PREPARTICIPATION PHYSICAL EXAMINATIONS (PPEs)

 Goals of PPE:

            1)       detect conditions predisposing to injury 
                            untreated/poorly treated illness/injuries, acute illness (mono),                                  inadequately rehabilitated injuries, congenital disease

            2)       detect life-threatening or disabling conditions

            3)       meet legal and insurance requirements 

History: the most important part of the screening process; more reliable than PE (Krowchuk); rely upon the athlete and the parents to provide adequate history; the history will guide the physical exam beyond the basic screening exam. History is vital in detecting the conditions predisposing the catastrophic outcomes. 

                                Cardiovascular History:

Realize the limitations, standard personal history has low specificity for detection of CV abnormalities that lead to sudden cardiac death in youngathletic population. More useful in the older athlete looking for predisposing risk factors to CV disease.

Standard of care follows recommendations of the American Heart Association                                      position statement

                                  Neurological History:

History of previous concussions, level/grade of concussions, previous w/u or treatment, any        current sx associated with post-concussive syndrome

History of recurrent burners/stingers may elicit info about cervical stenosis

History of HA, seizures

                                    Orthopedic History:

History of previous injuries, surgeries, rehab for injuries

Ongoing problems, overuse problems, gear questions toward the injury patterns of the sports

                                        Other history:

Previous heat illness

Symptoms of Exercise Induced Bronchospasm (asthma) – very important; under diagnosed

Weight questions – wrestlers, eating disorders (ballet, gymnastics), may lead to discussion of ergogenic aids (steroids, creatine)

Stressed out? Lead to questioning of potential health threatening behaviors (ETOH, drugs, tobacco), coping skills, depression, suicide

Female menstrual questions – female athlete triad, bone demineralization            

                                    Physical exam:

Height/Weight:

May uncover evidence of poor nutrition, eating disorders, obesity

Finding may spark investigation of Marfan’s Syndrome

Head Ears Eyes Nose Throat:

Visual acuity – important in determination of participation in those with one functional eye and need for eye protection for at risk sports

Pupil size – note unequal pupils at baseline; important in later assessment of head injury

Oral mucosa/ dental hygiene – may provide clues to eating disorder; high arched palate in Marfan’s

Cardiovascular:

BP – appropriate sized cuff, seated position back supported; initial elevations should be re-checked in 10-15 minutes

Palpation femoral and radial pulses

Auscultation --- standing, supine positions, note presence and character of any murmurs, clicks, S3 and S4

Maneuvers--- squat-to-stand – in HCM squatting will decrease outflow obstruction and make murmur softer, Valsalva and standing will increase obstruction and increase the murmur; in innocent murmurs Valsalva will decrease and squatting will increase the intensity

Pulmonary:

Search for wheezes, rubs, rales, etc – NORMAL EXAM DOES NOT R/O EIB

 Abdomen:

Ausculation, palpation --- looking for elnarged liver and spleen, masses, tenderness

Skin:

Presence of rashes, infections, infestations – especially important in personal contact sports – wrestling, karate

Musculoskeletal:

Yield is low in asymptomatic athletes

Use general screening exam ( 14 specific exercises to screen for problems with ROM, weakness of certain areas) if athlete has

no previous h/o injury to certain  body part

no pain, instability, weakness, atrophy

More in depth exam for these athletes not meeting above criteria

f time and resources permit it is good practice to center on body areas that are commonly injured in the particular athlete’s sports in order to do some preventative counseling, injury prevention, and help in developing training and conditioning programs that are sport specific.

Neurologic:

Motor system has been tested during musculoskeletal exam

Further testing with reflexes, sensory exams in those with recurrent burners, those with h/o disk problems of the back

Those with multiple or sever concussions may need further exam and baseline neuropsychologic testing

Clearance of Athletes:

·         Is athlete at risk for injury?

·         Is another participant at risk if this athlete participates?

·         Is the athlete at risk for only certain events?

·         Can athlete participate in a limited fashion?

Three categories of clearance:

1.        Complete clearance

2.        Clearance after completion of evaluation or rehabilitation

            EX.          Cardiac concern – murmurs, HTN, syncope needing further evaluation

                            Inadequately rehabilitated injury

                            Infectious disease – herpes infection in wrestler, acute mononucleosis    

3.        Not cleared for certain sports/activities

             EX.          Multiple concussions

                            One functional eye and unable to protect the other in sport

                            Inadequately controlled seizures in swimmer/diver

** Consider other sport**

CATC PROGRAM:

Station-Based Program

        Check-in - for administrative purposes

        BP/pulse check - performed by nurses and ATCs

        Orthopedic screening - performed by ATCs

        Medical Exam - performed by primary care physicians

        Clearance - review of all information by the team physician before clearance is determined