What Areas of the Physical Examination are Important in the Pre-participation Physical Examination?

Patient Presentation
A 14-year-old female came to clinic for her sports physical as part of her comprehensive examination. She had been a runner for a couple of years and participated in cross-country and track the previous year. She had 1 ankle sprain when she was tripped during a cross-country race that had healed without incident and had not caused her any problems. She denied any other injuries, concussions or head trauma, and said she didn’t have any problems with fatigue, shortness of breath, syncope, or her heart beating funny. She denied any loose or lax joints. “I just get really tired when our coach wants us to run sprints at the end of practice,” she offered. The past medical history was otherwise non-contributory The family history was positive for diabetes, and her maternal grandfather had a coronary bypass at age 68. The review of systems was normal including her menstrual history.

The pertinent physical exam showed a thin female growing along the 75%. Her vital signs were normal. Her examination was normal including the strength and range of motion in both ankles.

The diagnosis of a healthy female was made. The physician discussed healthy eating including getting enough calcium in her diet, the importance of sleep and provided a seasonal influenza vaccination.

Participation in organized or non-organized, recreational to elite sports activities can provide excellent recreational and leisure time activities and improve physical and mental health for participants. The Aspen Institute in 2018 reported that more kids are being physically active, more are trying different sports, and multisports play is increasing rather than strict specialization. Unfortunately they note that there is an economic inequality with children from lower-socioeconomic circumstances playing less organized sports. About 70% of children and youth participate in an individual or team sport, but unfortunately 17% still reported doing no physical activity.

The pre-participation examination sports examination (PPE) is important for identifying potential medical conditions that could become dangerous during physical activity. They are also important as the PPE may be the only contact with health care providers as many of these children/youth are well and do not seek care for other reasons. The PPE is different in that it is “…a more focused, system-based history and physical examination with specific questions and other elements used to identify issues that are known to affect sports participation.” It can be done as part of a more comprehensive health examination which would also include screening (i.e. mental health, psychosocial screening, drug use, etc.), health counseling (i.e. nutrition, sleep, etc.) and immunizations and laboratory screenings. The history is more focused and identifies about 75% of concerning medical conditions. The physical examination is also more focused concentrating mainly on the head and neck and neurological, cardiac, musculoskeletal components. “Between 3.2% and 13.9% of athletes require additional evaluation as a result of abnormal findings discovered during the PPE. Physicians disqualify 0.3% to 1.3% of athletes who undergo a PPE from athletic participation due to an underlying medical condition.”

Learning Point
The PPE consists of several areas

  • Cardiac screening
    • History
        Personal history of heart murmur, syncope or pre-syncope, chest pain, shortness of breath, fatigue, hypertension and previous cardiac testing should be asked about.
        Family history of heart disease or sudden cardiac death (SCD) and hypertrophic cardiomyopathy also should be asked. SCD can be difficult to determine as this may look like other problems such as a car accident or drowning.
    • Physical examination
        Hypertension that is consistent and not fully evaluated may require temporary disqualification from participation.
        Evaluation for Marfan syndrome stigmata and femoral pulse palpation (to exclude coaractation of the aorta) should be included in the examination.
        Heart murmurs that are grade 3 intensity, diastolic murmurs and those that increase in intensity when going from sitting to standing or with valsalva are more concerning.
    • Pre-participation electrocardiogram (ECG) is controversial. For highly trained or elite athletes, especially in certain groups such as male basketball players, there is a higher risk of cardiomyopathy or electrical abnormalities that can be noted on ECG.
      It is currently not recommended for the general pre-teen and teenage youth in sports unless there are other risk factors.
      With the new COVID 19 virus, cardiac and vascular anomalies are being reported, and evaluation and clearing patients after COVID-19 for athletics remains controversial.
  • Neurological screening
    • History
        Concussion screening is important. History of ever having a concussion, or hit/blow that caused headache, confusion or memory problems should be elicited.
        Multiple concussions, more severe symptoms or longer time to recover are certainly risk factors. The children and youth age groups are also a risk factor and data supports that these groups may take longer to recover from a concussion than collegiate and older athletes.
        Return to play and learning should be step-wise and follow current guidelines
    • Physical examination
        Usually the mental status and neurological examination will be normal during the PPE but evaluation for more acute problems should be done if appropriate.
  • Musculoskeletal screening
    • History
        History of any athletic injury or trauma including fractures (including stress fracture) or dislocations, any evaluation for an injury including going to the emergency room, or x-rays, any reason to use crutches, brace etc., any loose joints, muscles or bones that bother the patient are common questions that can be asked.
        Family history of any connective tissue disease, loose joints or arthritis can also be asked.
    • Physical examination
        All joints should be evaluated for motion, strength and stability with particular attention to any joint that was previously injured or is likely to be injured because of the activity (e.g. shoulder for a swimmer).
        Duck walking and hopping on one foot can help to identify lower extremity problems as well as balance.
        Knees are particularly vulnerable for females because of the mechanics of the body and the increased Q angle at the knee relative to males.
  • Other PPE physical examination areas
    • Height and weight – for obesity and weight changes including anorexia or female athlete triad
    • Skin – rashes and other lesions particularly that are of an infectious nature, but also to evaluate for underlying conditions that could be worsened with participation (e.g. eczema worsened by swimming pool chemical or irritated due to protective padding and equipment)
    • Eyes – acuity, anisocoria is important to note as this needs to be compared in a head trauma situation
    • Lungs – wheezing and potential evaluation for asthma
    • Abdomen – masses and organomegaly which need more evaluation and/or exclusion from some sports
    • Genitourinary – females are not necessarily examined usually, males should be evaluated for identifying hernias, absent or undescended testes or other genitourinary masses

Questions for Further Discussion
1. What conditions delay or disqualify a patient from sports participation? A review can be found here
2. What is female athlete triad and what problems can it cause?
3. What is the Q angle and why does it cause problems for females?

Related Cases

    Disease: Pre-participation Sports Physical Examination | Sports Fitness

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Health Checkup and Sports Fitness.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Heinke B, Mullner J. Common Issues Encountered in Adolescent Sports Medicine. Primary Care: Clinics in Office Practice. 2014;41(3):539-558. doi:10.1016/j.pop.2014.06.001

Roberts WO, Löllgen H, Matheson GO, et al. Advancing the pre-participation Physical Evaluation: An ACSM and FIMS Joint Consensus Statement. Clin J Sport Med. 2014;24(6):6.

Lehman PJ, Carl RL. The pre-participation Physical Evaluation. Pediatric Annals. 2017;46(3):e85-e92. doi:10.3928/19382359-20170222-01

Aspen Institute. State of Play Trends and Developments 2018. Accessed September 15, 2020. https://assets.aspeninstitute.org/content/uploads/2018/10/StateofPlay2018_v4WEB_2-FINAL.pdf?_ga=2.155438523.1669166024.1541103726-725764975.1540216190

CDC. Multisystem Inflammatory Syndrome in Children (MIS-C). Centers for Disease Control and Prevention. Published February 11, 2020. Accessed September 15, 2020. https://www.cdc.gov/mis-c/

Rajpal S, Tong MS, Borchers J, et al. Cardiovascular Magnetic Resonance Findings in Competitive Athletes Recovering From COVID-19 Infection. JAMA Cardiol. Published online September 11, 2020. doi:10.1001/jamacardio.2020.4916

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa