Residency · Residency · Physical Medicine Rehabilitation

The Pre-Participation Physical Examination

Overview

Systematic medical evaluation before athletic participation. Goals: identify conditions that predispose to injury or sudden death, establish baseline health, satisfy legal/administrative requirements. Required for most organized sports at scholastic and collegiate levels. Ideally performed 6-8 weeks before season (allows time for workup if needed). Multi-specialty consensus: PPE Monograph (AAP, AAFP, AMSSM, AOSSM, ACSM).

Components of the PPE

Medical History

Most important component (identifies 60-75% of conditions affecting clearance). Key history domains: Cardiovascular: syncope/near-syncope with exercise, chest pain, palpitations, shortness of breath disproportionate to exertion, family history of sudden cardiac death (<50 years), known heart murmur, hypertension. Concussion: prior concussions (number, recovery time), persistent symptoms, history of loss of consciousness.

Musculoskeletal: prior injuries, surgeries, joint instability, stress fractures. Respiratory: asthma, exercise-induced bronchoconstriction. Neurological: seizure disorder, stingers/burners, headaches. General: heat illness history, sickle cell trait status, eating disorders, menstrual history (female athletes), medication and supplement use.

Mental health: depression, anxiety screening (PHQ-2). Paired organs: single kidney, eye, testicle (risk of losing remaining organ).

Physical Examination

Cardiovascular Examination

Blood pressure measurement (both arms if initial reading elevated). Hypertension staging per pediatric/adult guidelines. Heart auscultation: supine and standing. Murmurs: dynamic auscultation (Valsalva, standing/squatting).

Hypertrophic cardiomyopathy murmur: increases with Valsalva and standing (decreased preload). Benign flow murmurs: decrease with Valsalva and standing. Femoral pulse palpation (coarctation screening). Stigmata of Marfan syndrome: tall stature, arm span > height, arachnodactyly, pectus excavatum, scoliosis, lens subluxation, joint hypermobility.

Musculoskeletal Examination

General screening: 2-minute orthopedic examination. Cervical ROM. Shoulder ROM, impingement, instability. Elbow ROM.

Hand and wrist ROM. Spine alignment (scoliosis screening - forward bend test). Hip ROM. Knee stability (valgus/varus, Lachman, pivot shift). Ankle stability. Single-leg hop (functional assessment). Focused examination based on history of prior injury.

Other Components

Vision screening (Snellen chart). Skin examination (communicable infections: herpes, impetigo, tinea in contact sports). Abdominal examination (hepatosplenomegaly - mononucleosis). Neurological screening (mental status, cranial nerves, reflexes if indicated). Genitourinary examination in males (single testicle, hernia) - if indicated.

<image>Two-minute musculoskeletal screening examination sequence for pre-participation physical examination</image>

Cardiovascular Screening

Conditions of Concern

Hypertrophic cardiomyopathy (HCM): most common cause of sudden cardiac death in young athletes in the US. Prevalence: 1:500. Asymmetric septal hypertrophy. Dynamic LVOT obstruction.

Clinical clues: systolic murmur increasing with Valsalva, syncope with exertion, family history. Coronary artery anomalies: second most common cause; anomalous origin of left coronary from right sinus. Commotio cordis: sudden death from blunt chest impact during vulnerable phase of cardiac repolarization. Long QT syndrome: channelopathy predisposing to ventricular arrhythmias.

Wolff-Parkinson-White syndrome: accessory pathway, tachyarrhythmias. Arrhythmogenic right ventricular cardiomyopathy (ARVC): most common cause of sudden cardiac death in athletes in Italy. Myocarditis: viral etiology, risk during active infection. Aortic root dilation: Marfan syndrome.

ECG Screening Debate

European/FIFA approach: history + physical + 12-lead ECG. Italian model reduced SCD by 89% over 25 years (Corrado et al.). Identifies ion channelopathies and cardiomyopathies that history/exam miss. US approach (AHA/ACC): history + physical exam ONLY (no routine ECG).

Concerns: false-positive rate (10-25% in uninterpretted ECGs), cost, psychological burden, limited resources for follow-up. False-positive rate reduced with modern interpretation criteria (International Criteria, 2017). International Criteria for ECG Interpretation in Athletes (2017): Normal/training-related findings: sinus bradycardia, early repolarization, isolated voltage criteria for LVH, incomplete RBBB.

Borderline findings: require ≥2 to be abnormal. Abnormal findings warranting further evaluation: T-wave inversions, ST depression, pathological Q waves, LBBB, WPW pattern, prolonged QTc.

<image>Normal athletic ECG findings versus abnormal findings requiring further cardiovascular workup using International Criteria</image>

Further Cardiac Testing (When Indicated)

Echocardiography: evaluate structural heart disease (HCM, valvular disease, aortic root). Cardiac MRI: ARVC, myocarditis, infiltrative disease. Exercise stress testing: provoke arrhythmias, assess functional capacity. Holter monitor: capture intermittent arrhythmias. Genetic testing: ion channelopathies, familial cardiomyopathies.

Clearance Decision-Making

Categories

Cleared without restriction: no conditions affecting participation. Cleared with recommendations: condition present but manageable (e.g., asthma with EIB plan, protective eyewear for single eye). Not cleared pending further evaluation: abnormality found requiring workup. Not cleared for certain sports: condition precludes specific activities (e.g., atlantoaxial instability and contact sports in Down syndrome). Not cleared for any sports: rare, reserved for life-threatening conditions pending treatment.

Conditions Requiring Special Consideration

Single kidney: contact sports contraindicated by some guidelines; shared decision-making with family. Splenomegaly (mononucleosis): no contact sports until spleen normalizes (typically 3-4 weeks). Sickle cell trait: universal precautions for exertional collapse (graduated conditioning, hydration, rest periods, avoid extreme heat/altitude). Atlantoaxial instability (Down syndrome): screening radiographs controversial; contact sports restriction if positive.

Seizure disorder: avoid sports with fall risk to water or height (swimming unattended, rock climbing); contact sports generally permitted if seizures controlled. Musculoskeletal abnormalities: functional assessment, may require sport modification or protective equipment.

Female Athlete Considerations

Relative Energy Deficiency in Sport (RED-S)

Formerly "Female Athlete Triad" - now recognized in both sexes. Spectrum: low energy availability → menstrual dysfunction (females) / low testosterone (males) → impaired bone health. Screening questions: menstrual history, dietary restrictions, weight concerns, stress fracture history. Management: increase energy availability, reduce training if needed, psychology/nutrition referral. Clearance considerations: active eating disorder or amenorrhea + stress fracture = restricted clearance.

Menstrual History

Menarche age, cycle regularity, use of hormonal contraception. Primary amenorrhea: no menses by age 15 or 3 years after thelarche. Secondary amenorrhea: absence of menses for ≥3 months in previously menstruating female. Oligomenorrhea: cycles >35 days apart.

Concussion History in PPE

Number of prior concussions. Duration of symptoms with each concussion. Any prolonged recovery (>4 weeks). Current symptoms.

Baseline neurocognitive testing (if available/mandated). Consider restricting clearance if: multiple concussions with prolonged recovery, declining cognitive function, persistent symptoms.

Medicolegal Considerations

PPE does not create ongoing physician-patient relationship (debated). Document all findings, recommendations, and clearance decisions. Shared decision-making with athlete, parents (minors), and coaching staff. Written clearance form with specific restrictions if any.

Liability for failure to identify conditions that were detectable on standard examination. Cannot guarantee prevention of sudden cardiac death - PPE is a screening tool, not a diagnostic evaluation.

<image>PPE clearance decision algorithm showing pathways from normal exam through restricted clearance</image>

Clinical Pearls

The medical history is the most important component of the PPE - it identifies 60-75% of potentially disqualifying conditions. A systolic murmur that increases with standing or Valsalva (decreased preload) should raise concern for HCM and warrants echocardiography. Sickle cell trait affects 1 in 12 African American athletes - universal precautions (gradual conditioning, hydration, rest in heat) should be implemented regardless of testing. The PPE is an opportunity to screen for mental health, eating disorders, and RED-S in addition to cardiovascular and musculoskeletal conditions. Always palpate femoral pulses - absence or delay suggests coarctation of the aorta, which is both a cause of hypertension and a risk for aortic rupture during exertion.

References

• PPE: Preparticipation Physical Evaluation. 5th ed. American Academy of Pediatrics; 2019.
• Drezner JA, et al. International criteria for electrocardiographic interpretation in athletes: consensus statement. Br J Sports Med. 2017;51(9):704-731.
• Maron BJ, et al. Assessment of the 12-lead ECG as a screening test for detection of cardiovascular disease in healthy general populations of young people. Circulation. 2014;130(15):1303-1314.
• Harmon KG, et al. Incidence, cause, and comparative frequency of sudden cardiac death in NCAA athletes: a decade in review. Circulation. 2015;132(1):10-19.
• Mountjoy M, et al. IOC consensus statement on relative energy deficiency in sport (RED-S): 2023 update. Br J Sports Med. 2023;57(17):1073-1097.

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