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The Importance of Physical Exam for Sports Participation
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Posted on: 11/20/2008
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Every parent knows that if their child wants to participate in organized sports, a preparticipation exam is required. The athlete must see a physician, have a form filled out, and turn the form in. While it may seem like we are jumping through hoops, the medical doctor must take this exercise very seriously.
Every year, there are reports of athletes suffering fatal heart or other life-threatening conditions on the field. Hypertrophic cardiomyopathy, (HCM or HOCM) is the most famous as a leading cause of sudden cardiac death in young athletes. Hypertrophic cardiomyopathy is a disease of the myocardium (heart muscle). Part of the myocardium becomes hypertrophied (thickened) without any obvious cause.
To help physicians perform an effective exam, a proposed preparticipation exam has been developed. A consensus approach was used to formulate the evaluation. Consensus means the opinions of many experts were gathered. Items agreed upon by the majority of doctors were included.
This article presents a summary of the consensus report along with specific cardiac recommendations from the American Heart Association. Many well-known medical groups contributed to the process. For example, the American Family of Family Physicians, American College of Sports Medicine, American Academy of Pediatrics, and American Orthopaedic Society for Sports Medicine participated (to name a few).
Guidelines for preparticipation screening of athletes are designed to ensure the health and safety of the 10 million school age and collegiate athletes who train and compete each year. The goal is to identify risk factors for injury, illness, and even sudden death.
The guidelines include timing of the evaluation, appropriate setting for the exam, questions to be asked, and tests to be performed. The preparticipation exam should be completed in the doctor's office at least six weeks before preseason activities. This allows enough time for follow-up if referral or consultation is needed.
Many schools require the preparticipation exam every year for liability reasons. There isn't any real data collected to show that this is necessary. Studies are needed to confirm that performing an annual exam actually reduces the risk of injury or death in student athletes.
The medical societies recommend an exam every two years for younger athletes, and every two-to-three years in older athletes. Specific ages have not been standardized as yet. A thorough exam is advised at the start of new phases (e.g., upon entering middle school, at the start of high school, when participating in sports for the first time).
A modified and less thorough update exam can be performed each year in-between major transition periods. Any important health changes can be noted at that time. This might include changes in height and weight, any new personal/family history of injury or illness, and current blood pressure.
Physicians are encouraged to obtain the most accurate history possible. This means interviewing both the athlete and his or her parent/guardian. Areas to include are: past hospitalizations and surgeries, current medications, allergies, and use of vitamins or other supplements. A social history is equally important with questions about tobacco use and alcohol or other drug use. A past history of medical disqualification raises a red flag requiring further investigation.
The physician follows a typical comprehensive physical exam including a systems review: head; ears, nose, throat; skin; gastrointestinal; and genitourinary function. Certain body systems require a closer look than others. For example, the cardiovascular, pulmonary, neurologic, and musculoskeletal systems must be reviewed in detail. Nutrition is also very important as well as looking for specific signs and symptoms that might suggest an eating disorder or risk factors for delayed growth.
Each of these areas is described in detail for physicians reviewing the current guidelines. Samples of forms and checklists with multiple questions are included for the reader. Drawings of tests used in the general musculoskeletal screening exam are provided. Tests for range-of-motion, muscle strength, scoliosis screening, balance, and flexibility are included.
There's still some debate about the need for special tests such as electrocardiograms (EKGs). Studies from Europe support the need for all competitive athletes to have routine EKGs. They report 90 per cent fewer deaths from cardiovascular causes.
But the American Heart Association says that a normal EKG doesn't mean the athlete won't have a significant heart-related event. These tests just aren't sensitive enough to detect all abnormalities, and they are expensive to conduct on everyone involved. False-positive tests lead to more tests that may be unnecessary. At the present time, there are too few athletes for whom this type of testing is really needed. There's no need to subject everyone to the test for the sake of a very few who might be affected.
It may be more effective to find tests and measures that are likely to predict a potentially life-threatening condition. For now, the American Heart Association encourages physicians to watch out for the following red flags:
Chest pain or discomfort with activity
Fainting with no known cause
Unexplained shortness of breath or unusual fatigue
History of heart murmur
High blood pressure
Family history of heart disease and/or sudden death (before age 50)
Any one of these positive findings must result in a referral for further cardiovascular assessment. The presence of (or risk for) hypertrophic cardiomyopathy and its potential consequences are too great to ignore. Other cardiac risks are also possible and must be kept in mind during the examination.
The authors conclude that studies have not identified the sensitivity of preparticipation screening examinations yet. Until the research catches up with current practice, a comprehensive screening tool with guidelines for physical evaluation is advised. An accurate, but practical approach to detecting life-threatening risk factors and/or conditions, will ensure the safety and health of all athletes.
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References:
Brandy L. Peaker, MD, and Robert Jones. Preparticipation Physical Evaluation: A Review of Guideline Updates. In Current Orthopaedic Practice. September/October 2008. Vol. 19. No. 5. Pp. 548-555.
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*Disclaimer:*The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic. |
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