.

• To decrease venous return: Valsalva maneuver and squat-to-stand

• To increase venous return: deep inspiration, stand-to-squat, and isometric hand grip

• General recommendations for murmurs requiring further evaluation before the athlete can participate:

• Any systolic murmur grade ≥III/VI in severity

• Any diastolic murmur

• Any murmur that gets louder with Valsalva maneuver

Marfan syndrome stigmata ( Fig. 3.3 (https://www.clinicalkey.com/#!/content/book/3-s2.0-B9780323796699000037#f0020) ): Tall stature,

arachnodactyly, kyphoscoliosis, anterior chest deformity, arm span greater than height, decreased upper body length to lower
body length ratio, heart murmur or midsystolic click, ectopic lens, thumb sign (the thumbs protrude from the clenched fists),
wrist sign (the distal phalanges of the first and fifth digits of one hand overlap when wrapped around the opposite wrist), and
family history of Marfan syndrome

Illustrations of the classic features of Marfan syndrome. A series of medical illustrations and a pedigree chart for Marfan syndrome. The
image shows a drawing of a tall, thin person with the characteristic features of Marfan syndrome, such as arachnodactyly long, thin fingers
and toes, pectus excavatum, and an arm span that exceeds the patient s height. The image also shows the Steinberg sign, which is a common
physical exam finding.

FIGURE 3.3
Marfan syndrome.

Pulmonary Assessment
• Focus on detecting abnormal breath sounds: wheezes, crackles, rubs, and abnormal inspiratory to expiratory ratio

• Asthma screening (e.g., exercise challenge test) has been suggested but is impractical in most preparticipation settings.
Abdominal/Gastrointestinal Assessment
Should be performed with athlete in the supine position. Examples of problems requiring further evaluation before
participation include organomegaly (liver and spleen), masses, bruits, tenderness, and/or rigidity and possible pregnancy in
females.

Genitourinary Assessment
• Male: Per the fifth PPPE Monograph. Indications for performing the male genital examination include history of groin pain,
inguinal bulge, possible testicular lump, or possible undescended testicle. If warranted by history or other findings, examine
in a private setting. Chaperones may be present during this part of the examination per patient and/or provider preference.

• Female: routine examination is not recommended; if warranted by history or other findings, examine in a private setting.

• Tanner staging is no longer recommended in PPPE monograph as a standard element; however, it may be useful for
counseling on growth and development and anabolic steroid use.

Musculoskeletal Examination
• Musculoskeletal examination is important to identify musculotendinous, bone, or joint problems that may limit athletic
participation or predispose to acute injury or long-term complications (e.g., shoulder instability, anterior cruciate–deficient
knee, unrehabilitated ankle sprain, or juvenile rheumatoid arthritis).

• General screening examination is most efficient for asymptomatic athletes with no prior musculoskeletal injuries ( Fig. 3.4
(https://www.clinicalkey.com/#!/content/book/3-s2.0-B9780323796699000037#f0025) ).

A composite of illustrations showing various maneuvers for a physical examination. A composite medical image of many illustrations
showing various physical examination maneuvers. The illustrations, numbered 1 to 14, depict a physician examining a patient for range of
motion of the head, neck, and shoulders. Other images show a physician examining the patient s muscle strength, joint mobility, and specific
joint movements. This composite provides a comprehensive overview of the physical examination of a patient.

FIGURE 3.4
General musculoskeletal screening examination comprising the following: (1) inspection, athlete standing and facing the
examiner (symmetry of trunk, upper extremities); (2) forward flexion, extension, rotation, and lateral flexion of neck (range of
motion, cervical spine); (3) resisted shoulder shrug (strength, trapezius); (4) resisted shoulder abduction (strength, deltoid); (5)
internal and external rotation of shoulder (range of motion, glenohumeral joint); (6) extension and flexion of elbow (range of
motion, elbow); (7) pronation and supination of elbow (range of motion, elbow and wrist); (8) clench fist and then spread
fingers (range of motion, hand and fingers); (9) inspection, athlete facing away from the examiner (symmetry of trunk, upper
extremities); (10) back extension with knees straight (spondylolysis/spondylolisthesis); (11) back flexion with knees straight,
facing toward and away from the examiner (range of motion, thoracic and lumbosacral spine; spine curvature; hamstring
flexibility); (12) inspection of lower extremities, contraction of quadriceps muscles (alignment, symmetry); (13) “duck walk”
four steps (motion of hip, knee, and ankle; strength, balance); (14) standing on toes and then on heels (symmetry, calf;
strength; balance).

© Rebekah Dodson.

• Joint-specific examination: recommended for problematic areas; most accurate and most time consuming.
• Back flexion is recommended in screening for thoracolumbar deformities such as scoliosis ( Fig. 3.5
(https://www.clinicalkey.com/#!/content/book/3-s2.0-B9780323796699000037#f0030) ).

Illustrations of the evaluation and physical examination for scoliosis. A series of medical illustrations of the evaluation for scoliosis. The
top illustrations show two sisters with severe and mild scoliotic curves. The middle illustrations show a physician using a plumb line to
gauge trunk alignment and a scoliometer to measure a rib hump. Another illustration shows a man measuring a woman s leg length to
determine pelvic obliquity. These are all common parts of a physical examination for scoliosis.

FIGURE 3.5
Clinical evaluation of scoliosis.

• Sport-specific examination: some advocate need for focusing on commonly injured or stressed areas in particular sports (e.g.,
shoulder examination for throwers, tennis players, and swimmers and knee examination for basketball, football, and soccer
players); also includes measures of endurance, strength, and flexibility in orthopedic screening but is time consuming and
requires in-depth knowledge of particular sports.

• Consider screening for flexibility (e.g., back, hamstrings, and Achilles tendon) because clinical anecdotal evidence suggests
that increasing flexibility reduces risk of overuse problems (e.g., mechanical back pain, patellofemoral pain, and medial tibial
stress syndrome); however, no study has supported a decreased risk of acute injury (e.g., sprains, strains, and dislocations).

• Functional movement screening (FMS) may be added to PPPE to assess movement quality based on the sport, accessibility,
and available resources.

Neurologic Assessment
Neurologic assessment (gross motor) is generally performed through musculoskeletal evaluation. Perform a more
comprehensive neurologic examination in athletes with unexplained strength deficits, paresthesia, history of burners/stingers,
history of head injury/concussion, or any focal or generalized neurologic deficit.

• The NCAA and others have recommended a baseline symptom score, cognitive examination, and balance assessment for all
athletes; an example of this is the Sideline Concussion Assessment Tool-3 (SCAT-3).

• Consider baseline assessment of vestibular ocular motor movement screening (VOMS) for athletes participating in contact
and collision sports.

Other Assessments
Assessment for other problems such as lymphadenopathy, thyromegaly, physical findings of eating disorders, and skin
conditions should be considered on an individual basis.

Fitness and Performance Evaluation

• Secondary (ideal) objective of PPPE
Performed more often in the group screening-station format
• Measures any or all of the following parameters:

• Body composition (e.g., skinfold, underwater weighing, and circumferences)

• Flexibility (e.g., sit-and-reach and goniometry)

• Strength (e.g., manual muscle testing, hand or leg dynamometer, bench press or leg press, push-ups, pull-ups, or sit-ups)

• Endurance (e.g., 12-minute and 1.5-mile run)

• Power (e.g., vertical and standing broad jump)

• Speed (e.g., 40-yard dash) and agility (e.g., agility run)

• Balance (e.g., stork stand, balance beam walking, and Balance Error Scoring System [BESS] included in SCAT-3)

• Vision performance testing and/or VOMS has been added in certain settings:

• Dynamic visual acuity

• Depth perception

• Visual tracking or pursuit

• Eye–hand and eye–body coordination

Screening Tests

Difference Between Routine Screening and Diagnostic Testing

A complete blood count in an asymptomatic female athlete is a screening test, whereas a complete blood count in a female
athlete with poor eating habits, heavy menstrual periods, fatigue, and pale conjunctiva becomes a diagnostic test.

• Does the burden of suffering resulting from the condition warrant screening?

• If the answer is “yes,” ask the following:

• What is the sensitivity of the proposed screening test?

• Are the potential risks and cost of the test acceptable?

• If the screening test identifies the condition, are proven and acceptable treatments available? Is there a clear advantage of
initiating such treatment during the asymptomatic phase of the condition?

Routine Screening Tests

Routine screening is not recommended, but specific screening tests (e.g., sickle cell screening required by the NCAA and
hemoglobin and ferritin for distance runners) are recommended as indicated.

Laboratory tests: urinalysis, complete blood count, chemistry profile, lipid profile, ferritin, sickle cell trait, sexually
transmitted disease, infectious hepatitis, and urine drug screening

Radiographs: chest, cervical spine, and joint radiographs

Cardiopulmonary tests: ECG, echocardiogram, exercise stress test, spirometry, exercise spirometry, and other exercise
challenge tests. Although certain studies suggest that using new ECG screening protocols (e.g., Seattle criteria) may decrease
false-positive screens, recommendation of ECG screening for athletes still remains controversial, even in select populations.
In 2014, the AHA published 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). It states:

• Screening with 12-lead ECG in association with comprehensive history-taking and physical examination to identify or
raise suspicion of genetic/congenital and other cardiovascular abnormalities may be considered in relatively small
cohorts of young healthy people aged 12–25 years but not necessarily limited to athletes (e.g., in high schools,
colleges/universities, or local communities), provided that close physician involvement and sufficient quality control can
be achieved; if undertaken, such initiatives should recognize known and anticipated limitations of 12-lead ECG as a
population screening test, including the expected frequency of false-positive and false-negative test results, as well as the
cost required to support these initiatives over time (Class IIb; Level of Evidence C).
 • Mandatory and universal mass screening with 12-lead ECG in large general populations of young healthy people aged
12–25 years (including on a national basis in the United States) to identify genetic/congenital and other cardiovascular
abnormalities is controversial and an area where further research is necessary (Class III, no evidence of benefit; Level of
Evidence C).

The “Italian Experience”

In Italy, a systematic, state-subsidized national program for mandatory annual PPPE of all athletes aged 12–35 years has been in
place for approximately 35 years. Minimum annual tests include a general examination and 12-lead ECG. Elite competitive
athletes undergo a more comprehensive medical and physiologic evaluation that includes routine ECG, the findings of which
are as follows:

• Detection of few definitive examples of potentially lethal cardiovascular abnormalities remains the norm.

• A reported 2.2%–2.5% of athletes are disqualified (approximately 51% because of cardiovascular abnormalities).

• A study by Basso and colleagues suggests that the Italian national screening program can decrease the incidence of SCD
among young athletes. During the study period, SCD occurred in 55 screened athletes versus 265 nonscreened nonathletes.

• Right ventricular dysplasia causes more athletic deaths than HCM. Reasons for the discrepancy in North American data
(where HCM causes more deaths in athletes aged <30 years) are unresolved. In addition, possible disqualification of athletes
through screening may contribute to this discrepancy.

With the rarity of potentially lethal cardiovascular abnormalities in young athletes and the overwhelming number of sports and
athletic participants in the United States, screening of the Italian magnitude would be challenging in most settings.

ESC and IOC

The European Society of Cardiology (ESC) and International Olympic Committee (IOC) recommend combining noninvasive
testing (e.g., 12-lead ECG) with the standard history-taking and physical examination for cardiovascular screening in large
populations of young trained athletes.

ECG and/or Echocardiogram

ECG should be considered in athletes with any significant cardiac symptoms or abnormal findings on examination or with a
family history of sudden death (unknown cause), SCD, or other cardiac conditions that are known predisposing factors for SCD
(e.g., right ventricular dysplasia, HCM, long QT syndrome, and Marfan syndrome) in a family member aged <50 years,
particularly a first-degree relative. Approximately 90% of people with HCM exhibit abnormal ECG findings.

Baseline Neuropsychological (NP) Testing

Baseline NP testing may be considered and recommended, if available, for athletes in sports considered to have a risk of head
injury. The utility of neuropsychological testing as a stand-alone test, as well as the need for baseline testing, remains
controversial. Nevertheless, baseline NP testing is valuable as part of a comprehensive concussion protocol injury (see Chapter
45 : “Head Injuries”).

Special Considerations for Transgender Athletes

Although the medical eligibility screening of transgender athletes is largely the same as the preparticipation physical evaluation
described earlier, providers should be aware of additional health concerns that disproportionately affect this group of patients.
Compared with cisgender counterparts, transgender individuals are at higher risk for depression, anxiety, disordered eating, and
other mental health illnesses, and they should be appropriately screened for these conditions at the PPPE. Additionally,
providers should screen for discrimination, bullying, and abuse in this population.

Providers should also be aware of local sports eligibility policies regarding transgender athlete participation and should
advocate for their patients’ competition status when necessary. One important way in which providers can help transgender
athletes achieve appropriate competition status is by helping them apply for a therapeutic use exemption (TUE) from
antidoping organizations (ADOs) if the athlete is taking testosterone, spironolactone, or other banned substances as part of their
hormone therapy.

Patients With Disabilities

The PPPE and clearance to participate for athletes with disabilities is important and should be performed with an
understanding of the medical and musculoskeletal issues that are present for the condition, as well as understanding the sport-
specific demands for the athlete (Preparticipation Physical Evaluation: The athlete with special needs form available at
https://www.aap.org/en-us/Documents/PPE-Athletes-with-Disabilities-Form.pdf; copyright 2019, accessed January 2021; for
additional information related to athletes with disability, see Chapter 14 : “The Athlete With Physical Disability”). A common
example is athletes with Down syndrome, with possible atlantoaxial instability.
Down Syndrome
Patients with Down syndrome and their parents should be closely questioned regarding signs or symptoms of atlantoaxial
instability. Cervical radiographs, including flexion and extension views, may be considered ( Fig. 3.6
(https://www.clinicalkey.com/#!/content/book/3-s2.0-B9780323796699000037#f0035) ).

• In asymptomatic patients, neurologic signs or symptoms may be more predictive of risk of injury progression than
radiographic abnormalities.

• The AAP acknowledges the potential but unproven value of lateral plain radiographs of the cervical spine but does not
recommend routine screening radiographs.

• Special Olympics requires cervical spine radiographs before athletic participation in all patients with Down syndrome in
judo, equestrian sports, gymnastics, diving, pentathlon, butterfly stroke, diving starts in swimming, high jump, Alpine skiing,
snowboarding, squat lift, and soccer.

• However, there is a lack of general agreement on the criteria for exclusion from sport.

Illustrations and radiographs of the craniocervical junction with occipitalization of the atlas. A composite medical image with illustrations
and radiographs of the craniocervical junction. The illustrations show a normal joint and two pathological conditions, Occipitalization of atlas
and Occipitalization with instability. The bottom images are lateral radiographs of a patient with occipitalization, taken in extension and flexion,
which show increased atlas-dens interval. This is a common finding in patients with atlantoaxial instability.

FIGURE 3.6
Congenital anomalies of the occipitocervical junction.

Clearance for Participation

• Clearance falls into four categories:

1. Full participation without restrictions

2. Participation pending further testing/evaluation

3. Participation just in certain sports

4. Disqualification

• Differentiation of categories is important.

• Familiarity with the demands of a specific sport is essential; use of a classification system for sports by contact and
strenuousness is helpful in this regard ( Table 3.3 (https://www.clinicalkey.com/#!/content/book/3-s2.0-B9780323796699000037#t0020) and Fig.
3.7 (https://www.clinicalkey.com/#!/content/book/3-s2.0-B9780323796699000037#f0040) ).
Table 3.3
Sports According to Risk of Impact and Educational Background

Junior High School High School/College

Impact Expected
American football American football

Ice hockey Soccer

Lacrosse Ice hockey

Wrestling Lacrosse

Karate/judo Basketball

Fencing Wrestling

Boxing Karate/judo

Downhill skiing

Squash

Fencing

Boxing

Impact May Occur

Soccer Field hockey

Basketball Equestrian

Field hockey Cycling

Downhill skiing Baseball/softball

Equestrian Gymnastics

Squash Figure skating

Cycling

Impact Not Expected

Baseball/softball Cricket

Cricket Golf

Golf Riflery

Riflery Volleyball

Gymnastics Swimming

Volleyball Track and field

Swimming Tennis

Track and field Cross-country skiing

Tennis Rowing

Figure skating Sailing

Cross-country skiing Archery

Rowing Weightlifting

Sailing Badminton

Archery

Weightlifting

Badminton
 A chart classifying sports based on their static and dynamic components. A conceptual chart classifying sports based on their static and
dynamic components. The chart is a three-by-three grid. The horizontal axis represents increasing dynamic components, and the vertical axis
represents increasing static components. The grid contains various sports, such as bowling low-low, swimming moderate-high, and
weightlifting high-high, to provide a reference for sports medicine professionals.

FIGURE 3.7
Classification of sports based on peak static and dynamic components achieved during competition; however, higher values
may be reached during training. The increasing dynamic component is defined in terms of the estimated percentage of
maximal oxygen uptake (V.O 2 max) achieved and results in an increasing cardiac output. The increasing static component is
related to the estimated percentage of maximal voluntary contraction reached and results in an increasing blood pressure
load. The lowest total cardiovascular demands (cardiac output and blood pressure) are shown in the palest color, with
increasing dynamic load depicted by increasing blue intensity, and increasing static load by increasing red intensity. Note the
graded transition between categories, which should be individualized on the basis of player position and style of play.
∗Danger of bodily collision (see Table 3.3 (https://www.clinicalkey.com/#!/content/book/3-s2.0-B9780323796699000037#t0020) for more detail on
collision risk). † Increased risk if syncope occurs.

Modified from Mitchell et al. with permission. Copyright © 2005, Journal of the American College of Cardiology . From
Recommendations for Competitive Athletes with Cardiovascular Abnormalities: Task Force 1: Classification of Sports:
Dynamic, Static, and Impact: A Scientific Statement from the American Heart Association and American College of
Cardiology. Circulation. 2015;132[22]:e262-266.

• Published guidelines for medical conditions and sports participation are helpful, but clinical judgment should be used in
applying general guidelines to individual athletes ( Box 3.3 (https://www.clinicalkey.com/#!/content/book/3-s2.0-B9780323796699000037#b0020) ).

BOX 3.3
Medical Conditions and Sports Participation

Athletes With the Following Diagnoses May Participate in Sports:

Asthma
Athletes with asthma or exercise-induced bronchospasm (EIB) may participate in sports, as long as their asthma or EIB
symptoms are well controlled.

• All athletes with asthma or EIB should have an asthma action plan and a rescue inhaler on-site.

• Athletes taking systemic steroids for asthma management may need a therapeutic use exemption (TUE) from
the World Anti-Doping Agency (WADA).
 • Counsel on increased risk of respiratory distress while scuba diving.

• Athletes with severe-persistent asthma may require activity modifications.

Diabetes Mellitus (DM)

Athletes may participate in any sport while paying attention to necessary adjustments to diet, blood glucose
concentration, and insulin regimen (if applicable). Regardless of exercise type, these athletes should be vigilant of their
blood glucose before, during, and after exercise, and they should continue to monitor blood glucose concentrations
throughout the evening, given increased risk of late-onset hypoglycemia.

• A combination of aerobic exercise and resistance training may improve glycemic control in patients with type
2 DM. However, each patient’s exercise goals and parameters should be individualized to his or her level of
training and comorbidities.

• Counsel athletes with type 1 DM that aerobic exercise generally leads to lower blood glucose concentrations,
which can be addressed by decreasing basal insulin or increasing carbohydrate consumption before exercise.
Conversely, anaerobic exercise may lead to a transient increase in blood glucose concentrations, which may
require modest insulin corrections.

• Each athlete should have an emergency hypoglycemia action plan.

HIV Infection
Athletes may participate in any sport, as appropriate for the athlete’s overall health status.

• The risk of transmission through contact sports, particularly among those on antiretroviral agents, is very low.

• Universal precautions should be maintained to avoid contact with blood and bodily fluids. These include the
use of gloves by healthcare workers and the use of cleaning supplies with antiviral properties to remove blood
off of floors, mats, uniforms, etc.

• Any bleeding wounds should be completely covered.

Migraines
Generally, athletes with migraine headaches may participate in sports as tolerated.

• Counsel the athlete that exertion may be a trigger for their migraines.

• Advise them that patients with migraines may experience prolonged symptoms following a sport-related
concussion.

• Review the patient’s migraine medication list for any substances that may require a TUE.

Obesity
Overweight or obese athletes may participate in sports.

• Counsel the athlete on increased risk of cardiovascular strain and heat illness, as well as the importance of
hydration and acclimatization.

• Provide nutrition recommendations as needed.

Seizure Disorder, Well-Controlled
There are no restrictions on sports participation in patients with a well-controlled seizure disorder. However, all
patients with a seizure disorder should avoid very high-risk activities such as skydiving and scuba diving.

• In patients with a poorly controlled seizure disorder, patients who have recently started or stopped
antiepileptic drugs, or patients who are within 2 months of their first seizure, restrictions may be required (see
later).

Sickle Cell Trait

Athletes with sickle cell trait may participate in all sports.

• Counsel on the risk of exertional heat illness, rhabdomyolysis, and sudden death.

• Counsel on the importance of hydration and acclimatization.

• Encourage the athlete to report cramping or muscle aches immediately to coaching and medical staff.

Undescended or Solitary Testicle

Athletes with a single or undescended testicle may participate in sports.

• Recommend the use of a protective cup during high-risk activities.

Viral Hepatitis
Athletes with viral hepatitis may participate in any sport as appropriate for the athlete’s overall health status.

• Universal precautions should be maintained to avoid contact with blood and bodily fluids, including the use
of gloves by healthcare workers at games and the use of agents with antiviral properties to clean any blood off
of floors, mats, uniforms, etc.

• Any bleeding wounds should be completely covered.

Athletes With the Following Diagnoses May Conditionally Participate in

Sports as Outlined:

Bleeding Disorder
Athletes with bleeding disorders should be individually assessed to determine their eligibility for sports. Generally,
patients with mild to moderate bleeding disorders may participate in vigorous exercise with appropriate supervision
and planning.

• Assess the degree of the athlete’s bleeding disorder, and ask about personal history of bleeds.

• Counsel the patient that a blow to the head can be life threatening.

• To minimize risk of injury, patients should undergo appropriate conditioning and strengthening before
beginning a sport.
 • Provide factor prophylaxis if appropriate.

• Have an emergency plan in case of acute bleed during sports.

• Encourage the use of appropriate protective equipment.

Transient Brachial Plexopathy (Burner or Stinger)

Athletes with a history of brachial plexopathy who are free of neck pain and radicular symptoms and who have full
strength and range of motion may participate in sports.

Celiac Disease
Athletes with celiac disease should undergo a nutritional workup, as well as assessment of associated conditions such as
anemia. These deficits should be adequately treated to allow full participation in sports.

Cerebral Palsy
Individual assessment of functional abilities related to sports-specific activities is recommended.

Cervical Cord Neuropraxia (CCN)

Individual assessment is recommended before returning to contact sports.

• Do not clear for sport if the athlete is demonstrating deficits in strength.

• Evaluate for cervical spine stenosis. If the athlete has documented spinal cord stenosis, recommend
neurosurgical evaluation before returning to sport.

Congenital Heart Disease

Individual assessment by a cardiologist is recommended to help determine eligibility for sports.

Cystic Fibrosis (CF)

Individual assessment is recommended. Generally, patients with CF can participate in sports as appropriate for the
athlete’s overall health status.

• Cardiopulmonary exercise testing can help a provider establish an individualized exercise and strengthening
plan for an athlete with CF.

• Counsel on the increased risk of heat illness and dehydration in CF.

• Recommend salt-containing fluids during exercise.

• Evaluate for vitamin and nutrient deficiencies.

• Counsel on the control of diabetes mellitus with exercise.

• Consider additional risk factors for contact sports such as splenomegaly, hepatomegaly.

Eating Disorder
Athletes with an identified eating disorder should be connected with a multidisciplinary team, including sports
nutrition and psychiatry. This multidisciplinary workup should be complete before determining eligibility for sport.
 • Evaluate for other signs and symptoms of relative energy deficiency, such as low bone mineral density or
menstrual dysfunction in females.

Heat Illness
In athletes with a history of heat illness, individual assessment is recommended to address any predisposing factors
and to create an appropriate prevention strategy.

• Recommend a strategy that includes conditioning, optimization of hydration and salt intake, acclimatization,
and sleep.

Hepatomegaly
Athletes with acute hepatomegaly may not return to sport until their hepatomegaly resolves and/or until workup for
hepatomegaly is complete. For athletes with chronic hepatomegaly, individual assessment is recommended before
permitting participation in contact sports.

• Consider associated conditions such as coagulopathy and nutritional deficiencies.

Hypertension
Athletes with persistent hypertension require individual assessment.

• Screen for family history of hypertension, as well as other risk factors such as caffeine, nicotine, anabolic
steroid, or other drug use.

• Child and adolescent athletes diagnosed with hypertension should undergo workup for secondary causes of
hypertension, as well as target organ disease. This evaluation should include a renal ultrasound.

• Athletes with stage 2 hypertension or findings of end-organ damage should not be cleared for sport until their
workups are complete and their hypertension is under control.

Juvenile Idiopathic Arthritis (JIA)

Outside of disease flares, most athletes with well-controlled JIA and typical flexibility/strength may participate in all
sports.

• In patients with systemic or polyarticular JIA with neck arthritis, obtain cervical spine imaging to assess the
risk for spinal cord injury.

• Consider cardiovascular assessment in athletes with systemic or HLA-B27–associated arthritis for possible
cardiac complications with exertion.

• Recommend ophthalmologic assessment in patients with uveitis and recommend eye protection during
sports when appropriate.

• Recommend mouth guards, particularly in patients with jaw involvement.

Kidney, Solitary
In athletes with a single functioning kidney, the provider should engage the athlete in shared decision-making
regarding participation in contact sports and other high-risk sports, such as off-road biking, extreme skiing, and horse
racing.
 • Counsel the athlete that a trauma to the functional kidney during sports, while uncommon, could lead to
catastrophic outcomes, including the need for transplantation or dialysis.

• Counsel the athlete that protective gear may provide some protection for the functional kidney, but there are
no published data to prove they reduce the risk of kidney injury.

Neurologic Trauma or Abnormality

In athletes with a history of cranial or spinal trauma (including epidural bleeding, subdural hematoma, intracerebral
hemorrhage, second-impact syndrome, vascular malformation, neck fracture, etc.), individual assessment is
recommended before allowing participation in sports.

• Refer to neurosurgery when appropriate.

Pregnancy/Postpartum
Individual assessment is recommended in collaboration with the athlete’s obstetrician.

• Reassessment is necessary as the pregnancy progresses.

• Recommend avoiding sports with high risk of falling or blunt trauma.

Seizure Disorder, Poorly Controlled

Individual assessment is recommended.

• Counsel the athlete that a concussion may exacerbate their seizure disorder.

• Recommend avoiding noncontact sports that put the athlete and others at increased risk of injury. Such sports
include archery, riflery, weightlifting, power lifting, water sports, strength training, and sports involving
heights.

Sickle Cell Disease

Athletes with sickle cell disease may not participate in contact and collision sports.

• Counsel the athlete that they should also avoid highly strenuous activity, as well as chilling, overheating, and
dehydration.

Skin Infections
Athletes with active skin infections or open wounds are not eligible for participation in certain sports until their
wounds are healed.

• Common examples of such skin infections include herpes simplex virus, molluscum contagiosum, verrucae,
Staphylococcal and Streptococcal infections, scabies, and tinea.

• Athletes with these skin conditions should avoid sports with high risk of transmission such as wrestling,
martial arts, gymnastics or cheerleading on mats, or contact/collision sports.
Splenomegaly
Acute splenomegaly carries an increased risk of rupture, and participation in contact sports should be avoided.

• For athletes with chronic splenomegaly, individual assessment is recommended before permitting
participation in contact sports.

Visual Disturbance (one-eyed, functionally one-eyed, detached retina,

significant myopia, history of eye surgery, history of severe eye injury,
connective tissue disorder)
Individual assessment and discussion are recommended.

• Recommend the use of eye guards or other protective gear with sports participation, but consider that
protective eyewear is not permitted or practical in certain sports.

• Discuss the potential consequences of sustaining an injury to the athlete’s functional or typical eye.

Athletes With the Following Diagnoses May Not Participate in Sports With
Certain Caveats:

Acquired Heart Disease/Dysrhythmia

The following conditions place athletes at risk for sudden cardiac death (SCD). They require evaluation by a cardiologist
with experience in treating athletes to determine medical eligibility. In some cases, athletes with milder conditions may
still be able to participate in certain sports, depending on the intensity of activity, as directed by a cardiologist.

• Hypertrophic cardiomyopathy (HCM)

• Coronary artery anomalies

• Arrhythmogenic right ventricular cardiomyopathy (ARVC)

• Dilated cardiomyopathy

• Myocarditis

• Aortic rupture (Marfan syndrome)

• Aortic stenosis

• Atherosclerotic coronary artery disease (CAD)

• Long QT syndrome

• Wolff-Parkinson-White syndrome

• Brugada syndrome

• Short QT syndrome

• Postoperative congenital heart disease

• Primary pulmonary hypertension

 Athletes With the Following Diagnoses May Not Participate in Sports:

Carditis
Athletes with carditis are at risk for sudden cardiac death with exertion.

Fever
Athletes with a fever are at higher risk of heat illness, dehydration, and orthostatic hypotension. Additionally, the fever
may accompany infections and/or inflammatory conditions that put the athlete at further risk.

• Additional considerations:

• How does the condition/illness affect the athlete’s risk of morbidity or mortality?
• How will the condition/illness affect other participants?

• Are there any limitations or modifications within the sport that allow the athlete to continue participation despite the
injury or illness? If so, is it reasonable to allow participation with limitations until the condition resolves?

• Most athletes are cleared for full participation without restriction or with minimal additional evaluation (e.g., reassessment of
visual acuity, blood pressure, or ligamentous instability; correction of improper rehabilitation; and additional
musculoskeletal consultation).

• Explain reasons for further evaluation to the athlete and parent/guardian (if athlete is <18 years old).

• Extensive updated information about a medical condition and the risk of participation often requires attention to specifics of
the medical problem and the individual athlete, as well as a breakdown of sport-specific requirements.

• Decisions to disqualify may require additional specialist consultations, as well as one or two “second expert opinions.” A total
of three opinions is suggested.

Areas of Concern

Ethical Issues Associated With PPPE

Ethical issues to consider as a team physician include:

• Confidentiality (e.g., compliance with Health Insurance Portability and Accountability Act [HIPAA], Family Educational Rights
and Privacy Act [FERPA], disclosing medical information, and drug testing results)

• Informed consent (e.g., discussion of all treatment options and balancing athletes’ desire to participate versus providing
optimal medical treatment)

• Influence of third parties (e.g., pressure from teammates, coaches, administrators, parents/guardians, or other people from
the community)

• Drug use (e.g., using pain medications to allow participation; pressure to supply, administer, or provide counsel regarding
illegal drugs; and illicit or performance-enhancing drugs)

Medicolegal Issues Associated With PPPE

Right to participate:

• Under enactments such as the Americans with Disabilities Act and the Federal Rehabilitation Act, an athlete may have a
legal right to participate against medical advice.

• If athletes choose to participate against medical advice, an exculpatory waiver or prospective release is highly
recommended. Despite questions of validity, these forms of written contracts are intended to demonstrate that the
athlete was fully informed of his or her condition, as well as the potential risks of participation. “Guidelines” for various
medical conditions (e.g., Concussion Guidelines and AHA/American College guidelines [formerly Bethesda Guidelines])
“are not intended to establish absolute mandates” and are better considered as recommendations for the team physician
 to consider when providing clearance decisions. Occasionally, these guidelines can provide support for the decision to
restrict participation, and in others, the team physician may deviate from the recommendations based on individualized
factors that might allow an athlete to participate. It is important that the physician fully informs the athlete of the
potential risks and has it acknowledged in a written format so that there is no doubt that a discussion took place.

• Compliance with school and governing body guidelines, standards, rules, regulations, and policies

• Compliance with privacy laws (HIPAA and FERPA) and local state and/or federal rules, regulations, and laws

• Documentation

“Good Samaritan” statutes: certain states have made an effort to protect volunteer examiners (PPPE) under “Good Samaritan”
statutes.

Mandated reporting: Those providers performing a PPPE are mandated reporters of suspected abuse or neglect, as they would
be in any other patient encounter.

Sexual harassment:

• Athlete expectations, lack of privacy during examinations, and inappropriate examinations (e.g., breast or gynecologic
examination in nonprivate settings) may contribute to such allegations.

• Clear communication with athletes, respect for their privacy, and presence of a chaperone (in certain situations) during
examinations minimize potential problems.

Confidentiality
• Good communication with other healthcare providers, parents, athletic trainers, and coaches is important, but it must take
place with respect for the athlete’s confidentiality.

• The newest PPPE form includes multiple pages—clearance considerations and recommendations are available as pages
separate from the detailed history and examination.

Team Physician Versus Personal Physician

• Team physicians may perform the PPPE but have minimal control over evaluation of specific problems uncovered in the
PPPE, particularly in high schools, smaller colleges, and managed care settings.

• Space is provided near end of the recommended PPPE form to write specific recommendations for further evaluation before
clearance (see Preparticipation Physical Evaluation: Clearance Form available at https://downloads.aap.org/AAP/PDF/PPE-
Medical-Eligibility-Form.pdf (https://downloads.aap.org/AAP/PDF/PPE-Medical-Eligibility-Form.pdf ) , copyright 2019). Communication and
documentation are essential for the physician and the athlete (and parent/guardian, if applicable), as well as with other
physicians.

Communication
• The team physician’s primary responsibility is toward the athlete, and parent/guardian if the athlete is younger than 18 years,
in terms of discussion and decision-making. Secondary responsibility is toward the university, school, or organization. This
distinction is often critical at the professional level. It is important, at times, to explain primary and secondary responsibility
to the coaching staff and administration in terms of sharing information. Emphasis must be placed on concerns regarding
long-term safety and health.

• The team physician must respect the athlete’s confidentiality with some understanding that if he or she is unable to
participate in practice or play, this information should be shared with the coach and other medical care providers.
Communication with athletic trainers, administrators, parents, and others, including the press, may be important. First,
discuss with the athlete what information must be disclosed.

• The team physician can arrange for follow-up communication. Have a plan for follow-up care and establish it in writing, if
appropriate. Arrange for additional evaluation and final clearance once additional testing requirements are met. Arrange for
further rehabilitation, functional testing, return to play with modifications, and progression, as necessary. Inform the athlete
regarding the risks and concerns of continued participation, and do not assume that the athlete will choose to participate.
Follow-up care is essential.

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