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Pre-Participation Physical Pre-Participation Physical
ExaminationsExaminationsDr.RAJAT JANGIRDr.RAJAT JANGIR
Consultant Arthroscopy and Orthopedic Consultant Arthroscopy and Orthopedic SurgeonSurgeon
Saket Hospital, MansarovarSaket Hospital, MansarovarAssistant Professor Assistant Professor
Mahatma Gandhi Medical College, JaipurMahatma Gandhi Medical College, Jaipur
Fellowship In Arthroscopy(South Korea)International Olympic Committee Diploma Sports Medicine(UK)Sports Physician RIO Olympic 2016
IPC Medical Code
Fitness to practice a sport46. Prior to engaging in competitive sport, and preferably with regular intervals throughout their athletic career, athletes should undergo pre- participation evaluation....
The International Olympic Committee (IOC) Consensus Statement on Periodic Health
Evaluation of Elite Athleteshttp://www.olympic.org/assets/importednews/documents/en_r eport_1448.pdfBr J Sports Med. 2009 Sep;43(9):631-643.
PPEPPE Goals of the PPEGoals of the PPE
Preparation for the PPEPreparation for the PPE
Medical historyMedical history
Components of the PPEComponents of the PPE
Clearance for participationClearance for participation
Goals of the PPEGoals of the PPE Determine general health and current Determine general health and current immunization statusimmunization status
Establish rapport with participantEstablish rapport with participant
Detect medical conditions that can Detect medical conditions that can predispose one to injury/illness so predispose one to injury/illness so treatment can be continued/initiatedtreatment can be continued/initiated
Identify health risk behaviors that can be Identify health risk behaviors that can be addressed with counselingaddressed with counseling
Goals of the PPEGoals of the PPE Establish baseline parameters for return to Establish baseline parameters for return to play decisionsplay decisions
Assess physical maturityAssess physical maturity
Evaluate physical fitnessEvaluate physical fitness
Make recommendations regarding Make recommendations regarding participation/exerciseparticipation/exercise
Meet legal requirements to athletic Meet legal requirements to athletic participationparticipation
Goals of the PPEGoals of the PPE
Specific focus of PPE varies amongst Specific focus of PPE varies amongst populationspopulations Pre-pubescentPre-pubescent
Undiagnosed congenital abnormalitiesUndiagnosed congenital abnormalities PubescentPubescent
Maturation level, establishing healthy behaviorsMaturation level, establishing healthy behaviors Young adultYoung adult
History of previous injury, sport-specific examHistory of previous injury, sport-specific exam AdultAdult
Overuse conditions predominateOveruse conditions predominate
SUDDEN DEATHSUDDEN DEATH
• Sudden death in athletics can occur from Sudden death in athletics can occur from direct or indirect causesdirect or indirect causes• direct - traumaticdirect - traumatic• indirect - atraumaticindirect - atraumatic
SUDDEN DEATHSUDDEN DEATH
• Most indirect causes are cardiac in origin.Most indirect causes are cardiac in origin.• A very small number of indirect causes of A very small number of indirect causes of
sudden death are noncardiacsudden death are noncardiac• heat strokeheat stroke• CVACVA• pulmonary emboluspulmonary embolus• drug abusedrug abuse
PPE: The HistoryPPE: The HistoryHistory forms are very helpfulHistory forms are very helpful athletes and parents should jointly complete a athletes and parents should jointly complete a
history form prior to the PPEhistory form prior to the PPE Review form: 75% of issues detected through Hx Review form: 75% of issues detected through Hx
alonealoneWeb based history forms may be more Web based history forms may be more convenient for the athletes (ePPE) convenient for the athletes (ePPE) Preparticipation form recommended by the Preparticipation form recommended by the AAFP, AAP, AMSSM, and AOSSM is available in AAFP, AAP, AMSSM, and AOSSM is available in the the Preparticipation Physical Evaluation, 4Preparticipation Physical Evaluation, 4thth ed. ed. 2010.2010.
Preparation for the PPEPreparation for the PPE
No one best/right way to do PPENo one best/right way to do PPE
Influenced by several factorsInfluenced by several factors Level of competitionLevel of competition Availability of personnel and Availability of personnel and facilitiesfacilities
Number of PPE being conductedNumber of PPE being conducted Personal preference/historyPersonal preference/history
Preparation for the PPEPreparation for the PPE
FormatFormat
TimingTiming
FrequencyFrequency
PPE FormatPPE Format
Primary care physician modelPrimary care physician model Enhanced knowledge of medical Enhanced knowledge of medical history, immunization status and history, immunization status and prior injuries that could limit prior injuries that could limit participationparticipation
Generally a more thorough examGenerally a more thorough exam Affords best privacy and better Affords best privacy and better environment for counselingenvironment for counseling
Cost is expensive – insurance?Cost is expensive – insurance?
PPE FormatPPE Format
Group/station modelGroup/station model Good for large number of PPE in Good for large number of PPE in given period of timegiven period of time
Individual personnel responsible Individual personnel responsible for given element of PPE at for given element of PPE at ““stationstation””
Clearance verified by team MD at Clearance verified by team MD at end of PPEend of PPE
Typically free of chargeTypically free of charge
PPE TimingPPE Timing Ideally completed several weeks Ideally completed several weeks prior to initial practiceprior to initial practice
Allows ability to address any Allows ability to address any problems identified on PPE (labs, problems identified on PPE (labs, tests, records) without impeding tests, records) without impeding participation statusparticipation status
Typically done within 1 week prior Typically done within 1 week prior to first scheduled activity – high to first scheduled activity – high schools often over summerschools often over summer
PPE FrequencyPPE Frequency
Entry-level PPE (complete) at Entry-level PPE (complete) at outset of participation for outset of participation for school/organizationschool/organization
Recommended annual re-Recommended annual re-evaluation without complete PPE evaluation without complete PPE unless warrantedunless warranted
Medical HistoryMedical History
Generally accomplished ahead of Generally accomplished ahead of time in yes/no formattime in yes/no format Often a supplemental form for femalesOften a supplemental form for females
For station model, qualified For station model, qualified evaluator must review history and evaluator must review history and red flag potential concerns for red flag potential concerns for further scrutiny/evaluationfurther scrutiny/evaluation
Components of the PPEComponents of the PPE
Vital signsVital signs General medical General medical problemsproblems
CardiovascularCardiovascular Pulmonary Pulmonary MusculoskeletalMusculoskeletal NeurologicNeurologic EyesEyes
Dental Dental Gastrointestinal Gastrointestinal GenitourinaryGenitourinary DermatologicDermatologic Examination for Examination for heat disordersheat disorders
Laboratory testsLaboratory tests
Vital SignsVital Signs
Establishes individualEstablishes individual’’s baseline s baseline parametersparameters Height/weightHeight/weight
Comparison to normative dataComparison to normative data Pulse/respiratory rate (60-100/12-16)Pulse/respiratory rate (60-100/12-16)
Observe quantity and qualityObserve quantity and quality Blood pressure (120/80)Blood pressure (120/80)
Cuff size very importantCuff size very important Body temperature (98.6/37.0)Body temperature (98.6/37.0)
Oral vs. tympanic vs. axillary (rectal)Oral vs. tympanic vs. axillary (rectal)
General Medical General Medical ProblemsProblems
Questions asked regardingQuestions asked regarding Currently being treated for Currently being treated for illness/injuryillness/injury
History of hospitalization or surgeryHistory of hospitalization or surgery History of progressive disease (MS, History of progressive disease (MS, MD, cancer)MD, cancer)
Current use of OTC/Rx medsCurrent use of OTC/Rx meds Allergies to meds, food, environmentAllergies to meds, food, environment
Cardiovascular Cardiovascular ExaminationExamination
Done in quiet area to maximize validityDone in quiet area to maximize validity
Auscultation of heart soundsAuscultation of heart sounds
Questions asked regardingQuestions asked regarding Fainting (syncope), dizziness, SOB, chest pain with Fainting (syncope), dizziness, SOB, chest pain with exertionexertion
Heart palpitations, tachycardia, dysrhythmia, known Heart palpitations, tachycardia, dysrhythmia, known murmurmurmur
Family member with sudden, early cardiac deathFamily member with sudden, early cardiac death
Positive responses to any necessitate referral Positive responses to any necessitate referral to cardiologist for further evaluationto cardiologist for further evaluation
Pulmonary ExaminationPulmonary Examination Done in quiet area to maximize validityDone in quiet area to maximize validity
Auscultation of breath sounds in all Auscultation of breath sounds in all lung lobes – look for symmetrical lung lobes – look for symmetrical movement of diaphragmmovement of diaphragm
Questions asked regardingQuestions asked regarding Excessive coughing during/after activityExcessive coughing during/after activity History of asthma, bronchitis, allergiesHistory of asthma, bronchitis, allergies SOB, unusual breath sounds during/after SOB, unusual breath sounds during/after activityactivity
History of collapsed lung (pneumothorax)History of collapsed lung (pneumothorax)
Musculoskeletal Musculoskeletal ExaminationExamination
Basic exam consists of observation Basic exam consists of observation for symmetry, ROM, strength tests for symmetry, ROM, strength tests for major muscles and specific tests for major muscles and specific tests for previously injured areasfor previously injured areas
Questions asked regardingQuestions asked regarding Focus on history of injury, time frame, Focus on history of injury, time frame, evaluation, treatment and rehabilitationevaluation, treatment and rehabilitation
Use of protective devicesUse of protective devices
Neurologic ExaminationNeurologic Examination Evaluation consists of cranial nerve Evaluation consists of cranial nerve tests including pupil function, tests including pupil function, sensory/motor tests of UE/LE, deep sensory/motor tests of UE/LE, deep tendon reflexestendon reflexes
Questions asked regardingQuestions asked regarding History of head injuriesHistory of head injuries Any previous loss of consciousnessAny previous loss of consciousness Numbness/tingling, loss of motor function in Numbness/tingling, loss of motor function in bodybody
History of seizures, burners/stingersHistory of seizures, burners/stingers
Eye ExaminationEye Examination Visual acuity assessed via Snellen chart, Visual acuity assessed via Snellen chart, both monocularly and binocularly (use both monocularly and binocularly (use corrective lenses)corrective lenses) Emmetropia (20/20 vision)Emmetropia (20/20 vision) Myopia (nearsightedness)Myopia (nearsightedness) Hypermetropia (farsightedness)Hypermetropia (farsightedness)
Questions asked regardingQuestions asked regarding Use of corrective lenses/typeUse of corrective lenses/type Blurring or double visionBlurring or double vision Color blindness, peripheral vision lossColor blindness, peripheral vision loss History of eye trauma, retinal detachmentHistory of eye trauma, retinal detachment
Dental ExaminationDental Examination
Typically done by dentist – not Typically done by dentist – not meant to perform preventative care meant to perform preventative care but to establish pre-existing but to establish pre-existing conditions for liability reasons in conditions for liability reasons in case of dental injurycase of dental injury
Allows opportunity for dental molds Allows opportunity for dental molds to be made for crafting of custom to be made for crafting of custom mouthguardmouthguard
Gastrointestinal Gastrointestinal ExaminationExamination
Evaluation of digestive system, eating habits Evaluation of digestive system, eating habits and nutritionand nutrition Concerns for athletes where image is important to Concerns for athletes where image is important to activityactivity
Evaluation done supine with palpation for Evaluation done supine with palpation for masses or organomegalymasses or organomegaly
Questions regardingQuestions regarding History of heartburn, indigestion, diarrhea or History of heartburn, indigestion, diarrhea or constipationconstipation
Prior history of organ injury (spleen, liver, kidney)Prior history of organ injury (spleen, liver, kidney)
Genitourinary Genitourinary ExaminationExamination
For males, questions asked regardingFor males, questions asked regarding Hernias, testicular torsion, absent or undescended Hernias, testicular torsion, absent or undescended testicletesticle
For females, questions asked regardingFor females, questions asked regarding Menstrual cycle, pregnancyMenstrual cycle, pregnancy
General questions asked regardingGeneral questions asked regarding History of bladder/urinary tract infections, STDsHistory of bladder/urinary tract infections, STDs Absence of one kidneyAbsence of one kidney
Can include urinalysis to look for proteins, Can include urinalysis to look for proteins, blood, sugar and hemoglobin in urineblood, sugar and hemoglobin in urine
Dermatologic Dermatologic ExaminationExamination
Skin evaluated for rashes, lesions, Skin evaluated for rashes, lesions, infections that can be contagious to infections that can be contagious to othersothers Herpes, fungal infections (tinea), Herpes, fungal infections (tinea), impetigo, STDs, acne/treatmentimpetigo, STDs, acne/treatment
Also look at existing blemishes (warts, Also look at existing blemishes (warts, moles, etc.)moles, etc.) Change in appearance (size, color, border, Change in appearance (size, color, border, etc.) in recent pastetc.) in recent past
Examination for Heat Examination for Heat DisordersDisorders
Especially important for activities Especially important for activities taking place under conditions of taking place under conditions of high temperature, high humidity or a high temperature, high humidity or a combination of the twocombination of the two
Questions asked regardingQuestions asked regarding History of heat illness (cramping, History of heat illness (cramping, syncope, exhaustion, stroke)syncope, exhaustion, stroke)
Current meds (diuretics, antihistamines)Current meds (diuretics, antihistamines) Use of caffeinated/alcoholic beveragesUse of caffeinated/alcoholic beverages Nutritional and hydration habitsNutritional and hydration habits
Laboratory TestsLaboratory Tests
Not typical associated with PPE – Not typical associated with PPE – usually due to cost of testing usually due to cost of testing proceduresprocedures
Often used when/if red flags Often used when/if red flags appear during PPEappear during PPE UrinalysisUrinalysis Blood workBlood work ECGECG
Clearance for Clearance for ParticipationParticipation
Conditions to be met to allow clearance Conditions to be met to allow clearance by ME at end of PPEby ME at end of PPE Will condition increase risk of injury to Will condition increase risk of injury to individual or others?individual or others?
Can participation be allowed if meds, rehab Can participation be allowed if meds, rehab or protective bracing/padding is used? If or protective bracing/padding is used? If so, can limited participation be allowed in so, can limited participation be allowed in interim?interim?
If clearance is denied for particular If clearance is denied for particular activity, can other safe activities be activity, can other safe activities be identified and clearance be granted for them?identified and clearance be granted for them?
Clearance for Clearance for ParticipationParticipation
Individuals have right to Individuals have right to participate in any activity participate in any activity regardless of pre-existing medical regardless of pre-existing medical condition/scondition/s
PhysicianPhysician’’s cannot exclude s cannot exclude individual from participation – can individual from participation – can only recommend against participationonly recommend against participation
Conditions that Conditions that Contraindicate Sports Contraindicate Sports
Participation Participation Active myocarditis or pericarditisActive myocarditis or pericarditis
Hypertrophic cardiomyopathy Hypertrophic cardiomyopathy Severe hypertension until Severe hypertension until Poorly controlled convulsive disorder Poorly controlled convulsive disorder
no archery, riflery, swimming, weight lifting no archery, riflery, swimming, weight lifting or power lifting, strength training or sports or power lifting, strength training or sports involving heights)involving heights)
Recurrent episodes of burning upper-Recurrent episodes of burning upper-extremity pain or weakness, or episodes extremity pain or weakness, or episodes of transient quadriplegia until stability of transient quadriplegia until stability of cervical spine can be assured (no of cervical spine can be assured (no contact or collision sports)contact or collision sports)
Conditions that Conditions that Contraindicate Sports Contraindicate Sports
ParticipationParticipation Sickle cell disease (no high-Sickle cell disease (no high-exertion, contact or collision exertion, contact or collision sports) sports)
Eating disorder where athlete is not Eating disorder where athlete is not compliant with therapy and follow-compliant with therapy and follow-up, or where there is evidence of up, or where there is evidence of diminished performance or potential diminished performance or potential injury because of eating disorderinjury because of eating disorder
Acute enlargement of spleen or liver Acute enlargement of spleen or liver