Preparticipation Physical Preparticipation Physical ExaminationExamination

Deb Jacobson, M.D.Deb Jacobson, M.D.

Goals and objectivesGoals and objectives

Eval general health Eval general health statusstatus

Determine fitness for Determine fitness for competitioncompetition

Foster injury preventionFoster injury prevention Discover Discover

diseases/injuriesdiseases/injuries Counsel on health-Counsel on health-

related issuesrelated issues

Goals and objectivesGoals and objectives

Detect conditions Detect conditions that may be life-that may be life-threatening or threatening or disablingdisabling

Determine sports Determine sports specific skill level specific skill level and conditioningand conditioning

Meet legal and Meet legal and insurance insurance requirementsrequirements

PPE is NOTPPE is NOT

Barrier to athlete participationBarrier to athlete participation Purpose not to exclude but Purpose not to exclude but

promote safetypromote safety Only 0.3-1.3% denied Only 0.3-1.3% denied

clearanceclearance Only 3.2-13.5% require Only 3.2-13.5% require

further evaluationfurther evaluation Not intended to substitute for Not intended to substitute for

regular health maintenanceregular health maintenance

Problems with PPEProblems with PPE

Previously Previously consisted of three consisted of three H’sH’s

Now has multiple Now has multiple objectivesobjectives

No clear purposeNo clear purpose No No

standardizationstandardization

Problems with PPEProblems with PPE

Is PPE a good screening Is PPE a good screening tool?tool?

NO! Rarity of serious NO! Rarity of serious medical conditions medical conditions found in millions of found in millions of athletes screenedathletes screened

Does serve a purposeDoes serve a purpose Best guideline is PPE Best guideline is PPE

monograph published by monograph published by Physician and SportmedPhysician and Sportmed

Timing of PPETiming of PPE

Ideally should be 6-8 Ideally should be 6-8 wks prior to wks prior to preseason practicepreseason practice

Allows sufficient time Allows sufficient time to rehab injuriesto rehab injuries

Allows time for Allows time for evaluation or evaluation or correction of identified correction of identified medical problemsmedical problems

Frequency of PPEFrequency of PPE

Most advocate full Most advocate full examination annuallyexamination annually

Some say prior to Some say prior to every sports seasonevery sports season

Some say prior to Some say prior to entering new school entering new school level with interim level with interim evaluationevaluation

Structure of PPEStructure of PPE

Office-based vs... station-basedOffice-based vs... station-based Advantages and disadvantages of eachAdvantages and disadvantages of each

HistoryHistory

Most important Most important element of PPEelement of PPE

75% of conditions 75% of conditions evident from historyevident from history

Only 39% of history Only 39% of history given by athlete given by athlete agreed with that of agreed with that of parentparent

Get parents involved!!!Get parents involved!!!

HistoryHistory

Start w/ general medical questionsStart w/ general medical questions Hospitalizations and surgeriesHospitalizations and surgeries Medications (including supplements, OTC, Medications (including supplements, OTC,

etc)etc) CV- 95% of sudden death in athletes under CV- 95% of sudden death in athletes under

age 30 due to structural cardiac problemsage 30 due to structural cardiac problems– history should include h/o syncope, chest history should include h/o syncope, chest

pain, palpitations, dizziness w/exercise pain, palpitations, dizziness w/exercise

HistoryHistory

Respiratory- wheeze, RAD, EIA, cystic fibrosisRespiratory- wheeze, RAD, EIA, cystic fibrosis Infectious disease- respiratory, skin, GIInfectious disease- respiratory, skin, GI Organs- paired, enlargedOrgans- paired, enlarged Metabolic- DM, eating disorders, female triad, Metabolic- DM, eating disorders, female triad,

obesity, heat illness, steroid use, sickle cellobesity, heat illness, steroid use, sickle cell Neurologic- repeated concussions, seizure d/o, Neurologic- repeated concussions, seizure d/o,

CPCP Musculoskeletal- prior trauma or injury, rehabMusculoskeletal- prior trauma or injury, rehab Psych/soc- stress, depression, anxiety, pressurePsych/soc- stress, depression, anxiety, pressure Social- tobacco, alcohol, drugs, STD preventionSocial- tobacco, alcohol, drugs, STD prevention

ExamExam

Vital signs, height and weightVital signs, height and weight Eyes- Visual acuity, pupils (document Eyes- Visual acuity, pupils (document

physiologic anisocoria)physiologic anisocoria) ENT- general well-beingENT- general well-being CV- BP, radial/femoral pulses, CV- BP, radial/femoral pulses,

auscultation in supine and standing auscultation in supine and standing position for rate, rhythm, and murmurs. position for rate, rhythm, and murmurs. Further eval w/ maneuvers as needed.Further eval w/ maneuvers as needed.– AHA guidelinesAHA guidelines

ExamExam

Be aware of ranges of normal w/ Be aware of ranges of normal w/ the “athlete’s heart”the “athlete’s heart”– bradycardiabradycardia– functional murmurfunctional murmur– physiologic gallopphysiologic gallop– ECG abnormalitiesECG abnormalities

ExamExam

Lungs- breath sounds, wheezing, ask Lungs- breath sounds, wheezing, ask about tobaccoabout tobacco

Abdomen- masses, HSMAbdomen- masses, HSM Genitalia Genitalia

– males- testicular presence/masses, hernia males- testicular presence/masses, hernia exam ONLY if indicatedexam ONLY if indicated

– females- not part of PPEfemales- not part of PPE Skin- rashes, lesions, infectionsSkin- rashes, lesions, infections

ExamExam

Musculoskeletal- 90 second screening Musculoskeletal- 90 second screening examexam

see handoutsee handout

– CaveatsCaveats top to bottomtop to bottom watch ROMwatch ROM look for symmetrylook for symmetry focused joint exam if abnormality discovered or focused joint exam if abnormality discovered or

history suggestshistory suggests can tailor exam for sports specificcan tailor exam for sports specific

Determining clearanceDetermining clearance

You picked up something abnormal on You picked up something abnormal on history or physicalhistory or physical– What now?What now?

Two good resourcesTwo good resources– ““Contraindications to Athletic Participation”. Contraindications to Athletic Participation”.

Physician and SportsmedicinePhysician and Sportsmedicine, vol 24, no. 8 & 9, vol 24, no. 8 & 9– 26th Bethesda Conference: Recommendations for 26th Bethesda Conference: Recommendations for

Determining Eligibility for Competition in Athletes Determining Eligibility for Competition in Athletes with CV Abnormalitieswith CV Abnormalities. . Medicine and Science in Medicine and Science in Sports and ExerciseSports and Exercise, 26(10), Supp, Oct ‘94, 26(10), Supp, Oct ‘94

Medicolegal considerationsMedicolegal considerations

Failure to diagnose/improper clearanceFailure to diagnose/improper clearance– Reggie Lewis, Hank GathersReggie Lewis, Hank Gathers– each state has own regulations, no each state has own regulations, no

universally accepted standarduniversally accepted standard Right to participateRight to participate

– Team M.D. often lose, courts rule with athlete Team M.D. often lose, courts rule with athlete under the Americans with Disabilities Actunder the Americans with Disabilities Act

Knapp v. NorthwesternKnapp v. Northwestern Pahulu v. University of KansasPahulu v. University of Kansas

Medicolegal considerationsMedicolegal considerations

Sexual harassment claimsSexual harassment claims– have chaperone, documenthave chaperone, document

Good Samaritan StatusGood Samaritan Status– does not apply in all statesdoes not apply in all states– must not accept any form of payment to be must not accept any form of payment to be

protectedprotected

ConclusionConclusion

Done correctly PPE can Done correctly PPE can enhance safety of enhance safety of sports participationsports participation

Also provides teachable Also provides teachable momentmoment

Need standardizationNeed standardization Get involved- IT’S FUNGet involved- IT’S FUN

ReferencesReferences Glover, D.W. et al. The Preparticipation Physical Examination: Glover, D.W. et al. The Preparticipation Physical Examination:

Steps Toward Consensus and Uniformity. The Physician and Steps Toward Consensus and Uniformity. The Physician and Sportsmedicine, 27(8).Sportsmedicine, 27(8).

Herbert, D.L. Practice Guidelines Take Center Court. The Herbert, D.L. Practice Guidelines Take Center Court. The Physician and Sportsmedicine, 24(3).Physician and Sportsmedicine, 24(3).

Mitchell, J.H. et al, editor, ACSM, ACC 26th Bethesda Mitchell, J.H. et al, editor, ACSM, ACC 26th Bethesda Conference: Recommendations for Determining Eligibility for Conference: Recommendations for Determining Eligibility for Competition in Athletes with Cardiovascular Abnormalities. Competition in Athletes with Cardiovascular Abnormalities. Medicine and Science in Sports and Exercise, 26(10).Medicine and Science in Sports and Exercise, 26(10).

Moeller, J.L. Contraindications to Athletic Participation: Moeller, J.L. Contraindications to Athletic Participation: Respiratory and Central Nervous System Conditions. Physician Respiratory and Central Nervous System Conditions. Physician and Sportsmedicine, 24(8): 47-58.and Sportsmedicine, 24(8): 47-58.

ReferencesReferences Moeller, J.L. Contraindications to Athletic Participation: Spinal, Moeller, J.L. Contraindications to Athletic Participation: Spinal,

Systemic, Dermatologic, Paired Organ and Other Issues. Systemic, Dermatologic, Paired Organ and Other Issues. Physician and Sportsmedicine, 24(9): 57-75.Physician and Sportsmedicine, 24(9): 57-75.

Preparticipation Physical Evaluation Monograph, second Preparticipation Physical Evaluation Monograph, second edition. Joint publication of AAFP,AAP, AMSSM, AOSSM, edition. Joint publication of AAFP,AAP, AMSSM, AOSSM, AOASM. Physician and Sportsmedicine, publisher, 1996.AOASM. Physician and Sportsmedicine, publisher, 1996.