Preparticipation Physical Exams and Young Athletes: Many Exams Fall Short

In 1999, Gomez et al (8) analyzed the preparticipation physical examination forms from 254 high schools and found that 47 (25.3%) included questions about exerciserelated symptoms, 97 (52.2%) included questions about a previous diagnosis of murmur or high blood pressure, and 57 (30.7%) had questions about a family history of early myocardial infarction or sudden death. Only 32 (17.2%) asked all three questions, which are part of the recommended cardiac screening.

The situation in colleges is similar. In 2000, Pfister et al (9) assessed the success of the AHA guidelines in 1,110 National Collegiate Athletic Association (NCAA) colleges. The response rate was 79%. A screening was considered adequate if nine of the 12 AHA-recommended items were included; it was considered inadequate if it contained four or fewer of the 12 items. Twenty-six percent of the programs were deemed adequate, 50% were intermediate, and 24% were inadequate.

When Should the Exam be Done?
The five-society monograph (2) recommends that the preparticipation physical examination be performed 6 weeks before preseason practice begins, to allow time for any problem to be corrected or rehabilitation to take place. After the full, initial screening preparticipation physical examination, interim examinations are recommended. Some experts believe that full screening should occur yearly, and others believe that an annual history and a focused physical examination is appropriate for athletes with abnormal findings.(2)

The AHA suggests that a comprehensive personal and family history be obtained from the athlete upon entering high school or college. In each of the subsequent 3 to 4 years, an interim history and blood pressure measurement should be obtained. Important changes in medical status or abnormalities detected during interim annual histories may signal that another physical examination and further testing should be performed. High school athletes should receive a complete physical examination every 2 years.(3)

Three Types of Examinations
There are three types of preparticipation physical examinations: office-based, assembly line, and station. It is unclear if one system is better than another. Each physician must make his or her own judgment about the system to use. Whichever type is chosen, it is imperative to perform the cardiac examination in a quiet environment, given that undiagnosed heart disease is the leading cause of death in athletes.

Office-Based Examination
One approach is for the athletes to see their primary care physicians in the office. This system is advantageous because the physician is familiar with the patient and may have more time and privacy for counseling about sensitive issues. The disadvantages include a lack of continuity from year to year if the athlete changes physicians, time restraints, possible lack of expertise, high cost, and possible communication problems.

Assembly Line Examination
This method, in which a single physician examines a large number of athletes in sequence, is low in cost and requires less time. Disadvantages include possible communication problems, lack of individual attention, possible insufficient history taking, and lack of continuity from year to year if different physicians are used.

Station Examination
This type, in which multiple examiners perform discrete functions in sequence, is cost effective and efficient and allows for more access, better communication, and the use of physicians with specialized expertise. The disadvantages include noise and confusion, possible compromised care, lack of privacy and time, and possible communication problems.

Cleveland Clinic Journal Of Medicine, Volume 71, Number 7, July 2004.