The Sports Preparticipation Exam (Lukacic, 3/23/2022)

Thanks to Dr. Allison Lukacic for her excellent presentation this week on the Preparticipation Exam (aka the other PPE).

A recording of her presentation is available HERE. 

Summary notes:

• 30 million US adolescents participate in organized sports
• there is a legal requirement in all 50 states to have some form of preparticipation exam for student athletes, 29 states use a standardized form
• said form should be signed by parent if athlete is <18
• goal is to maximize safe participation for young athletes, to identify medical conditions that put athletes at risk, identify those that require treatment/rehab prior to participation
• PPE is potentially  the only interaction they have with a healthcare provider (50-90% of athletes do not have a PCP)

PPE. . .

• should occur 6 weeks prior to sports season
• most states require PPE annually 

A thorough history is the most important part of the PPE-- history detects 88% of important medical conditions affecting sports participation, 66% of injuries

• screening for cardiac conditions: have they ever passed out, do they have chest pain, chest pain w/exertion, SOB?
• family history: anyone in family with sudden death during activity, cardiac disease <50, anyone with Marfan's syndrome?
• history of prior injuries: treatment and f/u
• burning sensation in extremities (suggesting cervical spine injuries)
• history of concussion, timing, healing time
• primary care: medications, substance use, supplements, energy drinks, getting in car w/drunk drivers

Physical Exam, key components

• blood pressure>> caution if > 99percentile
• BP >160/100 is cutoff, should be treated prior to participation
• look for secondary causes (caffeine, supplements), work up as needed
• elevated BP contraindication for static exertion (e.g. weightlifting)
• Marfanoid body habitus?
• vision screen (20/40 in at least one eye if want to do archery, rifles)
• lung exam: asthma adequately treated? PFTs if exercise-induced asthma
• cardiac: rate, rhythm, listening for murmurs (supine, standing/sitting w/Valsalva maneuver), PMI
• grade 3 or greater?
• increase with Valsalva maneuver?
• diastolic?
• abdomen: hepatic or splenic enlargement
• genitalia: undescended/single testes (should wear cup), hernia (should be referred for repair), testicular mass
• no genital exam in female
•  musculoskeletal exam, including supplemental knee/shoulder/ankle exams if history of injury
• range of motion in all joints, pain through motions, symmetry
• duck walk quickly assesses all lower extremity joints
• skin: molluscum, scabies, ringworm, HSV, impetigo

EKG, labs, urine drug tests are NOT recommended in standard PPE

Preparticipation Assessment (reminder goal is to get as many kids actively engaged in sports as possible)

1. unrestricted clearance
2. clearance w/notification to coach/trainer (e.g. brace, inhaler)
3. clearance deferred for further evaluation (e.g. echo w/murmur)
4. disqualification (very rare)

Sudden Death

rare, 0.75 per 100K athletes (<35 cases per year in the US)

hypertrophic cardiomyopathy (HCM) is the most common cause of sudden death (36%)

HCM affects approximately 1/500 individuals 

sarcomere mutation in the heart muscle, autosomal dominant

clinical diagnosis: EKG>> echo>> cardiac MRI

exam findings: systolic murmur in left 2nd intercostal space, lateral displacement of apical pulse (PMI), murmur increases in intensity when lying to standing/sitting, w/Valsalva (due to increased venous return)

EKG: LVH, LV strain, deep q waves lateral/inferior leaves, T wave inversion, sometimes WPW (Current US recommendations there is not enough evidence for EKG for all athletes and risk>>benefit, though Italy does do EKG for all PPE because they have evidence it decreased HCM)

2016 California passed Eric Paredes Sudden Cardiac Prevention Act, which requires discussion of sudden cardiac death during the PPE, also specific coach/trainer responsibilities

Exam findings in Marfan's

Female and Male Athlete Triad

in females: menstrual cycles, eating patterns, stress fractures (osteoporosis prevention)

male athlete triad (recently coined), but similar disordered eating, energy deficiency and reproductive dysfunction

athletes with these triad should not be cleared for participation until these issues are addressed

Concussions: important to document duration, frequency and recovery time

• in CA, athletes cannot return to play in less than 7 days from time of concussion (many athletes need a month to recover)
• Major goal to prevent second impact syndrome, chronic traumatic encephalopathy (football, 17+ injuries)
• balance error scoring and neuropsychological testing: all symptoms must resolve prior to return to play

Other medical conditions:

Asthma is a common diagnosis that may need to better controlled prior to clearance

Hemophilia or Von Willebrand's disease: no contact or collision

Sickle cell disease: no high exertion, contact, or collision sports

Sickle cell trait: cleared for ALL sports participation (though there have been deaths of NFL with just trait)

Epilepsy: any sport except w/ risk for fatal seizure (e.g. sky diving)

MSK injuries are the most common injury to have an athlete be restricted

Criteria for clearance: NO joint effusion, no decreased ROM, 80-90% of full strength

Resources:

• National Association of State High School Associations (NFHS)
• Standardized PPE form
• Pediatric Blood Pressure App