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.

Discussion
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

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

How Common Are Bone Spurs in Young Athletes?

Patient Presentation
An 18-year-old female came to clinic after twisting her knee during her varsity soccer practice 3 days previously. She had planted her foot and then turned her body causing pain in the lateral and anterior area of the left knee. She had stopped practice and iced the area. She did not hear a popping sounds, nor felt the joint catch. She had pain with walking but was improving. She had a soccer tournament the following weekend and wanted to return to play. The past medical history showed previous muscle strains, and a right sided ankle sprain. She had been playing high-intensity soccer for many years.

The pertinent physical exam revealed a medium-build female with a mild gait abnormality when walking. She had mild tenderness near the lateral joint line but her collateral and cruciate ligament tests were normal. She had mild pain during the maneuvers but nothing significant.

The diagnosis of a left lateral ligamentous injury was made but because of the high level of participation a radiograph was taken. The radiologic evaluation of the knee showed no bony abnormalities other than a tiny right notch osteophyte. The patient had not had any problems with her knee previous so it was felt this was an incidental finding. She was counseled about working with her athletic trainer and returning to play when pain free.

Discussion
The terminology of abnormal calcification of soft tissues and uses of the terms is often muddied. Especially as the causes may be similar and multiple adjacent tissues may be involved.

  • An exostosis is an abnormal proliferation of bone from the joint. They can appear in various forms and in many locations.
  • An osteophyte is also known as a bone spur and is type of exostosis. Osteophytes are thought to be periosteal or synovial mesenchymal stems cells that become calcified. They usually have a more narrow or pointed projection from the joint. Osteophytes are a very common feature of osteoarthritis.
  • Enthesophytes are abnormal bony projections at the attachment of a tendon or ligament. These are often due to trauma and examples commonly occur at the knee or heel, such as Osgood Schlater disease.

Exostosis variants include:

  • Osteochrondroma – usually a solitary, non-tender, slow-growing mass in long bones (more commonly lower extremity). Radiographically they can be sessile or stalked in appearance.
    This is the most common skeletal tumor (10-15%). They occur especially during the bony growth period. Complications occur in about 4% of patients and include fractures, bony deformation, and compression causing neurovascular problems.
  • Hereditary multiple exostosis – an autosomal dominant disorder with multiple masses in all parts of the body except the head. They are very common in the lower extremity particularly the knee. Short stature may also be seen.
  • Trevor’s disease – usually affects the tarsal bones or epiphyses of long bones. More common in lower extremities and usually unilateral.
  • Nora’s lesion – also known as bizarre parosteal osteochondromatous proliferation seen in the hands and feet. Generally seen in adults.
  • Subungual exostosis – these occur in both the hands and feet with feet more commonly affected particularly the great toe. These are felt to be traumatically related and the bony projection comes from the nail bed. These are usually seen in teens and adults.

Normal variations or congenital anomalies can be mistaken for exostoses such as the supracondylar process of the humerus, os intermetarsale or even the bony projection within the central spinal canal that tethers and splits the spinal cord in half in diastematomyelia. Periosteal reactions can also appear similar to exostoses and include entities such as osteomyelitis, osteoid osteoma, or osteosarcoma. Myositis ossificans from trauma can cause calcification of the muscle but if deep can also show abnormal ossification of the periosteum.

Learning Point
Risk factors for osteophytes include age (older), body mass index (heavier), physical activity (heavy physical activity), diet (low amounts of various nutrients) and genetic factors.

Osteophytes or bone spurs are usually thought of in older people who have osteoarthritis. However they can occur in young people. A cross-sectional, case-controlled study of young adults (<18-36 years) found that being an athlete had a higher risk of radiographic evidence of osteophytes in the knee (odds-adjusted ratio = 2.8) and if a patient had anterior cruciate ligament surgery (odds adjusted ratio = 7.0). While this study isn’t representative of the general population, it does show that young athletes are at risk for development of osteophytes even at a young age. While this study didn’t find a difference in males and females overall for osteophytes, young female athletes are at higher risk for knee injuries particularly in sports with “cutting” type activities such as basketball or soccer.

Questions for Further Discussion
1. What are common benign bone tumors? A review can be found here
2. What is the long-term outcome of ACL repair? A review can be found here
3. What are the positive aspects of organized sports activities?

Related Cases

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: Bone Diseases and Osteoarthritis.

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.

Richardson RR. Variants of exostosis of the bone in children. Semin Roentgenol. 2005;40(4):380-390. doi:10.1053/j.ro.2005.01.020

DaCambra MP, Gupta SK, Ferri-de-Barros F. Subungual exostosis of the toes: a systematic review. Clin Orthop Relat Res. 2014;472(4):1251-1259. doi:10.1007/s11999-013-3345-4

Roemer FW, Jarraya M, Niu J, Silva J-R, Frobell R, Guermazi A. Increased risk for radiographic osteoarthritis features in young active athletes: a cross-sectional matched case-control study. Osteoarthr Cartil. 2015;23(2):239-243. doi:10.1016/j.joca.2014.11.011

Nasr B, Albert B, David CH, Marques da Fonseca P, Badra A, Gouny P. Exostoses and vascular complications in the lower limbs: two case reports and review of the literature. Ann Vasc Surg. 2015;29(6):1315.e7-1315.e14. doi:10.1016/j.avsg.2015.02.020

Wong SHJ, Chiu KY, Yan CH. Review Article: Osteophytes. J Orthop Surg (Hong Kong). 2016;24(3):403-410. doi:10.1177/1602400327

Perez-Palma L, Manzanares-Cespedes MC, de Veciana EG. Subungual Exostosis Systematic Review and Meta-Analysis. J Am Podiatr Med Assoc. 2018;108(4):320-333. doi:10.7547/17-102

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

What are Potential Problems Associated with Helicobacter pylori?

Patient Presentation
Two pediatricians were talking about the coincidence of each having a family who were concerned about the transmission and testing for H. pylori. Both families had young, asymptomatic children and in one family the mother was affected and in the other family the father was affected. Both parents were being given their initial treatment for H. pylori. Both pediatricians had independently read the recent guidelines for management and had concluded that the children in each family should not be tested currently but be monitored for possible problems.

Discussion
Helicobacter pylori (H. pylori) is a microaerophilis, spiral bacterium that is a prevalent human pathogen. How this infection affects individuals is different in adults and children. Overall seroprevalence rate in children world-wide was estimated to be ~33%, but this seroprevalence rate is decreasing in the developed world for both adults and children. It is acquired in childhood and can persist through colonization throughout life if untreated. Fortunately, it often is asymptomatic and generally does not cause serious disease in children.

Some serotyping data shows that within families children acquire it more often from mothers than from fathers.

Learning Point
H. pylori causes gastritis (chronic), peptic ulcer disease (PUD), gastric adenocarcinoma and MALT (mucosal-associated lymphoid tissue lymphoma) in adults. Many of the studies have been conducted in adults and extrapolating to children is not appropriate. Potential clinical problem may not be caused by H. pylori but rather may only be associated with it in children. Many of those listed below are certainly not specific to H. pylori.

  • PUD can cause upper abdominal pain and potential gastrointestinal bleeding but is not common in children. Testing is recommended if PUD is identified.
  • Functional abdominal pain – testing is not recommended
  • Iron deficiency anemia – testing is not recommended for initial investigation, but may be appropriate for refractory anemia
  • Chronic immune thrombocytopenic purpura – testing may be considered
  • Short stature and failure to thrive – testing is not recommended
  • Henoch-Schonlein purpura – testing is not recommended
  • Obstructive sleep apnea – testing is not recommended
  • Diabetes mellitus – testing is not recommended
  • Asthma/atopic dermatitis – testing is not recommended
  • Celiac disease (having H. pylori possibly has a protective effect)

Guidelines for management for children and adolescents from Europe and North America were published in 2017 (see To Learn More below). Testing of relatives with gastric cancer that were previously included in guidelines have been removed from this iteration. Test and treat strategy for children is not recommended as the clinical goal is to identify the cause of the upper abdominal pain and/or other symptoms rather than identifying H. pylori infection. Patients should have appropriate diagnostic testing (i.e. endoscopy with biopsy, urea breath hydrogen testing, stool antigen testing) with antimicrobial susceptibility testing to guide treatment. Even with biopsies, H. pylori can be an incidental finding. Treatment depends on age, antibiotic susceptibility testing and include antibiotics and proton pump inhibitors for 7-14 days depending on the protocol. Adherence to protocol has been shown to be a key to treatment success and more than 90% adherence is recommended. The main cause of treatment failure is clarithromycin resistance and non-adherence. Post treatment re-testing for treatment success or failure is recommended at least 4 weeks after treatment. There has been a vaccine trial in China with children. The efficacy rate was “…71% and 55% at 12 months and 3 years after vaccination.” One problem was “…that 20% of younger children in the study were not protected [from H. pylori].”

Questions for Further Discussion
1. How common are gastric ulcers? A review can be found here
2. What are the ROME criteria for functional abdominal pain? A review can be found here
3. What causes abdominal pain? A review can be found here

Related Cases

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 this topic: Helicobacter Pylori infections

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.

Jones NL, Koletzko S, Goodman K, et al. Joint ESPGHAN/NASPGHAN Guidelines for the Management of Helicobacter pylori in Children and Adolescents (Update 2016). J Pediatr Gastroenterol Nutr. 2017;64(6):991-1003. doi:10.1097/MPG.0000000000001594

Kalach N, Bontems P, Raymond J. Helicobacter pylori infection in children. Helicobacter. 2017;22 Suppl 1. doi:10.1111/hel.12414

Kotilea K, Kalach N, Homan M, Bontems P. Helicobacter pylori Infection in Pediatric Patients: Update on Diagnosis and Eradication Strategies. Paediatr Drugs. 2018;20(4):337-351. doi:10.1007/s40272-018-0296-y

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

What Distinguishes Childhood Masturbation from Other Potential Diagnostic Entities?

Patient Presentation
A 3-year-old female came to clinic for followup after seeing an urgent care provider for possible urinary tract infection 3 days previously. The parent had complained that the child had been putting her hands in her genital area more frequently or “holding herself.” The provider had noticed some vulvar and vaginal irritation and had started her on antibiotics for possible urinary tract infection. Her mother had continued to see the behavior and was concerned. During the visit the child sat on a child-sized chair and would put her hand in her genital area and did some rocking back and forth. The mother said that this was the behavior she was worried about and had also videotaped it. The video showed the child at a table during a meal performing the same behavior. The pediatrician noted that the child did not seem distressed or worried when performing the behavior. The mother agreed and said that she seemed calmer. The mother noted that she was always aware/awake during the episodes as well and would stop the behavior her name was called out, a hand was put on her arm or otherwise distracted. The mother denied any concerns for child maltreatment. The past medical history was negative for any renal problems and the family history was negative for genital or renal problems. The review of systems showed no specific urinary frequency or dysuria, fever, or malodorous urine or vaginal discharge. Stooling was normal.

The pertinent physical exam showed a healthy female with normal vital signs and growth parameters. She had some mild vaginal irritation. The hymen was intact and no other lesions including bruises or rashes were noted in the genital area, abdomen or legs.

The diagnosis of vaginal irritation and childhood masturbation was made. “It can be difficult to tell if there was irritation which started her touching herself which then continued, or if she was touching herself which caused some irritation,” the pediatrician explained. “Either way, improving her hygiene will help the irritation,” she explained. The pediatrician also went on to explain the normal self exploration and stimulation that young children perform, and how the mother could explain to the child that this is normal but people don’t do this in public. The antibiotics were also stopped.

Discussion
Childhood masturbation (CM) is defined as self-stimulation of the genitalia in a prepubescent child.” CM is normal sexual behavior and can be noted at all ages including infancy. It becomes very common after puberty. It is one of the most common sexual behaviors. CM can resemble the same adult masturbatory activity including flushing, sweating, muscular contracting and breath holding or tachypnea. However in younger children these changes are not recognized, are interpreted differently or infants and young children may also have different activities. “…(1)stereotyped posturing of the lower extremities and/or mechanical pressure on the perineum or suprapubic area, (2) associated intermittent (quiet) grunting, irregular breathing, facial flushing and diaphoresis, (3) variable duration of the episode (lasting from a few seconds to several hours) and variable frequencies of episodes (range form once in a while to almost continuously), (4) no alteration of consciousness, (5) cessation with distraction, (6) the episodes cannot be explained by abnormalities on physical and other diagnostic (technical, laboratory) examinations.”

In young children CM is part of their curiosity of the world and in this case in exploring their own and other’s bodies (i.e. viewing genitalia) and in discovering pleasurable sensations. Sexual behaviors in puberty and post-pubertal youth and adults is more intentional with sexual arousal and/or orgasm as goals. Some parents especially worry that the behaviors are abnormal or excessive. There is no specific definition of normal or excessive and these are left to interpretation. Normative behavior is based on cultural, group or societal expectations with the idea that they support health or at least do not hinder it. For example, as children mature and reach school age, they are less likely to do CM activities in public as they have learned that certain behaviors are not acceptable in public. If the CM causes distress for the child, is outside the developmental range for the child’s age, or there are concerns for child maltreatment, or there are multiple behavioral problems, then simple normative CM may not be the only diagnosis to consider. In children with psychological stress, CM can be a regulating mechanism. It can also be a stimulatory activity for children with severe lack of external stimulation in their lives.

CM can occur in children who are victims of abuse. No specific behavior is pathognomonic of abuse and for many victims there are no symptoms at all. However sexualized behavior is one of the common symptoms of child abuse. Examples of inappropriate sexual behaviors include:

  • Putting mouth on breasts or genitals
  • Masturbating with objects
  • Inserting objects into vagina/anus
  • Inserting tongue while kissing
  • Imitating sexual sounds
  • Undressing with other people
  • Wanting to participate in sexual acts or imitating sexual intercourse including with dolls or toys
  • Wanting to see inappropriate video or television

Parental and societal views of CM are different and should be respected. Discussing normal growth and development of the child including their own sexuality usually normalizes the behavior and understanding for families. Based on the family’s beliefs, the child’s age and education, the child (and family) can be educated about their sexuality and taught to masturbate in a private location similar to other private activities such as elimination. Some people have strong feelings about the term masturbation and alternatives include self-stimulation or gratification.

Reasons that CM comes to attention can be attributing it to abdominal pain, seizures, dystonia, movement disorders, urinary tract infections, vaginal discharge or vaginitis, diaper rash, phimosis, balanitis, pinworms, eczema and lichen sclerosus. Sometimes it can be difficult to tell if the CM caused genital trauma which in turn leads to the child complaining of pain or holding or rubbing their genitals, or if it is the other way around. Videotaping the behavior can help with diagnosis as the behavior can be reviewed by the clinician and family together.

Learning Point
The key element which distinguishes CM from other differential diagnostic entities is that it ceases with distraction. Children are awake during the behavior.

Questions for Further Discussion
1. Describe common sexual behaviors in young children. A review can be found here
2. What is differential diagnosis of vulvovaginitis? A review can be found here

Related Cases

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: Sexual Health and Child Behavior Disorders.

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.

Mallants C, Casteels K. Practical approach to childhood masturbation – a review. European Journal of Pediatrics. 2008;167(10):1111-1117. doi:10.1007/s00431-008-0766-2

Strachan E, Staples B. Masturbation. Pediatr Rev. 2012;33(4):190-191. doi:10.1542/pir.33-4-190

Wilkinson B, John RM. Understanding Masturbation in the Pediatric Patient. J Pediatr Health Care. 2018;32(6):639-643. doi:10.1016/j.pedhc.2018.05.001

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