Continuing Education Activity

This activity covering the “sports physical,” otherwise referred to as “preparticipation physical evaluation,” will discuss the purpose of the sports physical, as well as outline essential components in a routine preparticipation physical evaluation. It will cover in more detail commonly tested findings related to preparticipation physical examinations in young athletes. This activity highlights the role of the sports medicine physician in conjunction with the interprofessional team, who is tasked with the evaluation of young athletes to ensure optimal safety of those who choose to participate in organized sporting activities.

Objectives:

• Describe the function of the sports physical, i.e. preparticipation evaluation.
• Outline the components of a routine sports physical.
• Review commonly tested diagnoses associated with the sports physical.
• Explain the importance of improving care coordination among the interprofessional team to enhance the delivery of care to athletes in the setting of the sports physical.

Introduction

The “sports physical,” otherwise referred to as “preparticipation physical evaluation,” is the result of a collaborative effort between organizations such as the American Academy of Orthopaedic Surgeons (AAOS), American Orthopaedic Society for Sports Medicine (AOSSM), American Family Physician (AFP), and American Academy of Pediatrics (AAP) whose goal is to identify conditions that predispose athletes to a higher risk of injury, illness, and even death. Today, children often fail to meet the recommended 60 minutes of daily moderate to vigorous physical activity. Organized sports is a proven strategy that increases the likelihood that a child or young adult will meet a recommenced number of hours each week engaged in beneficial physical exercise.[1] Physical inactivity leads to poorer health in both the short and long term. It contributes to such conditions as obesity, depression, decreased cardiovascular health, and less effective motor coordination, to name a few examples. 

The duties of the team physician, as defined by the American Orthopaedic Academy of Sports Medicine, are as follows: “The team physician should possess special proficiency in the care of musculoskeletal injuries and medical conditions encountered in sports. The team physician also must actively integrate medical expertise with other healthcare providers, including medical specialists, athletic trainers, and allied health professionals. The team physician must ultimately assume responsibility within the team structure for making medical decisions that affect the athlete’s safe participation.[2]

Indications

Preparticipation physicals are mandated in nearly every organized athletic program and are performed with the intent of identifying any condition that may preclude an athlete from safely participating in athletic events. It is also noteworthy that a preparticipation sports physical exam may be the only time that a child or adolescent actually sees a medical professional with the presumption that many of America’s youth do not regularly undergo physical exams or checkups. Thus, it is important to utilize this opportunity to screen athletes for physical and or psychological ailments that may warrant further workup and treatment by other healthcare professionals.[3]

Technique or Treatment

An appropriate preparticipation physical examination is composed of the following components:

• Medical and Family History
  • Providers must inquire of a personal history of chest pain, syncope, fatigue, murmurs, etc.
  • Providers should investigate a family history of premature death, disability from heart disease, and/or cardiac conditions. This line of questioning is particularly important in as much as it is not uncommon to find potentially dangerous cardiac abnormalities in an otherwise asymptomatic youth, which are discovered only because a family history of such prompted a more thorough evaluation.
  • Providers should obtain a thorough history of medication use.  This may include all medications and supplements taken by the athlete. Questions such as: "Have you ever taken anabolic steroids, or used any other performance-enhancing supplement?" and "Have you ever taken any supplements to help you gain or lose weight, or improve your performance?" may help to elicit pertinent information from athletes. Within this realm, it is advisable to ask sensitive questions about the possible usage of unwise or even dangerous products that a young athlete may be taking but would routinely deny in the presence of a parent or guardian.
• Physical Examination
  • General health screen: A general health screen should include the taking of the patient's vital signs, height, weight, blood pressure, vision testing, pulmonary testing, neurological testing, abdominal testing, thorough skin examination, and examination of genitals which includes the presence of two testicles within the male athlete.  It is not unheard of that an athlete somewhere within the country is found to have an undescended testicle on their sports preparticipation physical and, in so doing, is potentially saved from the possibility of testicular carcinoma.  If the exam is completed in an environment where a genital exam is inappropriate, the author has, over the many years of completing such preparticipation physicals, simply asked that the young athlete examine himself to confirm that he indeed has both testicles.
  • Cardiovascular screen: Cardiovascular screening should assess for heart murmurs, femoral pulses, and blood pressure measurements. Auscultation of the heart should be performed in both the supine, seated, and standing positions with and without the Valsalva maneuver.  Additionally, one should assess for marfanoid stigmata, including kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, hyperlaxity, myopia, mitral valve prolapse, and aortic insufficiency. Occasionally an EKG provider will approach the preparticipation physical provider and offer his or her services to complete screening EKGs for all participants.  While this is not considered bad practice, it does not appear to be warranted as a screening method.  Rather, cardiac abnormalities that become apparent upon a careful auscultation examination or by way of a review of either the athlete's or family's history should be sent for a complete examination which may entail an EKG or echocardiogram.Note that often, preparticipation physicals are performed in a noisy gymnasium or by practitioners who do not have extensive experience with a stethoscope. Ensuring a provider who is comfortable with the use of a stethoscope, as well as finding an appropriate environment where the heart can be appropriately auscultated, is an essential step in finding conditions that warrant further evaluation.[4][5][6]
  • Neurologic screen: Athletes should undergo a thorough sensory testing, motor control testing, and reflex examination. Providers should inquire about a history of concussions, seizure disorders, spinal cord injuries, and cervical spinal stenosis.[7] Such things as bilateral extremity numbness, recurrent stingers, and cervical pain are all warning signs that a more thorough workup of the cervical spine should likely occur.
  • Orthopedic screen: Providers should perform examinations specific to any prior or current injuries and site-specific examinations of strength, range of motion, deformities, instabilities, and asymmetries. Functional movement testing may have a greater sensitivity for screening athletes at a higher risk of musculoskeletal injury.[8] Again, as in the case of cardiopulmonary screening, a careful review of the athlete's history of injury is critical to identifying any ongoing pathology.  Each year, many preparticipation examinations find such things as chronic ligamentous injuries to the knee and shoulder that may have occurred but were never reported.  These are found in conjunction with asking the patient whether they have injured any aspect of their musculoskeletal system and disclosing exactly how it happened.
  • General medical screen: If medical history elicits concern for chronic diseases such as diabetes or anemia, additional laboratory tests could be performed.
• Nutritional Assessment 
  • Assess the athlete's nutritional status. Screen for disordered eating, particularly in female athletes and athletes who participate in a sport with a weight cut-off, such as wrestling. 
  • Mental health issues and psychological factors likewise can be discussed, particularly because pathologically aggressive personality traits can be a sign of anabolic steroid abuse.[9][10][11]
• Heat and Hydration Related Risk Factors
  • It is within the realm of educating young athletes about adequate hydration that most lives may be saved in sports and athletic venues where heat illness and heat stroke are possible. Encouraging the intake of at least 20 ounces of water one hour before game time and again half that much just before game time is always good advice and one the team physician should reinforce.
  • Screen athletes for risk factors related to previous problems in the heat. Athletes at risk for heat-related illness and heat stroke include those who have had a history of heat-related illness, use excessively caffeinated drinks, abuse performance enhancement medications, or who have an exaggerated BMI wherein the release of core body heat through convection is decreased.
  • Use this time to review guidelines for heat acclimatization.[12] Providing a list of graduated participation and protective gear utilization steps is always a good option to have in order that one can instruct both coaches and athletes on safe acclimatization. 
  • Sickle Cell disease symptoms can be worsened with dehydration. [13]
• Mental Health Assessment
  • Question the patient to assess mental status. Specifically, examiners should inquire about symptoms of sleep disturbances, level of interest in previously enjoyed activities, symptoms of guilt or worthlessness, fatigue or loss of energy, ability to concentrate, and suicidal or homicidal ideation. 
  • The lifetime prevalence of mental health problems in elite athletes is 51.7%, and symptoms often manifest at a young age. Therefore all athletes should be questioned carefully, with a referral for a more detailed examination should such be necessary.[14]

Clinical Significance

Much discussion is focused on the diagnosis and detection of cardiomyopathy, as it is a leading cause of cardiac arrest and death in young athletes. Hypertrophic subaortic stenosis and cardiomyopathy can be very difficult to identify on clinical examination, particularly for sports physicians who may not be familiar with cardiac pathology and stethoscope examinations.[15][2]

Thus, it is again of paramount importance that a physician knows the warning signs of such and never disregards a past history of difficulty breathing, loss of consciousness without head trauma, or a family history of cardiac abnormalities. Combined with abnormal findings or murmurs on an auscultation exam, such athletes should be restricted from play until an echocardiogram can be performed, and the athlete is examined by a component cardiologist or other heart specialist according to the guidelines proposed by the American College of Cardiology and the American Heart Association.[16]

• Etiology
  • Hypertrophic cardiomyopathy caused most frequently by an autosomal dominantly inherited mutation of the genes associated with myosin-binding protein C, or beta-myosin heavy chains leads to marked ventricular concentric hypertrophy with septal predominance. This leads to a diastolic dysfunction and outflow obstruction due to systolic anterior motion of the mitral valve, causing syncope and ventricular arrhythmias upon exertion.The decreased outflow tract caused by septal thickening leads to a systolic murmur that is best appreciated at the left sternal border. Thus increasing preload to the left ventricle widens the outflow tract and decreases the intensity of the murmur. Increasing afterload leads to a decrease in cardiac output, which also decreases the intensity of the murmur.[17][18][19]
• Physical examination findings
  • Patients with hypertrophic cardiomyopathy classically develop a systolic murmur related to left ventricular outflow obstruction and mitral regurgitation. Outflow obstructions caused by the characteristic septal hypertrophy and anterior motion of the mitral valve create a harsh crescendo-decrescendo systolic murmur that begins slightly after S1, heard best at the apex and lower left sternal border.  Increasing filling times decrease the intensity of the murmur due to a decreased preload, and conversely, increasing afterload will increase the intensity of the murmur.
  • Echocardiograms should be performed to assess for septal thickening and can help to guide management.  Family members of those diagnosed with hypertrophic cardiomyopathy should undergo genetic testing to assess for abnormality. Drugs that increase filling times, such as beta-blockers, are typically the first-line treatment.

Enhancing Healthcare Team Outcomes

An interprofessional team consists of a sports medicine team physician, the team's athletic trainer, the physical therapist, and any other associated medical staff.  The medical team must work in conjunction with the athletes, coaches, and, in the case of young athletes, the parents/guardians to achieve the best possible outcomes.

The ultimate goal of the preparticipation screening is to identify at-risk athletes for morbidity and mortality commonly associated with athletes. Therefore, providers have an ethical responsibility to rely on the entire healthcare team to provide high quality care and screening for athletes they serve.