Improving People’s Livesthrough innovations in personalized health care

The Preparticipation Physical Exam

Kelsey Logan, MD, MPH, FAAP, FACPOSU Sports Medicine

OSU Sports Medicine

I have nothing to disclose.

OSU Sports Medicine

Overview

Why do a PPE?

History components

Musculoskeletal exam

Medical exam Hot topics

OSU Sports Medicine

Published 2010 Collaboration between AAP, AAFP, ACSM, AMSSM,

AOSSM, AOASM Endorsed by AHA, NATA

OSU Sports Medicine

What’s it for?

PPE Objectives Screen for life-threatening or disabling conditions Screen for conditions that may predispose to injury or

illness

Get adolescents/young adults into the health care system Determine general health Discuss health and lifestyle issues

MEDICAL HOME!

OSU Sports Medicine

Other Goals

Fulfillment of legal and insurance requirements Establishing physician rapport with athletes Providing counseling to athletes Establishing a database and record-keeping systemArmsey et al, CJSM, 2004

OSU Sports Medicine

PPE Purpose Most physicians think PPE is not meant to take place of

yearly health maintenance exam by PCP Was never intended nor designed to replace regular

health maintenance exams What do the athletes think?

Most consider the PPE as an appropriate alternative to full evaluation

Parents? Most perceive PPE as a complete medical evaluation

Greydanus et al., Med Sci Mon, 2004

OSU Sports Medicine

PPE Frequency

Varies 35 states require yearly exam – Ohio included 11 states require every other year exam 3 states require exam every year with interval questionnaire in

non-exam yearsWingfield, CJSM, 2004

Recommended Every 2 years in younger athletes Every 2-3 years in older athletes Annual update: history questionnaire, focused exam if

needed

OSU Sports Medicine

Great Britain PPE’s not widely practiced Thought to be ineffective

Italy Aggressive approach Ages 12-35: annual medical clearance Detailed H&P, ECG, EST, PFT’s Echo required in professional soccer, boxing, cycling Physicians can be held accountable in criminal/civil

court for incorrect/missed diagnosis

OSU Sports Medicine

Who can/should perform the PPE?

Varies by state Ohio: MD, DO, DC (NP or PA with physician)

AAP recommends MD, DO having ultimate responsibility Multiple consensus statements supporting

MSSE 2000, AJSM 2000, MSSE 2001 Complete screen for problems potentially affecting

participation or placing athlete at risk Standardized forms help

OSU Sports Medicine

OSU Sports Medicine

OSU Sports Medicine

PPE Setting

The PCP has the advantage Allows for private discussion of sensitive topics Gives more time for patient education Allows for comprehensive ROS, more direct

questioning regarding family history Able to talk about psychosocial functioning/problems

? Disadvantage Knowledge of how any history/exam findings affect

the athlete in sport

OSU Sports Medicine

PPE Setting

If no PCP? Station approach

Can reduce costs for student-athletes Fosters line of communication between members of sports medicine team Allows participation from athletic trainers, team medical and orthopedic

staff, subspecialists Facilitates screening large number of athletes in relative efficiency

Optimize it! Physician medical coordinator – needs to sign off on all Get good history from parents Ensure privacy in exam areas; provide area for counseling Clear referral protocol to primary and subspecialty physicians Help athletes with needed follow-up Keep records

OSU Sports Medicine

Clearance

Clearance to play with no restrictions Cleared to play following further evaluation, treatment, or

rehabilitation Not cleared to play certain types of sports

Rare for athletes not to be cleared1.9% of high school athletes ruled ineligible as result of the PPE Smith, Mayo Clin Proc, 1998

OSU Sports Medicine

Musculoskeletal abnormalities accounted for 43.4% of athletes not cleared

Cardiac abnormalities accounted for 18.9% 2 athletes with severe HTN 1 with syncope 6 with dizziness/near-syncope 1 after heart operation None had family history of

cardiac death

OSU Sports Medicine

Vision abnormalities accounted for largest population of Cleared with Follow-Up Recommended dispositions – 53.5%

Musculoskeletal problems accounted for 27.8%

OSU Sports Medicine

The Most Important Part of the PPE

History

Exam

History Wins!•88% of medical conditions identified by history alone•67% of musculoskeletal conditions identifiedChun, CJSM, 2006

OSU Sports Medicine

The History is the Cornerstone…is it reliable? Athlete’s reliability should not be taken for granted

Inaccuracies may lead to unwarranted clearance

Carek, CJSM, 1999 Examined whether discrepancies exist between information given by

parents and student athletes Only 19.8% of histories were in complete agreement Many discrepancies found in cardiovascular and musculoskeletal

questions

Risser, Tex Med, 1995 Showed 33% HS athlete-parent agreement, 44% junior high

If station-based physicals used, encourage parental involvement in history form completion

In office-based physical, have parent present for review of medical history, family history

OSU Sports Medicine

History Components

Medical Recent/chronic problems Hospitalizations Surgical procedures Prescription/nonprescription medications Allergies or anaphylactic reactions to medications,

insects, foods, exercise

OSU Sports Medicine

History Components

Cardiac: family history, chest pain, (near) syncope Skin: warts, fungus, blisters Neurologic: HA, concussion, seizures Heat Illness – heat cramps, dehydration, etc. Use of Special Equipment Asthma and seasonal allergies

Prevalence of exercise-induced bronchospasm 10-35% of athletes Mick, Dimeff, CCJM, 2004

OSU Sports Medicine

History Components

Eyes Functionally one-eyed defined as having less than

20/40 corrected vision in one eye Musculoskeletal system

Sprains, strains, fractures, dislocations Weight concerns Psychosocial issues Immunizations Menstruation – screening for female athlete triad

components oligo/amenorrhea, bony stress injury, disordered eating

OSU Sports Medicine

The Physical Exam

Important areas Blood pressure Vision screening Musculoskeletal screening Cardiovascular screening

OSU Sports Medicine

Orthopedic Screening

2-minute, 12 step EXAM: Sensitivity: 50.8% Specificity: 97.5% to

identify orthopedic problems

HISTORY found to have 91.6% sensitivity

Gomez et al, AJDC, 1993

OSU Sports Medicine

The Musculoskeletal Exam/Issues

Take a history! Missed practice or games Do you wear a brace? Fracture (include stress fracture), dislocation History of imaging, injections, physical therapy

Exam If no previous injury or complaint, general screen

ROM, strength, muscle asymmetry Joint specific exam may be needed

OSU Sports Medicine

General Musculoskeletal Screen

General posture; symmetry Neck range of motion Resisted shoulder shrug and shoulder abduction Shoulder range of motion Elbow range of motion Forearm/wrist range of motion Clench fist, spread fingers

OSU Sports Medicine

Inspection of athlete from behind Back flexion and extension Duck walk Heel, toe stance/walk

OSU Sports Medicine

Joint Specific Exams

Low yield in asymptomatic athletes without prior injury Indicated by history and general screen findings Think about what sports the athlete is doing and

preparing to do – may help focus exams Ex: shoulder, elbow in baseball player

Symmetry Range of motion of all joints Stability of shoulders, elbows, knees, ankles Further joint assessment if problem found

OSU Sports Medicine

Examples of Problems in Joint-Specific Exams

Spine: Scoliosis, pain on extension (think about spondylolysis)

Shoulder: decreased internal rotation, signs of rotator cuff impingement, multidirectional instability

Elbow: pain over medial elbow (apophysitis, UCL injury) Hip: poor hamstring flexibility, pain on rotation,

tenderness over apophyses Knee: patellar malalignment, hypermobility Foot: pes cavus, rigid flatfoot, severe pes planus

OSU Sports Medicine

Clearance Question

16 yo female sophomore soccer player, history of right ankle sprain in club soccer over summer

What things do you want to know? When did it happen? Prior injuries? Mechanism of injury? Time missed? Current symptoms? Use brace/tape?

Exam shows decreased balance right foot, mild laxity in ATFL; able to run forward, backward, laterally

OSU Sports Medicine

What do you do?

Is she cleared for soccer? Why? Consider severity of injury, ability to compete safely Consider demands of sport

Cleared

Cleared with

restrictions/recommendations

Not Cleared

Further advice? Brace? Rehab?

OSU Sports Medicine

Medical Exam

Follow up on history questions Ever been disqualified from sport?

1-2% of athletes ever DQ’d from sport Ever been hospitalized? Do you have any problems you see a doctor for? Put history in context of specific sport

OSU Sports Medicine

Hot Topics

Obesity Weight alone should not disqualify Want to get these kids moving!

66-78% more likely to be obese at age 35 if obese at age 18 NIH, 2000

MSK exam: focus on hips, knees Counsel on heat injury avoidance

OSU Sports Medicine

Supplements

Most athletes will not mention supplements on form Ask about ‘protein drinks’, recovery aids

Good intro for energy drink discussion Most athletes don’t know what the ingredients are Discuss potential side effects Some medications banned in sport

Many supplements tainted unknowingly: 15% may contain anabolic agents Geyer et al. Int J Sports Med, 2004

NCAA banned drug list

OSU Sports Medicine

Sickle Cell Trait

Much press NCAA: D1 testing mandatory, DII/III coming No evidence screening prevents death

SCD: Avoid contact, collision sports, strenuous sports

Everyone should be asked about history of trait Ask about history of heat illness

Appropriate counseling, individual clearance based on history

Deaths reported with strenuous activity with altitude or heat stress

Avoid exhaustive exercise while still acclimatizing

Avoid dehydration

OSU Sports Medicine

Concussion

History Personal history of concussion

53% by high school Field et al., J Ped, 2003

Many don’t recognize ‘concussion’Length of recovery period, associated problems

Not just the number of injuries

Presence of chronic headaches, academic or learning issues

OSU Sports Medicine

Concussion Clearance

Never clear for contact sport if any symptoms present Ask about school, mood, sleep, headaches

When to DQ from sport? RARE (…Rare?) When a concussion does not resolve (PCS)

Physical, cognitive, emotional symptoms When concussions happen with less impact

OSU Sports Medicine

Cardiovascular Screening

Many questions on history section 75% of sudden death in athletes due to CV issues

80% of those in high school and college athletes Maron, Circulation, 2006

Higher occurrence in boys, African Americans

From Maron, JAMA, 1996

OSU Sports Medicine

Cardiovascular History

Should ask about Chest pain Syncope Exercise tolerance Palpitations Heart murmur history Elevated BP in past Family history of cardiac

problems

OSU Sports Medicine

CV Exam

Measure blood pressure Listen for heart murmurs

Supine, standing HCM murmur increases with standing, Valsalva

30-40% have murmur Palpate radial and femoral pulses Look for signs of Marfan syndrome

Kyphoscoliosis, high palate, pectus, arm span greater than height, etc.

OSU Sports Medicine

ECG, Echocardiogram

Very controversial AHA recommends against ECG, echo IOC, European Society of Cardiology, support

Italian experience Based on limited ability of History/PE to detect CV

abnormalities, adds 12 lead ECG Indicates 77% greater power for detecting HCM

compared with AHA recommendations Estimates 3x greater cost-effectiveness of Italian vs US

screening strategy for HCM Corrodo et al. European Heart Journal 2005

OSU Sports Medicine

Obstacles to Screening with ECG/Echo

Large population of athletes Major cost-benefit considerations Cannot eliminate risks of competitive sports Large number of false positive/borderline results False negatives where subtle but important lesions go

undetected

OSU Sports Medicine

“Although we should continue our endeavors to identify better tests to detect athletes at risk, I think we would do the public a service to acknowledge that we simply cannot prevent the vast majority of sudden cardiac deaths that will affect (high school athletes). Giving the public an honest answer about the futility of our efforts in this regard may help lessen some of the anger and frustration over the tragedies that do occur.”Karl Fields, Medicine & Science in Sports & Exercise, 2002

OSU Sports Medicine

Summary

Station based PPE are efficient but may miss important psychosocial problems

History is extremely important (may be more so) than physical exam

Ideally, athlete should still go through office-based evaluation, even if station-based exam was done

Drive athletes toward health care Volunteer for sports physicals Get to know school teams, athletes Be involved in your community

OSU Sports Medicine

sportsmedicine.osu.edu