Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
NCC Pediatrics Continuity Clinic Curriculum: Sports Physical I: Overview Faculty Guide Goals & Objectives: To understand the importance of the pre-participation exam and to gain the skills necessary to perform an adequate exam and recognize common problems. • Demonstrate knowledge and understanding of the components of the sports exam, including history and physical, including simple maneuvers to screen potential athletes. • Demonstrate knowledge of risk factors that may limit the type of or extent of sports participation, or disqualify the athlete entirely. Also to be cognizant of the psychosocial aspects of not being able to participate in sports. Sports Physical II (Summer Module) details CV Screening & Concussions Pre-Meeting Preparation: Please read the following enclosures: • “The Pre-Participation Sports Evaluation” (PIR, 2011) o “The 2-minute Orthopedic Exam” • Skim 2 excerpts from “Medical Conditions Affecting Sports Participation” o Table 1: Classification of Sports According to Contact o Table 2: Medical Conditions & Sports Participation Conference Agenda: • • • • Review Sports Physical I Quiz Complete Sports Physical I Case Hands-on Exercise 1: Choose a partner. Perform 2-min Orthopedic Exam. Time yourselves! Simulate abnormal results & discuss differential. Hands-on Exercise 2: Compare & Contrast local PPE forms. Post-Conference: Board Review Q&A Extra-Credit: • • • • • NCAA 2016-2017 Banned Drugs List: comprehensive list, referred to in article Eating Attitudes Test (EAT): referred to in article as screen for disordered eating Epilepsy & Driving Laws: seizure-free interval in MD is 3mo (links to other states) AAP PPE Form: includes supplemental history of children with special needs 2016 Sports Injury Prevention Tip Sheet: anticipatory guidance for injury prevention © 2016 Developed- MAJ Rachael Paz. Edited- MAJ Jennifer Hepps, MAJ Patricia Kapunan, LT Jack McDonnell Article sports medicine The Preparticipation Sports Evaluation Andrew R. Peterson, MD, MSPH,* David T. Bernhardt, MD† Author Disclosure Drs Peterson and Bernhardt have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/ Objectives After completing this article, readers should be able to: 1. Perform a preparticipation history and physical examination and identify children and adolescents who may be at increased risk of morbidity or mortality from sports participation. 2. Recognize that many adolescents make infrequent contact with the medical system and that the mandatory preparticipation evaluation serves as an opportunity to address medical issues not necessarily associated with sports participation. 3. Know the conditions that should be evaluated by a cardiologist before sports participation. 4. Discuss the importance of assessing and documenting neurocognitive function in a preparticipation sports examination. 5. Understand that disqualification from one sport does not imply disqualification from all sports. investigative use of a commercial product/device. Introduction Sports participation among people of all ages has increased steadily over the past 4 decades. This trend generally has been considered to be a positive development, with conventional wisdom asserting that sports participation teaches leadership and cooperative skills that have a lifelong impact. In addition, as the obesity pandemic worsens, organized sports participation and unstructured play or physical exercise can be a source of needed physical activity for children and adolescents. The pediatrician often is asked to evaluate a child’s or adolescent’s suitability for sports participation. The purpose of this evaluation has remained constant since it was first described in 1978. (1)(2) The goals are to fulfill the institution’s legal and liability requirements, provide some assurance to coaches that athletes will start the season at an acceptable level of health and fitness, provide an opportunity to discover treatable conditions, and aid in predicting and preventing future injuries. The evaluation should be practical and applicable to all sports. The specific objectives of the evaluation can vary, depending on viewpoint, which can create a situation in which parents, athletes, clinicians, and sponsoring institutions or organizations have discordant expectations. Parents may want to ensure the health and safety of their child. Clinicians may seek to provide preventive care and anticipatory guidance. Institutions and organizations may want to limit or transfer their liability for injuries or illnesses caused or worsened by sports participation. Finally, the athletes may just want to have their paperwork signed so they can Abbreviations go play with their friends. The clinician should coordinate and address the goals of parents, athletes, and organizations while ADHD: attention-deficit/hyperactivity disorder promoting safe participation in physical activity. AHA: American Heart Association The utility of the sports preparticipation evaluation (PPE) has DM1: type 1 diabetes mellitus been questioned in recent years. Very few athletes are disqualified EIB: exercise-induced bronchospasm from sports on the basis of findings from the PPE. In the largest NCT: neurocognitive testing evaluation of the PPE, only 1.9% of 2,729 high school athletes PPE: preparticipation evaluation were disqualified from sports participation and only 11.9% required TUE: therapeutic use exemption any type of follow-up evaluation. (3) A recent systematic review of VCD: vocal cord dysfunction the literature identified 310 studies of the PPE and concluded that *Department of Pediatrics, University of Iowa, Iowa City, IA. † Departments of Pediatrics and Orthopedics and Rehabilitation, University of Wisconsin, Madison, WI. Pediatrics in Review Vol.32 No.5 May 2011 e53 Downloaded from http://pedsinreview.aappublications.org/ by John McDonnell on July 1, 2016 sports medicine preparticipation sports evaluation the evaluation likely does little to prevent morbidity and mortality in screened athletes and is ineffective for identifying athletes at risk for sudden cardiac death or orthopedic injuries and at detecting exercise-induced bronchospasm (EIB). (4) However, use of the PPE is endorsed by the American Academy of Pediatrics, American Academy of Family Physicians, and American College of Sports Medicine because it allows for establishment of a medical home, updating of immunizations, identification and management of chronic health conditions, and provision of anticipatory guidance related to sports and other lifestyle risk factors. Structure of the Evaluation The PPE is required before practice and play by most sporting organizations. The requirement is typically in place to shield the organization from liability and to ensure that the athlete can participate safely in sports. The evaluation is required by law in many states and some countries. Nearly all high-school and middleschool athletes are required to obtain signed documentation of a completed examination every 1 to 2 academic years. Athletes engaged in club- or federation-level sports are also often required to have documentation of an evaluation, but this practice varies regionally and by sport. Rarely, sports competitions not affiliated with institutions or federations (eg, open races or tournaments) require documentation of the athlete’s suitability for competition. Generally, open or free play (such as on an open playground) does not require such documentation. However, the 2010 PPE Monograph emphasizes that clinicians should perform a PPE-type evaluation on all patients when promoting physical activity. (5) Most institutions and organizations that require an evaluation strictly prevent participation until proper documentation has been obtained. This practice seems to be due to a sense that protection from liability is not present until there is “proof” that the athlete is safe to participate. (6)(7) Although this concept has not been legally tested, a 1990 New York State Appellate Court decision (Murphy v. Blum) suggests that the issue of transfer of liability depends on the specifics of the relationship between the organization and the physician as well as between the physician and the athlete. (8) The athlete should be encouraged to schedule the PPE well in advance of the season, ideally at least 6 weeks before the start of practice. This timing allows sufficient time for full evaluation of issues that may arise during the initial visit. It also allows implementation of injury prevention programs or rehabilitation of injuries before the start of the season. The clinician should not be pressured into premature clearance of an athlete before appropriate evaluation is completed. The PPE can be completed in any of several formats, each of which has advantages and shortcomings. The most common and ideal format is the office-based PPE in which an athlete visits his or her primary care clinician in the office. The advantages of this strategy include improved continuity of care, access to medical records, time for anticipatory guidance, and ease of arranging follow-up diagnostic tests and treatment. The primary disadvantages are the time burden and cost of an office visit in addition to the possible limited availability of appointments before the start of sports seasons. To alleviate the time and cost burden of the PPE, the other strategy commonly employed is the station-based PPE. With this approach, the athlete cycles through a series of stations at which a single aspect of the evaluation is performed. Separate stations may address vital signs, visual acuity screening, medical history and physical examination, orthopedic history and physical examination, updating immunizations, and finally meeting with a clinician to review all of the accumulated data and make a decision regarding clearance. This approach is very efficient, can be inexpensive, and allows specialty care at each of the stations, limiting the need for a specialist. Entire teams or schools can be evaluated in a single session, reducing the administrative burden of scheduling each athlete privately. However, there are significant disadvantages to the station-based approach. Continuity of care is severely limited, including access to previous medical records. Coordination of care may be difficult for issues requiring follow-up. There is less privacy and time for anticipatory guidance, and the athlete may be less likely to discuss sensitive issues. Finally, athletes who previously have been disqualified from sports participation may attempt to take advantage of unfamiliar clinicians and use the station-based format as a second chance to get cleared. Obtaining the Medical History The history portion of the PPE is similar to the history in a typical health supervision visit for a child or adolescent of the same age. Although several efficient screening tools that have been designed specifically for the PPE are endorsed by multiple professional societies, they should not replace more extensive history collection when it is warranted. The history form from the 2010 PPE Monograph is shown in Figure 1. It is important to explore the past medical, surgical, family, social, and developmental histories, much as it would be done for a nonsports-related evaluation. It is e54 Pediatrics in Review Vol.32 No.5 May 2011 Downloaded from http://pedsinreview.aappublications.org/ by John McDonnell on July 1, 2016 sports medicine preparticipation sports evaluation Figure 1. History form for preparticipation evaluation. Pediatrics in Review Vol.32 No.5 May 2011 e55 Downloaded from http://pedsinreview.aappublications.org/ by John McDonnell on July 1, 2016 sports medicine preparticipation sports evaluation also important to interview a parent or guardian, if available, because athlete and parent histories are often inconsistent. (9)(10) Some aspects of the history require additional attention. Although the following list is not comprehensive, it represents some of the most common challenges to the clinician during the PPE. Cardiovascular The component of the PPE that receives the most attention from parents, coaches, administrators, the medical literature, and the popular press is the cardiovascular evaluation. Although a comprehensive discussion of the controversy surrounding preparticipation cardiovascular screening is beyond the scope of this article, Pediatrics in Review has published a summary of the topic, (11)(12) and clear guidelines from the American Heart Association (AHA) discuss the controversy surrounding the evaluation and the role of preparticipation electrocardiography and echocardiography. (13) The AHArecommended components of the preparticipation cardiovascular evaluation are listed in the Table. Several red flags that may appear in the past medical and family history should prompt further investigation. Known congenital heart disease, cardiac channelopathies (such as long QT or Brugada syndrome), any history of myocarditis, and coronary anomalies such as those caused by Kawasaki disease should be evaluated by a cardiologist before sports participation. A personal history of syncope, near-syncope, chest pain, palpitations, or excessive shortness of breath or fatigue with exertion should prompt a more thorough evaluation, either by the primary clinician or a cardiologist. Postexertional syncope is a common occurrence that is frequently elicited in the PPE history. This benign condition should be differentiated from exercise-associated collapse, which occurs during exertion and is an ominous sign of hemodynamically significant cardiovascular disease or ventricular tachyarrhythmias. All patients who experience syncope should undergo electrocardiography, with further testing on a case-by-case basis. A family history of early sudden cardiac death, Marfan syndrome, cardiomyopathy, and arrhythmias (especially long QT syndrome) should prompt further cardiovascular evaluation. Particular attention should be paid to any family history of unexplained or poorly characterized deaths, such as from drowning, unexplained motor vehicle crashes, or seizures. These events may represent unrecognized sudden cardiac death. Musculoskeletal The musculoskeletal history is a remarkably sensitive method for identifying abnormalities and injuries. Gomez and associates (14) found the sensitivity of a basic musculoskeletal history to be 92%, which compares favorably with the estimated 75% sensitivity of a general medical history. Inquiring about current injuries and a history of injuries requiring evaluation, casting, bracing, surgery, or missed practice or play captures nearly all musculoskeletal abnormalities that require evaluation or treatment before sports participation. A sports medicine specialist may ask about specific orthopedic injuries that are unique or common to the athlete’s sport, but this inquiry generally is not necessary for a primary care screening evaluation. Medications A review of the athlete’s list of current and past medications may provide clues to chronic or recurring medical conditions that may affect sports participation. In addition, the athlete’s institution or governing sports federation may ban some medications and substances. A comprehensive review of banned substances is beyond the scope of this article. In general, the athlete is responsible for knowing what medications may be banned in his or her sport. The clinician may assist athletes by directing them to their governing body’s website and banned substance list. Physicians who frequently care for college-, national-, and international-level athletes should be aware of the substances that are banned by the National Collegiate Athletic Association (15) and the World Anti-Doping Agency. (16) Comprehensive lists of banned substances can be found at: http://www. ncaa.org/wps /wcm/connect/public/ncaa/studentathlete⫹experience/ncaa⫹banned⫹drugs⫹list and http://www.wada-ama.org/en/World-Anti-DopingProgram/. Some medications can be taken if the athlete has a therapeutic use exemption (TUE) on file. In some cases, special testing may need to be obtained to meet the requirements of the TUE. TUEs should be filed well before the start of the season to avoid the possibility of miscommunication or a gap in treatment of chronic medical conditions. Often, a permitted medication can be substituted for a banned substance. Use of alcohol, tobacco, and other recreational drugs is common among teenagers, including athletes. It is useful to discuss these substances when discussing medications, vitamins, and supplements that the athlete may be taking. e56 Pediatrics in Review Vol.32 No.5 May 2011 Downloaded from http://pedsinreview.aappublications.org/ by John McDonnell on July 1, 2016 sports medicine Dermatologic preparticipation sports evaluation The 12-element American Heart Association Recommendations for Preparticipation Cardiovascular Screening of Competitive Athletes Athletes in certain sports are at addiTable. tional risk for dermatologic conditions associated with their environment or contact with other athletes. Open wounds should be cleaned and covered for practice and play to reduce the risk of blood-borne pathogen transMedical History mission. Methicillin-resistant Staphylo• Personal history coccus aureus infections have received –Exertional chest pain/discomfort –Unexplained syncope/near-syncope considerable attention because they –Excessive exertional and unexplained dyspnea/fatigue associated with can result in necrotizing fasciitis, sepexercise sis, and even amputation. Skin infec–Prior recognition of a heart murmur tions such as impetigo, molluscum –Elevated systemic blood pressure contagiosum, tinea, and herpes sim• Family history –Premature death (sudden and unexpected, or otherwise) before age 50 plex infection are common in sports years due to heart disease in first-degree relative that involve close skin-to-skin contact, –Disability from heart disease in a close relative younger than 50 years of such as wrestling and rugby. Each of age these conditions requires treatment to –Specific knowledge of certain cardiac conditions in family members: minimize the risk of transmission. hypertrophic or dilated cardiomyopathy, long QT syndrome and other ion channelopathies, Marfan syndrome, and clinically important arrhythmias Many sport federations have specific regulations for how skin infecPhysical Examination tions should be treated and how long • Heart murmur athletes should be asymptomatic or • Femoral pulses to exclude aortic coarctation under treatment before returning to • Physical stigmata of Marfan syndrome • Brachial artery blood pressure (sitting position) practice and competition. Some athletes and teams use prophylactic doses Data from American Heart Association, Inc. of antiviral medications, such as acyclovir, for prevention of herpes outically, the clinician should ask about any type of head breaks during the season. This practice has not been injury, feeling “dazed” or “foggy,” memory loss, headsystematically evaluated but anecdotally does seem effecaches following a hit to the head, difficulty playing or tive for decreasing herpes gladiatorum transmission practicing following a hit to the head, and any type of among wrestlers. injury that resulted in a loss of consciousness. The cliniAthletes who practice and compete in the sun should cian should be attuned to the fact that the presenting use a sun block lotion to minimize their risk of sun signs and symptoms of concussion can be subtle. damage and skin cancer. Controversy surrounds the apIf the athlete does provide a history of concussion, propriate sun protection factor for outdoor athletes. In more detailed questioning is required to determine the general, any over-the-counter sun block applied liberally presence or absence of frequent concussions, prolonged and frequently provides sufficient protection. Athletes postconcussion symptoms, and concussions that ocwho have already had significant sun exposure require a curred with seemingly trivial trauma. Athletes who have careful examination of the sun-exposed skin to monitor had rare, mild concussions that resolved spontaneously for skin cancer and precancerous lesions. do not need additional evaluation. For athletes who have had frequent concussions, are more easily concussed, or Neurologic have had prolonged postconcussive symptoms, careful Although sports-related concussions are most common discussion with the athlete and family is necessary to in contact and collision sports, all athletes should be understand the risks of repeated concussions. A sympasked about a personal history of concussion or other tomatic athlete should never be allowed to return to play, head injury. Often, directed questions about head injuand a graduated, stepwise approach should be used for ries are required to elicit a history of concussion because returning to physical activity. (17) many athletes do not consider an injury in which there Obtaining baseline computer-based neurocognitive was no loss of consciousness to be a concussion. SpecifPediatrics in Review Vol.32 No.5 May 2011 e57 Downloaded from http://pedsinreview.aappublications.org/ by John McDonnell on July 1, 2016 sports medicine preparticipation sports evaluation testing (NCT) before the start of the season is controversial. Although clinical assessment should be the mainstay of concussion evaluation, NCT increases the sensitivity for detecting residual concussion symptoms. (18) Specifically, if baseline NCT is available when a concussed athlete clinically appears ready to return to play, repeat NCT can provide an objective measurement of his or her recovery. However, NCT has poor specificity for concussion, and the utility of postinjury NCT in an athlete who does not have a baseline study is controversial. “Stingers,” also called “burners,” are injuries to the brachial plexus caused either by direct trauma or a traction injury. Symptoms are typically brief. Athletes who have had stingers with persistent symptoms of arm pain, paresthesia, or weakness may have more significant injuries to the brachial plexus or cervical nerve root injury. No athlete should be permitted to return to practice or play who has persistent symptoms. Cervical cord neurapraxia, also called transient quadriplegia, is a frightening condition characterized by temporary loss of motor control, with or without loss of sensation or paresthesia, caused by transient compression of the cervical spinal cord due to forced hyperextension, hyperflexion, or axial loading. The condition is more common in athletes who have cervical spinal stenosis. (19) Episodes are transient and typically last less than 15 minutes. It is very rare for symptoms to last longer than 48 hours. There is no increased risk of permanent spinal cord injury following a single episode, (19)(20) but athletes who have multiple episodes or persistent symptoms require additional evaluation. Those who are found to have instability, fractures, or degenerative changes in the cervical spine should not be allowed to return to contact or collision sports. Although athletes who have cervical spinal stenosis are at increased risk of cervical cord neurapraxia, it is unknown if they are at increased risk for permanent spinal cord injury. Whether athletes who have spinal stenosis should be allowed to play contact sports is controversial and should be evaluated on a case-by-case basis by a qualified physician. Heat Illness Heat illness kills more than 1,000 people in the United States every year. (21) Athletes who have had a history of heat illness are at risk for future heat illness, including heat stroke. Once identified, the athlete can take measures to assure proper hydration and acclimatization to minimize their risk. In addition, stimulants and antihistamines increase the risk of heat illness and should be avoided, if possible, during training and competition in warmer weather. Ophthalmologic Athletes who require corrective lenses for sports participation may need to work with an optometrist or ophthalmologist to ensure that they have appropriate lenses for sport. Some sports, such as wrestling, boxing, and rugby, do not allow eyewear, so athletes in need of corrective lenses must use contact lenses. Athletes whose bestcorrected vision is worse than 20/40 in one eye (also referred to as “functionally one-eyed”) must wear American Society for Testing and Materials-approved protective eyewear. (22) Athletes who practice and compete in the sun or on the snow should wear ultraviolet-blocking eyewear to prevent acute photoretinitis and possibly decrease the chance of developing cataracts. In addition, any baseline ocular abnormality or normal variant should be documented. Being aware of baseline anisocoria or abnormally shaped pupils can help to prevent an unnecessary evaluation if the athlete presents later with a head or eye injury. Pulmonary Athletes who have baseline lung disease may require additional evaluation or a change in their treatment regimen before the season. Athletes who have known EIB should have an active prescription for a bronchodilator such as albuterol. Such athletes may benefit from having multiple inhalers to keep in multiple settings, such as at home, at school, and with their coach or athletic trainer. In general, athletes who have isolated EIB do not benefit from inhaled corticosteroids. However, there is significant overlap between asthma and EIB. In general, if an athlete has symptoms in other settings and the EIB is poorly controlled with bronchodilator monotherapy, adding a controller medication, such as an inhaled corticosteroid, may be beneficial. (23) Some athletes compete in sports or under federation rules that require them to obtain a TUE before using bronchodilators. As mentioned, it is important to obtain appropriate pulmonary function tests and to complete the TUE paperwork well in advance of the season. Vocal cord dysfunction (VCD) is another common respiratory complaint among athletes. Triggers or associated risk factors for VCD include allergic rhinitis, gastroesophageal reflux disease, anxiety, and poorly controlled asthma. The diagnosis can be made with a history of isolated inspiratory stridor (typically worse in competition situations) or with laryngoscopy. Most athletes can e58 Pediatrics in Review Vol.32 No.5 May 2011 Downloaded from http://pedsinreview.aappublications.org/ by John McDonnell on July 1, 2016 sports medicine control their symptoms with special breathing techniques that require intensive teaching and are best taught by speech therapists or other professionals who are familiar with VCD. Like other chronic medical conditions, gaining control of VCD symptoms before the start of the sports season is important for increasing the likelihood of success. A history of other chronic pulmonary diseases, such as cystic fibrosis or chronic lung disease due to bronchopulmonary dysplasia, should not automatically disqualify a child or adolescent from sports participation. Careful partnership and close follow-up with a pulmonologist or other clinician who is familiar with the specific disorder is essential. It may be reasonable to dissuade children and adolescents who have severe lung disease from participating in sports that impose a high cardiovascular demand and steer them toward sports in which they are more likely to find success. Gastrointestinal Although gastrointestinal complaints are common among children and adolescents, very few require disqualification or modified sports participation. Diarrhea may put the athlete at increased risk of dehydration, but dehydration usually can be prevented with increased fluid intake. Gastroesophageal reflux disease can worsen with increased physical activity but usually can be controlled with diet modification. Gastric acid-suppressing medications (histamine-2 receptor blockers and proton pump inhibitors) may be necessary in some patients. Because inflammatory bowel disease can cause a profound anemia that can make physical activity more difficult and impair performance, close follow-up with a gastroenterologist to help ensure good control of symptoms is essential. Infectious Disease Mononucleosis and mononucleosis-like infection caused by viral infections (typically Ebstein-Barr virus, but occasionally cytomegalovirus) can cause splenomegaly and put the athlete at increased risk for splenic rupture. Any athlete who has mononucleosis should be disqualified from practice and competition in any sport in which there is a risk of abdominal trauma. Most athletes are safe to return to sport by 3 to 4 weeks after the start of symptoms. (24) Blood-borne pathogens, including human immunodeficiency virus and infectious hepatitis, should not prompt disqualification from sports. (25) The athlete may participate in any sport that his or her health allows. Universal precautions should be used for all athletes, and preparticipation sports evaluation skin lesions should always be covered properly, regardless of any known or suspected infectious disease. Genitourinary Few components of the genitourinary history should disqualify an athlete or require modified participation. Athletes who have a solitary or horseshoe kidney require individual assessment for contact and collision sports. (26) Protective equipment may be necessary to protect the remaining kidney, and the risks of injury should be weighed carefully against the benefits of contact or collision sport participation. Inguinal hernias may worsen with increased physical exertion, especially in sports such as weightlifting that impose a high static demand (increased muscle tension with relatively no change in muscle length or joint mobility). Females who experience amenorrhea or oligomenorrhea should be assessed for eating disorders and impaired bone health. Female adolescents who exercise intensively or play sports (especially those sports that emphasize leanness) are at risk for developing the “female athlete triad” of disordered eating, amenorrhea, and osteoporosis that is associated with significant health problems later in life. Psychological Eating disorders are common among athletes in weightrestricted and esthetic sports. Many athletes do not meet diagnostic criteria for anorexia nervosa or bulimia nervosa but clearly have disordered eating patterns. They can be diagnosed as having eating disorder not otherwise specified, which has been included in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders. (27) Screening for disordered eating should be performed as part of every PPE. Several validated screening instruments are available, but the most commonly used is the 26-item Eating Attitudes Test. (28) Screening tools for disordered eating generally assess the patient’s body image and screen for abnormal eating behaviors, such as irrational avoidance of certain foods, ritualistic approaches to meals (eg, very slow eating, cutting food into very small pieces, extraordinary calorie counting), vomiting, or engaging in excessive exercise after meals. Disordered eating is one of the three elements of the female athlete triad, along with amenorrhea and decreased bone mineral density. The presence of any one of these conditions should prompt the clinician to evaluate for the other two. The female athlete triad puts the athlete at risk for stress fractures. Although not an absolute contraindication to sports participation, complications of an eating disorder (including electrolyte abnorPediatrics in Review Vol.32 No.5 May 2011 e59 Downloaded from http://pedsinreview.aappublications.org/ by John McDonnell on July 1, 2016 sports medicine preparticipation sports evaluation malities and cardiac rhythm disturbances) need to be monitored. A multidisciplinary team, including physicians, dietitians, and mental health professionals, is essential for the necessary care of an athlete who has an eating disorder. Depression and anxiety are common mental health problems that can appear in athletes. Unless severe, these conditions should not disqualify the athlete from sports participation. Mental health professionals may help the athlete to cope better with his or her psychological symptoms. Often, athletes can be persuaded to use mental health services by discussing the possible performance improvements that might come from controlling their depression or anxiety. The prevalence of attention-deficit/hyperactivity disorder (ADHD) among athletes is similar to the prevalence among other children and adolescents of the same age. Stimulant medications are a common treatment but may require a TUE or documentation of ADHD testing before the start of the sports season. Immunization The PPE provides an opportunity to review the immunization history and provide catch-up immunizations. Although missing immunizations should not be criteria for sports disqualification, athletes and clinicians should be aware that some immunizations are required by schools and colleges for enrollment. In addition, athletes who are competing internationally may need documentation of specific immunizations to gain entry into certain countries. have mild-to-moderate hypertension (⬎95th percentile for age, sex, and height) require evaluation but should be encouraged, rather than prohibited, from participating in sports. Athletes who have severe hypertension (characterized as ⬎5 mm Hg over the 99th percentile for age, sex, and height) should be disqualified from sports characterized by a high static demand and avoid heavy weight training and powerlifting. (29)(30) Head and Neck Corrected visual acuity should be better than 20/40 in both eyes. If not, protective lenses are required for contact sports participation. (22) Auricular cartilage damage should prompt the clinician to remind the athlete to use ear protection for sports such as wrestling and rugby. Nasal septum damage should prompt referral to an otolaryngologist. Dental carries may indicate overuse of sports drinks or eating disorders such as bulimia. Cardiovascular The AHA-recommended elements of the cardiovascular evaluation are listed in the Table. In general, any cardiac abnormality that is not clearly benign should be fully evaluated before sports participation. A pediatric cardiologist who is familiar with the demands of sport participation should perform the follow-up evaluation. It is best to avoid ordering echocardiography and other advanced cardiac testing from facilities that are unfamiliar with congenital heart disease and sport participation in children. Genitourinary The Physical Examination The PPE physical examination varies little from the standard health supervision evaluation, although a few components require additional attention in the athlete. Vital Signs The vital signs of an athlete may be different from what a clinician is used to seeing in nonathletes. A child or adolescent who has a high degree of cardiovascular fitness may have bradycardia and a wide pulse pressure. Respiratory rate may be lower than expected when resting but may be elevated for several hours after exercise. Body mass index may be an inaccurate method of screening for overweight and obesity in some athletes who are very muscular. The blood pressure should be normal. Elevated blood pressure in children and adolescents, regardless of sports participation, requires evaluation and treatment. For idiopathic or “essential” hypertension, one of the first-line treatments is exercise. Athletes who The female genitourinary examination is not a standard part of the PPE. However, any concerns raised by findings on the patient’s history should be evaluated appropriately. Males should have two descended testicles. Any male who has an undescended or absent testicle should be evaluated by a urologist. Athletes who have only one functional testicle may participate in all sports but should be encouraged to use a protective cup to decrease the risk of injury in contact or collision sports. The PPE allows the clinician an opportunity to discuss testicular selfexamination with the older adolescent. Males who have a history of groin pain should be evaluated for an inguinal hernia with a digital examination of the inguinal ring. Asymptomatic athletes do not need to be screened for hernias. (5) Dermatologic Any infectious skin condition should be treated before the athlete’s return to sport. Any skin lesions that are e60 Pediatrics in Review Vol.32 No.5 May 2011 Downloaded from http://pedsinreview.aappublications.org/ by John McDonnell on July 1, 2016 sports medicine suspicious for malignancy should be removed and evaluated by a pathologist. Neurologic Any history of neurologic injury, including concussions and stingers, should prompt a detailed neurologic evaluation. The assessment should include cognitive function, cranial nerves, sensation, strength, tone, reflexes, and cerebellar function. Any abnormality should be evaluated thoroughly before sports participation. Musculoskeletal Clinicians often feel compelled to perform a detailed musculoskeletal examination on athletes who present for a PPE. However, as discussed, the physical examination adds little diagnostic value to the orthopedic history. (14) A cursory evaluation of strength and range of motion is sufficient for athletes who have no musculoskeletal complaints. Focused, detailed examinations of specific joints can be reserved for evaluating previous injuries or current complaints. The Laboratory Evaluation No screening laboratory or imaging tests are required as part of a routine PPE. Significant controversy surrounds the use of screening echocardiography and electrocardiography to detect occult congenital heart disease. (13) In addition, the utility of testing for hemoglobinopathies, anemia, bleeding disorders, infectious diseases, cardiovascular risk factors (such as hypercholesterolemia), and other chronic diseases that may affect athletic performance or general health is unclear. preparticipation sports evaluation and uncommon medical conditions affect sports participation should see the American Academy of Pediatrics Council on Sports Medicine and Fitness’s report on “Medical Conditions Affecting Sports Participation.” (26) Seizures The child or adolescent who has a well-controlled seizure disorder should not be disqualified from sports participation. (26) In these athletes, the risk of having a seizure during practice or competition is very low, partially due to their already low seizure frequency but also due to the antiepileptic effects of exercise. It is sometimes surprising to officials and policy makers that athletes who have known seizure histories can be allowed to participate in contact and collision sports and in sports where they would seem to be at increased risk of injury should they have a seizure. The clinician may need to advocate for the athlete in such situations. A useful point of reference is the individual state’s legal seizure-free interval before individuals who have epilepsy are allowed to return to driving. In most states, it is 3 to 6 months. Children and adolescents who have poorly controlled epilepsy also benefit from physical exercise, but more care must be taken to ensure the safety of these athletes and those around them. An individual assessment should be made to determine the athlete’s suitability for contact and collision sports. The following sports should be avoided: ● ● ● Special Situations ● Fewer than 2% of PPEs result in disqualification of the athlete from sport. However, many medical conditions require adaptation or close monitoring for complications related to sports participation. In addition, sporting activities are heterogeneous in their physical and cardiovascular demands as well as in their level of contact. Certain medical conditions may be incompatible with particular static or dynamic (changes in muscle length or joint mobility with relatively small change in muscle tension) demands or with the risks associated with contact or collision sports. A comprehensive review of the medical conditions affecting sports participation is beyond the scope of this article, but several conditions that frequently come to clinical attention during the PPE are discussed. This list is far from exhaustive, and the reader who is interested in learning more about the specific demands of sports participation and how many common ● ● ● Archery Power lifting Riflery Swimming Weight lifting Weight training Sports involving heights (eg, parachuting, hanggliding) Down Syndrome Down syndrome, also known as trisomy 21, is a genetic syndrome involving multiple congenital anomalies. Children born with Down syndrome often require interdisciplinary care to maximize their health outcomes and quality of life, regardless of sports participation. Of note, instability of the cervical spine (primarily atlantoaxial instability, but also occipitoatlantal instability) has been reported in up to 30% of patients who have Down syndrome. (31) The Special Olympics® organization requires radiographic evaluation of the cervical spine before sports participation. It is common for patients Pediatrics in Review Vol.32 No.5 May 2011 e61 Downloaded from http://pedsinreview.aappublications.org/ by John McDonnell on July 1, 2016 sports medicine preparticipation sports evaluation who have had normal cervical spine radiographs to acquire cervical instability. For this reason, patients who have Down syndrome should be prohibited from participating in collision sports regardless of the radiographic appearance of their spines. However, no other limitations need be imposed for patients who have normal cervical spine radiographs. Patients who have radiographic evidence of cervical instability but no neurologic signs or symptoms should be disqualified from “neckstressing” sports. Special Olympics considers diving, gymnastics, butterfly stroke, high jumping, soccer, and pentathlon to be “neck-stressing.” Athletes who have Down syndrome and cervical instability may use a cervical collar, but this practice does not change their sport restriction. Down syndrome is associated with other abnormalities that may influence sports participation, such as cardiac abnormalities (septum defects in particular), cataracts, diabetes, thyroid disease, hip and patellar instability, and foot abnormalities. Each of these conditions, if present, requires evaluation before sports participation. However, no other special precautions need to be taken for these children. Acute Febrile Illness Athletes who have a fever should be prohibited from practice and competition. (26) Fever puts the athlete at risk for acute heat illness (due to increased heat storage), reduced maximal exercise capacity, and hypotension (due to decreased peripheral vascular tone and possibly dehydration). Type 1 Diabetes Mellitus Athletes who have type 1 diabetes mellitus (DM1) are permitted to participate in any sport without restriction. (26) However, DM1 monitoring and treatment often becomes more complex with the varying demands of organized sports. Careful evaluation and monitoring of blood glucose, diet, insulin types and doses, and hydration status are essential. Blood glucose should be checked more frequently than usual. At a minimum, athletes who have DM1 should measure their blood glucose every 30 minutes during continuous exercise, 15 minutes after completion of exercise, and at bedtime. For optimum control and performance, many athletes who have DM1 find that they need to measure their blood glucose and modulate their insulin and carbohydrate intake frequently. Insulin pumps and rapid-acting insulins have allowed athletes to fine-tune their glycemic control much more effectively than in the past. It is not uncommon for athletes who have DM1 to develop com- plex treatment plans involving both pump and injectable insulin therapy. The Disabled Athlete Disabled athletes may face special challenges, but the clinician should encourage exercise and sports participation for the same reasons they are encouraged in ablebodied athletes. (5) Good communication among athletes, coaches, parents, and clinicians is essential for ensuring safe and successful sports participation. The supplemental history form from the 2010 PPE monograph (Fig. 2) can help to facilitate this communication. When to Disqualify an Athlete From Sports Participation Although most complaints and abnormalities identified during the PPE are not absolute contraindications to sports participation, several conditions should prompt disqualification from sport. Most of these are cardiovascular conditions and have been outlined in the 36th Bethesda Conference guidelines: (32) ● ● ● ● ● ● ● ● ● ● ● Pulmonary vascular disease with cyanosis or a hemodynamically significant right-to-left shunt Severe pulmonary stenosis (untreated) Severe aortic stenosis or regurgitation (untreated) Severe mitral stenosis or regurgitation (untreated) Any cardiomyopathy Vascular Ehlers-Danlos syndrome Coronary anomalies (especially anomalous coronary origins) Catecholaminergic polymorphic ventricular tachycardia Acute pericarditis Acute myocarditis Acute Kawasaki disease Although the guidelines from the 36th Bethesda conference only comment on disqualification for these specific conditions, any cardiovascular disease should be thoroughly evaluated and treated by a pediatric cardiologist to ensure the athlete’s safe participation in sports. In addition to cardiac abnormalities, any condition that cannot be well controlled and puts the athlete at risk of significant injury or death or endangers the health of teammates or competitors requires further evaluation or disqualification from sport. For example, a musculoskeletal injury that impairs the athlete’s ability to protect him- or herself during practice and competition should prompt disqualification until the athlete is safely able to return to play. For a discussion of the evaluation and e62 Pediatrics in Review Vol.32 No.5 May 2011 Downloaded from http://pedsinreview.aappublications.org/ by John McDonnell on July 1, 2016 sports medicine preparticipation sports evaluation Figure 2. Supplemental history form for athletes who have special needs. Pediatrics in Review Vol.32 No.5 May 2011 e63 Downloaded from http://pedsinreview.aappublications.org/ by John McDonnell on July 1, 2016 sports medicine preparticipation sports evaluation 6. Herbert DL. Legal Aspects of Sports Medicine. 2nd ed. Canton, Summary OH: PRC Publishers; 1995 7. Gallup EM. Law and the Team Physician. Champaign, IL: • In general, the evidence base for the PPE is limited. (5) • The clinician should coordinate and address the goals of parents, athletes, and organizations while promoting safe participation in physical activity. • Based on at least fair evidence, the PPE does little to prevent morbidity and mortality in athletes. (4) • Based on expert opinion, the PPE is best performed well in advance of the competitive season. (5) • Based on expert opinion, the office-based PPE is preferable to the station-based approach. (5) • Based on at least fair evidence, clinicians should focus on the medical and musculoskeletal history because most conditions that affect participation are elicited from that history. (5)(13)(14) • Based on expert opinion, athletes who have suffered a concussion should not be allowed to return to play while symptomatic and should follow a stepwise progression of graduated return to full activity. (17) • Based on expert opinion, screening echocardiography and electrocardiography should not be routine parts of the PPE. (13) • Based on expert opinion, athletes who have lost a paired organ may compete in any sport with proper protective equipment. (22)(26) • Based on expert opinion, most athletes who have chronic medical conditions can compete safely in most sports. (26) management of specific sports-related injuries, please see the recent Pediatrics in Review article, “Managing Sports Injuries in the Pediatric Office.” (33) In performing the PPE, the clinician’s first responsibility is to ensure the health and safety of the patient. However, the physical and psychological benefits of exercise and sport participation should weigh heavily on decisions to disqualify an athlete from sport. References 1. Garrick JG. Preparticipation orthopedic screening evaluation. Clin J Sport Med. 2004;14:123–126 2. Garrick JG, Requa RK. Injuries in high school sports. Pediatrics. 1978;61:465– 469 3. Smith J, Laskowski ER. The preparticipation physical examination: Mayo Clinic experience with 2,739 examinations. Mayo Clin Proc. 1998;73:419 – 429 4. Hulkower S, Fagan B, Watts J, Ketterman E, Fox BA. Clinical inquiries: do preparticipation clinical exams reduce morbidity and mortality for athletes? J Fam Pract. 2005;54:628 – 632 5. Bernhardt DT, Roberts WO, American Academy of Family Physicians, American Academy of Pediatrics. PPE: Preparticipation Physical Evaluation. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2010 Human Kinetics Publishers; 1995 8. Murphy v Blum, 160 AD 2d 914: NY, Apellate Div, (1990) 9. Risser WL, Hoffman HM, Bellah GG Jr. Frequency of preparticipation sports examinations in secondary school athletes: are the University Interscholastic League guidelines appropriate? Tex Med. 1985;81:35–39 10. Carek PJ, Futrell M, Hueston WJ. The preparticipation physical examination history: who has the correct answers? Clin J Sport Med. 1999;9:124 –128 11. Singh A, Silberbach M. Consultation with the specialist: cardiovascular preparticipation sports screening. Pediatr Rev. 2006;27:418 – 424 12. Vitiello R. Commentary: the value of the ECG in the preparticipation sports physical examination: the Italian experience. Pediatr Rev. 2006;27:e75– e76 13. Maron BJ, Thompson PD, Ackerman MJ, et al. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation. Circulation. 2007; 115:1643–1455 14. Gomez JE, Landry GL, Bernhardt DT. Critical evaluation of the 2-minute orthopedic screening examination. Am J Dis Child. 1993;147:1109 –1113 15. NCAA Drug Testing Program. Accessed February 2011 at: http://www.ncaa.org/wps/wcm/connect/public/ncaa/studentathlete⫹experience/ncaa⫹banned⫹drugs⫹list 16. World Anti-Doping Agency. Accessed February 2011 at: http://www.wada-ama.org/ 17. McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. Br J Sports Med. 2009;43(suppl 1):i76 –i90 18. Van Kampen DA, Lovell MR, Pardini JE, Collins MW, Fu FH. The “value added” of neurocognitive testing after sports-related concussion. Am J Sports Med. 2006;34:1630 –1635 19. Pavlov H, Torg JS, Robie B, Jahre C. Cervical spinal stenosis: determination with vertebral body ratio method. Radiology. 1987; 164:771–775 20. Torg JS, Pavlov H, Genuario SE, et al. Neurapraxia of the cervical spinal cord with transient quadriplegia. J Bone Joint Surg Am. 1986;68:1354 –1370 21. Centers for Disease Control and Prevention. Heat-related Deaths — United States, 1999 –2003. MMWR Morb Mortal Wkly Rep. 2006;55:796 –798 22. Protective eyewear for young athletes. Pediatrics. 2004;113: 619 – 622 23. Expert Panel Report 3 (EPR-3): guidelines for the diagnosis and management of asthma-summary report 2007. J Allergy Clin Immunol. 2007;120(5 suppl):S94 –S138 24. Putukian M, O’Connor FG, Stricker P, et al. Mononucleosis and athletic participation: an evidence-based subject review. Clin J Sport Med. 2008;18:309 –315 25. Committee on Sports Medicine and Fitness. American Academy of Pediatrics. Human immunodeficiency virus and other blood-borne viral pathogens in the athletic setting. Pediatrics. 1999;104:1400 –1403 e64 Pediatrics in Review Vol.32 No.5 May 2011 Downloaded from http://pedsinreview.aappublications.org/ by John McDonnell on July 1, 2016 sports medicine 26. Rice SG. Medical conditions affecting sports participation. Pediatrics. 2008;121:841– 848 27. American Psychiatric Association Task Force on DSM-IV. Diagnostic and Statistical Manual of Mental Disorders. DSM-IV-TR. 4th ed. Washington, DC: American Psychiatric Association; 2000 28. Garner DM, Olmsted MP, Bohr Y, Garfinkel PE. The Eating Attitudes Test: psychometric features and clinical correlates. Psychol Med. 1982;12:871– 878 29. McCambridge TM, Benjamin HJ, Brenner JS, et al. Athletic participation by children and adolescents who have systemic hypertension. Pediatrics. 2010;125:1287–1294 30. The fourth report on the diagnosis, evaluation, and treatment preparticipation sports evaluation of high blood pressure in children and adolescents. Pediatrics. 2004;114(2 suppl):555–576 31. Winell J, Burke SW. Sports participation of children with Down syndrome. Orthop Clin North Am. 2003;34:439 – 443 32. Pelliccia A, Zipes DP, Maron BJ. Bethesda Conference #36 and the European Society of Cardiology consensus recommendations revisited: a comparison of U.S. and European criteria for eligibility and disqualification of competitive athletes with cardiovascular abnormalities. J Am Coll Cardiol. 2008;52: 1990 –1996 33. Metzl JD. Managing sports injuries in the pediatric office. Pediatr Rev. 2008;29:75– 84 HealthyChildren.org Parent Resources from AAP The reader is likely to find material to share with parents that is relevant to this article by going to this link: http://www.healthychildren.org/English/healthy-living/sports/ Pages/default.aspx Pediatrics in Review Vol.32 No.5 May 2011 e65 Downloaded from http://pedsinreview.aappublications.org/ by John McDonnell on July 1, 2016 2-Minute Orthopedic Exam 1 STEP 1: Patient stands straight with arms at sides, facing examiner. 3 Normal findings: symmetry of upper and lower extremities and trunk. Common abnormalities: Enlarged AC joint, enlarged sterno-clavicular joint, asymmetric waist (leg-length difference or scoliosis), swollen knee and swollen ankle. STEP 2: Patient looks at the ceiling, looks at the floor, touches right/ left ear to shoulder and looks over right/ left shoulder. Normal findings: patients should be able to touch chin to chest, ears to shoulders and look equally over the shoulders. Common abnormalities: loss of flexion, loss of lateral bending and loss of rotation— may indicate previous neck injury. 2 STEP 3: Patient stands in front of examiner with arms at side. Examiner tries to hold shoulder down while patient tries to shrug. Common abnormalities include atrophy or weakness of muscles indicating shoulder, neck or trapezius nerve abnormalities. STEP 4: Patient holds arms out from sides horizontally and tries to lift them (while examiner holds arms down). Normal findings: strength should be equal in both arms, and deltoid muscles should be equal in size. Common abnormalities: loss of strength and wasting of the deltoid muscle. 4 STEP 5: Patient holds arms out from sides with elbows bent at 90 degrees; patient raises hands vertically as far as they will go. 6 Normal findings: Hands go back equally and at least to upright vertical position. Common abnormalities: loss of external rotation, which may indicate shoulder problem or old dislocation. STEP 6: Patient holds arms out from sides, palms up, and completely straightens and bends elbows. Normal findings: motion should be equal on left and right sides. Common abnormalities, which include loss of extension and loss of flexion, may indicate old elbow injury, dislocation, fractures, etc. 5 STEP 7: Patient holds arms down at sides with elbows bent at 90 degrees, then twists palms up and down. 8 Normal findings: palms should go from facing the ceiling to facing the floor. Common abnormalities, which include lack of full supination and full pronation, may indicate an old injury of the forearm, wrist or elbow. STEP 8: Patient makes a fist, opens the hand and spreads the fingers. Normal findings: fist should be tight and fingers straight when spread. Common abnormalities, which include a knuckle protruding from the fist and a swollen or crooked finger, may indicate old finger fractures or sprains. 7 10 9 STEP 10: Patient stands up straight with arms at sides (with back to the examiner). Normal findings: symmetry of shoulders, waist, thighs and calves. STEP 9: Patient squats on heels, duck-walks four steps and stands up. Common abnormalities include high shoulder (scoliosis) or low shoulder (muscle loss), prominent rib cage (scoliosis), high hip or asymmetric waist (leg-length difference or scoliosis), and small calf or thigh (weakness from an old injury). Normal findings: maneuver is painless, heel-to-buttock distance is equal on left and right sides and knee flexion is equal during the walk. Common abnormalities include inability to fully flex one knee and inability to stand up without twisting or bending to one side. STEP 11: Patient bends forward slowly with knees straight and touches the toes. 11 12 STEP 12: Patient stands on the heels and then rises up on the toes. Normal findings: patient bends forward straightly and smoothly. Normal findings: equal elevation on right and left sides, symmetry of calf muscles. Common abnormalities include patient twisting to one side (low back pain) and asymmetric back (scoliosis). Common abnormalities include wasting of calf muscles (Achilles injury or old ankle injury). Classification of Sports According to Contact (Compare to Table 3—Classification According to Type of Exercise— in Sports Physical II) Sports Physical I Quiz 1. Which of the following is/are the goal(s) of the Sports PPE? Are these goals actually met? A. B. C. D. E. Fulfill a school or league’s legal and liability requirements Provide some assurance to coaches that athletes are healthy and fit Provide an opportunity to discover treatable conditions Predict and prevent future injuries All of the above *B, C, & D may not be met: A literature review concluded that the PPE does little to prevent morbidity and mortality in screened athletes and is ineffective for identifying athletes at risk for sudden cardiac death or orthopedic injuries and at detecting exercise-induced bronchospasm. 2. When is the ideal time for a Sports PPE to be done? At least 6 wks prior to start of practice. 3. How often should the PPE be performed? At least every 2 years, most states require it yearly. 4. What percentage of PPEs results in disqualification for a sport? Fewer than 2%. 5. Review the NCAA List of Banned Substances. Which of the following is/are prohibited? Is there any “work-around”? A. Adderall * Some medications can be taken if the athlete has a B. Anastrazole therapeutic use exemption (TUE). Often, a permitted C. Furosemide medication can be substituted for a banned substance. D. Salbutamol E. All of the above 6. Rate the following conditions based on ability to participate in sports: Yes, Qualified Yes, Qualified No, No a. Atlantoaxial Instability: Qual’d Yes b. Infectious Diarrhea: Qualified No c. Diabetes Mellitus: Yes d. Functionally one-eyed: Qual’d Yes* e. Fever: No * May require proper protective equipment f. g. h. i. j. HIV Infection: Yes Malignant Neoplasm: Qualified Yes Absent Kidney: Qualified Yes Obesity: Yes Absence of ovary/testicle: Yes* 7. What counseling would you give a patient with seizures who wishes to participate in sports? • Determine type & severity of seizures? Is patient is well-controlled or not? • Which sports? Patients with uncontrolled seizures may not participate in archery, power-lifting, riflery, swimming, weight lifting/training, sports involving heights. • What sort of special protective equipment might they need to participate? (e.g. helmets) 8. What are the requirements for athletes with Down Syndrome? (see Module for further info) The Special Olympics requires XR of the cervical spine before sports participation to r/o atlantoaxial instability. Regardless of the XR results, T21 athletes should avoid collision sports. If XR shows cervical instability without neurologic s/s, T21 athletes should avoid “neck stressing” sports (e.g. diving, gymnastics, high jumping, soccer, pentatholon). Of note, the AAP no longer recommends screening all children with Down Syndrome prior to sports participation. Sports Physical I Case Rebecca is a 14 year-old female coming to see you with her mother for you to fill out her sports clearance forms for the new school year. She reports that she has always been active in sports in primary school and summer leagues, but has never played on a truly competitive team before. She is excited to try out for her new high school’s Volleyball and Track & Field teams. What further history would you like to know? Every person at the table should list 1 item: • • • • • • • • Past medical, surgical, family, social, developmental histories Past history of CV symptoms: e.g. syncope, near-syncope, dizziness, exercise intolerance, chest pain, palpitations, SOB or fatigue with exertion, or any symptoms with exercise (see Table: 12element AHA Recommendations for Pre-participation CV Screening) Past history of or current MSK injuries (especially those involving medical evaluation, casting, bracing, surgery, or missing practice/play) Medications, supplements, substances. History of eating disorder. Personal history of skin conditions: impetigo, molluscum, tinea, HSV, MRSA Personal history of concussion or head injury, including frequency, number, circumstances, postconcussive symptoms, and any current or persistent symptoms History of heat illness/injury. Use of corrective lenses Past history of Pulm symptoms: asthma, symptoms of exercise-induced bronchospasm What family history is particularly important to elicit? Cardiovascular history, especially history of sudden or unexpected death before age 50 (e.g. drowning, unexplained MV crash, seizures), congenital heart disease, arrhythmias or pro-arrhythmic diseases (Long QT, WPW, Brugada), cardiomyopathy, Marfan Syndrome. Her vital signs are all normal for age. Her height is 66 in and her weight is 100 lbs. What is her BMI and the percentile? Is this normal for her age? Are you concerned? Why or why not? • • 16.1 kg/m2, 6th %ile (See Growth Chart, HERE) BMI is low, <10%ile for age. Concerned for possible eating disorder in this female athlete. Look at past growth trends, discuss her current eating habits and exercise regimen. Think femaleathlete triad: disordered eating, amenorrhea, and osteoporosis. What is especially important to include as part of your physical exam of this athlete? • • Good cardiovascular exam, listening both supine and sitting, and possibly squatting.. Make sure BP is part of your vitals. Orthopedic exam and ROM of major joints. 2-minute orthopedic exam is good general screening. Can then do specific joint maneuvers if history of injury or any abnormalities. Will you order any screening laboratory or imaging tests on this athlete? In general, no lab or imaging tests are required as part of a routine PPE. Because we identified possible F.A.T., would consider further evaluation with CBC, CMP, U/A, TFTs. If amenorrhea, would consider LH, FSH, E2, PRL, hCG, and DEXA (see Nutrition III). Would you clear her to participate in sports? It depends. . . If patient’s weight is normal and stable, and she is not participating in dangerous compensatory behaviors (e.g. purging, laxative abuse), it is reasonable to clear her to participate with close monitoring. In contrast, if clear ED, then should be excluded from all activities. Ability to participate in sports may be a good motivator for behavior change. Sports Physical I Board Review 1. You are seeing a 15-year-old girl for her annual health supervision visit. Her menarche occurred at age 12 years, and she had normal monthly menses over the first 2 years. In the last year, however, her periods became progressively more irregular and stopped 4 months ago. Her mother notes that the girl has been very health-conscious since she entered puberty. She has gained no weight over the last 3 years and is on the cross-country team at school. On physical examination, her body mass index is 17 kg/m2, her heart rate is 55, she has no acne or hirsutism, and she is at SMR 5 genital development. The remainder of the physical exam is normal. Of the following, the MOST likely cause of this girl's amenorrhea is A. ergogenic agents B. exercise regimen C. heart disease D. physiologic anovulation E. school stress The American College of Sports Medicine coined the term "the female athlete triad" in 1992. It comprises three interrelated components: disordered eating, amenorrhea, and osteoporosis. The risk of the disorder is greatest among those participating in endurance sports. Athletes are distributed along a spectrum between health and disease, and those at the pathologic end may not exhibit all of the components simultaneously. The girl described in the vignette has amenorrhea that is related to her exercise and inadequate nutrition. Nutrition issues underlie most of the pathophysiology of the female athlete triad. Energy availability is defined as dietary energy intake minus exercise energy expenditure. Exercise-induced amenorrhea can be an indicator of decreased energy availability that may be inadvertent, intentional, or psychopathological. Bone density loss results from the low estrogen environment and is concerning because 50% of adult skeletal mass is laid down during adolescence, with peak bone mass attained between 18 and 25 years. The first aim of treatment for any triad component is to increase energy availability by increasing energy intake, reducing exercise energy expenditure, or both. Nutrition counseling and monitoring are sufficient for many athletes, but significantly disordered eating warrants more intensive intervention. Education of athletes, parents, coaches, trainers, judges of competitions, and administrators is a priority for prevention and early intervention. Athletes should be assessed for the triad during pre-participation physical examination or the annual health screening examination and whenever an athlete presents with any of the triad's symptoms or signs. Sports administrators should consider rule changes to discourage unhealthy weight loss practices. Athletes who have eating disorders should be required to meet established weight criteria to continue exercising, and their training and competition may need to be modified. Ergogenic aids are dietary supplements used to enhance athletic performance. The most commonly used are those that have supposed anabolic effects because they mimic the effects of steroids and are legal for use. Creatine is the most widely used such supplement taken by both professional and recreational athletes. It causes weight gain from muscle hypertrophy and fluid retention. It does not alter vital signs or cause menstrual changes. The girl described in the vignette has no symptoms referable to the cardiovascular system; her low heart rate likely is a result of her inadequate nutrition and exercise. In the first 2 years following menarche, irregular menses may be the result of immaturity of the hypothalamic pituitary axis (physiologic anovulation). However, this girl's regular menses in the first 2 years make physiologic anovulation a less likely cause of the amenorrhea. Psychological stress in an adolescent may cause amenorrhea, but the history and exam are most consistent with amenorrhea resulting from exercise. 2. As the sports physician for the local high school football team, you are asked to give a lecture to coaches about medical conditions and safe sports participation. You tell them that some conditions are relative or absolute contraindications to playing football because of increased risk to the athlete's health. Of the following, the condition that is a CONTRAINDICATION to playing football is A. diabetes mellitus B. febrile illness C. human immunodeficiency virus infection D. seizure disorder E. sickle cell disease Sports participation can help children and adolescents learn physical fitness and team-building skills. However, some medical conditions warrant special consideration with regard to participation, and both the type of sport and nature of the medical condition should be considered when making decisions. Sports are classified according to contact and intensity, and specific guidelines for participation in each sport have been outlined in the 36th Bethesda conference. Absolute contraindications to participation in any sport include carditis, which may result in sudden death with exertion, and febrile illness, which can result in decreased heat tolerance, increased risk of heat illness, and dehydration. In addition, fever may be the heralding sign of an underlying condition that may put the athlete at additional risk during exercise, such as myocarditis, pulmonary infection, or infectious mononucleosis with splenomegaly. Athletes should avoid sports until the febrile illness has resolved. Children and adolescents who have diabetes mellitus and sickle cell disease may participate in sports, but special care should be taken to avoid dehydration and overheating, and blood glucose should be monitored frequently for those who have diabetes mellitus. Because the risk of transmitting HIV to others during sports is very low, those who have the infection should be encouraged to participate in sports. Skin lesions should be covered fully, and sports requiring high skin contact, including wrestling and boxing, should be avoided if the viral load is elevated. Children who have seizure disorders may participate in sports, but if seizures are not well controlled, they should avoid sports such as swimming, weightlifting, riflery, and archery because of risk of harm to themselves or others. 3. A 14-year-old boy presents for a pre-participation sports evaluation for baseball. He plays shortstop. His mother is very concerned about his playing because of the injuries she has heard about in professional and collegiate athletes. You explain to her that appropriate equipment, including a batting helmet, is needed to provide protection for her son. Of the following, the LARGEST percentage of baseball injuries can be prevented by using A. a mouth guard B. a protective cup C. elbow pads D. knee pads E. polycarbonate goggles More than 50% of all high school students participate in athletics, and injury prevention should be a mainstay of sports participation for youth. Both parents and coaches should provide and insist on the use of equipment and safety rules to prevent injury in young athletes. Mouth injuries, along with other head injuries, account for the majority of injuries (48%) sustained by youth in baseball. Injuries generally are caused by contact with sports equipment. Most serious injuries result from being struck by a batted ball and are more common among infield players. Other injuries include those to the leg and groin as well as the chest. Use of a protective cup in all sports is recommended to prevent testicular injury Dental and facial injuries may be prevented best by using a mouth guard both in the field and at the plate in baseball to avoid injury by pitched and batted balls. Plastic and metal helmets with face protection have been available for batters for several years but are used uncommonly in high school athletics. Clearly, use of a helmet with face protection is important to prevent cranial injuries for the catcher. Even with the use of a helmet, mouth guards protect further against injuries of teeth and from teeth to the oral mucosa. The American Association of Orthodontists recommends that mouth guards be used for the following sports: baseball, football, soccer, basketball, wrestling, softball, ice and field hockey, volleyball, and lacrosse. Elbow and knee pads may be helpful in prevention of abrasions and other minor injuries, but they are unlikely to prevent serious injury. Polycarbonate goggles are recommended for batting, but evidence for their routine use in fielding is lacking. Eye protection is afforded by most helmets with face protection. 4. A 16-year-old football player presents for evaluation of a 1-week history of fever, progressively worsening fatigue, and a sore throat. Physical examination shows a tired-appearing teenager who has a temperature of 38.9°C, moderate tonsillar enlargement with exudates, a liver edge that is palpable 3 cm below the right costal margin, and a spleen tip that is easily palpable 2 cm below the L costal margin. Results of the spot test for infectious mononucleosis are positive. Of the following, the MOST appropriate management for this patient includes A. avoidance of contact sports B. bed rest for 1 week C. oral acyclovir D. oral amoxicillin E. oral steroids The patient described in the vignette has acute infectious mononucleosis (IM), the most common cause of which is Epstein-Barr virus (EBV), a herpesvirus. Humans are the only source of EBV, and close personal contact is needed for transmission. The spectrum of disease manifestations is wide, ranging from asymptomatic to fatal infection. Infections frequently are unrecognized in infants and young children. Classic IM is an acute illness characterized by the clinical findings of exudative tonsillopharyngitis, fever, lymphadenopathy, and hepatosplenomegaly. Anorexia, malaise, myalgias, and fatigue are common. Nonspecific tests for heterophile antibodies frequently are used for diagnosis. The heterophile antibody response is a transient immunoglobulin M response that is present in about 85% to 90% of cases of EBV IM in adolescents and adults. The antibody appears during the first 2 weeks of illness and gradually disappears over a 6-month period. The results of heterophile antibody tests are often negative in children 4 years of age and younger. Serologic testing is used routinely for the detection and diagnosis of EBV. Treatment of IM is primarily supportive. The patient’s level of activity is tailored to what he or she can tolerate comfortably. Bed rest may be needed, but there is no specific recommendation for its use and little evidence to support that this shortens the course of disease or prevents complications. Contact sports should be avoided until the patient is fully recovered and the spleen no longer is palpable. Neither ampicillin nor amoxicillin should be given to patients who have suspected mononucleosis because their use is associated with the development of a nonallergic morbilliform rash in a large proportion of patients, leading to an incorrect suspicion of allergy. Most importantly, antibiotics do not treat the infection. The routine use of corticosteroids in patients who have IM is not recommended. A short course of corticosteroids may be considered only for those who have marked tonsillar inflammation with impending airway obstruction, massive splenomegaly, myocarditis, hemolytic anemia, or hemophagocytic syndrome. Even though acyclovir has in vitro against EBV, this agent has no proven value in the treatment of IM.