Managing Sports Physicals

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

1. What sport(s) does the athlete plan to participate in?
2. Has the athlete completed a PPE history form (preferably the standardized form from PPE Monograph 5th Edition)?
3. Has the athlete ever fainted, passed out, or had chest pain during exercise?
4. Has the athlete ever had a seizure or been told they have a heart murmur?
5. Has anyone in the family died suddenly before age 50, or had unexpected heart problems?
6. Has the athlete had any prior concussions? If so, how many and when was the most recent?
7. Does the athlete have any chronic conditions (asthma, diabetes, seizures, single organ)?
8. Is the athlete taking any medications or supplements?
9. For female athletes: menstrual history (age of menarche, regularity, amenorrhea)?
10. 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:

1. Chest pain/discomfort/tightness/pressure with exertion
2. Unexplained syncope/near-syncope (especially during or immediately after exercise)
3. Excessive or unexpected dyspnea or fatigue with exercise
4. Prior recognition of a heart murmur
5. Elevated systemic blood pressure
6. Prior restriction from sports for a cardiac reason
7. 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:

1. Stand facing examiner: symmetry of trunk, shoulders, and extremities; inspect for scoliosis
2. Look at ceiling, floor, over both shoulders: cervical spine ROM
3. Shrug shoulders (resisted): trapezius strength
4. Abduct shoulders 90°, externally rotate (resisted): rotator cuff strength
5. Full extension/flexion of elbows: elbow ROM
6. Arms at sides, flex elbows 90°, pronate/supinate: forearm ROM
7. Spread fingers, make fists: hand ROM and grip strength
8. Duck walk 4 steps: hip, knee, and ankle ROM under load
9. Stand on toes, stand on heels: calf strength, Achilles, anterior tibialis
10. 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

Return-to-Play Protocol (Berlin Consensus 2023)

After diagnosed concussion, stepwise return:

1. Symptom-limited activity (daily activities that don't provoke symptoms)
2. Light aerobic exercise (walking, swimming, stationary cycling; no resistance)
3. Sport-specific exercise (running drills, no contact)
4. Non-contact training drills (may resume resistance training)
5. Full-contact practice (after medical clearance)
6. 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

Conditions Requiring Restriction or Disqualification

Checkpoint B — Sports Physical Review

• PPE history form completed and reviewed (signed by parent if < 18)
• AHA 14-element cardiovascular screen completed
• Cardiac auscultation performed in supine and standing positions
• Blood pressure measured with appropriate cuff size and classified
• Musculoskeletal screening exam performed and documented
• Prior injuries assessed for complete rehabilitation
• Concussion history documented with number, dates, and recovery
• Female athlete triad/RED-S screening completed (if applicable)
• Sickle cell trait status documented
• Vision screening documented
• Clearance determination stated with category
• Recommendations/restrictions specified if not fully cleared
• All [VERIFY] flags resolved or escalated

Quality Audit

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