Give your sports physicals a performance boost
A new evidence-based guideline can help you improve your approach to the preparticipation physical. Two downloadable forms can streamline the process.
Conduct a general musculoskeletal exam
A brief evaluation of strength and mobility of each joint and muscle group is sufficient to determine if a student has adequate baseline musculoskeletal function to compete.3 A joint-specific exam will not only help to assess the particular function and stability of each joint, but may reveal subtle deficits of particular joints or muscle groups that may be amenable to rehabilitation or other treatments prior to the start of the sport season.
The emphasis here, too, may vary based on the sport the patient plans to participate in. If you examine the ankles of a volleyball or soccer player and find ligamentous laxity from a prior injury, for example, consider prescribing a brace or physical therapy.
Follow up with a neurologic exam, which is often paired with the musculoskeletal exam and is considered adequate if the patient possesses full strength in all muscle groups. A patient with a history of multiple stingers may warrant a more detailed examination of strength, reflex, and sensation in the upper extremities to screen for signs of residual nerve injury. Similarly, a patient with a history of multiple concussions may need a more detailed exam that includes the cranial nerves, evaluation of balance, and possibly baseline neuropsychological testing.
Screen for Marfan syndrome
This genetic disorder involves mutations of the fibrillin gene that lead to a diverse presentation of abnormalities in multiple organ systems. Primarily because of the effects of Marfan syndrome on the cardiovascular system, it is important to identify it as part of the PPE. Individuals with this disorder have an increased risk for valvular disorders and for aortic dilation that can lead to dissection or rupture. If the history reveals that the patient has a family member with this disorder or has a history of spontaneous pneumothorax or mitral valve prolapse, look closely for the following skeletal and cardiac abnormalities:
- pectus carinatum or excavatum
- arm span-to-height ratio >1.05
- arachnodactyly
- pes planus
- scoliosis
- reduced elbow extension
- highly arched palate
- murmur of mitral valve prolapse or regurgitation.
If you find any of these abnormalities, postpone sports clearance until the patient undergoes further evaluation.28 To establish a diagnosis of Marfan syndrome, the patient must have major criteria in 2 organ systems, with involvement of a third system.
Make a determination: Should the patient be cleared?
The final part of the PPE, of course, is your decision as to whether the patient should be cleared to engage in competitive activities. Clearance falls into 4 categories: (1) Clearance without restriction; (2) clearance with recommendations for further evaluation or treatment; (3) not cleared; restricted until completion of further testing/consultation; (4) complete restriction from certain or all sports.
The goal of the PPE is to provide safe participation in sports for all athletes, not to disqualify anyone. Fortunately, the vast majority of student athletes qualify for clearance without restriction. About 3% to 10% of those who undergo preparticipation screening require further evaluation prior to sports clearance, and less than 1% are disqualified.3
Being prevented from participating in sports can be a major stressor that interferes with the student’s sense of well-being. The inability to exercise or participate in organized sports poses a risk to the patient’s overall health, and may contribute to social isolation. In fact, being restricted from playing organized sports has been reported to be as stressful as the death of a close friend.29
Help in making the determination. Nonetheless, there are circumstances when restriction is necessary. In addition to the new PPE, there are 2 sources you can turn to for help in making that determination. The Bethesda guidelines—Eligibility Recommendations for Competitive Athletes with Cardiovascular Abnormalities, published by the American College of Cardiology and available at https://content.onlinejacc.org/cgi/content/full/45/8/1318, call for disqualifying students only when the activity would pose a clear danger to their health.23
The American Academy of Pediatrics (AAP) has published a set of sports participation guidelines of its own (available at https://www.guideline.gov/summary/summary.aspx?doc_id=13439) for children with conditions that range from diabetes mellitus and human immunodeficiency virus to mitral valve prolapse, rheumatoid arthritis, and bleeding disorders. There are, of course, some disorders for which the AAP would disqualify students from participation, but in many cases it recommends a “qualified Yes.”27,30
CORRESPONDENCE Jason Womack, MD, UMDNJ - Robert Wood Johnson Medical School, 1 Robert Wood Johnson Place, Department of Family Medicine, MEB 2nd floor, New Brunswick, NJ 08903; womackja@umdnj.edu
