Sports preparticipation physical

Sports preparticipation physical exams (or preparticipation physical exams [PPEs]) are clinical exams used to evaluate athletes for injuries, illnesses, or other conditions that might increase the risk of harm to themselves or others when participating in sports.​​​[1]MacDonald J, Schaefer M, Stumph J. The preparticipation physical evaluation. Am Fam Physician. 2021 May 1;103(9):539-46. https://www.aafp.org/pubs/afp/issues/2021/0501/p539.html http://www.ncbi.nlm.nih.gov/pubmed/33929170?tool=bestpractice.com ​​[2]Wingfield K, Matheson GO, Meeuwisse WH. Preparticipation evaluation: an evidence-based review. Clin J Sport Med. 2004 May;14(3):109-22. http://www.ncbi.nlm.nih.gov/pubmed/15166898?tool=bestpractice.com [3]Maron BJ, Douglas PS, Graham TP, et al. Task Force 1: preparticipation screening and diagnosis of cardiovascular disease in athletes. J Am Coll Cardiol. 2005 Apr 19;45(8):1322-6. http://www.ncbi.nlm.nih.gov/pubmed/15837281?tool=bestpractice.com [4]Rice SG; American Academy of Pediatrics Council on Sports Medicine and Fitness. Medical conditions affecting sports participation. Pediatrics. 2008 Apr;121(4):841-8. http://pediatrics.aappublications.org/content/121/4/841.long http://www.ncbi.nlm.nih.gov/pubmed/18381550?tool=bestpractice.com American Medical Society for Sports Medicine: preparticipation physical evaluation history form Opens in new window​ Although the PPE is often considered a screening tool, it can also be used to evaluate the suitability of athletes with known conditions in order for them to participate in a particular athletic endeavor.

A PPE is a legal or administrative requirement for many competitive athletes in the US.[5]National Collegiate Athletic Association. 2014-15 NCAA Sports medicine handbook: guideline 1C medical evaluations, immunizations and records. Jun 2011 [internet publication]. https://www.ncaapublications.com/productdownloads/MD15.pdf ​ It can be an excellent vehicle for discussing health promotion and maintenance issues with young athletes. However, there is great variability in the way PPEs are performed and little objective data demonstrating that it leads to improved health outcomes.[1]MacDonald J, Schaefer M, Stumph J. The preparticipation physical evaluation. Am Fam Physician. 2021 May 1;103(9):539-46. https://www.aafp.org/pubs/afp/issues/2021/0501/p539.html http://www.ncbi.nlm.nih.gov/pubmed/33929170?tool=bestpractice.com ​

Adding a screening ECG to a history and physical increases the likelihood of detecting potentially life-threatening cardiovascular conditions, and has been associated with a decrease in the rate of sudden cardiac death in athletes in Italy.[6]Van Camp SP, Bloor CM, Mueller FO, et al. Nontraumatic sports death in high school and college athletes. Med Sci Sports Exerc. 1995 May;27(5):641-7. http://www.ncbi.nlm.nih.gov/pubmed/7674867?tool=bestpractice.com [7]Corrado D, Basso C, Pavei A, et al. Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program. JAMA. 2006 Oct 4;296(13):1593-601. http://jamanetwork.com/journals/jama/fullarticle/203513 http://www.ncbi.nlm.nih.gov/pubmed/17018804?tool=bestpractice.com [8]Corrado D, Basso C, Schiavon M, et al. Pre-participation screening of young competitive athletes for prevention of sudden cardiac death. J Am Coll Cardiol. 2008 Dec 9;52(24):1981-9. http://www.onlinejacc.org/content/52/24/1981 http://www.ncbi.nlm.nih.gov/pubmed/19055989?tool=bestpractice.com [9]Corrado D, Drezner J, Basso C, et al. Strategies for the prevention of sudden cardiac death during sports. Eur J Cardiovasc Prev Rehabil. 2011 Apr;18(2):197-208. http://www.ncbi.nlm.nih.gov/pubmed/21567995?tool=bestpractice.com ​​​ However, it is debatable whether implementing standard ECG screening in PPEs across the US would show similar benefit and the debate on augmented cardiac screening continues.[5]National Collegiate Athletic Association. 2014-15 NCAA Sports medicine handbook: guideline 1C medical evaluations, immunizations and records. Jun 2011 [internet publication]. https://www.ncaapublications.com/productdownloads/MD15.pdf [10]Shephard RJ. Is electrocardiogram screening of North American athletes now warranted? Clin J Sport Med. 2011 May;21(3):189-91. http://www.ncbi.nlm.nih.gov/pubmed/21519295?tool=bestpractice.com [11]Steinvil A, Chundadze T, Zeltser D, et al. Mandatory electrocardiographic screening of athletes to reduce their risk for sudden death: proven fact or wishful thinking? J Am Coll Cardiol. 2011 Mar 15;57(11):1291-6. http://www.onlinejacc.org/content/57/11/1291 http://www.ncbi.nlm.nih.gov/pubmed/21392644?tool=bestpractice.com [12]Drezner J, Corrado D. Is there evidence for recommending electrocardiogram as part of the pre-participation examination? Clin J Sport Med. 2011 Jan;21(1):18-24. http://www.ncbi.nlm.nih.gov/pubmed/21200166?tool=bestpractice.com [13]Borjesson M, Dellborg M. Is there evidence for mandating electrocardiogram as part of the pre-participation examination? Clin J Sport Med. 2011 Jan;21(1):13-7. http://www.ncbi.nlm.nih.gov/pubmed/21200165?tool=bestpractice.com [14]Pelliccia A, Corrado D. Can electrocardiographic screening prevent sudden death in athletes? Yes. BMJ. 2010 Sep 14;341:c4923. http://www.ncbi.nlm.nih.gov/pubmed/20841394?tool=bestpractice.com [15]Bahr R. Can electrocardiographic screening prevent sudden death in athletes? No. BMJ. 2010;341:c4914. http://www.ncbi.nlm.nih.gov/pubmed/20841393?tool=bestpractice.com ​​​ There is a growing body of evidence suggesting possible benefit from augmented screening,​​ with a study demonstrating higher rates of ECG abnormalities in young males of black African descent.[16]Rizzo M, Spataro A, Cecchetelli C, et al. Structural cardiac disease diagnosed by echocardiography in asymptomatic young male soccer players: implications for pre-participation screening. Br J Sports Med. 2012 Apr;46(5):371-3. http://www.ncbi.nlm.nih.gov/pubmed/21791458?tool=bestpractice.com [17]Magalski A, McCoy M, Zabel M, et al. Cardiovascular screening with electrocardiography and echocardiography in collegiate athletes. Am J Med. 2011 Jun;124(6):511-8. http://www.ncbi.nlm.nih.gov/pubmed/21605728?tool=bestpractice.com ​​​​[18]Wilson MG, Chatard JC, Carre F, et al. Prevalence of electrocardiographic abnormalities in West-Asian and African male athletes. Br J Sports Med. 2012 Apr;46(5):341-7. http://bjsm.bmj.com/content/46/5/341.long http://www.ncbi.nlm.nih.gov/pubmed/21596717?tool=bestpractice.com Possibly legal and social pressures may result in a change of attitude in the US regarding this issue. However, the costs, ramifications of false positives, and lack of appropriate health system infrastructure to manage the athletes involved make it difficult to apply in the US, and these issues are likely to prevent widespread adoption of an Italian-style program in the near future.[19]Maron BJ. National electrocardiography screening for competitive athletes: feasible in the United States? Ann Intern Med. 2010 Mar 2;152(5):324-6. http://www.ncbi.nlm.nih.gov/pubmed/20194239?tool=bestpractice.com The American Heart Association recommendations remain unchanged on this issue. While recognizing the limitations of the standard history and physical PPE, the AHA does not recommend routine augmented screening with ECG or other cardiovascular testing as part of the PPE at present, and instead continues to recommend the 14-point cardiovascular history and physical exam.[1]MacDonald J, Schaefer M, Stumph J. The preparticipation physical evaluation. Am Fam Physician. 2021 May 1;103(9):539-46. https://www.aafp.org/pubs/afp/issues/2021/0501/p539.html http://www.ncbi.nlm.nih.gov/pubmed/33929170?tool=bestpractice.com [20]Maron BJ, Friedman RA, Kligfield P, et al. Assessment of the 12-lead ECG as a screening test for detection of cardiovascular disease in healthy general populations of young people (12-25 Years of Age): a scientific statement from the American Heart Association and the American College of Cardiology. Circulation. 2014 Oct 7;130(15):1303-34. https://www.ahajournals.org/doi/10.1161/CIR.0000000000000025 http://www.ncbi.nlm.nih.gov/pubmed/25223981?tool=bestpractice.com ​​​​[21]Maron BJ, Thompson PD, Ackerman MJ, et al. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update. Circulation. 2007 Mar 27;115(12):1643-455. http://circ.ahajournals.org/content/115/12/1643.full http://www.ncbi.nlm.nih.gov/pubmed/17353433?tool=bestpractice.com

Despite lack of objective data, the PPE may be an excellent vehicle for screening athletes for high-risk behaviors and medical conditions that would otherwise have a profound effect on their lifelong health, if not directly on their short-term athletic performance.

Although estimates vary, studies find that only a small percentage of athletes (<1%) are denied clearance to participate.​[22]Smith J, Laskowski ER. The preparticipation physical examination: Mayo Clinic experience with 2,739 examinations. Mayo Clin Proc. 1998 May;73(5):419-29. http://www.ncbi.nlm.nih.gov/pubmed/9581581?tool=bestpractice.com

The American College of Cardiology has produced a list of key points concerning cardiovascular care of college athletes. American College of Cardiology: cardiovascular care of college student-athletes Opens in new window