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Medscape Reference Reference

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Author: Anthony J Saglimbeni, MD; Chief Editor: Craig C Young, MD more... Updated: Jun 7, 2011

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In the US alone, millions of athletes undergo preparticipation evaluations, and millions of healthcare hours are spent on performing these evaluations each year. Because the yield of significant abnormalities in this relatively healthy population is low, the cost-effectiveness of these evaluations has been questioned.[1]

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The approach to preparticipation evaluations varies depending on the practitioner and practice situation, as well as on the athlete, his or her level of competition, and the institution and its requirements. At this time, 50 of 51 states (including the District of Columbia) require some form of physical evaluation before participation in sports at the high school level, of which some are legal requirements. Some practitioners approach sports physicals as thorough, periodic health evaluations, whereas others consider these evaluations to be risk-based screening examinations. Neither approach is perfect, and no universal standard exists for what constitutes an adequate or appropriate evaluation for this population. To complicate matters further, the positional statement of the American Medical Association (AMA) regarding such evaluations is vague and may be interpreted in many ways.[2] According to the AMA, every athlete has the right to a thorough preseason evaluation. Typically, these evaluations are not considered substitutes for thorough medical care, and they are described as screening tools with the purpose of identifying high-risk situations.

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The main athletic assessment issues can be classified into 3 categories: administrative, coaching/athletic, and medical. Athletic directors are the ones who usually address the administrative issues, which are often based on institutional policy and on local, state, or national laws. These administrative issues involve liabilities, matters to do with insurers, and the rights of athletes to participate in competitive sports. The administrators rely on the physician to assess athletes for compliance with the relevant administrative codes. The coaching/athletic issues involve both the coaches and athletes. The athletes want medical clearance so they can safely compete and train. If they have a history of injuries or medical problems, the athletes desire information about how to treat or rehabilitate those conditions to improve their performance and safety. Coaches are interested in fielding a team of healthy athletes. When injuries or illness preclude their athletes from competing, coaches
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need to know the time period that is required for the injury or illness to heal so they can make decisions about finding capable substitutes. Both athletes and coaches depend on the physician to help them in making these types of decisions. Medical issues are handled by the physician, athlete, coaching staff, and administrators. The goal is to ensure, as completely and accurately as possible, that an athlete with a specific medical condition can compete safely. Achieving this goal is usually straightforward, but a particular situation can become complicated. Although a number of guidelines are available, many are difficult to interpret or implement. Furthermore, some conditions that affect an athlete's participation in sports do not have clear-cut guidelines. The physician's role is vital in these cases. He or she must not only determine the athlete's safety but also assist team coaches in making decisions about administrative and legal matters.

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The goals of a preparticipation sports evaluation can be summarized as follows: Determine that the athlete is in general good health. Assess the athlete's present fitness level. Detect conditions that predispose the athlete to new injuries. Evaluate any existing injuries of the athlete. Assess the size and developmental maturation of the athlete. Detect congenital anomalies that increase the athlete's risk of injury. Detect poor preparticipation conditioning that may put the athlete at increased risk. For excellent patient education resources, visit eMedicine's Public Health Center. Also, see eMedicine's patient education articles Walking for Fitness and Strength Training, as well as the Medscape article Sports Medicine in the Primary Care Setting.

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The timing of an athletic preparticipation evaluation is dependent upon the season of the sport. Many evaluations are performed throughout an entire institution that has teams competing in many sports during various seasons. In this circumstance, one approach is to perform the evaluations before each major season. This approach may be optimal for each sport in its season, but it also requires organization and frequent involvement by the medical team. Another approach is to conduct all physical examinations for the institution at the same time each year. Although this approach is more convenient for the medical team, the evaluations may not be optimally timed for all sports. The optimal timing for the preparticipation sports evaluation is approximately 6 weeks before the onset of the sports season because this period affords time for the further evaluation of any problems that are discovered, if indicated. If treatable problems are detected, some rehabilitation success can be achieved during those 6 weeks. Furthermore, unconditioned athletes may have an opportunity to improve their conditioning in this time and, thus, hopefully prevent other injuries. If the physical examination is performed less than 6 weeks before the start of a sports season, some athletes may not have time to recover, become conditioned, or complete a specific evaluation that may necessitate medical clearance for play. As a result, athletes may miss part of the sports season. If the preparticipation evaluation is performed earlier, there is time for other conditions to develop, and the findings of the initial evaluation may no longer be up to date.

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No requirements are established for the frequency of these physical evaluations. Approaches vary from annual evaluations to season-specific examinations to single evaluations performed when an athlete enters a sports program. High schools typically require annual evaluations before a student's participation. These are usually considered valid for the entire academic season and may diminish the number of evaluations needed by multisport athletes. Many higher-level institutions use thorough initial evaluations upon the student's admission to its athletic
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programs, with annual follow-up examinations that are focused on particular items and a review of the athlete's medical history. Some of these follow-up examinations may address only the history if the individual is healthy. If abnormalities are detected on the history screening, these problems are evaluated thoroughly. In a number of organized professional sports, such as football, preseason and postseason physical examinations are the standard.

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Two extremes exist in the spectrum of the types of athletic preparticipation evaluations: one by the athlete's personal physician and the other by multiple providers in a multistation setting. Either evaluation is adequate if the proper documentation is completed. At one end of the spectrum is an evaluation in a private office setting or by the athlete's personal physician. These make up a small percentage of all sports evaluations. The private office examination is ideal from the standpoint of continuity of care. Furthermore, the athlete may feel at ease in the surroundings of a familiar physician. The main drawback to this approach is the difficulty of performing many of these evaluations in the office settings. At the other end of the spectrum of athletic preparticipation examinations is the multistation evaluation, which involves multiple providers and examination-based specialists. In this approach, a primary care physician may review the patient's history; check his or her vital signs; and examine the abdomen, lungs, and genitals. A cardiologist may then examine the heart, a neurologist performs neurologic testing, a physiatrist assesses the athlete's flexibility, and an orthopedist completes the musculoskeletal evaluation. This multistation approach requires a coordinated effort of many more personnel. These types of evaluations are often performed in gymnasiums, locker rooms, or auditoriums; thus, privacy for the patient is lost. Multistation evaluation is ideal for large volumes of athletes and provides immediate access to a specialist if abnormalities surface. To achieve patient cooperation, personnel such as coaches may assist in supervising athletes who are waiting to be examined. Trainers and therapists are often used to assess vital signs, evaluate visual acuity, and assess flexibility and range of motion. See Table 1 for common requirements for station-based setup. Table 1. Requirements for Station-Based Preparticipation Physical Evaluations (Open Table in a new window) Sai Required Pe e

Ancillary personnel (coach, nurse, community volunteer)

Sign in

Ancillary personnel

Height and weight

Ancillary personnel

Vital signs

Ancillary personnel

Vision

Physician

Physical examination*

Physician

Medical history review, assessment, and clearance

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Optional

Dietitian

Nutrition

Dentist

Dental

Physician

Injury evaluation

Athletic trainer, physical therapist

Flexibility

Athletic trainer, exercise physiologist, physical therapist

Body composition

Athletic trainer, coach, exercise physiologist, physical therapist

Strength Athletic trainer, coach, exercise physiologist

Speed, agility, power endurance, balance

*The physical examination can be subdivided if more than 1 physician is present. Qualified medical personnel may perform the musculoskeletal examination under the direction of a physician. A station for the evaluation of musculoskeletal injury may be used to provide a more complete evaluation when a musculoskeletal injury is detected during the required musculoskeletal screening examination. With the multistation approach, a lead physician should be designated. This physician reviews the results from all the stations and signs the needed forms to clear the athlete for play. The lead physician also checks to ensure that nothing is missed and supplies the appropriate personnel information about athletes who have abnormalities, including those who are still able to compete.

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A thorough medical history is the most fruitful tool in the athletic preparticipation evaluation. When completed and thoroughly reviewed, this history supplies most of the information that is needed to decide if an athlete can safely compete in a given sport. Many established tools are available to facilitate the collection of key medical information. Much research and thought has gone into the forms that are jointly recommended by the American Osteopathic Academy of Sports Medicine (AOASM), the American Academy of Family Physicians (AAFP), the American Medical Society for Sports Medicine (AMSSM), and the American Orthopaedic Society for Sports Medicine (AOSSM). These forms are easily accessible. An athlete's medical history should focus on the detection of previous and current disease, previous and current injuries, cardiovascular abnormalities, and musculoskeletal abnormalities. If the athlete's medical history suggests the presence of any of these problems, question him or her for further details, and strongly consider other testing to evaluate these problems.
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Key issues that must be addressed in a sports medical history include the following: Demographic data: Updated information is critical, especially in athletes who are minors. Telephone contact numbers are also essential because the authorization to treat specific conditions may be needed. Tetanus status: With any athletic endeavor, the risk of abrasion and laceration increases as the risk of injury increases. All athletes should be current regarding tetanus immunization. History of excessive weight loss or gain: Changes in weight can indicate eating disorders, steroid abuse, and purging behavior. These disorders are seen not only in female athletes in gymnastics, dance, figure skating, and diving, but also in wrestlers and other athletes. History of anaphylactic reactions: This finding is especially important if an athlete has known anaphylaxis with insect bites. Because many sports take place in an outdoor environment, insect bites are possible. If an athlete has such a history of anaphylaxis, he or she can be advised to always keep an anaphylaxis kit at hand. Furthermore, advance knowledge of an athlete's allergy can alert coaches, trainers, and team physicians to be prepared to treat this life-threatening condition. (See also the eMedicine article Anaphylaxis.) Recent and previous concussions: Although the mortality rate associated with head injury in sports is low, more evidence regarding the morbidity associated with repetitive head injuries is emerging.[3] Because athletes, especially those in certain sports, are at risk of head trauma, the athlete's concussion history must be assessed to identify individuals who are at risk and to determine whether they should continue playing contact or collision sports. Dizziness or collapse with exertion: Although this symptom has multiple etiologies, the possibility of heart disease and sudden cardiac death warrants an in-depth evaluation of symptoms, when present. [See also the eMedicine article Commotio Cordis.) Family history of exercise-related death: This is a historical finding that puts direct relatives at higher risk for the same condition. Therefore, in cases in which a family history of collapse with exercise is found, the athlete should be evaluated in depth. History of asthma: Because asthma is often triggered by exercise or exertion, the severity of the previous episodes should be evaluated further. In addition, adequate instruction about treatment can help prevent dire consequences from this condition. (See also the eMedicine articles Exercise-Induced Asthma [in the Sports Medicine Section] and Asthma [in the Pulmonology section].) Loss or dysfunction in 1 of a pair of organs: If the remaining organ of a pair is injured, entire function can be lost. For the most part, this assessment applies to the eyes, kidneys, and testicles. Menstrual history: An abnormality in menstrual function can be a clue to significant underlying medical conditions, including pregnancy, osteoporosis, nutritional deficits, drug abuse, psychiatric conditions, and eating disorders. (See also the eMedicine article Female Athlete Triad.) Use of contact lenses, dental appliances, and other devices: It is important to be aware of the athlete's use of any lenses or devices because they may become dislodged during competition, and some items should not be worn during competition. In addition, athletes may wear jewelry or have body piercings; these should be noted and assessed. Recent or recurrent fractures, dislocations, and other injuries: A history of these types of injuries may indicate a condition that requires further treatment or surgery, or it may indicate an abnormality in the athlete's playing mechanics, style, or equipment. Previous heat illness: This finding is important for certain sports that have peak play seasons during hot seasons and for sports that require the use of heavy restrictive equipment. Individuals with 1 episode of heat illness are at high risk of recurrence. (See also the eMedicine article Heat Exhaustion and Heatstroke.) Source of the history: Because many athletes are minors, their medical and surgical histories must be obtained with a parent or guardian present. If this is not convenient, history forms could be completed and then sent to a parent or legal guardian for his or her signature. Without the parent's or guardian's involvement, the athlete's history cannot always be considered reliable.

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The physical examination must be global and complete because any abnormality can affect an athlete's sports participation. However, the examination is still somewhat focused on screening for major anomalies. The athletic preparticipation physical evaluation includes a medical examination, an orthopedic examination, and performance testing. However, if the athlete's medical history reveals any problems, those problems should be examined thoroughly and not just for the purposes of screening. A review of the skills of physical examination is beyond the scope of this article. However, the following is a list of areas that should receive specific attention in an athletic preparticipation evaluation.
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Height and weight: These measures indicate growth and development and may reflect general fitness (eg, obesity) and pathology (eg, eating disorders). These measures are also valuable in evaluating an athlete's risks for competing at certain levels. For example, these data may be useful in determining if a thin freshman should play varsity football. A common minimum weight for varsity football participation is 120 lb, although this is not a strict guideline. Furthermore, some sports are classified according to the athlete's size or weight, and these measures may affect the athlete's class. Blood pressure (BP): Although a BP measurement is rarely an indication for disqualification from sports, abnormalities are often first noted during the sports physical examination setting. Athletes with BP changes can be referred for follow-up care with a primary physician. Certain sports may cause significant BP elevations, and this may be a reason to limit an athlete's participation. The BP must be evaluated more than once, and normal BPs for the athlete's age must be considered. Rough guidelines are a BP of 125/80 mm Hg or less for those aged 10-15 years and 130/85 mm Hg for those aged 16 years and older. See Table 2. Visual acuity: Visual acuity does not need to be 20/20 for sports participation, but poor vision can affect the athlete's performance and increase the likelihood of injury. If the athlete's visual acuity is abnormal, interventions can be recommended before his or her participation in sports activities. Some recommendations advocate clearance without intervention for any person with visual acuity of 20/40 or better using both eyes. Skin: Certain sports, such as wrestling, disqualify athletes who have infectious dermatoses, which include impetigo, herpes, and forms of tinea. Other conditions (eg, acne, scabies, nevi) can be detected, and the athlete should be counseled in such cases. Eyes: Pupil reactivity and anisocoria should be noted. Knowledge of preexisting abnormalities can be useful information at a later time in case an athlete has a head injury. Heart: Routine auscultation for murmurs or irregular rhythms is indicated, and auscultation should be obtained with the patient in at least 2 positions (usually sitting and supine), which increase the likelihood of detecting subtle abnormalities. A familiarity with the definitive findings of different valvular lesions is essential. The most common cause of sudden cardiac death in athletes is hypertrophic cardiomyopathy, also known as hypertrophic obstructive cardiomyopathy (HOCM) and Brock disease. The classic murmur in this anomaly is a systolic murmur along the left sternal border, which is accentuated by Valsalva maneuvers and standing; the murmur decreases with handgrip and squat maneuvers. These auscultation examinations can reveal many murmurs, which are mostly benign systolic-flow murmurs, but the examiner must have a trained ear to be able determine the need for further evaluation. Abdomen: The abdominal examination should be conducted to assess organomegaly, especially splenomegaly, because of the risk of rupture in contact sports. Genitalia: The need for a genital examination is an area of controversy among sports medicine physicians. This examination can be used for Tanner staging in adolescents to classify athletes by maturity; thus, developmental delays can be detected. The genital examination can also be used to assess males for the presence of a single testicle and to evaluate for the presence of hernias. Some sports physicians omit the genital examination unless the history indicates a single testicle or inguinal or scrotal swelling; the medical history may be adequate for finding these problems. Furthermore, unless hernias are incarcerated, sports participation may not be prohibited. Musculoskeletal: If the screening history is negative, this evaluation can be quickly completed by using the 90-second orthopedic evaluation as outlined below. Note the general body habitus. Assess the cervical range of motion. Assess shoulder function by having the athlete perform shoulder shrugs, abduction to 90, and internal and external rotation. Visually inspect the forearms and have the athlete supinate and pronate the forearms with his or her elbows flexed to 90. Evaluate the hands for rotational deformities by asking the athlete to open and close his or her fists and spread the fingers. Have the athlete perform a duck walk to evaluate function of the hips, knees, and ankles. Assess knee extension and patellar tracking. Ask the athlete to toe walk and heel walk. Ask the athlete to touch his or her toes to check for scoliosis.

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Coaches and trainers often perform this test, and the physician may not be needed. The main concern in the performance evaluation is assessing the athlete's flexibility and endurance.
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Flexibility can be assessed in many ways. Charts and goniometry may be used to compare ranges of motion on the right and left sides. A simple sit-and-reach test can be used to measure general lower-extremity flexibility. This information is useful in planning exercise programs for specific athletes. Endurance can be measured with timed tests. One such test is a 12-minute run, during which the athlete's ability to complete the test and the distance covered are measured. Another evaluation is a 1.5-mile run, which is similarly used to assess the athlete's ability to complete the test and the time needed to run the distance. Other tests may include single maximal weight lifting, timed sprinting, broad jumping, and vertical leaping. Table 2. Classification of Hypertension by Age Group[4] (Open Table in a new window) Sig ifica H e e i , Se e e H e e i ,

Age G

Hg

Hg

S Children 122

ic BP Dia 78

ic BP S 130

ic BP Dia 86

ic BP

6-9

126

82

134

90

10-12

Adolescents

136

86

144

92

13-15

142

92

150

98

15-18

Source: Report of the Second Task Force on Blood Pressure Control in Children, 1987.[4]

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The role of other screening evaluations before sports participation has been questioned. For the most part, authorities have recommended against random screening with these tools. Some of these tests are expensive, and some have been evaluated and deemed to have no significant advantage over a thorough medical history and physical evaluation. Also, false-positive findings can lead to unnecessary evaluation and investigation, which can have legal implications that set legal precedents. One evaluation that has been considered for all athletes is electrocardiography to evaluate cardiac rhythm and cardiac size. Echocardiography is also considered a screening tool for detecting anomalies that may place the athlete at risk for sudden cardiac death. The state of Oregon proposed a protocol approach to help teach providers the most useful screening methods and to collect data over time to help focus future efforts.[5] In time, this effort
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may shed light on alternative approaches to screening young athletes for life-threatening cardiac anomalies. A study of 964 athletes found abnormalities in 35% of the echocardiograms 10% of the total deemed to require an echocardiogram. Ultimately, 0.6% of the athletes had conditions that required disqualifications from activity or further treatment or evaluations beyond echocardiography. The echocardiograms revealed no additional abnormalities when added to history, physical examination, and ECG findings.[6] Urinalysis had long been part of the sports physical evaluation, but this test eventually proved to yield several false-positive results. At one point, complete blood cell (CBC) counts were measured to evaluate for anemias, which are common among elite athletes; however, the findings are of questionable significance at times. Orthopedic evaluations often include radiography of the cervical spine, especially among football players. The purpose is to try to detect an athlete's risk for spinal cord injury. Studies show that this kind of screening may not be effective. Most guidelines for athletic preparticipation evaluations do not include the above tests. Some institutions do require such studies, but these tests are generally not good as screening tools, and they should not be performed in patients with an unremarkable medical history. However, when a risk is evident, a full workup should be performed. For example, some clinicians advocate radiography of the cervical spine in athletes with Down syndrome because these individuals have a higher incidence of congenital instability in the upper cervical spine. (See also the eMedicine article Down Syndrome and the Medscape articles Part I: Clinical Practice Guidelines With Down Syndrome From Birth to 12 Years and Part II: Clinical Practice Guidelines for Adolescents and Young Adults With Down Syndrome: 12-21 Years.)

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An athlete should be medically cleared for sports participation only after the medical history and physical evaluation are deemed unremarkable. If the history or physical findings raise concerns, a negative complete workup can help in clearing the athlete for participation. Even then, however, the physician must realize that the athlete is only cleared for a specific sport. Sports with different levels of contact, static activity, and dynamic activity have different criteria for participation clearance. A single athlete may qualify to participate in 1 sport but not in another. Likewise, clearance for participation in 1 sport may not apply to another sport or another level of the same sport. To help clarify the risks of different sports, the American Academy of Pediatrics (AAP) developed 2 sports classifications based on the level of contact and the level of intensity, as determined by the dynamic and static demands of the sport. Neither classification is all-inclusive, but most of the common sports are included. These range from popular sports, such as football, baseball, hockey, soccer, and basketball, to less common sports, such as skiing, sailing, rodeo, and weight lifting. (Note: Although water sports have their own concerns, the AAP does not consider them a category of sports.) Contact is divided into 3 categories: contact/collision, limited contact, and noncontact (see Table 3). Intensity is divided into 2 categories: high to moderate intensity and low intensity. Sports with high to moderate intensity can be subdivided into those with high-dynamic and high-static demands, those with high-dynamic and low-static demands, and those with low-dynamic and high-static demands (see Table 4). Low-intensity sports have low-dynamic and low-static demands; these sports include bowling, cricket, curling, golf, and riflery. Medical clearance for a sport is easily granted in most cases because the athletes' medical histories and physical findings are often unremarkable. However, when an abnormality is detected, the sport and the severity of the abnormality must be considered together in making a decision about an athlete's participation. The AAP addresses common conditions that arise in athletic preparticipation evaluations and discusses how they are related to clearance for different sports (see Table 5). The physician in charge makes 1 of the following 4 choices [7] : Unrestricted participation for a particular sport: If an athlete is cleared to participate in a contact sport with high dynamic and static demands, the athlete could potentially qualify to participate in any sport. However, this is not always the case. Clearance with notification of the coach, trainer, and team physician: This choice may be selected for athletes with conditions that allow their participation in a sport; however, these athletes may need special treatment on occasion. A good example is an athlete with mild to moderate and well-controlled, exerciseinduced asthma. (See also the eMedicine article Exercise-Induced Asthma.)
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Deferred clearance: This category can be used when suspicious symptoms or signs indicate further workup should be conducted in an athlete, who may eventually be cleared. A good example is an athlete with a newly discovered cardiac murmur that has suspicious characteristics or an individual with a recent concussion and postconcussion syndrome. Disqualification: This category is used when a known condition prohibits an athlete's participation in the given sport. Generally, this decision is not reversible for that particular sport; however, the condition may not preclude the athlete's participation in a sport with a lower safety risk. Sports are classified by contact level in the table below. Table 3. Classification of Sports by Contact level (Open Table in a new window) C ac /C i i S Li i ed-C Baseball ac S Archery N c ac S

Basketball

Boxing*

Bicycling

Badminton

Diving

Cheerleading

Bodybuilding

Field hockey

Canoeing/kayaking (white water)

Canoeing/kayaking (flat water)

Football (flag or tackle)

Fencing

Crew/rowing

Ice hockey

Field events (high jump, pole vault)

Curling

Lacrosse

Floor hockey

Dancing

Martial arts

Gymnastics

Field events (discus, javelin, shot put)

Rodeo

Handball

Golf

Rugby

Horseback riding

Orienteering

Ski jumping

Racquetball

Power lifting

Soccer

Skating (ice, inline, roller)

Race walking

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Team handball

Skiing (cross-country, downhill, water)

Riflery

Water polo

Softball

Rope jumping

Wrestling

Squash

Running

Ultimate Frisbee

Sailing

Volleyball

Scuba diving

Windsurfing/surfing

Strength training

Swimming

Table tennis

Tennis

Track

Weight lifting

*Participation not recommended by the AAP.[7] The AAFP, AMSSM, AOASM, and AOSSM have no recommendation against boxing. Table 4. Sports of High to Moderate Intensity (Open Table in a new window) S D Wi h High M de a e a ic a d S a ic De a d S Wi h High M de a e D a ic a d L S a ic De a d Badminton S High Archery Wi h L D a ic a d M de a e S a ic De a d

Boxing*

Crew/rowing

Baseball

Auto racing

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Cross-country skiing

Basketball

Diving

Cycling

Field hockey

Equestrian activities

Downhill skiing

Lacrosse

Field events (jumping)

Fencing

Orienteering

Field events (throwing)

Football

Table Tennis

Gymnastics

Ice hockey

Race walking

Karate or judo

Rugby

Racquetball

Motorcycling

Running (sprinting)

Soccer

Rodeo

Speed skating

Squash

Sailing

Water polo

Swimming

Ski jumping

Wrestling

Tennis

Water skiing

Volleyball

Weight lifting

*Participation not recommended by the AAP.[7] The AAFP, AMSSM, AOASM, and AOSSM have no stand against boxing. Table 5. Medical Conditions and Sports Participation[7] (Open Table in a new window) C di i E a ai Pa ici a i Qualified yes

Atlantoaxial The athlete needs evaluation to assess the risk of spinal cord injury during instability sports participation. (instability of the joint between cervical vertebrae 1 and 2)*
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Bleeding disorder* Carditis (inflammation of the heart) Hypertension (high BP)

The athlete needs an evaluation. Carditis may result in sudden death with exertion.

Qualified yes No

Those athletes with significant essential (unexplained) hypertension should avoid weight lifting and power lifting, body building, and strength training. Those with secondary hypertension (hypertension caused by a previously identified disease) or severe essential hypertension need evaluation.

Qualified yes

Congenital heart Those athletes with mild forms of congenital heart disease may participate disease fully. Those with moderate or severe forms and those who have undergone (structural heart surgery need evaluation. defects present at birth) Dysrhythmia (irregular heart rhythm) Mitral valve prolapse (abnormal heart valve Heart murmur The athlete needs evaluation because some types of cardiac dysrhythmia require therapy, make certain sports dangerous, or both. Those athletes with symptoms (chest pain, symptoms of possible dysrhythmia) or evidence of mitral regurgitation (leaking) on physical examination need evaluation. All others may participate fully. If the murmur is innocent (ie, it does not indicate heart disease), full participation is permitted. Otherwise, the athlete needs an evaluation (see Congenital heart disease and Mitral valve prolapse, above). The athlete needs an evaluation. If the diabetes is well controlled, the athlete can play in all sports with proper attention to diet, hydration, and insulin therapy. Particular attention is needed for activities that last 30 minutes or more.

Qualified yes

Qualified yes

Qualified yes

Qualified yes

Cerebral palsy* Diabetes mellitus* Diarrhea

Qualified yes Yes

Unless the disease is mild, no participation is permitted because diarrhea may Qualified no increase the risk of dehydration and heat illness. (See Fever, below.) Qualified yes

Anorexia nervosa, Patients need both medical and psychiatric assessments before sports bulimia nervosa participation. Functionally 1eyed athlete, loss of an eye, detached retina, previous eye surgery, or serious eye injury

A functionally 1-eyed athlete has a best-corrected visual acuity (BCVA) of Qualified yes better than 20/40 in the worse eye. These athletes could experience a significant disability if the better eye is seriously injured, as can those athletes with the loss of an eye. Athletes who have previously undergone eye surgery or who have had a serious eye injury may be at increased risk of injury because of weakened eye tissue. Use of eye guards approved by ASTM International (formerly the American Society for Testing and Materials [ASTM]) and other protective equipment may allow the athlete to participate in most sports, but this approach must be judged on an individual basis. Fever can increase cardiopulmonary effort, reduce maximum exercise No capacity, make heat illness more likely, and increase orthostatic hypotension during exercise. In rare cases, fever may accompany myocarditis or other infections that may make exercise dangerous. Because of the increased likelihood of the recurrence of heat illness, the athlete needs an individual assessment to determine the presence of predisposing conditions and to arrange a prevention strategy. Because of the apparent minimal risk to others, all sports may be played, as allowed by the patient's state of health. In all athletes, skin lesions should be properly covered, and athletic personnel should use universal precautions when handling blood or body fluids with the presence of visible blood. Qualified yes

Fever

Heat illness, history of Human immunodeficiency virus (HIV) infection

Yes

Kidney, absence The athlete with 1 kidney needs individual assessment for contact/collision of one and limited contact sports. Liver, enlarged
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Qualified yes

If the liver is acutely enlarged, athletic participation should be avoided because Qualified yes
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Malignancy* Musculoskeletal disorders History of serious head or spine trauma, severe or repeated concussions, or craniotomy Convulsive disorder, well controlled Convulsive disorder, poorly controlled

of a risk of rupture. If the liver is chronically enlarged, individual assessment is needed before contact/collision or limited contact sports are played. The athlete needs an individual assessment. Qualified yes The athlete needs an individual assessment. The athlete needs an individual assessment for participation in contact/collision or limited contact sports and also for noncontact sports if deficits in judgment or cognitions are present. Recent research supports a conservative approach to the management of concussions.[3] Qualified yes Qualified yes

The risk of convulsions during sports participation is minimal.

Yes

The athlete needs an individual assessment before participation in contact/collision or limited contact sports. Because a convulsion may pose a risk to the athlete or to others, the following noncontact sports should be avoided: archery, riflery, swimming, weight lifting or power lifting, strength training, and sports involving heights. Because of the risk of heat illness, obese persons need careful acclimatization and hydration. The athlete needs an individual assessment.

Qualified yes

Obesity Organ transplant recipient*

Qualified yes Qualified yes Yes Qualified no

Ovary, absence of The risk of severe injury to the remaining ovary is minimal. one Pulmonary compromise, including cystic fibrosis* Asthma Acute upper respiratory infection Sickle cell disease The athlete needs an individual assessment, but generally, all sports may be played if oxygenation remains satisfactory during a graded exercise test. Patients with cystic fibrosis need acclimatization and good hydration to reduce the risk of heat illness. With proper medication and education, only athletes with the most-severe asthma need to modify their participation.

Yes

Upper respiratory obstruction may affect pulmonary function. Athletes, with the Qualified yes exception of those with mild disease, need an individual assessment. (See Fever, above.) The athlete needs an individual assessment. In general, if the status of the illness permits, the athlete may play all sports except high-exertion, contact/collision sports. Overheating, dehydration, and chilling must be avoided. Qualified yes

Sickle cell trait

Individuals with the sickle cell trait (AS) are unlikely to have an increased risk Yes of sudden death or other medical problems during athletic participation in most conditions. Exceptions include the most extreme conditions of heat; humidity; and, possibly, increased altitude. Like all athletes, those with the sickle cell trait should be carefully conditioned, acclimatized, and hydrated to reduce any possible risk. During the periods in which the patient is contagious, participation in gymnastics with mats, martial arts, wrestling, or other contact/collision or limited-contact sports is not allowed. Herpes simplex virus is probably not transmitted via mats. Qualified yes

Skin boils, herpes simplex, impetigo, scabies, molluscum contagiosum

Spleen, enlarged Patients with an acutely enlarged spleen should avoid all sports because of the risk of rupture. Those with chronically enlarged spleens need an individual assessment before playing contact/collision or limited-contact sports. Testicle, absent or undescended Athletes in certain sports may require a protective cup.

Qualified yes

Yes
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Note: This table is designed to be understood by medical and nonmedical personnel. In the Explanation column, a notation that the athlete needs an evaluation means that a physician with appropriate knowledge and experience should determine whether an athlete with the listed medical condition can safely participate in a given sport. Unless otherwise noted, these evaluations are generally recommended because of variations in the severity of disease and in the risk of injury in specific sports.[7] *Not discussed in text of the AAP source monograph.

See Table 4 above.

Mild, moderate, and severe congenital heart disease are defined elsewhere (26th Bethesda Conference, Med Sci Sports E erc, 1994).[8]

See the APP recommendation[7] as indicated for qualifications by other commentators.

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The decision to disqualify an athlete from sports participation is made in light of the specific sport for which the individual seeks medical clearance to participate. When the situation is vague, the guidelines described above (see Clearance for Sports Participation) can help in clinical decision making about granting clearance. The AAP guidelines [7] are broad and not specific in many areas. If obscure cardiac defects are detected, the current criterion standard for decision making is the 26th Bethesda Conference on cardiac anomalies and participation in sports.[8] Articles by Torg[9, 10] are often referenced, as well as those of Torg et al[11, 12, 13] for cases involving congenital or acquired cervical spinal deformities. Fortunately, obscure conditions that may require such referencing are rare, and usually, a general guideline like that of the AAP is most often used. This resource is valuable because the associated categorizations (contact and intensity) can be used to make recommendations for the athletes that are denied sports participation. A pitfall to keep in mind is discouraging athletes from general sports participation when they are disqualified from a particular sport; athletes might still be able to compete in other sports and experience the benefits of participation. Furthermore, an optimistic approach is always important when problems are detected in young and impressionable athletes. Many disqualifying conditions can be resolved or controlled with medical or surgical intervention, enabling future sports participation. In a study by Rifat et al[14] , the authors showed that the great majority of disqualifications as a result of athletic preparticipation evaluations involved the following 7 findings: 1. 2. 3. 4. 5. 6. 7. Dizziness with exercise Asthma history Unfavorable body mass index Systolic BP elevation Visual acuity defect Presence of a heart murmur Musculoskeletal abnormality

However, many of these conditions were further evaluated and deemed low risk, and clearance was eventually granted to the affected athletes. Other conditions can be treated with medical intervention, and the athlete may eventually return to the sport. Other athletes can be redirected to different sports in which they can have a good and safe athletic experience.

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An athletic preparticipation evaluation can be performed efficiently and thoroughly when protocols and tools are in place. Use of a reliable medical history questionnaire and a good screening physical examination are usually adequate to meet these needs. The following issues should always be emphasized: Demographic data (eg, name, age, sex, sport, telephone numbers, current medications, allergies to medications) History of exercise-induced loss of consciousness Family history of sudden cardiac death History of poorly controlled asthma History of recent or previous concussions History of fractures or major musculoskeletal problems History of heat stroke History of environmental anaphylactic reactions, as with insect bites History of loss or dysfunction of 1 of a pair of organs History of chronic illness requiring regular physician intervention History of drastic weight change For females only First menstrual period, menstrual irregularity, last menstrual period Parental signature on history forms for minors A focused physical examination should emphasize the following: Vital signs (eg, height, weight, BP) Visual acuity Infectious dermatoses Anisocoria Wheezing Heart murmurs or irregular heart rhythms Abdominal organomegaly If abnormalities are detected during the physical examination, further workup should be pursued as indicated. Finally, the participation status of the athlete for the specific sport should be determined. The main goals of the athletic preparticipation evaluation are as follows: To discover any abnormalities that places the individual at sport-specific risk of injury To inform the athlete of correctible abnormalities before the start of the sport's season To determine the safety of the athlete's participation To provide a database that team physicians, coaches, and administrators can use for reference To provide a platform of interaction between athletes and physicians Participation in sports is a benefit to which everyone is entitled. Ensuring an athlete's safety can promote a healthy lifelong habit of physical activity in which the athlete can learn about discipline, teamwork, physical fitness, and camaraderie.

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Author A h J Sag i be i, MD President, South Bay Sports and Preventive Medicine Associates; Private Practice; Team Internist, San Francisco Giants; Team Internist, West Valley College; Team Physician, Bellarmine College Prep; Team Physician, Presentation High School; Team Physician, Santa Clara University; Consultant, University of San Francisco, Academy of Art University, Skyline College, Foothill College, De Anza College Anthony J Saglimbeni, MD, is a member of the following medical societies: California Medical Association and Santa Clara County Medical Association Disclosure: Nothing to disclose. Specialty Editor Board A d e D Pe , MD Residency Director, Department of Emergency Medicine, Maine Medical Center
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Andrew D Perron, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Sports Medicine, and Society for Academic Emergency Medicine Disclosure: Nothing to disclose. F a ci c Ta a e a, Pha D, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Medscape Salary Employment He T G i , MD Academic Chair and Associate Director, Detroit Medical Center Sports Medicine Institute; Director, Education, Research, and Injury Prevention Center; Co-Director, Orthopaedic Sports Medicine Fellowship Henry T Goitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Orthopaedic Society for Sports Medicine Disclosure: Nothing to disclose. J B Whi eh , MD Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America Disclosure: Nothing to disclose. Chief Editor C aig C Y g, MD Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Director of Primary Care Sports Medicine Fellowship, Medical College of Wisconsin Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, and Phi Beta Kappa Disclosure: Nothing to disclose.

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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. Mar 27 2007;115(12):1643-455. [Medline]. [Full Text]. 28. Ryan AJ. Qualifying exams: a continuing dilemma (editorial). Ph s Sportsmed. 1980;8:10. Medscape Reference 2011 WebMD, LLC

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