Physical Examination for Athlete

dr. M.Ikhwan Zein, Sp.KO

 EXPOSURE
Physical &
Psychological
Training & Competition

ATHLETE
Subject of Sports Medicine

Kurniarobbi J, Kurniawan A. Establishing Sports Medicine Team. 2010

Physical Examination for Athlete

Physical
Examination

Health/medica
Performance
l

To help Optimal
maintain the training &
health and enhancing
safety of performance
athlete
MEDICAL EXAMINATION
IN
ATHLETE
Time And Frequency
Pre Participation Examination (PPE)

• Prior to participation in high school, college / start

professional level

Periodic Health Examination

• During active athlete (every 6 month – 1 years)

Evaluation Area
No System
1. cardiology
2. pulmonary
3. Neuromuscular
4. Hematology
5. Gastrointestinal
6. Endocrine/metabolic
7. Urological
8. Opthalmological
9. Dermatological
10. Ear, nose, throat
11. Dental

6
Components

Anamnesis &
History Taking Dental

Physical
Examination Laboratorium

• Whaley M H. ACSM’s Guidelines for exercise testing and prescription 7 th ed. 2006. USA: Lippincott Williams&
Wilkins
• The International Olympic Committee (IOC) Consensus Statement on Periodic Health Evaluation of Elite 7
Athletes, March 2009
Anamnesis
& History
Taking
1. Baseline Data
 Identity, age, sex, kind of sports
 Vital Sign : Blood Pressure, Frequency rate, heart rate,
temperature
 Body Composition
◦ Body Mass Index
◦ Waist circumference
◦ % Body Fat
Blood Pressure in Children

Second task force on Blood Pressure control in children

Cleared for participation Not be cleared for participation (until

further evaluation)
•Children with significant HTN • Children with severe HTN
•Adult with HTN stage I (140-159/90-99 • Adult with HTN stage II (> 159/99)
2. Anamnesis
 Medical History is the most important part of health examination
 Medical history can identify 75% problems affecting athletes,
including chronic conditions and medications that may require
adjustment or closer monitoring
 Scheduled at least 6 weeks before sports season starts  allow
time for follow up testing or consultation
 Structured and systematic
 All body system, mainly :
◦ Cardiorespiratory
◦ Neuromuscular
 Including bahaviour ec : smoking, alcohol, sleeping habit, anxiety
level, drug & medicine consumption (steroid, vitamin etc)
a. cardiovascular system

AHA recommended a 12-parts evaluation of

the heart

Consist of 8 history question and 4 physical

exam component

Syncope, chest pain and dyspnea

particularly if associated with exertion, may
be signs of underlying cardiac disorders that
warrant confirmatory testing

85% sudden death Sudden cardiac

Screening school aged
in young athletes death occur 1 in
200,000 high athletes for potential
are related to causes of sudden cardiac
cardiac abnormality school athletes
death is primary
objective of the PPE
SCA
 Sudden Cardiac Death
• Sudden cardiac death in athlete/caused by sports = 0.5 – 1 death per
100.000 person/years
• Italia : 2.1 death per 100.000 person
• Etiology :

• Cardiomyopathy (atlet)
• Acute Coronary Disease (non –athlete population)

Priori SG et al: Sudden cardiac death, 2006

Maron BJ: How should we screen competitive athletes for cardiovascular disease? 2005
Papadakis M et al: Preparticipation screening for cardiovascular abnormalities in young competitive athletes, 2008
Sudden Cardiac Death in Athlete
Cardiomyopathy

Detected by Electrocardiography or
echocardiography
b. Respiratory System : Asthma, Exercise induced Asthma
 Patient with EIA are normally asymtomatic at rest with no disturbance of
peak expiratory flow
During Exercise :
1. Cough Pulmonary
2. Chest thightness
function test
3. Wheezing
4. Dyspnea to confirm EIA
5. Loss of endurance

 Any athlete who reports symptom of asthma, whether or not it is

exercise-induced, requires treatment to prevent serious respiratory
sequelae
In up to 80% of
EIA affects 10- athlete with EIA, use
50% of athletes, of inhaled short acting
depending on the beta agonist prior to Identifying any respiratory
sport participation to
prevent symptom conditions is vital to ensure
adequate treatment and
optimal performance
c. Neurology

Identify a history of concussion,

nerve injury, neurogical deficit
Ask about neuropraxia (also
known as a “stinger” or “burner”)
Identify patients who require
further evaluation

Head injury
Concussion is and Neuropraxia
sustained by Prevent future
concussion is sustained
6.5-18.5% of can lead the by 50-65% of injury and to avoid
injuries in risk for college rugby worsening of a
collegiate second player current disability
contact sports impact
syndrome
d. Body Image and Mental Health
e. Female athlete triad
 When examining young women, be alert to signs and
symptom of the female athlete triad (a syndrome of
disordered eating, amenorrhea and osteopenia or
osteoporosis)
 A study noted that nearly 6% of young female athletes met
the criteria for 2 of 3 components of the triad, and as many
as 20% had at least 1
Female athlete triad
 Health probelem in female athlete (marathon, gymnastic, martial art)
 Triad : anorexia, amenorhea dan osteoporosis

High volume of training

Body
image

Body fat decrease (over

the lower limit)
Poor
nutrition
/intake
Hormonal disturbance

Amenorhea ,
osteoporosis and multiple
fracture
 Physical
Examination
Physical Examination
 Head to Toe
 General Physical Examination (IAAP), mainly focusing in :
◦ Cardiopulmonary Examination (incl. marfan syndrome)
◦ Musculoskeletal examination
 Simple neuromuscular test : Look, Feel, Move
 Special orthopedic examination
 Gait examination
 Leg Length Discrepancy
 Valgus-varus knee
 Foot abnormalities (High arch & flat foot)
 Posture assessment
Physical Examination : Eyes/ears/nose

Examine the eyes Examine the ears Examine the nose

• Check vision, both with • evaluation of the ears, • Examines the nares,
and without corrective including tympanic inspecting the septum
lenses membranes and for sign of deviation or
external auditory perforation
• Student whose canals
corrected vision is • A swimmer with
20/50 or worse in 1 perforated tympanic
eye must wear full eye membrane should be
protection during adviced to wear ear
athletic activities plugs to protect the
middle ear
• Attention to the
presence of cauliflower
ear for any athlete
who plans to join a
wrestling
Cardiovascular : The Heart
Listen to all 4 standard regions, with patient in
both supine and standing position

If detect a murmur, perform auscultation while the patient

squats and while performing the valsava manuver

Hypertropic cardiomyopathy

Systolic murmur

Increasing with standing and the valsava manuver

Decreasing with squatting and supine position

Murmur that is 3/6 or greater in sound or characteristic of HCM needs further

evaluation

Palpate the femoral pulses. Absence of, or decreased, femoral pulses

compared with brachial pulses may suggest coartio of the aorta
Lungs, abdomen and Skin

Examine the Examine the Asses the condition

Examine the lung
abdomen genitourinary of the skin

• Auscultate the • assess the • Check for the • Infectious skin

breath sound presence of presence of both condition should
organomegaly testicle and be treated before
• Any patient with • Mononucleosis is palpate for the athlete
abnormal breath associated with a masses and participated
sounds requires 0.1-0.2% rate of inguinal hernia
further evaluation spleen rupture
• Athlete with • A patient with a
organomegaly solitary testicle
should not be will require
cleared for protective gear to
athletic activity prevent injury
without further
evaluation
Conduct a General Neuromuscular Examination
Musculoskeletal
examination
• Evaluation of strength and
mobility of each joint and
muscle group
• consider prescribing a brace
or physical therapy for
patient with ligamentous
laxity
Neurological examination
• often paired with the
musculoskeletal exam
• Its considered adequate if the
patient possesses full strength
in all muscle group
• A patient with a history of
multiple stingers may warrant a
more detailed examination in
strength, reflex and sensation in
upper extremities to screen for
signs of residual nerve injury
• A patient with history of
multiple concussions need more
detailed exam, include : the
cranial nerve, evaluation of
balance, and possibly baseline
neuropsychological testing
Simple Musculoskeletal Examination
 Check any Pain, Range of Motion (ROM) and Strength
 Simple method :
◦ LOOK : swelling, hematoma, scar, abnormal alignment etc
◦ FEEL : Palpate for any pain, tenderness, warm surface
◦ MOVE : check all ROM and strength both of side (for
comparison)
Orhopedic Exam
Identify Marfan Syndrome
Tall and thin

Arm span
exceeds his
height

cardiac
abnormality

Can be identified
by medical check
up
 It is important to identify marfan
syndrome because of the effect of it
on the CV system
 Individuals with this disorder have an
increased risk for valvular disorder
and for aortic dilatation that can lead
to dissection or rupture
Skeletal and cardiac abnormality
Pectus carinatum or excavatum
Arm span to height ratio > 1.05
Arachnodactyly
Pes planus
Scoliosis
Reduced elbow extension
Highly arched palate
Murmur or mitral valve prolapse or regurgitation
Check Musculoskeletal Abnormalities ;
Valgus or Varus Leg
Musculoskeletal Abnormalities :
LEG LENGTH DISCREPANCY
 Panjang tungkai:
◦ True leg length: panjang tungkai yang sesungguhnya;
diukur dari Spina Iliaka Anterior Superior (SIAS) ke
maleolus medial,
◦ Apparent leg length: panjang tungkai yang tampak;
diukur dari umbilikus ke maleolus medial.
 Leg length discrepancy (LLD): kondisi dimana
panjang ekstremitas bawah tidak sama antara
kanan dan kiri.
 Secara klinis, penanganan terhadap LLD tidak
membutuhkan pembedahan apabila
perbedaan panjang tungkai tidak lebih dari 2
cm.
LEG LENGTH DISCREPANCY

Perbedaan panjang tungkai fungsional:
◦Populasi umum: 60%
◦Tim atletik: ± 90%
◦Tim basket di tingkat universitas (collegiate basketball): belum ada
angka pasti, tetapi telah ditemukan beberapa kasus perbedaan
panjang tungkai fungsional karena gerakan lompat berulang dan
mendarat dengan satu kaki.


Kelainan yang berhubungan dengan Leg Length Discrepancy:
◦Nyeri punggung bawah (low back pain)
◦Skoliosis
◦Patologi panggul, lutut, dan kaki
◦Stress fractures
◦Osteoartritis.
Foot Abnormality
Metode Pemeriksaan Arkus Plantaris

1.Radiology (x-ray)
2.Caliper
3.Digital photo
4.Footprints
Modifikasi Wet Foot Test
Penilaian Hasil Footprints

 Keunggulan:
◦ Mudah & murah
 Kerugian:
◦ Sulit diintepretasikan dan dibuat standardisasi
 Metode penilaian footprints dari Rao, 1992:

 Bila jarak terlebar dari A ke B kurang

dari 1 cm, maka masuk kedalam
kategori Flatfoot (kanan)
 Bila jarak terlebar dari B ke C kurang
dari 1 cm, maka masuk kedalam
kategori High Arch (tengah)
 Semua yang tidak termasuk kategori
diatas, masuk kategori normal (kiri)
Posture
Postur Tubuh
Definisi:
 Postur : posisi atau kesejajaran dari bagian-bagian tubuh
(Thibodeau & Patton, 1993)
 Postur merupakan keselarasan dari bagian-bagian tubuh
baik pada saat berdiri, berbaring, duduk ataupun bergerak.
Postur yang baik adalah yang memungkinkan bagian-bagian
tubuh berfungsi seefektif mungkin dengan mengeluarkan
energi seefisien mungkin dan menimbulkan stres seminimal
mungkin pada tubuh (Corbin et al, 2009)
Laboratorium
 Cardiovaskular
◦ EKG Resting
◦ EKG Stress test
◦ Echocardiografi
 Pulmonary
◦ Ro Thorax  Indonesia TB no 5 di dunia
◦ Spirometri
 CT scan & MRI  Atas indikasi?
 Lab darah
Cardiovascular

Electrocardiography Echocardiography
Pulmonary
 Lung Function test
 Highlight
◦ Asthma, Exercise induced asthma
◦ Tuberculosis
 2011  Indonesia 5th rank of TBC endemic in the world
 Start from kids
 Significant to decrease performance
Abnormal Normal

Spirometry
X-Ray, MRI, or CT Scan
 Indication needed (not a routine exam)
 Commonly for injury diagnosis
◦ X-ray : Bone fracture, joint dislocation
◦ MRI : Soft tissue injury (ligament & Tendon rupture,
meniscus tear)
◦ US G Musculoskeletal : Muscle tear (strain)
Laboratorium
Complete Haematology

Serum Iron (Fe)

Liver function
• SGOT & SGPT

Renal function
• Ureum, Creatinin, Uric Acid

Lipid Profile
• Cholesterol, LDL, HDL, Trigliseride

Glucose profile
• Fasting blood glucose, 2 hours pp,

Hepatitis
• HBsAg, Anti HBs

Other infection
• Malaria, Typhoid, Dengue, TB, other tropical infection?
Dental care
 Routine check every 6 month
 Caries, 3th molar impact
Make a determination : Should the patient be cleared?

 Clearance falls into 4 categories :

1. Clearance without restriction

2. Clearance with recommendations

for further evaluation or treatment

3. Not cleared; restricted until completion

of further testing/consultation

4. Complete restriction from certain or all

sports

 Majority of student athletes qualify for clearance without restriction.

3-10% require further evaluation prior to sports clearance, and less
than 1 % are disqualified
PHYSICAL FITNESS TEST
IN
ATHLETE
Kebugaran Fisik
Kebuga
ran
Jantun
g paru

Kelincah
an
Kompo
Health Related Fleksibi
sisi Fitness litas Waktu Keseimb
Tubuh
reaksi angan
Skills
Kekuat Related
an dan
Ketaha
Kecepat
Fitness Daya
nan ledak
Otot an
otot

Koordin
asi
 Kelincahan
Daya Ledak otot
Keseimbangan• Athletic fitness
Kecepatan
Koordinasi
Waktu reaksi

Komposisi tubuh • Physical fitness

Fleksibilitas
Kekuatan dan daya tahan otot
(traditional)
Kebugaran jantung paru
Contoh Px.Kebugaran PPITKON

Balance Kelincahan
Antisipasi

Power kekuatan Kardio

Leg Length Discrepancy
Posture & Balance
Fungsional Test
Flexibility
QUESTIONS & ANSWERS