Recommended Components of the Pre-Participation Physical Examinations
Medical screening tools used to determine clearance for athletic participation include the health history questionnaire and the pre-participation examination. The 12-element cardiovascular screening and the 90-second musculoskeletal screening are 2 components that should be included in the physical (clinical) examination. Policies or legal mandates may require additional screenings to determine athlete readiness and/or maturity (ie, Tanner Maturation Scale).
Health History Questionnaire
A comprehensive medical and family history gives the athlete the ability to disclose any past illness, injuries, or conditions critical to sport participation. Most medical professionals identify the history as the most critical component of an evaluation. A comprehensive medical history is the most sensitive and specific component of the PPE.1,10 Research supports that a comprehensive history identifies 75% to 92% conditions that can affect athletic participation.1,10 The Health History Questionnaire contains over 50 questions organized by system,1 but the validity of Questionnaire recommended in the PPE-4 has not been determined. The PPE-4 recommended example of a Health History Questionnaire can be found at www.aap.org/en-us/about-the-aap/ Committees-Councils-Sections/Council-on-sports-medicine-and-fitness/Pages/PPE.aspx.
For minors, it is highly recommended that parents assist their children in completing this form; however, parents and student-athletes may not provide reliable and historical information. This is typical of self-report research data possibly due to inadequate information retrieval. The PPE-4 attempts to limit this by including an educational section for parents and athletes to assist them in understanding the terms, the significance of the questions, and the importance of answering them honestly.1 Furthermore there appears to be some support for an e-History form. A study completed at Stanford University Athletics, indicated a significant increase in compliance and accuracy with an online history form.12
While the history questionnaire probes individual body systems, the history form asks questions specific to the recommendations by the American Heart Association for cardiovascular screening of competitive athletes.1 Another important component of the history is the section on the musculoskeletal system. Additional recommendations to be highlighted and reviewed include nutritional assessment, heat/hydration-related illness risk factors, and mental health considerations. The PPE-4 also emphasizes menstrual cycle and disordered eating in female athletes. The final portion of the history includes questions regarding the mental health status of the athlete. Any yes answers will require a follow up with the physician to determine follow up assessments and/or referral.
A general health screening should include vital signs (height, weight, blood pressure, temperature), visual acuity (Snellen Eye Chart), cardiovascular, neurologic, musculoskeletal (orthopedic) and a systematic general medical examination (pulmonary and abdominal screening includes auscultation of the lungs and the abdomen, skin, genitalia for males).2 Additional recommendations of the general health screening include a review of all medications and supplements used by the athlete. The general health screening is used to determine if any additional testing is required. Laboratory or diagnostic screenings (urinalysis, complete blood count, lipid profiles) are not recommended or required. If the athlete has a history of anemia, hemoglobin and ferritin levels should be measured and the athlete should be advised on treatment. If an athlete presents with diabetes, the athlete should be educated on blood glucose monitoring during sport participation as well as being required to have an annual eye, neurological, and cardiovascular exam, and routinely be evaluated for foot conditions (sensory, motor and reflex). The NCAA requires sickle cell screening if their hemoglobinopathy status is unknown. If an athlete is identified as having sickle cell trait, he or she should be aware of concerns related to hydration, conditioning, and acclimatization. The PPE-4 recommended format is available at; https://www.aap.org/en-us/about-the-aap/Committees-Councils-Sections/Council-on-sports-medicine-and-fitness/Pages/PPE.aspx.
The Musculoskeletal Examination
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Because one of the strongest independent predictors of sports injuries is a previous injury,6,10 including a musculoskeletal component to the PPE is critical.2 Both the PPE-4 and the NATA position statement recommend the 90-second orthopedic screening examination as one component of the PPE (Table 10-1).
The 90-second assessment simply has the clinician instruct the patient to move their upper limbs, lower limbs, neck, and trunk allowing for basic observation of movement (amount, symmetry, and absence of pain).
A study by Gomez et al13 found that 91.6% of musculoskeletal conditions were detected by history alone. When comparing an orthopedic examination and the 90-second screening, 14 significant injuries were missed by the detailed orthopedic examination, but were detected by the 90-second screening examination. The results of this study determined the sensitivity