STANDING OPERATING PROCEDURE (SOP)

PRE-PARTICIPATION EVALUATION (PPE)

OF ATHLETES

Introduction:-

1. Screening is a strategy used in a population to detect a disease in individuals

without signs or symptoms of that disease. Athletes in sports are involved in high
performance and injury prone circumstances, hence PPE is vital to detect the early
presence of any illness/ disabilities and early intervention as well as to prevent any
catastrophic event during sports participation (1).

2. In competitive sports, PPE is very crucial due to the increased risk of sudden death
in competitive athletes as compared to non-athletes (2). Although Sudden Cardiac Death
is rare i.e. 1/40000 to 1/80000 athletes-person years, with 2.5 times higher incidence in
competitive athletes than non-athletes, this can be tragic for the individual, his/ her family
and the team. As there are no universal templates for PPE across the globe, this Standard
Operating Procedure on PPE is prepared to provide a standardized protocol to aid the
medical personnel (3,4).

Aim

3. The aim of this SOP is to provide standardized protocol incorporating the current
medical evidence for conducting the PPE in competitive athletes of Sports Authority of
India.

Objectives

4. The objectives of PPE are broadly categorized as follows:-

(a) Primary Objectives:-

(i) Screening for injuries or medical conditions that may place an athlete
at risk for safe participation.

(ii) Early detection of asymptomatic conditions.

(ii) Assessing medical suitability to engage in a particular sport or event.

(b) Secondary Objectives:-

(i) Determine general health.

(ii) Review existing illness, medications and supplements.

(ii) Screen for any risk factors for future injury.

(iv) Provide an opportunity to initiate discussion on health‐related topics.

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(v) Prevent spread of infectious conditions amongst

teammates/spectators

Basic Principles of PPE

5. A set of basic principles that have been applied in developing this SOP on Pre
participation screening are as follows:-

(a) Consent of the athlete

(b) Scientific and evidence based medical criteria

(c) Primary interest of the athlete

(d) Responsibilities of a physician trained in Sports Medicine

(e) Decision considering individual factors like geographical region, sport

played, position, competition level, age and gender of the athlete.

(f) Respect the privacy of the athlete.

(g) Informed decision involving athlete, coaches and parents.

Timing and Frequency of PPE

6. The primary goal of PPE is to assess for medical condition that promotes safe
participation in the sport/ event and hence timing of the examination is crucial. The PPE
must be done before participation in sports per se and must include periodic medical
examination to assess the athlete longitudinally (1,5). The timing of PPE may be as shown
below:-
(a) Pre-Season:- An appropriate time to perform a pre participation medical
screening as this provides an opportunity to meet the new players/ coaches, plan
injury prevention programs along with the team, educate the players on anti-
doping procedures / supplements use and reassess injured athletes. The
advisable time frame by American Medical Society for Sports Medicine (AMSSM)
in their interim guidance for Pre participation screening during COVID-19
pandemic is at least 6 weeks before start of practice (5).

(b) End of season:- A shorter focused medical screening is performed to

assess for any injuries, initiate injury rehabilitation and formulate an exercise
program during off-season to prevent detraining effects.

(c) Targeted Screening Exam:- Depending on the sports and competition,

targeted pre-participation screening for medical conditions are done prior to
participation in the event.
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Follow‐Up

7. Following a detailed PPE annually, a shorter version of follow up medical screening

can be done prior to events that focus on any injuries or illnesses that have occurred since
the entry examination (1). The PPE frequency/timing also may change with COVID-19 and
other healthcare requirements. This information from federations need to be updated by
the Sports Physician performing the PPE (5). Tele-health questionnaire based check-ups
can be performed or the Physician can do in-person physical medical check-ups as per
the guidelines of the Sports Federations.

MEDICAL CONDITIONS AFFECTING SPORTS PARTICIPATION (1)

Medical Condition Recommendation for participation

Atlantoaxial instability Medical evaluation necessary

Bleeding disorder, blood thinning Medical evaluation necessary. Contact sport
medications usually discouraged
Cardiovascular disease

 Myocarditis/Cardiomyopathy  All exercise contraindicated

 Hypertension  Those with severe hypertension (>99th
percentile for age plus 5 mmHg) should
avoid heavy weight and power lifting,
bodybuilding, strength training and sports
with a high static component. Those with
sustained hypertension (>95th percentile for
age) need medical evaluation
 Congenital heart disease  Medical evaluation necessary
 Arrhythmia  Medical evaluation necessary
 Heart murmur  Medical evaluation necessary
Structural/acquired heart disease

 Hypertrophic cardiomyopathy  All exercise normally contraindicated

 Coronary artery anomalies
 Arrhythmogenic right
ventricular cardiomyopathy
 Acute rheumatic fever with
carditis
 Ehlers-Danlos syndrome, AV
vascular malformations
 Marfan syndrome
 Mitral valve prolapse
 Anthracycllne use
 Vasculitis/vascular disease
Cerebral palsy
 All exercise normally contraindicated
 All exercise normally contraindicated
 All exercise normally contraindicated
 All exercise normally contraindicated
 Medical evaluation necessary
 Medical evaluation necessary
 Medical evaluation necessary
 Medical evaluation necessary
Medical evaluation necessary
Diabetes Mellitus
Infectious diarrhea
Eating disorders
Eye conditions
 Functionally one-eyed athlete
 Loss of an eye
 Detached retina or family
history of retinal detachment at
a young age
 High myopia
 Connective tissue disorder,
such as Marfan or
 Stickler's syndromes
 Previous Intraocular eye
surgery or serious eye Injury
 Infectious conjunctivitis
Fever
Gastrointestinal conditions
 Malabsorption syndromes
(coeliac disease, cystic
fibrosis)\
 Short bowel syndrome or other
disorders requiring specialised
nutritional support including
parenteral or enteral nutrition
Hepatitis, infectious
Human immunodeficiency virus
(HIV) infection
Participation normally allowed with proper
attention to diet, blood glucose concentration.
hydration and insulin therapy
All sports normally contraindicated, unless
symptoms are mild and the athlete is fully
hydrated
Medical and psychological evaluation
necessary. Sports participation contraindicated
when athlete is not compliant with therapy and
follow-up, or where there is evidence of
diminished performance or potential injury
because of eating disorder
Medical evaluation necessary. Protective
eyewear may be appropriate, although in some
sports (e.g. boxing, martial arts) it is not
permitted
May be unfit for sports requiring binocular
vision
Swimming contraindicated
All exercise contraindicated
Medical evaluation necessary
Medical evaluation necessary
Participation normally allowed in all sports
where the athlete's state of health permits and
acute symptoms absent. Athletes should
receive Hepatitis B immunization and universal
precautions should be used when handling
blood or body fluids with visible blood
Participation normally allowed in all sports
where the athlete's state of health permits and
acute symptoms absent. Universal precautions
should be used when handling blood or body
fluids with visible blood. Sports with a high risk
of viral transmission (e.g. boxing and wrestling)
should be avoided
Infectious mononucleosis-acute or
with splenic enlargement
Absence of one kidney
Acute liver enlargement
Chronic liver enlargement
Malignant neoplasm
Neurological disorders
 History of serious head or
Spine trauma or abnormality,
including Craniotomy, Epidural
bleeding, Subdural
haematoma, Intracerebral
haemorrhage, Second-impact
syndrome, Vascular
malformation and Spine
fractures
 History of simple concussion
 Myopathies
 Seizure disorder with risk of
seizure during participation
 Organ transplant recipient (and
those taking
immunosuppressive
medications)
 Pregnancy
Moderate/intense exercise and participation in
collision and contact sports contraindicated
Medical evaluation necessary for collision,
contact and limited-contact sports. Protective
equipment may be available to protect the
remaining kidney.
All exercise normally contraindicated
Medical evaluation necessary, particularly for
collision, contact and limited-contact sports
Medical evaluation necessary
Medical evaluation necessary
Medical evaluation necessary. Research
supports a conservative approach to
concussion management, including no athletic
participation while symptomatic or when deficits
in judgment or cognition are detected, followed
by a graduated sequential return to full activity
Medical evaluation necessary.
Athlete needs individual assessment for
collision, contact or limited-contact sports. The
following non-contact sports should be avoided:
archery, shooting, swimming, weight or power
lifting, strength training, or sports involving
heights or high velocities (e.g. cycling, motor
racing). In these sports, occurrence of a
seizure during the activity may pose a risk to
self or others
 Medical evaluation necessary, particularly
for collision, contact and limited-contact
 Medical evaluation necessary. As
pregnancy progresses, modifications to
usual exercise routines will be necessary.
 Activities with a high risk of falling or
abdominal trauma, scuba diving and
activities posing a risk of altitude sickness
should be avoided. Postpartum, physiologic
and morphologic changes of pregnancy
take 4-6 weeks to return to baseline

Respiratory conditions

 Pulmonary compromise,  Medical assessment necessary,

Including Cystic Fibrosis participation normally allowed. Athletes with
cystic fibrosis have an increased risk of heat
illness

 Asthma  Medical assessment necessary prior to

scuba diving

 Acute upper-respiratory  Upper-respiratory obstruction may affect

infection pulmonary function. Athlete needs individual
assessment for all but mild disease. If fever is
present, all exercise is

 contraindicated
Rheumatologic diseases

 Juvenile Rheumatoid Arthritis,  Medical assessment necessary

Juvenile
Dermatomyositis, ldiopathic
Myositis or Systemic Lupus
Erythematosus
 Care should be taken when exposing
 Raynaud's phenomenon
hands and feet to cold
Sickle cell disease
Medical assessment necessary. In
general, if status of the illness permits, all
sports may be played; however, any sport or
activity that entails overexertion, overheating,
dehydration and chilling should be avoided.
Participation at high altitude, especially when
not acclimatized, also poses risk of sickle cell
crisis.

Skin infections-including Herpes During contagious period, participation in

Simplex, Molluscum Contagiosum, gymnastics with mats, martial arts, wrestling or
Verrucae (warts), Staphylococcal and other collision, contact or limited-contact sports
Streptococcal infection is contraindicated
(Furuncle/Boils, Carbuncle, Impetigo,
Methicillin Resistant Staphylococcus
Aureus/Cellulitis/ abscess/Necrotizing
fasciitis), Scabies, Tinea

Enlarged spleen If the spleen is acutely enlarged, participation

should be avoided because of risk of rupture. If
 the spleen is chronically enlarged, individual
assessment is needed before collision, contact
or limited-contact sports are played

PPE STRUCTURE
 Pre -Participation
Evaluation

To be evaluated by
To be filled by Athlete
Sports Physician

General Physical
Personal particulars
Examination

Systemic Examination
–
Medical History
RS, CVS, Abdomen,
CNS

Musculo-Skeletal
Family History
Examination in detail

Laboratory
Mental Health History
Investigations

Physician Details and

Treatment History
Remarks

Declaration by the
Athlete

Note:-
1. PPE may be performed by any qualified Physician but Final certification for Sports
will be given by a duly qualified (MCI recognized) Sports Physician only.

2. PPE should be done with an Athlete health first policy and external factors like
game, coach, management etc should not be a factor in the decision making process.

3. Any conditions not listed above may be certified as per opinion of a Specialist in the
concerned field and finally by a Sports Physician.

4. Specialist opinion of specialists/ specialized investigations may be obtained prior to

final clearance of the athlete.

5. The final clearance may mention Fit for Sport/ Fit with restrictions/ Unfit for Sport as
the case may be.

6. The above SOP is a guideline only and the final medico legal and ethical clearance
shall rest upon the Sports Physician. In case of any dispute the case may be referred to
the CAIMS/NRRT as deemed appropriate.

Acknowledgements:-

PPE Form - Col (Dr) Sandipan DasSarma

SOP - Wg Cdr (Dr) CS Guru & Col (Dr) Anup Krishnan

REFERENCES:-
1. Brukner P. Brukner & Khan’s Clinical Sports Medicine: Injuries/ Peter Brukner. 5th
ed. Vol. Injuries. McGraw-Hill Education (India) Pvt Ltd; 2017. 991–1001 p.

2. Dursun M, Bilir E, Kaymaz K, Sakarya S. Pre-participation screening of the athletes

in Turkey: approach of primary care physicians. Eur J Public Health.
2019;29(Supplement_4):ckz186-421.

3. Baggish AL. Pre-participation athlete screening: there is no’one size fits all’.
OXFORD UNIV PRESS GREAT CLARENDON ST, OXFORD OX2 6DP, ENGLAND;
2016.

4. Castelletti S, Solberg EE. Pre-participation sport screening: Don’t miss focus. Eur J
Prev Cardiol. 2020;2047487320931641.

5. Diamond AB, Narducci DM, Roberts WO, Bernhardt DT, LaBella CR, Moffatt KA, et
al. Interim Guidance on the Preparticipation Physical Examination for Athletes During the
SARS-CoV-2 Pandemic. Curr Sports Med Rep. 2020 Nov;19(11):498–503.