Physical Examinations for Young Athletes

Height, Weight, and Vital Signs
Take the athlete's brachial blood pressure while he or she is sitting. The sphygmomanometer bladder should encircle at least two thirds of the arm-the most common cause of an abnormal value is improper cuff size. If the initial value is elevated, two subsequent readings should be obtained before making the diagnosis of hypertension. Hypertension in the adolescent can be a marker of endocrinologic, renal, cardiac, or central nervous system abnormalities or substance abuse.

Extensive data on blood pressure are not available for children in the United States, but standards have been developed by the Task Force on Blood Pressure Control in Children of the National Heart, Lung, and Blood Institute, part of the National Institutes of Health.13 These standards differ according to gender and height. We recommend using Table 2, which is a simplification of these standards developed by the American Academy of Pediatrics Committee on Sports Medicine and Fitness.(14)

Eyes, Ears, Nose, and Throat
Measure visual acuity and equality of pupils, and conduct a general examination of the ears, nose, oral cavity, and neck. Poor dentition may indicate an eating disorder. A high, arched palate can be a sign of Marfan syndrome.

Heart
Auscultate the chest with the athlete supine, standing, and using the Valsalva maneuver. Listen for murmurs consistent with dynamic left ventricular outflow obstruction (ie, that increase upon standing). Such murmurs indicate hypertrophic cardiomyopathy or mitral valve prolapse. To further differentiate the murmurs, have the athlete perform a sustained hand grip; in hypertrophic cardiomyopathy, the murmur becomes softer; in mitral valve prolapse, it becomes louder.

Assess the femoral arteries to exclude aortic coarctation.

Look for the stigmata of Marfan syndrome: disproportionately tall stature, thoracic deformity, joint contracture or laxity, subluxation or dislocation of the lens (ectopia lentis) and myopia, aortic dilation and dissection, and mitral valve prolapse.

Pulmonary Auscultation
Remember that a normal examination does not preclude the possibility of exercise-induced bronchospasm.

Abdominal Palpation
This assessment checks for pregnancy in female athletes and the health of the liver and spleen. Splenic rupture occurs in the first 3 to 4 weeks of the onset of systemic signs of infectious mononucleosis. If splenomegaly is suspected, ultrasound or computed tomography should be used to evaluate the size of the spleen.(15)

Genitalia
Assess for single testicle, hernia, and undescended testicles. Tanner staging of sexual development is not recommended.

Skin
Evaluate the skin for rashes, infections, and infestations. Increased acne on the back may indicate steroid use.

Musculoskeletal System
If there is a history of injury to the musculoskeletal system, perform an examination specific to the problem. Otherwise, the following maneuvers should be performed:
• Inspection
• Forward flexion, extension, and lateral flexion of the neck
• Resisted shoulder shrug
• Internal and external rotation of the shoulders
• Resisted shoulder abduction
• Extension and flexion of the elbows
• Pronation and supination of the elbows
• Fist clench and finger spread
• Inspection of the back
• Back extension
• Back flexion
• Inspection of the lower extensors
• Duck walk
• Standing on toes.

Neurologic examination should be performed only if the musculoskeletal examination is abnormal or if the patient has a history of concussion with symptoms.