Sports Exams and Young Athletes: Clearance and Nonclearance

• Cleared to play with no restrictions
• Cleared to play following further evaluation, treatment, or rehabilitation
• Not cleared to play certain types of sports.

In general, it is rare for athletes not to be cleared. Smith and Lakowski (16) compiled data from nine large-scale studies of preparticipation physical examination of 26,247 athletes and examined the rates on nonclearance. Only 249 of the 26,247 athletes screened were not cleared. The range of disallowed athletes in the study was between 0 and 2.6%.

In their own series, (16) Smith and Lakowski found that 1.9% of 2,729 high school athletes were ruled ineligible as a result of the preparticipation physical examination. Musculoskeletal abnormalities accounted for the largest number of nonclearances, and cardiac abnormalities (18.9%) and vision limitations (13.2%) were the next highest.

In a study of 10,000 athletes, Magnes et al17 reported that abnormalities associated with hypertension and vision were the leading causes for referral and disqualification.

Conditions that Can Limit Participation
A variety of abnormalities can make it unsafe for an athlete to participate in sports. A familiarity with these abnormalities and the limitations they might confer is crucial.

Drug use. Know the regulations of the organization under which the athlete competes.

Acute illness. Diagnosis of acute illness relies on individual assessment, and clearance to play depends on the likelihood of the illness worsening or being spread with participation. Athletes with fever or diarrhea need to have a high fluid intake to prevent dehydration.

Blood-borne pathogens. Athletes with HIV may participate unless their health is compromised. The risk of transmission is thought to be less than 1 in 1,000,000 games.(15)

Heart disease. Follow the recommendations set forth by the 26th Bethesda Conference.(18) Refer the athlete to a cardiologist if a murmur is detected or an abnormality suspected. An athlete who has hypertension but no end-organ damage may participate. Severe hypertension (Table 2) requires removal from athletics until control is achieved. (14)

A wide pulse pressure with systolic hypertension suggests aortic valve insufficiency, patent ductus arteriosus, or an atrioventricular malformation. A benign functional murmur and mild mitral valve prolapse are not reasons for disqualification, but pathologic murmurs (ie, diastolic, grade 3/6 or more systolic, holosystolic, abnormal splitting of S2 or S4, or harsh murmurs) and moderate to severe mitral valve regurgitation need to be carefully evaluated.

Other red flags include syncope secondary to arrhythmia, a family history of sudden death secondary to mitral valve prolapse, an embolic event, and arrhythmia that is worse with exercise.

Athletes with arrhythmias should be referred to a cardiologist. Athletes with hypertrophic cardiomyopathy should not be cleared to play unless the sport is of low intensity. However, the leading disqualifiers are rhythm and conduction abnormalities, systemic hypertension, and valvular heart disease rather than hypertrophic cardiomyopathy.

Skin. Athletes with contagious lesions or skin conditions should not participate in sports that require the use of mats or the sharing of helmets.

Eating disorder/female athlete triad. Participation of athletes with these disorders requires a multidisciplinary approach and cooperation of the athlete and coach.

Eyes. Refer an athlete with an eye condition that has required surgery to an ophthalmologist for clearance. The American Academy of Pediatrics and the American Academy of Ophthalmology recommend mandatory protective eyewear for functionally one-eyed athletes and those who have had surgery or trauma. A functionally one-eyed athlete can participate only in sports that permit the use of protective eyewear and do not involve projected objects (eg, swimming, track and field, gymnastics). Wrestling, boxing, and martial arts are contraindicated for these athletes.(19)

Gynecology. Athletes with a menstrual disorder may be cleared while the evaluation is in process. Pregnant athletes may not be cleared for contact, collision, or strenuous sports.

Heat illness. Athletes with recurrent heat illness may be cleared if the cause is secondary to obesity, medication, dehydration, febrile illness, or insufficient acclimation and is corrected. Those with a history of heat stroke or heat-related rhabdomyolysis may have restricted clearance. Physicians can screen for a tendency toward exertional hyperthermia by asking about a history of heat-related illness. Athletes with this condition are usually allowed to participate, but temperature extremes must be avoided, and hydration must be ensured.

Hepatomegaly or splenomegaly. An athlete with acute hepatomegaly should be disqualified until the condition resolves. Splenomegaly is a contraindication to participation.

Inguinal hernia. Athletes with no symptoms can participate fully.

Kidney abnormalities. Athletes with only one kidney should be referred to a nephrologist for evaluation. The American Academy of Pediatricians recommends that such athletes do not participate in high-contact sports. A flack jacket should be used for moderatecontact sports.(20)

Musculoskeletal disorders. Clearance is made on the basis of the degree and type of injury, the risk to the athlete, and the demands of the sport. Padding, taping, and other preventive measures should be considered. Athletes who receive treatment and rehabilitation must be reevaluated before they are cleared.

Neurologic disorders. Return to play after a concussion remains controversial.(21-23) In general, athletes are ready to play when they have no symptoms with exercise, a normal neurologic examination, and have returned to baseline neuropsychological functioning.

Athletes with brachial plexus injuries that have fully resolved may be cleared. Full resolution requires a pain-free range of motion and normal sensory and motor examinations. If unresolved, flexion, extension, anteroposterior, lateral, and open-mouth odontoid cervical spine radiographs are required.

A spine specialist should evaluate cervical spinal neuropraxia and transient quadriplegia.

Seizure disorder is not a contraindication to sports participation if the seizures are well controlled. However, any athlete who has had one or more seizures in the last 6 months should be withheld from competition, especially high-risk competition (eg, skiing, gymnastics, high diving, collision sports, shooting, archery). These athletes should be evaluated by a neurologist.(20)

Lungs. Asthma is not a contraindication to participation as long as symptoms are well controlled.

Athletes with pulmonary insufficiency (ie, forced expiratory volume in 1 second <50 %) require further evaluation to rule out pulmonary hypertension or corpulmonale.

Sickle cell trait or disease carries no restrictions under normal conditions.

Testicles. Athletes with a unilateral testis must wear a protective cup. Those with an undescended testicle should be informed of the increased risk of cancer and referred to a urologist.