Physical Examination

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The physical examination should include measurement of height and weight. Significant, unexpected changes should warn physicians of the potential of eating disorder or steroid use. General assessment of the head, ears, eyes, nose, and throat is performed. If the athlete has corrected vision less than 20/40, one eye, or history of eye trauma or surgery, then eye protection is required. Anisocoria, astigmatism, strabismus, refractive errors, and poor visual acuity should also be evaluated in athletes and noted in the chart for possible assessment of head injuries in the future.7

For the physical examination of the cardiovascular system, the American Heart Association recommends checking blood pressure, auscultating for murmurs, palpating peripheral pulses to determine for coarctation, and assessing for Marfan syn-drome.9 The heart should be auscultated with the athlete in the standing and supine positions. Murmurs that need further evaluation by a cardiologist include 3/6 or higher systolic murmur, any diastolic murmur, and any murmur that increases with standing or with Valsalva maneuver.

Sudden cardiac death is the most common cause of non-traumatic death in young athletes and occurs in approximately one in 200,000 with a few cases each year.9 Many cases occur in individuals with pre-existing heart disease.4 In the United States, most cases are due to hypertrophic cardiomyopathy (26.4%), followed by commotio cordis (19.9%), and coronary artery anomalies (13.7%).13 The American Heart Association and 26th Bethesda Conference have developed various guidelines and recommendations for athletic screening and participation14 (Table 2-2).

Abnormal cardiovascular examinations are uncommon in athletes younger than the age of 35. In one study of high school athletes, it was found that 0.37% of the participants had either severe hypertension or syncope that prompted further evalua-tion.15 Many studies have been conducted on the effectiveness and cost efficiency of electrocardiography in risk stratifying athletes who need further evaluation by a cardiologist. Today, there is no consensus on the use of electrocardiography in the prepar-ticipation examination. Another tool for sports medicine physicians to evaluate athletes at risk for sudden cardiac death is echocardiography. It has been proposed, because of its low positive predictive value and cost, that echocardiography should only be used as a follow-up examination in selected patients and not as a primary screening tool.10 Noninvasive screening tests may be developed in the future to help sports medicine physicians diagnose athletes who are at significant risk of cardiac sudden death. This may potentially include a portable echocar-diography machine and genetic screening for coronary disease.10

The athlete must be further evaluated if chest tightness, shortness of breath, cough, or wheezing within the first 10 minutes after exercise is noted. The lungs should be auscultated for any wheezes, crackles, or rubs. If the athlete is found to have any of the features, they must be suspected of having exercise-induced bronchospasm, especially if the athlete has a history of asthma.7 It is now recommended that all elite athletes in swimming, cycling, rowing, snow skiing, cross-country skiing, scuba diving, and figure skating have a bronchial provocation test prior to competition to exclude exercise-induced bronchospasm.16 The eucapnic voluntary hyperpnea challenge test is recom

Table 2-2 26th Bethesda Conference Guidelines for Athletic Participation for Selected Cardiovascular Abnormalities

Hypertrophic cardiomyopathy

Exclusion from most competitive/noncompetitive sports, with possible exception of low-intensity sports, regardless of medical treatment, absence of symptoms, or implantation of defibrillator.

Coronary artery abnormalities

Exclusion from all competitive sports. Participation may be considered 6 months after surgical correction and after exercise stress testing.

ARVD

Exclusion from all competitive sports.

Mitral valve prolapse

Exclusion if history of syncope is associated with arrhythmia, family history of mitral valve prolapse and sudden death, documented arrhythmia, or moderate to severe mitral regurgitation.

Ebstein's anomaly

Severe disease precludes participation in all sports. After surgical repair, low-intensity sports are permitted if tricuspid regurgitation is absent or mild, heart size is normal, and no arrhythmias are present on Holter monitoring and stress testing.

Marfan syndrome

Exclusion from contact sports. Patients with aortic regurgitation and marked dilation of aorta are excluded from all competitive sports. Others may participate in low-intensity sports, with biannual echocardiography.

Long QT syndrome

Exclusion from all competitive sports.

Myocarditis

Athletes with history of myocarditis in previous 6 months are excluded from all competitive sports.

Wolff-Parkinson-White syndrome

Patients with normal exercise testing ± electrophysiologic study may be eligible for participation in all sports.

Coronary artery disease

Individual risk assessment based on ejection fraction, exercise tolerance, presence of inducible ischemia or arrhythmias, and presence of hemodynamically significant coronary stenoses on angiography.

ARVD, arrhythmogenic right ventricular dysplasia.

Reprinted from American College of Sports Medicine and American College of Cardiology: 26th Bethesda Conference. Recommendations for determining eligibility for competition in athletes with cardiovascular abnormalities. Med Sci Sport Exerc 1994;26:5223-5283, with permission from the American College of Cardiology Foundation.

ARVD, arrhythmogenic right ventricular dysplasia.

Reprinted from American College of Sports Medicine and American College of Cardiology: 26th Bethesda Conference. Recommendations for determining eligibility for competition in athletes with cardiovascular abnormalities. Med Sci Sport Exerc 1994;26:5223-5283, with permission from the American College of Cardiology Foundation.

mended by the International Olympic Committee (IOC) for elite athletes. This test has two different protocols: stepped and single stepped. The stepped protocol is indicated for athletes with severe or unstable airway disease and involves increasing the athlete's ventilation over three stages. The single-stepped protocol is indicated for athletes with asthma or exercise-induced bronchospasm and involves a single level of ventilation for 6 minutes. Each protocol measures lung function and a decrease of more than 10% from baseline indicates exercise-induced bronchospasm.17 The type of test to perform for confirmation of exercise-induced bronchospasm is determined by what is most readily available.

For the abdominal examination, one should pay particular attention to abdominal distention and tenderness, organomegaly, rigidity, or masses. A hernia by itself is not a disqualifying factor but needs further evaluation and possible treatment prior to play. Female athletes should be questioned about the possibility of pregnancy. If there is a possibility of pregnancy, pain, or enlargement of the abdomen, a pelvic examination should be performed in a private setting prior to participation.7

In the past, physicians have provided a male testicular examination during the preparticipation examination. Today, the evidence has shown that counseling, describing the examination, and having athletes do the examination at home allows the athlete to learn more about testicular cancer and its symptoms.17 The sports medicine physician should ask about history of unde-scended testes, masses, loss of a testicle, and inguinal hernias, and, if positive, then a testicular examination may be warranted. Tanner staging is no longer recommended as part of the prepar-ticipation examination. Its use is mainly for evaluating musculoskeletal injuries in the physically immature.

The musculoskeletal examination should be done in an orderly manner with attention to identifying potential abnormalities in musculature and bone structure. An example that is evidence based is the 14-point examination6 (Table 2-3; Figs.

2-1 through 2-3), as outlined in the consensus monograph, with additions to measure supraspinatus strength and a dynamic strength test (balancing on one foot).18 This examination is good for most athletes, but a more detailed examination should be performed for certain populations (e.g., professional athletes).19 If an athlete has a history of an injury (e.g., fracture, joint pain) or answers yes to any musculoskeletal question in the original history form, then that athlete should be evaluated further with a detailed examination of that bone or joint. A major goal of the orthopedic examination is that full rehabilitation of injuries is accomplished prior to participation in the sport. Some sports medicine physicians have included measurements of endurance, strength, and flexibility with the preparticipation examination, but these measurements add significant time to the overall process.

Neurologic examination should be done while performing the musculoskeletal examination. Any neurologic deficits (e.g., loss of strength, paresthesias) should be explored, as should a history of stingers/burners or head injury. The athlete must be without signs or symptoms of neurologic deficit prior to starting sports. The preparticipation examination may give the sports medicine physician the opportunity to assess baseline neuropsychological function. This can be a helpful tool for guiding return to play decisions in the concussed athlete.20

Any skin problems (e.g., rashes, infections, abrasions, blisters) should be assessed during the examination. By addressing these skin reactions early and prior to the start of the season, the athlete can be treated and participate in sports. Skin infections need to be treated prior to participating in sports involving body contact.

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