What Kind of Physical Examination does a Young Athlete Need before Participating in Sports?

Despite the large number of preparticipation physical examinations performed every year, many exams are inadequate. In this article, we will discuss the recommendations for screening and the advantages and disadvantages of different types of screening, from oneon- one exams to mass screenings.

Nonetheless, even when exams are performed according to guidelines, the history and physical exam does not guarantee that all potential cardiac anomalies will be detected, a fact parents and athletes need to understand.

Two Sets of Recommendations
Despite the large numbers, no national standard exists for these examinations. The content of the examination varies from state to state, and so does the person allowed to perform it. In 21 states, nurses and physician assistants can perform the examination, and in 11 states, so can chiropractors.(1)

Nevertheless, there are two sets of recommendations on the proper performance of preparticipation physical examinations:

• A monograph from five medical societies (the American Medical Society for Sports Medicine, the American Academy of Family Physicians, the American Academy of Pediatrics, the American Orthopaedic Society for Sports Medicine, and the American Osteopathic Academy of Sports Medicine),(2) produced in an attempt to set a standard, which provides a useful form for physicians to complete.

•A consensus statement on cardiovascular screening from the American Heart Association (AHA).(3)

What is the Purpose of the Exam?
According to the five-society monograph, (2) the primary goals of the examination are to detect conditions that may predispose to injury, disability, or death and to meet legal and insurance requirements.

The secondary goals are to determine the general health of the athlete, to counsel the athlete on health-related issues, and to assess the athlete's fitness for specific sports.

In general, the philosophy is to help athletes participate safely in sports rather than to exclude them. If a medical condition makes it unsafe for an athlete to participate, he or she can be held out of the sport either until the problem is corrected or indefinitely if the problem is sufficiently serious.

The preparticipation physical examination is not meant to be a regular health maintenance visit, but physicians can take advantage of the opportunity to discuss health maintenance topics such as seat belt use, tobacco use, safe sex, and birth control-if there is time. Usually, however, there is no time.

Nevertheless, the preparticipation physical examination is the only yearly health examination that some children ever receive. In a study of 701 Connecticut high school students, (4) 234 (44%) reported that the school sports examination was their only health assessment in 2 years. In another study, 88% of 557 Texas high school athletes reported that the preparticipation physical examination was their only source of routine health care.(5)

Detecting Life-Threatening Conditions
For adolescent athletes, the most common cause of death during sports activities is congenital cardiovascular disease. According to the National Center for Catastrophic Sports Injury Research,(6) cardiovascular conditions accounted for 100 of the 136 nontraumatic athlete deaths that occurred between 1983 and 1993. Of these deaths, 51 were due to hypertrophic cardiomyopathy and 16 were due to anomalous coronary arteries.

In view of these rare but tragic deaths, the AHA committee3 specifically recommended that cardiovascular screening be included in the preparticipation physical examination, that the examination be standardized, and that it be performed by physicians who are knowledgeable about cardiovascular disease (Table 1). Whether physicians can hope to detect conditions that predispose to sudden cardiac death is not known, however.

Table 1
Recommendations for cardiovascular screening during preparticipation examinations
Athletic screening should be performed by a health care worker with the requisite training, medical skills, and background to reliably obtain a detailed cardiovascular history, perform a physical examination, and recognize heart disease.

The screening should include a complete medical history and physical examination that includes brachial artery blood pressure measurement.

The cardiovascular history should include questions designed to determine the prior occurrence of:
• Exertional chest pain or discomfort
• Syncope or near syncope
• Excessive, unexpected, and unexplained shortness of breath with exercise
• The past detection of a heart murmur or elevated blood pressure
• A family history of premature death (sudden or otherwise)
• Significant disability from cardiovascular disease in close relatives younger than 50 years
• Specific knowledge of the occurrence of hypertrophic cardiomyopathy, Marfan syndrome, arrhythmias, long QT syndrome, or dilated cardiomyopathy
• Parental involvement in completing the history portion for high school students should be encouraged.

The cardiovascular examination should emphasize the assessment of:
• Femoral artery pulses to exclude coarctation of the aorta
• Precordial auscultation in the supine and standing positions to identify heart murmurs consistent with dynamic left ventricular outflow obstruction
• Recognition of the physical stigmata of Marfan syndrome
•Brachial blood pressure measurement in the sitting position.

Adapted from Maron BJ, Thompson PD, Puffer JC, et al. Cardiovascular Preparticipation Screening of Competitive Athletes: A Statement for Health Professionals from the Sudden Death Committe and Congenital Cardiac Defects Committee, American Heart Association. Circulation 1996; 94:850-856 (Addendum Published in Circulation 1998; 97:2294).

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