The Preparticipation Physical Exam Kelsey Logan MD MPH

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The Preparticipation Physical Exam Kelsey Logan, MD, MPH, FAAP, FACP OSU Sports Medicine Improving

The Preparticipation Physical Exam Kelsey Logan, MD, MPH, FAAP, FACP OSU Sports Medicine Improving People’s Lives through innovations in personalized health care

§ I have nothing to disclose. OSU Sports Medicine

§ I have nothing to disclose. OSU Sports Medicine

Overview § Why do a PPE? § History components § Musculoskeletal exam § Medical

Overview § Why do a PPE? § History components § Musculoskeletal exam § Medical exam Hot topics OSU Sports Medicine

§ Published 2010 § Collaboration between AAP, AAFP, ACSM, AMSSM, AOASM § Endorsed by

§ Published 2010 § Collaboration between AAP, AAFP, ACSM, AMSSM, AOASM § Endorsed by AHA, NATA OSU Sports Medicine

What’s it for? § PPE Objectives Screen for life-threatening or disabling conditions Screen for

What’s it for? § PPE Objectives Screen for life-threatening or disabling conditions Screen for conditions that may predispose to injury or illness § Get adolescents/young adults into the health care system § Determine general health § Discuss health and lifestyle issues MEDICAL HOME! OSU Sports Medicine

Other Goals Fulfillment of legal and insurance requirements Establishing physician rapport with athletes Providing

Other Goals Fulfillment of legal and insurance requirements Establishing physician rapport with athletes Providing counseling to athletes Establishing a database and record-keeping system Armsey et al, CJSM, 2004 OSU Sports Medicine

PPE Purpose § Most physicians think PPE is not meant to take place of

PPE Purpose § Most physicians think PPE is not meant to take place of yearly health maintenance exam by PCP Was never intended nor designed to replace regular health maintenance exams § What do the athletes think? Most consider the PPE as an appropriate alternative to full evaluation § Parents? Most perceive PPE as a complete medical evaluation Greydanus et al. , Med Sci Mon, 2004 OSU Sports Medicine

PPE Frequency § Varies § 35 states require yearly exam – Ohio included §

PPE Frequency § Varies § 35 states require yearly exam – Ohio included § 11 states require every other year exam § 3 states require exam every year with interval questionnaire in non-exam years Wingfield, CJSM, 2004 § Recommended Every 2 years in younger athletes Every 2 -3 years in older athletes Annual update: history questionnaire, focused exam if needed OSU Sports Medicine

§ Great Britain PPE’s not widely practiced Thought to be ineffective § Italy Aggressive

§ Great Britain PPE’s not widely practiced Thought to be ineffective § Italy Aggressive approach Ages 12 -35: annual medical clearance Detailed H&P, ECG, EST, PFT’s Echo required in professional soccer, boxing, cycling Physicians can be held accountable in criminal/civil court for incorrect/missed diagnosis OSU Sports Medicine

Who can/should perform the PPE? § Varies by state Ohio: MD, DO, DC (NP

Who can/should perform the PPE? § Varies by state Ohio: MD, DO, DC (NP or PA with physician) § AAP recommends MD, DO having ultimate responsibility § Multiple consensus statements supporting MSSE 2000, AJSM 2000, MSSE 2001 § Complete screen for problems potentially affecting participation or placing athlete at risk § Standardized forms help OSU Sports Medicine

OSU Sports Medicine

OSU Sports Medicine

OSU Sports Medicine

OSU Sports Medicine

PPE Setting § The PCP has the advantage Allows for private discussion of sensitive

PPE Setting § The PCP has the advantage Allows for private discussion of sensitive topics Gives more time for patient education Allows for comprehensive ROS, more direct questioning regarding family history Able to talk about psychosocial functioning/problems § ? Disadvantage Knowledge of how any history/exam findings affect the athlete in sport OSU Sports Medicine

PPE Setting § If no PCP? § Station approach Can reduce costs for student-athletes

PPE Setting § If no PCP? § Station approach Can reduce costs for student-athletes Fosters line of communication between members of sports medicine team Allows participation from athletic trainers, team medical and orthopedic staff, subspecialists Facilitates screening large number of athletes in relative efficiency § Optimize it! Physician medical coordinator – needs to sign off on all Get good history from parents Ensure privacy in exam areas; provide area for counseling Clear referral protocol to primary and subspecialty physicians Help athletes with needed follow-up Keep records OSU Sports Medicine

Clearance § Clearance to play with no restrictions § Cleared to play following further

Clearance § Clearance to play with no restrictions § Cleared to play following further evaluation, treatment, or rehabilitation § Not cleared to play certain types of sports Rare for athletes not to be cleared 1. 9% of high school athletes ruled ineligible as result of the PPE Smith, Mayo Clin Proc, 1998 OSU Sports Medicine

§ Musculoskeletal abnormalities accounted for 43. 4% of athletes not cleared § Cardiac abnormalities

§ Musculoskeletal abnormalities accounted for 43. 4% of athletes not cleared § Cardiac abnormalities accounted for 18. 9% 2 athletes with severe HTN 1 with syncope 6 with dizziness/near-syncope 1 after heart operation None had family history of cardiac death OSU Sports Medicine

§ Vision abnormalities accounted for largest population of Cleared with Follow-Up Recommended dispositions –

§ Vision abnormalities accounted for largest population of Cleared with Follow-Up Recommended dispositions – 53. 5% § Musculoskeletal problems accounted for 27. 8% OSU Sports Medicine

The Most Important Part of the PPE § History § Exam History Wins! •

The Most Important Part of the PPE § History § Exam History Wins! • 88% of medical conditions identified by history alone • 67% of musculoskeletal conditions identified Chun, CJSM, 2006 OSU Sports Medicine

The History is the Cornerstone…is it reliable? § Athlete’s reliability should not be taken

The History is the Cornerstone…is it reliable? § Athlete’s reliability should not be taken for granted § Inaccuracies may lead to unwarranted clearance § Carek, CJSM, 1999 Examined whether discrepancies exist between information given by parents and student athletes Only 19. 8% of histories were in complete agreement Many discrepancies found in cardiovascular and musculoskeletal questions § Risser, Tex Med, 1995 Showed 33% HS athlete-parent agreement, 44% junior high § If station-based physicals used, encourage parental involvement in history form completion § In office-based physical, have parent present for review of medical history, family history OSU Sports Medicine

History Components § Medical Recent/chronic problems Hospitalizations Surgical procedures Prescription/nonprescription medications Allergies or anaphylactic

History Components § Medical Recent/chronic problems Hospitalizations Surgical procedures Prescription/nonprescription medications Allergies or anaphylactic reactions to medications, insects, foods, exercise OSU Sports Medicine

History Components § Cardiac: family history, chest pain, (near) syncope § Skin: warts, fungus,

History Components § Cardiac: family history, chest pain, (near) syncope § Skin: warts, fungus, blisters § Neurologic: HA, concussion, seizures § Heat Illness – heat cramps, dehydration, etc. § Use of Special Equipment § Asthma and seasonal allergies Prevalence of exercise-induced bronchospasm -35% of athletes Mick, Dimeff, CCJM, 2004 OSU Sports Medicine 10

History Components § Eyes Functionally one-eyed defined as having less than 20/40 corrected vision

History Components § Eyes Functionally one-eyed defined as having less than 20/40 corrected vision in one eye § Musculoskeletal system Sprains, strains, fractures, dislocations § Weight concerns § Psychosocial issues § Immunizations § Menstruation – screening for female athlete triad components oligo/amenorrhea, bony stress injury, disordered eating OSU Sports Medicine

The Physical Exam § Important areas Blood pressure Vision screening Musculoskeletal screening Cardiovascular screening

The Physical Exam § Important areas Blood pressure Vision screening Musculoskeletal screening Cardiovascular screening OSU Sports Medicine

Orthopedic Screening § 2 -minute, 12 step EXAM: Sensitivity: 50. 8% Specificity: 97. 5%

Orthopedic Screening § 2 -minute, 12 step EXAM: Sensitivity: 50. 8% Specificity: 97. 5% to identify orthopedic problems § HISTORY found to have 91. 6% sensitivity Gomez et al, AJDC, 1993 OSU Sports Medicine

The Musculoskeletal Exam/Issues § Take a history! Missed practice or games Do you wear

The Musculoskeletal Exam/Issues § Take a history! Missed practice or games Do you wear a brace? Fracture (include stress fracture), dislocation History of imaging, injections, physical therapy § Exam If no previous injury or complaint, general screen ROM, strength, muscle asymmetry Joint specific exam may be needed OSU Sports Medicine

General Musculoskeletal Screen § General posture; symmetry § Neck range of motion § Resisted

General Musculoskeletal Screen § General posture; symmetry § Neck range of motion § Resisted shoulder shrug and shoulder abduction § Shoulder range of motion § Elbow range of motion § Forearm/wrist range of motion § Clench fist, spread fingers OSU Sports Medicine

§ Inspection of athlete from behind § Back flexion and extension § Duck walk

§ Inspection of athlete from behind § Back flexion and extension § Duck walk § Heel, toe stance/walk OSU Sports Medicine

Joint Specific Exams § Low yield in asymptomatic athletes without prior injury § Indicated

Joint Specific Exams § Low yield in asymptomatic athletes without prior injury § Indicated by history and general screen findings § Think about what sports the athlete is doing and preparing to do – may help focus exams Ex: shoulder, elbow in baseball player § Symmetry § Range of motion of all joints § Stability of shoulders, elbows, knees, ankles § Further joint assessment if problem found OSU Sports Medicine

Examples of Problems in Joint-Specific Exams § Spine: Scoliosis, pain on extension (think about

Examples of Problems in Joint-Specific Exams § Spine: Scoliosis, pain on extension (think about spondylolysis) § Shoulder: decreased internal rotation, signs of rotator cuff impingement, multidirectional instability § Elbow: pain over medial elbow (apophysitis, UCL injury) § Hip: poor hamstring flexibility, pain on rotation, tenderness over apophyses § Knee: patellar malalignment, hypermobility § Foot: pes cavus, rigid flatfoot, severe pes planus OSU Sports Medicine

Clearance Question § 16 yo female sophomore soccer player, history of right ankle sprain

Clearance Question § 16 yo female sophomore soccer player, history of right ankle sprain in club soccer over summer § What things do you want to know? When did it happen? Prior injuries? Mechanism of injury? Time missed? Current symptoms? Use brace/tape? § Exam shows decreased balance right foot, mild laxity in ATFL; able to run forward, backward, laterally OSU Sports Medicine

What do you do? § Is she cleared for soccer? Why? Consider severity of

What do you do? § Is she cleared for soccer? Why? Consider severity of injury, ability to compete safely Consider demands of sport § Cleared with restrictions/recommendations § Not Cleared § Further advice? Brace? Rehab? OSU Sports Medicine

Medical Exam § Follow up on history questions Ever been disqualified from sport? 1

Medical Exam § Follow up on history questions Ever been disqualified from sport? 1 -2% of athletes ever DQ’d from sport Ever been hospitalized? Do you have any problems you see a doctor for? Put history in context of specific sport OSU Sports Medicine

Hot Topics § Obesity Weight alone should not disqualify Want to get these kids

Hot Topics § Obesity Weight alone should not disqualify Want to get these kids moving! 66 -78% more likely to be obese at age 35 if obese at age 18 NIH, 2000 MSK exam: focus on hips, knees Counsel on heat injury avoidance OSU Sports Medicine

Supplements § Most athletes will not mention supplements on form Ask about ‘protein drinks’,

Supplements § Most athletes will not mention supplements on form Ask about ‘protein drinks’, recovery aids Good intro for energy drink discussion Most athletes don’t know what the ingredients are Discuss potential side effects Some medications banned in sport Many supplements tainted unknowingly: 15% may contain anabolic agents Geyer et al. Int J Sports Med, 2004 NCAA banned drug list OSU Sports Medicine

Sickle Cell Trait § Much press NCAA: D 1 testing mandatory, DII/III coming No

Sickle Cell Trait § Much press NCAA: D 1 testing mandatory, DII/III coming No evidence screening prevents death § SCD: Avoid contact, collision sports, strenuous sports § Everyone should be asked about history of trait Ask about history of heat illness § Appropriate counseling, individual clearance based on history § Deaths reported with strenuous activity with altitude or heat stress § Avoid exhaustive exercise while still acclimatizing § Avoid dehydration OSU Sports Medicine

Concussion § History Personal history of concussion 53% by high school Field et al.

Concussion § History Personal history of concussion 53% by high school Field et al. , J Ped, 2003 Many don’t recognize ‘concussion’ Length of recovery period, associated problems § Not just the number of injuries Presence of chronic headaches, academic or learning issues OSU Sports Medicine

Concussion Clearance § Never clear for contact sport if any symptoms present Ask about

Concussion Clearance § Never clear for contact sport if any symptoms present Ask about school, mood, sleep, headaches § When to DQ from sport? RARE (…Rare? ) When a concussion does not resolve (PCS) Physical, cognitive, emotional symptoms When concussions happen with less impact OSU Sports Medicine

Cardiovascular Screening § Many questions on history section § 75% of sudden death in

Cardiovascular Screening § Many questions on history section § 75% of sudden death in athletes due to CV issues 80% of those in high school and college athletes Maron, Circulation, 2006 § Higher occurrence in boys, African Americans From Maron, JAMA, 1996 OSU Sports Medicine

Cardiovascular History § Should ask about Chest pain Syncope Exercise tolerance Palpitations Heart murmur

Cardiovascular History § Should ask about Chest pain Syncope Exercise tolerance Palpitations Heart murmur history Elevated BP in past Family history of cardiac problems OSU Sports Medicine

CV Exam § Measure blood pressure § Listen for heart murmurs Supine, standing HCM

CV Exam § Measure blood pressure § Listen for heart murmurs Supine, standing HCM murmur increases with standing, Valsalva 30 -40% have murmur § Palpate radial and femoral pulses § Look for signs of Marfan syndrome Kyphoscoliosis, high palate, pectus, arm span greater than height, etc. OSU Sports Medicine

ECG, Echocardiogram § Very controversial AHA recommends against ECG, echo IOC, European Society of

ECG, Echocardiogram § Very controversial AHA recommends against ECG, echo IOC, European Society of Cardiology, support § Italian experience Based on limited ability of History/PE to detect CV abnormalities, adds 12 lead ECG Indicates 77% greater power for detecting HCM compared with AHA recommendations Estimates 3 x greater cost-effectiveness of Italian vs US screening strategy for HCM Corrodo et al. European Heart Journal 2005 OSU Sports Medicine

Obstacles to Screening with ECG/Echo § Large population of athletes § Major cost-benefit considerations

Obstacles to Screening with ECG/Echo § Large population of athletes § Major cost-benefit considerations § Cannot eliminate risks of competitive sports § Large number of false positive/borderline results § False negatives where subtle but important lesions go undetected OSU Sports Medicine

“Although we should continue our endeavors to identify better tests to detect athletes at

“Although we should continue our endeavors to identify better tests to detect athletes at risk, I think we would do the public a service to acknowledge that we simply cannot prevent the vast majority of sudden cardiac deaths that will affect (high school athletes). Giving the public an honest answer about the futility of our efforts in this regard may help lessen some of the anger and frustration over the tragedies that do occur. ” Karl Fields, Medicine & Science in Sports & Exercise, 2002 OSU Sports Medicine

Summary § Station based PPE are efficient but may miss important psychosocial problems §

Summary § Station based PPE are efficient but may miss important psychosocial problems § History is extremely important (may be more so) than physical exam § Ideally, athlete should still go through office-based evaluation, even if station-based exam was done § Drive athletes toward health care Volunteer for sports physicals Get to know school teams, athletes Be involved in your community OSU Sports Medicine

sportsmedicine. osu. edu OSU Sports Medicine

sportsmedicine. osu. edu OSU Sports Medicine