Managing Sports Physicals
Structures the pre-participation physical evaluation (PPE) for pediatric and adolescent athletes using the AAP/AAFP/AMSSM PPE Monograph 5th Edition framework. Covers targeted cardiovascular screening with the AHA 14-element assessment, musculoskeletal screening, concussion history evaluation, and clearance determination with sport-specific risk stratification.
Why This Skill Exists
Sudden cardiac death (SCD) in young athletes, while rare (estimated 1:50,000-1:80,000 per year), is the leading cause of death during sport participation. The pre-participation physical evaluation is designed to detect conditions that predispose to SCD (hypertrophic cardiomyopathy, anomalous coronary arteries, Long QT syndrome, arrhythmogenic right ventricular cardiomyopathy) as well as musculoskeletal conditions that increase injury risk. A standardized PPE also screens for concussion history, heat illness risk, sickle cell trait, and psychosocial concerns. This skill enforces the 5th Edition PPE Monograph standards.
Checkpoint A — Intake Verification
Required Intake Questions
- What sport(s) does the athlete plan to participate in?
- Has the athlete completed a PPE history form (preferably the standardized form from PPE Monograph 5th Edition)?
- Has the athlete ever fainted, passed out, or had chest pain during exercise?
- Has the athlete ever had a seizure or been told they have a heart murmur?
- Has anyone in the family died suddenly before age 50, or had unexpected heart problems?
- Has the athlete had any prior concussions? If so, how many and when was the most recent?
- Does the athlete have any chronic conditions (asthma, diabetes, seizures, single organ)?
- Is the athlete taking any medications or supplements?
- For female athletes: menstrual history (age of menarche, regularity, amenorrhea)?
- Does the athlete have sickle cell trait status known?
Required Documents
- Completed PPE history form (signed by parent/guardian if < 18)
- Prior PPE records (if available)
- Specialist clearance letters (if prior cardiac, orthopedic, or neurologic restrictions)
- Concussion history documentation
- Current medication list
Step 1 — Cardiovascular Screening (AHA 14-Element Assessment)
History Elements (12 Questions)
Personal History:
- Chest pain/discomfort/tightness/pressure with exertion
- Unexplained syncope/near-syncope (especially during or immediately after exercise)
- Excessive or unexpected dyspnea or fatigue with exercise
- Prior recognition of a heart murmur
- Elevated systemic blood pressure
- Prior restriction from sports for a cardiac reason
- Prior cardiovascular testing ordered by a physician (ECG, echo, stress test)
Family History:
8. Premature death (sudden and unexpected) before age 50 attributed to heart disease in ≥ 1 relative
9. Disability from heart disease in a close relative < 50
10. Specific knowledge of: hypertrophic cardiomyopathy, dilated cardiomyopathy, Long QT syndrome, short QT syndrome, Brugada syndrome, ARVC, Marfan syndrome, or clinically significant arrhythmia
Physical Examination:
11. Heart murmur (auscultation in supine and standing positions; assess with Valsalva)
12. Femoral pulse diminished or delayed (suggesting aortic coarctation)
13. Physical stigmata of Marfan syndrome (tall, arm span > height, pectus excavatum, joint hypermobility, arachnodactyly, lens subluxation)
14. Brachial artery blood pressure (sitting; use appropriate cuff size)
Interpretation
- Any positive cardiac history element or abnormal cardiac exam → further evaluation BEFORE clearance
- Dynamic murmur (louder with standing or Valsalva) → suspect HCM → echocardiogram before clearance
- Fixed murmur (unchanged with position) → likely benign flow murmur; Still's murmur is most common benign murmur in children
- Marfan features → echocardiogram to assess aortic root diameter; refer to genetics/cardiology
- Family history of SCD → ECG minimum; consider cardiology referral for echo, exercise stress test, or genetic testing
- Elevated BP → repeat measurement; confirm per AAP 2017 BP guidelines; stage 2 hypertension requires workup before clearance
ECG Screening (Not Currently Recommended Universally in the US)
- AHA/AAP do NOT recommend universal ECG for PPE (cost, false-positive rate, limited evidence for mortality reduction)
- European and some international guidelines DO recommend ECG
- ECG should be obtained if ANY of the 14 AHA elements are positive
- Refer abnormal ECG to pediatric cardiologist before clearing
Step 2 — Musculoskeletal Screening
2-Minute Musculoskeletal Screening Exam
Perform the following systematic screen:
- Stand facing examiner: symmetry of trunk, shoulders, and extremities; inspect for scoliosis
- Look at ceiling, floor, over both shoulders: cervical spine ROM
- Shrug shoulders (resisted): trapezius strength
- Abduct shoulders 90°, externally rotate (resisted): rotator cuff strength
- Full extension/flexion of elbows: elbow ROM
- Arms at sides, flex elbows 90°, pronate/supinate: forearm ROM
- Spread fingers, make fists: hand ROM and grip strength
- Duck walk 4 steps: hip, knee, and ankle ROM under load
- Stand on toes, stand on heels: calf strength, Achilles, anterior tibialis
- Single-leg hop: balance, ankle stability
Sport-Specific Evaluation
- Overhead sports (baseball, volleyball, swimming): detailed shoulder exam (Neer, Hawkins, apprehension/relocation tests)
- Running sports: hip flexor, hamstring, IT band flexibility; knee stability (Lachman, valgus/varus stress)
- Contact sports (football, wrestling, hockey): cervical spine exam, Spurling test, prior injury history
Prior Injury Assessment
- Document all prior musculoskeletal injuries with treatment and recovery status
- Incomplete rehabilitation is the strongest predictor of re-injury
- Clear for sport only if: full ROM, full strength, sport-specific functional testing passed
Step 3 — Concussion History Evaluation
Concussion Screening Questions
- How many prior concussions? (Document each with approximate date and recovery duration)
- Were any associated with loss of consciousness? Duration?
- Did any require prolonged recovery (> 4 weeks)?
- Did any require hospitalization or imaging?
- Does the athlete currently have any persistent symptoms (headaches, difficulty concentrating, dizziness, sleep problems)?
- Was the athlete ever held out of a full season due to concussion?
Risk Stratification
| History |
Risk Level |
Action |
| 0 prior concussions |
Standard risk |
Clear if exam normal |
| 1-2 concussions, full recovery |
Moderate risk |
Clear; educate on graduated return-to-play protocol |
| 3+ concussions or prolonged recovery |
High risk |
Consider neurology referral before clearance; discuss sport selection |
| Current persistent symptoms |
Not cleared |
Do not clear until symptom-free; neurology referral |
Return-to-Play Protocol (Berlin Consensus 2023)
After diagnosed concussion, stepwise return:
- Symptom-limited activity (daily activities that don't provoke symptoms)
- Light aerobic exercise (walking, swimming, stationary cycling; no resistance)
- Sport-specific exercise (running drills, no contact)
- Non-contact training drills (may resume resistance training)
- Full-contact practice (after medical clearance)
- Return to competition
- Minimum 24 hours at each step before advancing
- Any recurrence of symptoms → return to previous step for 24 hours
Step 4 — Special Screening Considerations
Female Athlete Triad / RED-S (Relative Energy Deficiency in Sport)
- Screen all female athletes for: menstrual irregularity, disordered eating, stress fractures
- Triad: low energy availability → menstrual dysfunction → decreased bone mineral density
- RED-S: broader concept including males; impaired physiological function from chronic energy deficiency
- Screening questions: "Have you ever missed a period? Are you trying to lose weight? Have you ever been told you have a stress fracture?"
- Amenorrhea (primary: no menarche by age 15; secondary: absence of menses for ≥ 3 months) → workup: pregnancy test, TSH, prolactin, FSH/LH, estradiol
- Refer to sports medicine or endocrinology if triad/RED-S suspected
Sickle Cell Trait (SCT)
- NCAA requires SCT status for Division I-III athletes
- Most states include hemoglobin electrophoresis in newborn screen
- SCT athletes have increased risk of exertional sickling (collapse, rhabdomyolysis) during intense exertion, especially at altitude or in heat
- Precautions: adequate hydration, acclimatization, avoidance of maximum exertion sprints without conditioning, access to supplemental oxygen
Single Organ (Kidney, Testicle, Eye)
- Athletes with single kidney, single testicle, or single functioning eye: counsel on collision/contact sport risk
- Not an absolute disqualification but requires informed discussion and protective equipment
- Document the discussion and family decision
Step 5 — Clearance Determination
Clearance Categories
| Category |
Definition |
| Cleared |
No restrictions for the desired sport(s) |
| Cleared with recommendations |
May participate with specific conditions (protective equipment, monitoring, position restrictions) |
| Not cleared |
Pending further evaluation OR unable to participate in desired sport due to medical condition |
| Not cleared for specific sports |
May participate in some but not others (e.g., cleared for swimming but not football) |
Conditions Requiring Restriction or Disqualification
| Condition |
Sport Restriction |
| Symptomatic HCM |
No competitive sports (until cardiology clearance with guidelines) |
| Long QT syndrome (symptomatic) |
No competitive sports pending risk assessment |
| Uncontrolled seizures |
No swimming, climbing, or activities where loss of consciousness = life-threatening |
| Acute concussion |
No sport until graduated return-to-play protocol completed |
| Atlantoaxial instability (Down syndrome) |
No contact/collision sports without cervical spine imaging clearance |
| Splenomegaly (acute mono) |
No contact sports until spleen normalizes (typically 3-4 weeks) |
| Uncontrolled asthma |
Treat before clearance; ensure rescue inhaler available at practices/games |
Checkpoint B — Sports Physical Review
Quality Audit
| Item |
Requirement |
Pass? |
| AHA 14 elements |
All 14 elements addressed and documented |
|
| Cardiac auscultation |
Supine AND standing; Valsalva if murmur detected |
|
| Blood pressure |
Measured, cuff size appropriate, classified per AAP 2017 |
|
| MSK screening |
Systematic screen performed (not just "ROM WNL") |
|
| Concussion history |
Number, dates, recovery documented; current symptoms assessed |
|
| Female triad screen |
Menstrual history obtained for all female athletes |
|
| SCT status |
Documented or noted as unknown |
|
| Clearance category |
Explicitly stated (cleared / cleared with conditions / not cleared) |
|
| Sport-specific risk |
Evaluated against athlete's condition(s) |
|
| No unexplained [VERIFY] tags |
All flagged items resolved or escalated |
|
Guidelines
- Follow PPE Monograph 5th Edition (AAP/AAFP/AMSSM/AOSSM/AOASM) for PPE structure and content
- Apply AHA Scientific Statement on cardiovascular screening of competitive athletes (14-element assessment)
- Follow AAP 2017 Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children/Adolescents
- Berlin Consensus Statement on Concussion in Sport (2023, 6th International Conference) for concussion management
- Female Athlete Triad Coalition Consensus Statement for RED-S screening and management
- NCAA Sickle Cell Trait Policy for athlete screening and precautions
- AAP Policy Statement on Medical Conditions Affecting Sports Participation (updated periodically)
- ECG screening: not universally recommended in US per AHA/AAP; obtain when history or exam is positive
- Marfan syndrome: aortic root diameter ≥ 4.0 cm (adults) is a threshold for restriction from collision sports; pediatric thresholds are Z-score-based
- Mononucleosis: no contact sports for minimum 3 weeks; return only after spleen normalizes clinically
- This skill produces clinical documentation; it does not replace clinical judgment
1---2name: managing-sports-physicals3description: Structures pre-participation physical evaluations with cardiac screening and clearance decisions. Use when performing sports physicals, screening for cardiac conditions, or documenting athletic clearance.4---5
6# Managing Sports Physicals
7
8Structures the pre-participation physical evaluation (PPE) for pediatric and adolescent athletes using the AAP/AAFP/AMSSM PPE Monograph 5th Edition framework. Covers targeted cardiovascular screening with the AHA 14-element assessment, musculoskeletal screening, concussion history evaluation, and clearance determination with sport-specific risk stratification.
9
10## Why This Skill Exists
11
12Sudden cardiac death (SCD) in young athletes, while rare (estimated 1:50,000-1:80,000 per year), is the leading cause of death during sport participation. The pre-participation physical evaluation is designed to detect conditions that predispose to SCD (hypertrophic cardiomyopathy, anomalous coronary arteries, Long QT syndrome, arrhythmogenic right ventricular cardiomyopathy) as well as musculoskeletal conditions that increase injury risk. A standardized PPE also screens for concussion history, heat illness risk, sickle cell trait, and psychosocial concerns. This skill enforces the 5th Edition PPE Monograph standards.
13
14---
15
16## Checkpoint A — Intake Verification
17
18### Required Intake Questions
191. What sport(s) does the athlete plan to participate in?
202. Has the athlete completed a PPE history form (preferably the standardized form from PPE Monograph 5th Edition)?
213. Has the athlete ever fainted, passed out, or had chest pain during exercise?
224. Has the athlete ever had a seizure or been told they have a heart murmur?
235. Has anyone in the family died suddenly before age 50, or had unexpected heart problems?
246. Has the athlete had any prior concussions? If so, how many and when was the most recent?
257. Does the athlete have any chronic conditions (asthma, diabetes, seizures, single organ)?
268. Is the athlete taking any medications or supplements?
279. For female athletes: menstrual history (age of menarche, regularity, amenorrhea)?
2810. Does the athlete have sickle cell trait status known?
29
30### Required Documents
31- Completed PPE history form (signed by parent/guardian if < 18)
32- Prior PPE records (if available)
33- Specialist clearance letters (if prior cardiac, orthopedic, or neurologic restrictions)
34- Concussion history documentation
35- Current medication list
36
37---
38
39## Step 1 — Cardiovascular Screening (AHA 14-Element Assessment)
40
41### History Elements (12 Questions)
42**Personal History:**
431. Chest pain/discomfort/tightness/pressure with exertion
442. Unexplained syncope/near-syncope (especially during or immediately after exercise)
453. Excessive or unexpected dyspnea or fatigue with exercise
464. Prior recognition of a heart murmur
475. Elevated systemic blood pressure
486. Prior restriction from sports for a cardiac reason
497. Prior cardiovascular testing ordered by a physician (ECG, echo, stress test)
50
51**Family History:**
528. Premature death (sudden and unexpected) before age 50 attributed to heart disease in ≥ 1 relative
539. Disability from heart disease in a close relative < 50
5410. Specific knowledge of: hypertrophic cardiomyopathy, dilated cardiomyopathy, Long QT syndrome, short QT syndrome, Brugada syndrome, ARVC, Marfan syndrome, or clinically significant arrhythmia
55
56**Physical Examination:**
5711. Heart murmur (auscultation in supine and standing positions; assess with Valsalva)
5812. Femoral pulse diminished or delayed (suggesting aortic coarctation)
5913. Physical stigmata of Marfan syndrome (tall, arm span > height, pectus excavatum, joint hypermobility, arachnodactyly, lens subluxation)
6014. Brachial artery blood pressure (sitting; use appropriate cuff size)
61
62### Interpretation
63- Any positive cardiac history element or abnormal cardiac exam → further evaluation BEFORE clearance
64- **Dynamic murmur** (louder with standing or Valsalva) → suspect HCM → echocardiogram before clearance
65- **Fixed murmur** (unchanged with position) → likely benign flow murmur; Still's murmur is most common benign murmur in children
66- **Marfan features** → echocardiogram to assess aortic root diameter; refer to genetics/cardiology
67- **Family history of SCD** → ECG minimum; consider cardiology referral for echo, exercise stress test, or genetic testing
68- **Elevated BP** → repeat measurement; confirm per AAP 2017 BP guidelines; stage 2 hypertension requires workup before clearance
69
70### ECG Screening (Not Currently Recommended Universally in the US)
71- AHA/AAP do NOT recommend universal ECG for PPE (cost, false-positive rate, limited evidence for mortality reduction)
72- European and some international guidelines DO recommend ECG
73- ECG should be obtained if ANY of the 14 AHA elements are positive
74- Refer abnormal ECG to pediatric cardiologist before clearing
75
76---
77
78## Step 2 — Musculoskeletal Screening
79
80### 2-Minute Musculoskeletal Screening Exam
81Perform the following systematic screen:
82
831. **Stand facing examiner**: symmetry of trunk, shoulders, and extremities; inspect for scoliosis
842. **Look at ceiling, floor, over both shoulders**: cervical spine ROM
853. **Shrug shoulders (resisted)**: trapezius strength
864. **Abduct shoulders 90°, externally rotate (resisted)**: rotator cuff strength
875. **Full extension/flexion of elbows**: elbow ROM
886. **Arms at sides, flex elbows 90°, pronate/supinate**: forearm ROM
897. **Spread fingers, make fists**: hand ROM and grip strength
908. **Duck walk 4 steps**: hip, knee, and ankle ROM under load
919. **Stand on toes, stand on heels**: calf strength, Achilles, anterior tibialis
9210. **Single-leg hop**: balance, ankle stability
93
94### Sport-Specific Evaluation
95- Overhead sports (baseball, volleyball, swimming): detailed shoulder exam (Neer, Hawkins, apprehension/relocation tests)
96- Running sports: hip flexor, hamstring, IT band flexibility; knee stability (Lachman, valgus/varus stress)
97- Contact sports (football, wrestling, hockey): cervical spine exam, Spurling test, prior injury history
98
99### Prior Injury Assessment
100- Document all prior musculoskeletal injuries with treatment and recovery status
101- Incomplete rehabilitation is the strongest predictor of re-injury
102- Clear for sport only if: full ROM, full strength, sport-specific functional testing passed
103
104---
105
106## Step 3 — Concussion History Evaluation
107
108### Concussion Screening Questions
109- How many prior concussions? (Document each with approximate date and recovery duration)
110- Were any associated with loss of consciousness? Duration?
111- Did any require prolonged recovery (> 4 weeks)?
112- Did any require hospitalization or imaging?
113- Does the athlete currently have any persistent symptoms (headaches, difficulty concentrating, dizziness, sleep problems)?
114- Was the athlete ever held out of a full season due to concussion?
115
116### Risk Stratification
117| History | Risk Level | Action |
118|---------|-----------|--------|
119| 0 prior concussions | Standard risk | Clear if exam normal |
120| 1-2 concussions, full recovery | Moderate risk | Clear; educate on graduated return-to-play protocol |
121| 3+ concussions or prolonged recovery | High risk | Consider neurology referral before clearance; discuss sport selection |
122| Current persistent symptoms | Not cleared | Do not clear until symptom-free; neurology referral |
123
124### Return-to-Play Protocol (Berlin Consensus 2023)
125After diagnosed concussion, stepwise return:
1261. Symptom-limited activity (daily activities that don't provoke symptoms)
1272. Light aerobic exercise (walking, swimming, stationary cycling; no resistance)
1283. Sport-specific exercise (running drills, no contact)
1294. Non-contact training drills (may resume resistance training)
1305. Full-contact practice (after medical clearance)
1316. Return to competition
132
133- Minimum 24 hours at each step before advancing
134- Any recurrence of symptoms → return to previous step for 24 hours
135
136---
137
138## Step 4 — Special Screening Considerations
139
140### Female Athlete Triad / RED-S (Relative Energy Deficiency in Sport)
141- Screen all female athletes for: menstrual irregularity, disordered eating, stress fractures
142- Triad: low energy availability → menstrual dysfunction → decreased bone mineral density
143- RED-S: broader concept including males; impaired physiological function from chronic energy deficiency
144- **Screening questions**: "Have you ever missed a period? Are you trying to lose weight? Have you ever been told you have a stress fracture?"
145- Amenorrhea (primary: no menarche by age 15; secondary: absence of menses for ≥ 3 months) → workup: pregnancy test, TSH, prolactin, FSH/LH, estradiol
146- Refer to sports medicine or endocrinology if triad/RED-S suspected
147
148### Sickle Cell Trait (SCT)
149- NCAA requires SCT status for Division I-III athletes
150- Most states include hemoglobin electrophoresis in newborn screen
151- SCT athletes have increased risk of exertional sickling (collapse, rhabdomyolysis) during intense exertion, especially at altitude or in heat
152- Precautions: adequate hydration, acclimatization, avoidance of maximum exertion sprints without conditioning, access to supplemental oxygen
153
154### Single Organ (Kidney, Testicle, Eye)
155- Athletes with single kidney, single testicle, or single functioning eye: counsel on collision/contact sport risk
156- Not an absolute disqualification but requires informed discussion and protective equipment
157- Document the discussion and family decision
158
159---
160
161## Step 5 — Clearance Determination
162
163### Clearance Categories
164| Category | Definition |
165|----------|-----------|
166| **Cleared** | No restrictions for the desired sport(s) |
167| **Cleared with recommendations** | May participate with specific conditions (protective equipment, monitoring, position restrictions) |
168| **Not cleared** | Pending further evaluation OR unable to participate in desired sport due to medical condition |
169| **Not cleared for specific sports** | May participate in some but not others (e.g., cleared for swimming but not football) |
170
171### Conditions Requiring Restriction or Disqualification
172| Condition | Sport Restriction |
173|-----------|-----------------|
174| Symptomatic HCM | No competitive sports (until cardiology clearance with guidelines) |
175| Long QT syndrome (symptomatic) | No competitive sports pending risk assessment |
176| Uncontrolled seizures | No swimming, climbing, or activities where loss of consciousness = life-threatening |
177| Acute concussion | No sport until graduated return-to-play protocol completed |
178| Atlantoaxial instability (Down syndrome) | No contact/collision sports without cervical spine imaging clearance |
179| Splenomegaly (acute mono) | No contact sports until spleen normalizes (typically 3-4 weeks) |
180| Uncontrolled asthma | Treat before clearance; ensure rescue inhaler available at practices/games |
181
182---
183
184## Checkpoint B — Sports Physical Review
185
186- [ ] PPE history form completed and reviewed (signed by parent if < 18)
187- [ ] AHA 14-element cardiovascular screen completed
188- [ ] Cardiac auscultation performed in supine and standing positions
189- [ ] Blood pressure measured with appropriate cuff size and classified
190- [ ] Musculoskeletal screening exam performed and documented
191- [ ] Prior injuries assessed for complete rehabilitation
192- [ ] Concussion history documented with number, dates, and recovery
193- [ ] Female athlete triad/RED-S screening completed (if applicable)
194- [ ] Sickle cell trait status documented
195- [ ] Vision screening documented
196- [ ] Clearance determination stated with category
197- [ ] Recommendations/restrictions specified if not fully cleared
198- [ ] All [VERIFY] flags resolved or escalated
199
200---
201
202## Quality Audit
203
204| Item | Requirement | Pass? |
205|------|-------------|-------|
206| AHA 14 elements | All 14 elements addressed and documented | |
207| Cardiac auscultation | Supine AND standing; Valsalva if murmur detected | |
208| Blood pressure | Measured, cuff size appropriate, classified per AAP 2017 | |
209| MSK screening | Systematic screen performed (not just "ROM WNL") | |
210| Concussion history | Number, dates, recovery documented; current symptoms assessed | |
211| Female triad screen | Menstrual history obtained for all female athletes | |
212| SCT status | Documented or noted as unknown | |
213| Clearance category | Explicitly stated (cleared / cleared with conditions / not cleared) | |
214| Sport-specific risk | Evaluated against athlete's condition(s) | |
215| No unexplained [VERIFY] tags | All flagged items resolved or escalated | |
216
217---
218
219## Guidelines
220
221- Follow PPE Monograph 5th Edition (AAP/AAFP/AMSSM/AOSSM/AOASM) for PPE structure and content
222- Apply AHA Scientific Statement on cardiovascular screening of competitive athletes (14-element assessment)
223- Follow AAP 2017 Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children/Adolescents
224- Berlin Consensus Statement on Concussion in Sport (2023, 6th International Conference) for concussion management
225- Female Athlete Triad Coalition Consensus Statement for RED-S screening and management
226- NCAA Sickle Cell Trait Policy for athlete screening and precautions
227- AAP Policy Statement on Medical Conditions Affecting Sports Participation (updated periodically)
228- ECG screening: not universally recommended in US per AHA/AAP; obtain when history or exam is positive
229- Marfan syndrome: aortic root diameter ≥ 4.0 cm (adults) is a threshold for restriction from collision sports; pediatric thresholds are Z-score-based
230- Mononucleosis: no contact sports for minimum 3 weeks; return only after spleen normalizes clinically
231- This skill produces clinical documentation; it does not replace clinical judgment
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