The preparticipation athletic exam process.

Annotation: The resources related to surveying of athletes, the triage and the decision-making related to athletic participation remains varied and confusing. At secondary school levels, there is disagreement and local variation, especially in the efforts to screen for cardiovascular disorders and potential problems. Dr. Reed offers his thoughts as a state leader in South Carolina in this area.

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The preparticipation examination (PPE) for too long has been a mandatory yearly athletic examination and not the foundation for continuous athletic care. Unless the periodic history and physical examination becomes an integral part of athletic health care delivery, it may become a perfunctory examination looking for relevance. Questions about the efficacy of the routine physical examination have already been raised by the Institute of Medicine. The purpose of a preparticipation examination should be to detect underlying or preexisting conditions that may predispose the athlete to life-threatening or disabling events. This should be a screening examination and cannot take the place of a complete history and physical performed by a personal physician who is able to discuss age-appropriate concerns in a private and confidential environment. As a screening examination it should identify individuals with health risks or unrecognized disease relevant to sport participation by applying rapid and simple tests or examinations to differentiate asymptomatic or subtly affected individuals from normal. (1) Whether performed by an athlete's personal physician, by team physicians, or as a station examination by a group of physicians and other health care providers, it is the detailed history that the athlete and the athlete's family submit before the examination that provides the greatest yield. All aspects of the physical examination must be directed at confirming the accuracy of the history and determining the presence of abnormalities, which may require more history.

Background

The athletic examination has been performed in many forms and levels of sophistication. In its purest form it has come to symbolize the process of protecting the health and safety of the athlete in competition, and training and practice for that competition. In some settings it is the annual physical. To some it is the entree to the health care process and an opportunity for counseling on health-related issues. For some it is merely a legal or insurance requirement. (2) Whatever the benefits of this time-honored process, the PPE remains a screening examination, and its other limitation is that it is a static evaluation for a dynamic state of high-level physical activity. This paradox has led to current concerns for validity and reproducibility. Should future efforts be focused on more dynamic assessment?

Previous Positive Efforts

Most authorities agree that the history should at least contain the recommendations of the lead organizations involved in athletic care (AAFP, AAP, AMSSM, AOSSM, and AOASM), found in a monograph published in its second edition in 1997. (3) This has led to a standard form only in a few settings, but has not been updated. A third edition will be entertained in the fall of 2003. However, better screening questions for potential cardiac catastrophe, (4) unrecognized head injury, (5) prior injury, and for problems unique to the female athlete (6) have been added in some states. An accurate and current history allows the physician to target the examination toward history of prior symptoms, illness, or injury. The "orthopaedic examination" has seen very little change, and is performed much like preemployment, insurance, or the admission "H and P". A musculoskeletal examination, like the two-minute musculoskeletal screen, (7) is frequently used. A more detailed examination can target where history and findings on screening lead. This has become the most efficient method of combining history and physical. It leaves much to be desired in areas of cardiac, neurologic, and health-risk behavior evaluation.

Although station examinations have had the advantage of creating consistency of recording and reporting, this information has not necessarily been used. In addition, this approach receives strong criticism from primary care physicians. Many team physicians use a modification of the station examination to utilize the complete athletic medical unit (8) to carry out portions of the examination.

For the Future

Controversy over when to order a 12-lead electrocardiogram and echocardiogram to identify abnormalities such as hypertrophic cardiomyopathy may be resolved by better examination criteria. (9) With the emphasis on body mass index (BMI) as a tool to identify obesity, this calculation should be entered with height and weight. It can then be used to monitor weight loss or gain and fluid requirements. Since our awareness of more subtle forms of minor traumatic brain injury and cumulative effects of concussion in high school athletes (10) has been raised by findings with improvements in sideline assessment, neuropsychological testing as part of the PPE may be warranted. (11)

Because the musculoskeletal examination is frequently cited as the most important part of the physical examination, a better initial screen could include the highest yield stability tests for shoulder, knee, and ankle. More is needed to quantitate prior injury. Adding an area to amplify the athlete's history of injury will allow the examiner to document prior injury through the examination, and grade the previous injury through a more thorough history, or by the ultimate impact or outcome, which takes into consideration time lost and treatment used. (12)

Pertinent information from the PPE should be available in a condensed form to athletic trainers or coaches with clinical paths outlined. The trainer or team physician could have a card generated from the completed PPE. It should contain emergency information, allergies, and the positive findings on the PPE. Individual information should be used by the coach or trainer to improve preseason conditioning and training, and to reduce in-season injury.

The wealth of information collected in the thousands of PPEs done each year should be incorporated into population studies or epidemiologic applications such as injury prevention. The availability of electronic recording methods may allow individually performed examinations to be grouped for data retrieval, yet maintain the confidential relationship of the patient and physician. Regulations from the Health Insurance Portability and Accountability Act of 1996 are not clear on the sharing of information with coaches and trainers, but waivers including all of the health care unit are recommended before carrying out the examination. Electronically generated data may lend itself to demographic information, outcome analysis, and performance measure. In compiling this data, we should improve our methods of examination and determine if our examinations truly measure what they are purported to.

If injury recording is kept current and documented as to disposition and status (injury surveillance), and intercurrent health history obtained and updated, the entire PPE process would not have to be repeated every year.

Whether you think that you can, or that you can't, you are usually
right.
--Henry Ford

Accepted May 21, 2004.

References

1. Sackett DL, Haynes RB, Guyatt GH, et al. Clinical Epidemiology: A Basic Science for Clinical Medicine. Boston, Little Brown & Co, 1991, ed 2, pp 153-172.

2. Maron BJ, Brown RW, McGrew CA, et al. Ethical, Legal and practical considerations affecting medical decision-making in competitive athletes. J Am Coll Cardiol 1994;24:854-860.

3. American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, Osteopathic Academy of sports Medicine. The PPE physical examination, in Preparticipation Physical Examination. Minneapolis, McGraw-Hill, 1997, ed 2.

4. American Heart Association. Cardiovascular preparticipation screening of competitive athletes. Circulation 1996;94:850-856.

5. Bailes JE, Cantu RC. Head injury in athletes. Neurosurgery 2001;48:26-45.

6. Committee on Sports Medicine and Fitness Medical Concerns in the Female Athlete (RE0003) Policy Statement. Pediatrics 2000;96:610-613.

7. Smith N. For the Practitioner: Orthopaedic Screening Examination for Participation in Sports (12 activities-2 minutes). AAP and Ross Laboratories, 1981.

8. Lyznicki JM, Riggs JA, Champion, HC, Certified Athletic Trainers in Secondary Schools: Report of the Council on Scientific Affairs AMA. J of Athletic Training 1999;34:272-276.

9. Marion BJ, Gordin JM, Flack JM, et al. Prevalence of hypertrophic cardiomyopathy in a general population of young adults: echocardiographic analysis of 4111 subjects in the CARDIA study. Circulation 1995;92:785-789.

10. Collins MW, Lovell M. Cumulative effects of concussion in high school athletes. Neurosurgery 2002;51:1175-1179.

11. Collins MW, Iverson GL. On-field predictors of neuropsychological and symptom deficit following sports-related concussion. Clin J Sports Med, in press.

12. Reed FE. Improving the preparticipation exam process. J S Carolina Med Assoc 2001;97:342-346.

Frederick E. Reed Jr, MD

From the Medical University of South Carolina, Peninsula Orthopaedics, Charleston, SC.

Reprint requests to Frederick E. Reed Jr, MD, Clinical Professor, Medical University of South Carolina, Peninsula Orthopaedics, 125 Doughty, Suite 170, Charleston, SC 29403.