Pre-Participation Physical Examinations

Dr.RAJAT JANGIR
Consultant Arthroscopy and Orthopedic Surgeon
Saket Hospital, Mansarovar
Assistant Professor
Mahatma Gandhi Medical College, Jaipur

Fellowship In Arthroscopy(South Korea)

International Olympic Committee Diploma Sports Medicine(UK)
Sports Physician RIO Olympic 2016
IPC Medical Code

Fitness to practice a
sport
46. Prior to engaging in
competitive sport, and
preferably with regular
intervals throughout their
athletic career, athletes
should undergo pre-
participation evaluation....
The International Olympic Committee (IOC)
Consensus Statement on Periodic Health
Evaluation of Elite Athletes
http://www.olympic.org/assets/importednews/documents/en_r
eport_1448.pdf
Br J Sports Med. 2009 Sep;43(9):631-643.
 PPE
 Goals of the PPE

 Preparation for the PPE

 Medical history

 Components of the PPE

 Clearance for participation

 Goals of the PPE
 Determine general health and current immunization
status

 Establish rapport with participant

 Detect medical conditions that can predispose one to

injury/illness so treatment can be continued/initiated

 Identify health risk behaviors that can be addressed with

counseling
 Goals of the PPE
 Establish baseline parameters for return to play
decisions

 Assess physical maturity

 Evaluate physical fitness

 Make recommendations regarding participation/exercise

 Meet legal requirements to athletic participation

 Goals of the PPE
 Specific focus of PPE varies amongst
populations
 Pre-pubescent
 Undiagnosed congenital abnormalities
 Pubescent
 Maturation level, establishing healthy behaviors
 Young adult
 History of previous injury, sport-specific exam
 Adult
 Overuse conditions predominate
 SUDDEN DEATH
• Sudden death in athletics can occur from
direct or indirect causes
• direct - traumatic
• indirect - atraumatic
 SUDDEN DEATH
• Most indirect causes are cardiac in origin.
• A very small number of indirect causes of
sudden death are noncardiac
• heat stroke
• CVA
• pulmonary embolus
• drug abuse
 PPE: The History
History forms are very helpful
 athletes and parents should jointly complete a history form
prior to the PPE
 Review form: 75% of issues detected through Hx alone
Web based history forms may be more convenient for
the athletes (ePPE)
Preparticipation form recommended by the AAFP,
AAP, AMSSM, and AOSSM is available in the
Preparticipation Physical Evaluation, 4th ed. 2010.
 Preparation for the PPE
 No one best/right way to do PPE

 Influenced by several factors

 Level of competition
 Availability of personnel and facilities
 Number of PPE being conducted
 Personal preference/history
 Preparation for the PPE
 Format

 Timing

 Frequency
 PPE Format
 Primary care physician model
 Enhanced knowledge of medical history,
immunization status and prior injuries that
could limit participation
 Generally a more thorough exam
 Affords best privacy and better environment
for counseling
 Cost is expensive – insurance?
 PPE Format
 Group/station model
 Good for large number of PPE in given period
of time
 Individual personnel responsible for given
element of PPE at “station”
 Clearance verified by team MD at end of PPE
 Typically free of charge
 PPE Timing
 Ideally completed several weeks prior to initial
practice

 Allows ability to address any problems identified

on PPE (labs, tests, records) without impeding
participation status

 Typically done within 1 week prior to first

scheduled activity – high schools often over
summer
 PPE Frequency
 Entry-level PPE (complete) at outset of
participation for school/organization

 Recommended annual re-evaluation

without complete PPE unless warranted
 Medical History
 Generally accomplished ahead of time in
yes/no format
 Often a supplemental form for females

 For station model, qualified evaluator must

review history and red flag potential
concerns for further scrutiny/evaluation
 Components of the PPE
 Vital signs  Dental
 General medical  Gastrointestinal
problems  Genitourinary
 Cardiovascular  Dermatologic
 Pulmonary  Examination for heat
 Musculoskeletal disorders
 Neurologic  Laboratory tests
 Eyes
 Vital Signs
 Establishes individual’s baseline parameters
 Height/weight
 Comparison to normative data
 Pulse/respiratory rate (60-100/12-16)
 Observe quantity and quality
 Blood pressure (120/80)
 Cuff size very important
 Body temperature (98.6/37.0)
 Oral vs. tympanic vs. axillary (rectal)
 General Medical Problems
 Questions asked regarding
 Currently being treated for illness/injury
 History of hospitalization or surgery
 History of progressive disease (MS, MD,
cancer)
 Current use of OTC/Rx meds
 Allergies to meds, food, environment
 Cardiovascular Examination
 Done in quiet area to maximize validity

 Auscultation of heart sounds

 Questions asked regarding

 Fainting (syncope), dizziness, SOB, chest pain with exertion
 Heart palpitations, tachycardia, dysrhythmia, known murmur
 Family member with sudden, early cardiac death

 Positive responses to any necessitate referral to

cardiologist for further evaluation
 Pulmonary Examination
 Done in quiet area to maximize validity

 Auscultation of breath sounds in all lung lobes –

look for symmetrical movement of diaphragm

 Questions asked regarding

 Excessive coughing during/after activity
 History of asthma, bronchitis, allergies
 SOB, unusual breath sounds during/after activity
 History of collapsed lung (pneumothorax)
 Musculoskeletal Examination
 Basic exam consists of observation for
symmetry, ROM, strength tests for major
muscles and specific tests for previously injured
areas

 Questions asked regarding

 Focus on history of injury, time frame, evaluation,
treatment and rehabilitation
 Use of protective devices
 Neurologic Examination
 Evaluation consists of cranial nerve tests
including pupil function, sensory/motor tests of
UE/LE, deep tendon reflexes

 Questions asked regarding

 History of head injuries
 Any previous loss of consciousness
 Numbness/tingling, loss of motor function in body
 History of seizures, burners/stingers
 Eye Examination
 Visual acuity assessed via Snellen chart, both
monocularly and binocularly (use corrective lenses)
 Emmetropia (20/20 vision)
 Myopia (nearsightedness)
 Hypermetropia (farsightedness)

 Questions asked regarding

 Use of corrective lenses/type
 Blurring or double vision
 Color blindness, peripheral vision loss
 History of eye trauma, retinal detachment
 Dental Examination
 Typically done by dentist – not meant to
perform preventative care but to establish
pre-existing conditions for liability reasons
in case of dental injury

 Allows opportunity for dental molds to be

made for crafting of custom mouthguard
 Gastrointestinal Examination
 Evaluation of digestive system, eating habits and
nutrition
 Concerns for athletes where image is important to activity

 Evaluation done supine with palpation for masses or

organomegaly

 Questions regarding
 History of heartburn, indigestion, diarrhea or constipation
 Prior history of organ injury (spleen, liver, kidney)
 Genitourinary Examination
 For males, questions asked regarding
 Hernias, testicular torsion, absent or undescended testicle

 For females, questions asked regarding

 Menstrual cycle, pregnancy

 General questions asked regarding

 History of bladder/urinary tract infections, STDs
 Absence of one kidney

 Can include urinalysis to look for proteins, blood, sugar

and hemoglobin in urine
 Dermatologic Examination
 Skin evaluated for rashes, lesions, infections
that can be contagious to others
 Herpes, fungal infections (tinea), impetigo, STDs,
acne/treatment

 Also look at existing blemishes (warts, moles,

etc.)
 Change in appearance (size, color, border, etc.) in
recent past
Examination for Heat Disorders
 Especially important for activities taking place
under conditions of high temperature, high
humidity or a combination of the two

 Questions asked regarding

 History of heat illness (cramping, syncope,
exhaustion, stroke)
 Current meds (diuretics, antihistamines)
 Use of caffeinated/alcoholic beverages
 Nutritional and hydration habits
 Laboratory Tests
 Not typical associated with PPE – usually
due to cost of testing procedures

 Often used when/if red flags appear

during PPE
 Urinalysis
 Blood work
 ECG
 Clearance for Participation
 Conditions to be met to allow clearance by ME
at end of PPE
 Will condition increase risk of injury to individual or
others?
 Can participation be allowed if meds, rehab or
protective bracing/padding is used? If so, can limited
participation be allowed in interim?
 If clearance is denied for particular activity, can other
safe activities be identified and clearance be granted
for them?
 Clearance for Participation
 Individuals have right to participate in any
activity regardless of pre-existing medical
condition/s

 Physician’s cannot exclude individual from

participation – can only recommend against
participation
 Conditions that Contraindicate
Sports Participation
 Active myocarditis or pericarditis
Hypertrophic cardiomyopathy
 Severe hypertension until
 Poorly controlled convulsive disorder
 no archery, riflery, swimming, weight lifting or power
lifting, strength training or sports involving heights)
 Recurrent episodes of burning upper-extremity
pain or weakness, or episodes of transient
quadriplegia until stability of cervical spine can
be assured (no contact or collision sports)
 Conditions that Contraindicate
Sports Participation
 Sickle cell disease (no high-exertion,
contact or collision sports)
 Eating disorder where athlete is not
compliant with therapy and follow-up, or
where there is evidence of diminished
performance or potential injury because of
eating disorder
 Acute enlargement of spleen or liver