As a FNP you will be called upon to complete many sports physicals for children and teens. These physicals are meant to clear these children for participation in strenuous?sports activi

Pre-participation physical evaluations for athletes

Abstract: The pre-participation physical evaluation helps keep athletes safe.

This article discusses the essential components of the PPE history and physical.

Findings that should prompt further evaluation of the athlete, including those

consistent with risk for sudden cardiac death, are discussed.

Key words: clinical microsystems, immunization, social determinants of health

Pre-participation physical evaluations for athletes

Key words: clinical microsystems, immunization, social determinants of health

any people have fond memories of engaging in sports. Stories are shared about the “glory days” and old football injuries, and trophies are proudly

displayed. Healthcare providers have the responsibility to ensure that athletes are able to participate in sports safely.

When performing the pre-participation physical evalu- ation (PPE) for adolescent, teenage, and collegiate athletes, clinicians must keep in mind that the overall objective is not to disqualify athletes from participation but to promote safe involvement. Less than 2% of athletes will not be cleared for sports based upon fi ndings by clinicians on the PPE. Up to 14% who are cleared to participate may be referred for further evaluation and management based on findings noted in the history and physical.1

■ Purpose of the PPE When performing the PPE, the provider must be cognizant of the multiple purposes for the exam. Through perform- ing the PPE, state, school, and insurance requirements can be met. The provider will screen for conditions that are contraindications to participation or those that increase the athlete’s risk for injury.2 Another purpose of the PPE is to find any conditions or prior injuries that need to be rehabilitated. It can also be used to assess an athlete’s cur- rent level of fi tness, which can include a baseline fl exibility and strength evaluation performed in conjunction with an athletic trainer. An athlete may be identifi ed as having an

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By Michael E. Zychowicz, DNP, ANP, ONP, FAANP

Key words: athletes, pre-participation physical evaluation, sports participation clearance

www.tnpj.com The Nurse Practitioner • November 2012 41

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Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

42 The Nurse Practitioner • Vol. 37, No. 11 www.tnpj.com

Pre-participation physical evaluations for athletes

increased risk for injury due to a suboptimal level of phys- ical conditioning.3

The PPE may be the primary entry point to the health- care system for some student athletes. Unfortunately, for some, the PPE has replaced the complete annual physical exam. This is an opportunity for healthcare providers to establish or strengthen a relationship with an athlete. The PPE provides an excellent opportunity to deliver health education and wellness information.4

■ The process Obtaining clearance prior to participating in sports may be seasonal or annual depending on school policy and state/ insurance regulations. The PPE should be performed at least 6 to 8 weeks prior to starting the sport, allowing enough time for rehabilitation if necessary. To enhance effi ciency, NPs should require all forms to be completed and submitted prior to, or at the time of the appointment.1

There are several process approaches to performing the PPE. Some athletes will obtain one from their primary care provider while others will have it performed by a single pro- vider, who may contract with a school to examine the entire team. Finally, a team approach may be used, in which mul- tiple examiners will perform the exams. The examination team may include a primary care provider, cardiologist, orthopedist, neurologist, physiatrist, and athletic trainer.1,3,4

■ Taking a history A good health history is always a key component of any PPE. Clinicians can identify much of the information necessary to determine if an athlete can be cleared for sports during the health history. A thorough health history can ascertain nearly 75% of conditions affecting athletes.1

To ensure information accuracy for a student athlete, a parent or guardian should help complete the health history forms;5 this is most important for patients that are minors. Some clinicians may require parental review and a signature on the history forms for collegiate athletes to ensure accu- racy of the information. Parental consent must be obtained for exam (as with any other healthcare visit) for those pa- tients younger than 18 years of age.

Several PPE health history forms may be available for use. The American Academy of Family Physicians, in con- junction with several professional organizations, published a comprehensive health history and physical exam screening form; the form focuses on evaluating for, and identifying conditions that may put the athlete at increased and unac- ceptable medical risk during athletic participation.1 A free downloadable version of this form can be found on the AAFP website by searching under Preparticipation Evalua- tion Forms.

When obtaining the athlete’s health history, there should be clear attention to neuromuscular and cardiovascular abnormalities. The clinician should also investigate for any past or present injury, disease, or disability.2 When the health history suggests the presence of any of these issues or additional abnormalities, further in-depth information and evaluation should be performed. The provider should also keep in mind that this PPE may be the athlete’s only entry into the healthcare system and may be well suited for broad and comprehensive health screening beyond just athletic participation.1

A patient’s general history should focus on new or chronic illness, hospitalizations, or surgeries. Prior injuries (including heat-related injuries and concussion) should be noted and further evaluated. Inquire about immunizations, prescription medications, or supplements that the athlete may be taking. They should also be asked if there are any braces and/or orthotics that are being utilized. A history of excessive weight gain or loss may prompt the practitioner to consider steroid abuse or an eating disorder.1,3 In addition, a menstrual his- tory should be elicited. Amenorrhea, in conjunction with a possible eating disorder in an athlete, should prompt the provider to further investigate Female Athlete Triad.6

After obtaining an athlete’s head, eyes, ears, nose, and throat history, participation should be withheld if the patient has had eye surgery, retinal detachment, eye infection, a high degree of myopia, or surgical aphakia; these individuals should be evaluated by an ophthalmologist for consideration of clearance for sports.4

The cardiovascular history should be investigated for prior syncope, dizziness, chest pain, shortness of breath, palpitations, or fatigue with exercise. The provider should inquire about a history of a severe viral infection in the past month or other potential evidence of mononucleosis. A family history of collapse or early death with exercise increases the athlete’s risk for exercise-related death and should prompt the provider to initiate further evaluation.7

A history of head injury, loss of consciousness, concus- sion, seizure, memory loss, or severe headache should be elicited. Prior musculoskeletal injuries including fracture, strain/sprain, dislocation, or neuritis should be investigated. These prior orthopedic injuries with exam fi ndings may require additional rehabilitation or treatment.2,3,8

Asthma, allergy, and anaphylaxis are also to be consid- ered; the athlete should have an adequate understanding of treatment and prevention for these conditions. The coach/ trainer should be aware of the asthma or anaphylaxis his- tory and prepared to identify and treat these potentially life-threatening conditions.3,9 A written action plan for the prophylactic and urgent care of asthma or anaphylaxis may be developed in conjunction with the athlete’s healthcare

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Pre-participation physical evaluations for athletes

www.tnpj.com The Nurse Practitioner • November 2012 43

provider; it should be shared with the athlete, coach, and trainer.3,4

■ Increased risk The patient’s history should identify risk factors for heat- related illness and potential heat-related morbidity. There are several conditions that increase an athlete’s risk for heat illness including physical deconditioning, sickle cell disease, prior heat illness, or obesity.1

Athletes with the sickle cell trait are at greater risk for conditions such as heat injury, metabolic acidosis, acute renal failure, splenic infarction, and ischemic rhabdomy- olysis. This trait does not disqualify an athlete from par- ticipation, and they should be able to partake in athletics without diffi culty. Considerations for the athlete with the sickle cell trait must include maintaining good hydration, preservation of physical conditioning, and gradual acclima- tization.1

A patient with diabetes should be allowed to participate in non-high-risk sports if they do not have any complica- tions of their disease. High-risk sports are those that put the athletes at risk for increased morbidity and mortality such as rock climbing, scuba diving, ultra-marathons, motor sports, or cycling.1,3 This is due to an increased probability of a hypoglycemic episode and lack of support that may be available to them.

■ The exam The examination component of the PPE is fairly broad in scope. This screening should consist of a general medical exam, focused exam for neuromuscular and cardiovascular conditions, and a thorough exam of potential conditions identifi ed in the health history; performance testing of the athlete may also be included.1,3

Height and weight evaluation will allow the clinician to determine an athlete’s body mass index (BMI). Obese patients are at greater risk for heat-related injury and illness as well as cardiovascular disease and earlier mortality. Those who are found to have a low BMI may necessitate further evaluation for anorexia or bulimia. Individuals who are identifi ed as over or underweight may benefi t from referral for nutritional counseling.4,9

Examination of the head, eyes, ears, nose, and throat will focus primarily on visual acuity and pupillary reactiv- ity. Athletes should have at least 20/40 vision bilaterally with corrective lenses. Recommendation for further evaluation, corrective lenses, or other intervention is warranted if the patient’s vision is worse than 20/40 in their dominant eye.3,5

Additionally, when considering clearance to play a sport for patients with a prior eye injury, poor visual acuity, or only one eye, the clinician must consider the specifi c sport,

utilization of eye protection, and the risk for eye injury. Equality of the athlete’s pupils (or anisocoria) should be evaluated. Physiologic anisocoria, without underlying pa- thology, should be noted and communicated with the coach as valuable data (especially if the patient sustains a head injury while playing a sport). Nasal polyps or a deviated septum are not troublesome fi ndings and do not inhibit athletic participation. In addition, cerumen impaction should be removed prior to sport participation.1,3

On examination of the lungs, patients who are experi- encing wheezing, pleural fi ction rub, or a cough with forced expiration require a further workup. Exercise-induced bron- choconstriction should be considered in patients who have shortness of breath, wheezing, chest tightness, or cough with exercise; these patients should be referred for evaluation and management.4,9

In performing the cardiac exam, auscultating a heart murmur is relatively common. If there is suspicion for hypertrophic cardiomyopathy, clearance for sports should be withheld in addition to referring the patient to a cardi- ologist for further evaluation. Murmurs that accompany hypertrophic cardiomyopathy include those that are sys- tolic in timing, greater than 3/6 in intensity, worsen with Valsalva maneuver, or change in position from seated to standing.7,10

Patients with a history or new physical fi nding of hyper- tension should be treated for this condition. If athletes with hypertension are being treated and there is no evidence of end-organ damage, there should be no issues in having them participate in sports. Those with hypertension that is not controlled and/or have evidence of end-organ dam- age should have further evaluation and management. Hypertensive patients who are 18 years or older with a systolic or diastolic BP greater than 159/99 must have their participation held until their BP is under control. Addition- ally, athletes less than 18 years of age should have their participation held if their systolic or diastolic BP is greater than 130/90.1,7,10,11

Abdominal masses, tenderness, rigidity, and hepato- splenomegaly require withholding clearance for sports and referral for further evaluation and treatment. Although athletes who have asymptomatic hernias can participate in sports, they should be monitored. If the individual develops a symptomatic hernia that interferes with sports, they should then be referred for surgical evaluation.1,3 Male athletes in the appropriate age range should be evaluated for and edu- cated about testicular cancer. Those who have an unde- scended testicle can play sports; however, they should be referred for further surgical evaluation. An athlete with a single testicle can also play sports but should be counseled to utilize a protective cup.4,9

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44 The Nurse Practitioner • Vol. 37, No. 11 www.tnpj.com

Pre-participation physical evaluations for athletes

The dermatologic exam should evaluate for the presence of rashes, infections, or acne. Patients who have potentially contagious lesions such as herpes simplex, scabies, or a fungal infection should have sport clearance held until there is effective treatment. Noncontagious suspicious skin lesions on athletes should not affect clearance for sports. However, they should be referred for further evaluation and manage- ment as needed.1,5

The main components of the neuromuscular exam include inspection, palpation, range of motion, stability, strength, refl exes, and sensation of the extremities. The neck and back should be inspected for deformity including sco- liosis as well as palpated and put through range of motion. Asymmetry on any component of the neuromuscular exam should prompt the examiner toward further evaluation.2,3,8

When hyperrefl exia is noted on examination, the exam- iner should consider the need for further evaluation to identify a possible central nervous system lesion. Any patient who has pain with motion or palpation, weakness with strength testing, muscular atrophy, joint instability, or lock- ing of a joint on examination requires further workup or referral. Idiopathic scoliosis noted on examination should not inhibit an athlete from playing sports; however, progres- sive worsening of this should be monitored. For athletes who have been under the care of another provider for a recent injury, the treating provider should be responsible for clearance of the athlete to participate specific to the injury the provider was treating.3,8

■ Sudden cardiac death risk The risk of sudden cardiac death of an athlete is increased with Marfan syndrome and hypertrophic cardiomyopathy. Ehlers-Danlos syndrome, acquired or congenital heart dis- ease, and Wolff-Parkinson-White syndrome are among other conditions that contribute to an increased risk for sudden cardiac death. Marfan syndrome is a connective tissue disease that is manifested by several characteristics: skeletal, optic, and cardiac fi ndings. Patients will usually be hyperfl exible, tall, and thin (with long arms, legs, and fi n- gers). Athletes who have Marfan syndrome will frequently have pes planus, hammer toes, and inguinal hernias. In addition, they may have a high narrow palate, kyphoscolio- sis, pectus carinatum, or pectus excavatum. Optic fi ndings may include myopia, glaucoma, or retinal detachment. Car- diac manifestations of Marfan syndrome may consist of mitral valve prolapse, aortic stenosis, aortic murmur, or aortic dissection. A patient with Marfan may experience heart failure or a myocardial infarction.7,10

Patients with hypertrophic cardiomyopathy will expe- rience ventricular hypertrophy and thickening of the ven- tricular septum. This pathology will lead to decreased

ventricular fi lling and an outfl ow obstruction, which can be further evaluated using an ECG or echocardiogram. Ventricular tachycardia is the common cause of sudden death in these patients. Individuals with hypertrophic car- diomyopathy may have a history of syncope, dizziness with exercise, or a family history of sudden cardiac death. Some patients may not experience any of the classic symptoms of dizziness, angina, or dyspnea. On physical exam, the provider may only note a systolic murmur at the left ster- nal border that decreases with squatting but increases with standing.1,7 The clinician may choose to refer the patient to a cardiologist for further evaluation and management.1,7

■ Diagnostic testing Some controversy and lack of clarity in the literature exists around screening tests as a regular component of the PPE. Diagnostic testing and lab work should be obtained primar- ily based upon the athlete’s history, physical, and any insti- tutional guidelines. Much of the controversy is specifi c to the cost-effectiveness of routine PPE diagnostic testing as well as the concern for a large number of false-positive results. A urinalysis, complete blood cell count, and cervical spine X-rays may be used by some clinicians as regular components of the PPE. There is controversy and questionable signifi – cance in performing these tests on athletes who are asymp- tomatic due to the incidence of false-positive results.1,3,12

The National Collegiate Athletic Association (NCAA) recommends all athletic departments confi rm an athlete’s sickle cell status if it is unknown. In NCAA Division I schools, it is a requirement to perform or have the results of an athlete’s sickle cell solubility test. Knowing an athlete has the sickle cell trait enables them and their athletic depart- ment to proactively institute precautionary measures to reduce the risk of distress or sickle cell collapse.13

The one test that is developing evidence for reducing sudden cardiac death is the ECG. This has been discussed as a possible required test for all athletes during the PPE to evaluate cardiac size and for any rhythm disturbances. A study by Papadakis and Sharma demonstrated some evidence in decreasing the incidence of sudden cardiac death in ath- letes.14 Pelliccia and Maron have also demonstrated the utility of the routine ECG for athletes in identifying hyper- trophic cardiomyopathy in the previously undiagnosed.15

■ Who gets cleared? Clearance for sports is determined on a case-by-case basis; the provider must consider any problem that might be present on history and physical. First, the provider should consider if the athlete is at increased risk for injury or illness if cleared to participate in sports. They also need to con- sider the safety of other athletes and whether or not they are

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Pre-participation physical evaluations for athletes

www.tnpj.com The Nurse Practitioner • November 2012 45

at increased risk for injury or illness after sport clearance. If a defi cit is noted on examination, could the athlete par- ticipate fully in sport with treatment? This may include padding, bracing, medication, or rehabilitation. If full par- ticipation is not safe, could the athlete engage in limited participation while receiving treatment? Finally, could the athlete possibly participate in a different sport safely if they are not cleared for the one the athlete requested clearance for? Perhaps a runner who develops a tibia stress fracture can maintain cardiovascular fi tness by swimming while he or she takes time out from running.1,3,4,9

In considering a patient’s medical conditions, there are a few absolute contraindications to participation such as carditis, fever, moderate-to-severe diarrhea, or acute sple- nomegaly.1 Some medical conditions are generally consid- ered no problem for the athlete to participate. These include conditions such as well-controlled diabetes, hepatitis, HIV disease, well-controlled seizure disorder, a single ovary or testicle, sickle cell, or an innocent murmur. Several condi- tions exist that should prompt the provider to initiate further evaluation and consider possible athlete participa- tion (see Conditions prompting further evaluation).1-3

Most athletes will be cleared to play sports without any restrictions. A very small percentage will not be cleared for athletic activity based upon history or physical fi ndings. Some will be cleared to play with specifi c recommendations for further evaluation/treatment of specifi c fi ndings; these generally do not impact their performance. Finally, some athletes may be cleared for specifi c types of activities and not for others. For example, an athlete may not be cleared

for contact or collision sports but may be cleared to par- ticipate in non-contact or limited-contact sports.1,3,4,9

■ PPE as a substitute The PPE is an essential component of the athletic participa- tion experience and should be focused primarily on the cardiovascular and neuromuscular systems. The clinician must remember that athletes may substitute their annual physical exam with the PPE, so providing a comprehensive history and physical does have merit. Unfortunately, some athletes will not be cleared to play sports, but this is a small percentage. Additionally, the time that the clinician inter- faces with the athlete can be utilized for health promotion and education of the athlete.

REFERENCES 1. Preparticipation Physical Evaluation. 4th ed. American Academy of Family

Physicians; American Academy of Pediatrics; American College of Sports Medicine; American Medical Society for Sports Medicine; American Orthopaedic Society for Sports Medicine; and American Osteopathic Academy of Sports Medicine. American Academy of Pediatrics: China; 2010.

2. Sarwark JF. Essentials of Musculoskeletal Care. 4th ed. Rosemont, IL: American Academy of Orthopedic Surgeons; 2010.

3. Rizzo TD. The pre-participation evaluation. In: Frontera WR, Herring SA, Micheli LJ, Silver JK. eds. Clinical Sports Medicine: Medical Management and Rehabilitation. China: Saunders; 2007.

4. Feinstein RA, McCambridge TM. The preparticipation physical examination: a pediatrician’s responsibility. Pediatr Ann. 2002;31(1):18-25.

5. Carek PJ, Mainous AG. A thorough yet effi cient exam identifi es most problems in school athletes. J Fam Pract. 2003;52(2):127-134.

6. De La Torre DM, Snell BJ. Use of the preparticipation physical exam in screening for the female athlete triad among high school athletes. J Sch Nurs. 2005;21(6):340-345.

7. Maron BJ, Douglas PS, Graham TP, Nishimura RA, Thompson PD. Task Force 1: preparticipation screening and diagnosis of cardiovascular disease in athletes. J Am Coll Cardiol. 2005;45(8):1322-1326.

8. Garrick JG. Preparticipation orthopedic screening evaluation. Clin J Sports Med. 2004;14(3):123-126.

9. Womack J. Give your sports physicals a performance boost. J Fam Pract. 2010;59(8):437-444.

10. Giese EA, O’Connor FG, Brennan FH, Depenbrock PJ, Oriscello RG. The athletic preparticipation evaluation: cardiovascular assessment. Am Fam Physician. 2007;75(7):1008-1014.

11. Wheeler MT, Heidenrich PA, Froelicher VF, Hlatky MA, Ashley EA. Cost effectiveness of preparticipation screening for prevention of sudden cardiac death in young athletes. Ann Intern Med. 2010;152(5):276-286.

12. Patel A, Lantos JD. Can we prevent sudden cardiac death in young athletes: the debate about preparticipation sports screening. Acta Pediatr. 2011; 100(10):1297-1301.

13. 2009-2010 NCAA Sports Medicine Handbook. 20th ed. Indianapolis, IN: The National Collegiate Athletic Association; 2009.

14. Papadakis M, Sharma S. Electrocardiographic screening in athletes: the time is now for universal screening. Br J Sports Med. 2009;43(9):663-668.

15. Pelliccia A, Maron BJ. Preparticipation cardiovascular evaluation of the competitive athlete: perspectives from the 30-year Italian experience. Am J Cardiol. 1995;75(12):827-829.

Michael E. Zychowicz is the director of the MSN Program at Duke University School of Nursing in Durham, N.C.

The author has disclosed that he has no fi nancial relationships related to this article.

DOI-10.1097/01.NPR.0000421431.70048.87

Conditions prompting further evaluation1-3

• Obesity • Single functional eye • Hypertension or cardiac dysrhythmia • Congenital heart disease • Heart murmur • Bleeding disorder • Pulmonary disease • Upper respiratory infection without fever • Mild diarrhea • Anorexia or bulimia • Hepatomegaly • Chronic splenomegaly • One kidney with malposition • Renal cysts or hydronephrosis • Musculoskeletal disorders • Prior head injury or spinal trauma • Atlantoaxial instability • Poorly controlled seizure disorder • Cerebral palsy • History of heat-related illness • Contagious skin lesions • Malignancy

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Pre-participation Examination

To be completed by athlete or parent prior to examination.

Name School Year Last First Middle

Address City/State

Phone No. Birthdate Age Class Student ID No.

Parent’s Name Phone No.

Address City/State

HISTORY FORM Medicines and Allergies: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking Do you have any allergies?  Yes  No If yes, please identify specific allergy below.  Medicines  Pollens  Food  Stinging Insects

Explain “Yes” answers below. Circle questions you don’t know the answers to. GENERAL QUESTIONS Yes No

1. Has a doctor ever denied or restricted your participation in sports for any reason?

2. Do you have any ongoing medical conditions? If so, please identify below:  Asthma  Anemia  Diabetes  Infections Other: _ __________

3. Have you ever spent the night in the hospital?

4. Have you ever had surgery?

HEART HEALTH QUESTIONS ABOUT YOU Yes No

5. Have you ever passed out or nearly passed out DURING or AFTER exercise?

6. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?

7. Does your heart ever race or skip beats (irregular beats) during exercise?

8. Has a doctor ever told you that you have any heart problems? If so, check all that apply:  High blood pressure  A heart murmur  High cholesterol  A heart infection  Kawasaki disease Other: ___ ______

9. Has a doctor ever ordered a test for your heart? (For example, ECG/EKG, echocardiogram)

10. Do you get lightheaded or feel more short of breath than expected during exercise?

11. Have you ever had an unexplained seizure?

12. Do you get more tired or short of breath more quickly than your friends during exercise?

HEART HEALTH QUESTIONS ABOUT YOUR FAMILY Yes No

13. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 50 (including drowning, unexplained car accident, or sudden infant death syndrome)?

14. Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia?

15. Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator?

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