The pre-participation evaluation of athletes is an essential component of fostering the well-being and performance potential for sports participants of all ages and levels of competition. In the United States, a pre-participation physical evaluation (PPE), commonly referred to as a “sports physical,” is required for children and adolescents prior to participation in sports by most states. Even if not required by law, all physically active individuals should have an annual evaluation specifically tailored to address the elements of the PPE prior to beginning a competitive season.

There are two main elements of the PPE: (1) An assessment of the athlete’s medical history and (2) A physical examination with pertinent emphases for the active individual.

Medical history:

The medical history should review past illness and surgeries, current ongoing conditions and a focused family medical history. Specifically, it’s important to know about any heart conditions the athlete is aware of in him/herself or family members, like murmurs, high blood pressure or an enlarged heart. It’s also important for the physician to be aware of any symptoms the athlete has experienced during exercise that could raise concern for heart problems; these symptoms might include chest discomfort, feeling short of breath, sensing skipped heartbeats, feeling lightheaded or fainting.

A review of past injuries to muscles or bones is included, as well as a review of concussion history. Other focus areas include discussing history of blood disorders, asthma, seizures, infections, vision, nutrition and response to exercising in the heat.

In regards to blood disorders, athletes should discuss known sickle cell disease with their physician, since the dehydration that can accompany sports participation is a risk factor for a sickle cell crisis.

Knowing about a history of asthma is important, for example, so the practitioner can ensure the athlete will have a rescue inhaler available at all practices and games.

As far as infections, it’s important to know if an athlete has been diagnosed with infectious mononucleosis (“mono”). Mono is usually transmitted by a virus and can cause enlarged spleen with a risk of rupture during contact sports. It’s also significant to know if an athlete is prone to skin infections with staph bacteria, particularly MRSA, to allow the physician to counsel the athlete on how to minimize recurrence and transmission of the bacteria to teammates.

Discussing nutrition is imperative because athletes have very specialized caloric demands and personalized dietary needs in order to maintain a healthy weight and perform optimally. Various different body types are desired for different sports and positions. For example, distance runners and dancers typically strive for lean body types, while offensive linemen celebrate large muscular forms. It’s important for practitioners to ensure athletes know how to fuel their bodies appropriately to keep a healthy body composition while still achieving their athletic goals.

Any allergies are important to note so teams may avoid allergic foods (such as peanuts or shellfish) and also any medication allergies. Knowing the severity of the allergy is important, as well, so proper prevention and resources for a reaction are available, such as an Epi-pen and Benadryl.

Physical examination:

A comprehensive physical examination should always be performed for every athlete. This includes vital signs and an exam of each of the following: general appearance, vision, hearing, lymph nodes, heart, lungs, abdomen, skin, nervous system and musculoskeletal system. In males, an exam to screen for hernias or testicular masses is included as part of a general comprehensive physical exam. However, finding a hernia that is not otherwise causing symptoms for the athlete will not prevent sports participation clearance.

The heart exam should include the practitioner listening to the athlete’s heart while the athlete is standing, lying down and squatting; this technique is better than a standard sitting heart exam for detecting the murmurs which can be more dangerous in athletes. The musculoskeletal exam should assess strength, range-of-motion, asymmetries or deficiencies and functional analysis with special tests like the “duck-walk” and “single leg hop test.”

What happens if there is concern for an athlete’s heart health?

One of the most concerning and potentially important findings during a PPE is a murmur consistent with an enlarged heart, termed “hypertrophic obstructive cardiomyopathy”. This is a heart muscle disease thought to be due to a gene mutation, and it could have no symptoms at all. While rare, it can be life-threatening. The biggest risk with this condition is sudden cardiac death. If there is a concern for enlarged heart during the PPE, or a concern for any other heart condition, the athlete will be referred for further medical workup including an electrocardiogram (ECG), echocardiogram (ultrasound of the heart) and/or referral to a cardiologist prior to clearance for sports participation. Some schools include an ECG as part of their routine screening although this is not a universal recommendation.

Does the physical include testing for brain health?

In short, yes. A neurological exam is universally performed which could detect focal deficits due to disease of the brain or spinal cord. There is more variation, however, in the application of baseline testing for concussion. This type of testing is becoming more common, specifically if the athlete has a known history of concussions or plays a contact sport or position prone to head injuries. It can be valuable, but it is not mandatory. The assessment could include a neurologic-specific questionnaire, balance and coordination testing, written testing and/or computer-based testing.

Conclusion of the PPE

After the above components are sufficiently addressed, the physician makes a decision to clear the athlete for all sports without restriction, to clear the athlete with recommendations for further evaluation and/or treatment or to not clear the athlete. The “not cleared” designation could be pending further testing, not cleared for certain sports or not cleared for all sports. If an athlete is not cleared, there is apparent clinical concern for the athlete’s wellbeing. The overarching goal of physicians performing PPEs is to promote physical activity and sports participation in all athletes while ensuring maximal health and safety.

To reference the pre-participation physical evaluation (PPE) form developed by American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine and American Osteopathic Academy of Sports Medicine, please visit: www.amssm.org/PPEMono.php

AMSSM Member Authors
Aloiya Earl, MD