Pre-Participation Examinations

The Pre-Participation Exam otherwise known as the (PPE) has become a critical aspect in both sport and recreation, however currently there is no standardized instrumentation. The PPE is designed to screen for injuries, illnesses, or other factors that increase an athlete’s risk for injury or illness. Experts in the field of athletic training, sports medicine, orthopaedics, family medicine, pediatrics, and osteopathics all agree that the identification of predisposing factors that threaten one’s safety are vital to participation in sport and will serve to improve the health and safety of athletes and active individuals.

 

What are the Current Requirements?

The NFHS and the NCAA both recommend pre-participation exams (PPEs), however many are required independently by state high school athletic associations and collegiate institutions. High school requirements often vary state to state and many do not follow the guidelines set forth by the American Heart Association (AHA) regarding appropriate cardiac screening. Most NCAA athletic associations have their own forms that they have modified to include all of the components of a PPE (see below). Currently youth sports do not require a PPE however some leagues/clubs have moved in this direction.

 

Who is Qualified to Perform the PPE? How do the athletes get cleared?

A licensed physician (doctor of medicine or doctor of osteopathy) with sports medicine specialization or experience or an advanced practice registered nurse is the most appropriate person to conduct the PPE. At the time of the visit the healthcare provider will make the decision to clear the athlete based on previously published guidelines and evidence. At the college level team physicians can restrict an individual from participating in athletics.

 

How often and when should the PPE be administered?

A complete PPE should be performed before the athlete enters a new level of participation and when changes in status may warrant a new exam. This should occur 4-6weeks before training begins however in many collegiate settings using a “multi-station approach” this can occur 1-2 days prior.

 

Components of an Appropriate PPE

1.  Medical and Family History

  • Personal History questions regarding chest pain, syncope, fatigue, murmurs, blood pressure
  • Family History questions regarding premature death, disability from heart disease and cardiac conditions in family members.

2.  Physical Examination

  • General Health Screen
    • Vital signs, height, weight, blood pressure, vision testing, pulmonary, neurological, abdominal, skin and genitalia exam
  • Cardiovascular Screen
    • Hear murmurs, femoral pulses, Marfan syndrome characteristics, blood pressure
    • Auscultation of the heart in both seated and standing positions
  • Neurologic Screen
    • Sensory, reflex and motor control testing, concussion history, seizure disorder, spinal cord injury and cervical spinal stenosis  Orthopaedic Screen
    • Musculoskeletal screening of previous and current injuries, site specific examination of strength, range of motion, deformity, and asymmetries
  • General Medical Screen
    • Signs and symptoms of or previous history of diabetes, anemia, and low ferritin levels my benefit from additional routine laboratory tests

3.  Medication Use

  • Medications and supplements utilized should be examined

4.  Nutritional Assessment

  • Questions to determine the nutritional status and plan for disordered eating

5.  Heat and Hydration Related Risk Factors

  • Screening of risk factors related to previous problems in the heat and review of guidelines for heat acclimatization

6.  Metal Health Considerations

  • Questions to determine the mental status and a plan for referral should be initiated

 

Sample PPE

A sample PPE recommended by the American Academy of Pediatrics in the “PPE Preparticipation Physical Evaluation 4th Edition (make this the link) currently meets the requirements of a PPE and is encouraged to be used at all levels of sport. This document is endorsed by the American Heart Association and the National Athletic Trainers’ Association and authored by the following:

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

American Osteopathic Academy of Sports Medicine

Follow this Link for the Sample PPE

 

References

  1. American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, American Academy of Pediatrics. PPE: Preparticipation Physical Evaluation. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2010.
  2. Bonci CM, Bonci LJ, Granger LR, et al. National Athletic Trainers’Association position statement: preventing, detecting, and managing disordered eating in athletes. J Athl Train. 2008;43(1):80–108. 204.
  3. Carek PJ, Futrell M, Hueston WJ. The preparticipation physical examination history: who has the correct answers? Clin J Sport Med. 1999;9(3):124–128.
  4. Carek PJ, Hunter L. The preparticipation physical examination for athletics: a critical review of current recommendations. J Med Liban. 2001;49(5):292–297.
  5. Carek PJ, Mainous AG. A thorough yet efficient exam identifies most problems in school athletes. J Fam Pract. 2003;52(2):127– 134.
  6. Casa DJ, Csillan D, Armstrong LE, et al. Preseason heat- acclimatization guidelines for secondary school athletics. J Athl Train. 2009;44(3):332–333.
  7. Conley K, Bolin D, Carek P, Konin J, Neal T, Violette D. National Athletic Trainers’ Association Position Statement: Preparticipation Physical Examinations and Disqualifying Conditions. J Athl Train. 2014;49(1):102-120.
  8. Kurowski K, Chandran S. The preparticipation athletic evaluation. Am Fam Physician. 2000;61(9):2683–2690.
  9. Lombardo JA, Badolato SK. The preparticipation physical examination. Clin Cornerstone. 2001;3(5):10–25.
  10. 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(12):1643–1455.
  11. Wingfield K, Matheson GO, Meeuwisse WH. Preparticipation evaluation: an evidence-based review. Clin J Sport Med. 2004;14(3):109–122.