Key Points

• The primary objective of the preparticipation physical evaluation is to detect preexisting medical or musculoskeletal conditions that predispose an athlete to injury, disability, or catastrophic injury.

• Syncope that occurs during exercise is a serious warning sign and warrants a comprehensive cardiology evaluation to rule out an underlying cardiac disorder that predisposes to sudden death.

• Any athlete with a systolic murmur of grade 3/6 in severity, a murmur that gets louder with a Valsalva maneuver or on standing (suspicious for hypertrophic cardiomyopathy), a diastolic murmur, a family history of premature sudden cardiac death, or concerning exertional symptoms should be further evaluated by a cardiovascular specialist.

A preparticipation physical evaluation (PPE), or "sports physical," is frequently required for medical clearance before participation in organized sports. The Preparticipation Physical Evaluation monograph, first introduced in 1992, provides recommendations for the content and format of the evaluation (AAFP et al., 2005). The third edition of the monograph, updated in 2005, is supported by six national medical societies: American Academy of Family Physicians (AAFP), American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. The fourth edition published in 2010 also includes collaboration with the American Heart Association (AHA) regarding the preparticipation cardiovascular evaluation. The primary objectives of the PPE include the following:

1. Detection of potentially life-threatening or disabling medical or musculoskeletal conditions before athletic clearance.

2. Identification of preexisting conditions that may predispose athletes to injury.

3. Satisfying legal or administrative requirements.

Secondary objectives of the PPE include the following:

1. Promoting the health and safety of athletes in training and competition.

2. Serving as an entry point into the health care system for adolescents.

3. Providing an opportunity for a general health assessment.

The recommended frequency of the PPE varies widely according to the requirements of the specific school, organization, or state. AHA first published consensus recommendations for cardiovascular screening in athletes in 1996 and reaffirmed these recommendations in 2007, which have influenced the format and timing of the PPE (Maron et al., 1996b, 2007). A comprehensive PPE is recommended on entry into middle school, high school, and college before participation in competitive sports. For youth and high school athletes, a comprehensive PPE should be repeated every 2 years. For years not requiring a comprehensive PPE, annual updates consisting of a comprehensive history and determination of height, weight, and blood pressure, along with a problem-focused evaluation of new concerns, illnesses, or injuries, should occur on interval years for youth and high school athletes and on all subsequent years for college athletes.

The PPE history focuses on symptoms related to exercise, such as exertional syncope, lightheadedness, chest pain, palpitations, dyspnea, wheezing, or fatigue with less than expected activity (Box 29-1). A past medical history of preexisting cardiac or pulmonary conditions, murmurs, hypertension, coronary artery disease risk factors, asthma, concussions, illicit drug use, prior orthopedic injuries, or other medical conditions that place an athlete at risk of injury should be noted. Specific questions to identify a family history of premature death, cardiovascular disease, and hereditary cardiac disorders, such as hypertrophic cardiomyopathy, Marfan's syndrome, and long QT syndrome, are also recommended.

The PPE examination consists of both medical and mus-culoskeletal components. The cardiovascular examination is a major focus of the medical evaluation and consists of a blood pressure measurement, palpation of the radial and femoral artery pulses, cardiac auscultation with the patient both supine and standing, and recognition of the physical manifestations of Marfan's syndrome (Maron et al., 1996b; Maron et al., 2007). Any heart murmur detected should be further assessed during the Valsalva maneuver or while moving the patient from a squatting to a standing position. These maneuvers decrease venous return and may accentuate the murmur of hypertrophic cardiomyopathy, the leading cause of sudden cardiac death in young athletes. However, hyper-trophic cardiomyopathy is difficult to detect on examination alone because outflow tract obstruction, which causes the harsh systolic murmur, is present in only about 25% of patients with the disorder (Maron, 1997) (Fig. 29-1).

The musculoskeletal assessment serves as a screening evaluation of the spine and upper and lower extremities. Joint range of motion, strength, and stability should be tested. Several functional tests, such as hopping, squatting, and "duck walking," assess many anatomic areas at once and make the evaluation more efficient. Previous orthopedic injuries can also be evaluated in more detail to detect problems that require further rehabilitation or protective bracing before sports participation.

Box 29-1 Preparticipation Physical Evaluation (PPE): Cardiovascular History Questions

Have you ever passed out or nearly passed out during or after exercise? Have you ever had discomfort, pain, pressure, or tightness in your chest during exercise? Do you get lightheaded or feel more short of breath than expected during exercise? Does your heart ever race or skip beats (irregular beats) during exercise?

Has a doctor ever told you that you have a heart problem, high blood pressure, high cholesterol, a heart murmur, a heart infection, Kawasaki's disease, or an unexplained seizure disorder?

Has a doctor ever ordered a test for your heart, for example, an ECG or echocardiogram?

Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 50 (including drowning, motor vehicle crash, or sudden infant death syndrome)? Has anyone in your family had unexplained fainting, seizures, or near-drowning? Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator?

Does anyone in your family have hypertrophic cardiomyopathy, Marfan's syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia?

Figure 29-1 Hypertrophic cardiomyopathy. A, Gross appearance; B, histologic appearance. Note the myocardial fiber disarray.

(From Braunwald E. Essential Atlas of Heart Diseases, 3rd ed. Philadelphia, Current Medicine, 2000.)

Figure 29-1 Hypertrophic cardiomyopathy. A, Gross appearance; B, histologic appearance. Note the myocardial fiber disarray.

(From Braunwald E. Essential Atlas of Heart Diseases, 3rd ed. Philadelphia, Current Medicine, 2000.)

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