KIN 188 – Prevention and KIN 188 – Prevention and Care of Athletic InjuriesCare of Athletic Injuries

Pre-Participation Physical Pre-Participation Physical ExaminationsExaminations

PPEPPE Goals of the PPEGoals of the PPE

Preparation for the PPEPreparation for the PPE

Medical historyMedical history

Components of the PPEComponents of the PPE

Clearance for participationClearance for participation

Goals of the PPEGoals of the PPE Determine general health and current Determine general health and current

immunization statusimmunization status

Establish rapport with participantEstablish rapport with participant

Detect medical conditions that can predispose one Detect medical conditions that can predispose one to injury/illness so treatment can be to injury/illness so treatment can be continued/initiatedcontinued/initiated

Identify health risk behaviors that can be Identify health risk behaviors that can be addressed with counselingaddressed with counseling

Goals of the PPEGoals of the PPE Establish baseline parameters for return to play Establish baseline parameters for return to play

decisionsdecisions

Assess physical maturityAssess physical maturity

Evaluate physical fitnessEvaluate physical fitness

Make recommendations regarding Make recommendations regarding participation/exerciseparticipation/exercise

Meet legal requirements to athletic participationMeet legal requirements to athletic participation

Goals of the PPEGoals of the PPE Specific focus of PPE varies amongst Specific focus of PPE varies amongst

populationspopulations Pre-pubescentPre-pubescent

Undiagnosed congenital abnormalitiesUndiagnosed congenital abnormalities PubescentPubescent

Maturation level, establishing healthy behaviorsMaturation level, establishing healthy behaviors Young adultYoung adult

History of previous injury, sport-specific examHistory of previous injury, sport-specific exam AdultAdult

Overuse conditions predominateOveruse conditions predominate

Preparation for the PPEPreparation for the PPE No one best/right way to do PPENo one best/right way to do PPE

Influenced by several factorsInfluenced by several factors Level of competitionLevel of competition Availability of personnel and facilitiesAvailability of personnel and facilities Number of PPE being conductedNumber of PPE being conducted Personal preference/historyPersonal preference/history

Preparation for the PPEPreparation for the PPE FormatFormat

TimingTiming

FrequencyFrequency

PPE FormatPPE Format Primary care physician modelPrimary care physician model

Enhanced knowledge of medical history, Enhanced knowledge of medical history, immunization status and prior injuries immunization status and prior injuries that could limit participationthat could limit participation

Generally a more thorough examGenerally a more thorough exam Affords best privacy and better Affords best privacy and better

environment for counselingenvironment for counseling Cost is expensive – insurance?Cost is expensive – insurance?

PPE FormatPPE Format Group/station modelGroup/station model

Good for large number of PPE in given Good for large number of PPE in given period of timeperiod of time

Allows better understanding of demands of Allows better understanding of demands of activityactivity

Individual personnel responsible for given Individual personnel responsible for given element of PPE at “station”element of PPE at “station”

Clearance verified by team MD at end of PPEClearance verified by team MD at end of PPE Typically free of chargeTypically free of charge

PPE TimingPPE Timing Ideally completed several weeks prior to Ideally completed several weeks prior to

initial practiceinitial practice

Allows ability to address any problems Allows ability to address any problems identified on PPE (labs, tests, records) identified on PPE (labs, tests, records) without impeding participation statuswithout impeding participation status

Typically done within 1 week prior to first Typically done within 1 week prior to first scheduled activity – high schools often scheduled activity – high schools often over summerover summer

PPE FrequencyPPE Frequency Entry-level PPE (complete) at outset Entry-level PPE (complete) at outset

of participation for of participation for school/organizationschool/organization

Recommended annual re-evaluation Recommended annual re-evaluation without complete PPE unless without complete PPE unless warrantedwarranted

Medical HistoryMedical History Generally accomplished ahead of Generally accomplished ahead of

time in yes/no formattime in yes/no format Often a supplemental form for femalesOften a supplemental form for females

For station model, qualified evaluator For station model, qualified evaluator must review history and red flag must review history and red flag potential concerns for further potential concerns for further scrutiny/evaluationscrutiny/evaluation

Components of the PPEComponents of the PPE Vital signsVital signs General medical General medical

problemsproblems CardiovascularCardiovascular Pulmonary Pulmonary MusculoskeletalMusculoskeletal NeurologicNeurologic EyesEyes

Dental Dental Gastrointestinal Gastrointestinal GenitourinaryGenitourinary DermatologicDermatologic Examination for Examination for

heat disordersheat disorders Laboratory testsLaboratory tests

Vital SignsVital Signs Establishes individual’s baseline Establishes individual’s baseline

parametersparameters Height/weightHeight/weight

Comparison to normative dataComparison to normative data Pulse/respiratory rate (60-100/12-16)Pulse/respiratory rate (60-100/12-16)

Observe quantity and qualityObserve quantity and quality Blood pressure (120/80)Blood pressure (120/80)

Cuff size very importantCuff size very important Body temperature (98.6/37.0)Body temperature (98.6/37.0)

Oral vs. tympanic vs. axillary (rectal)Oral vs. tympanic vs. axillary (rectal)

General Medical ProblemsGeneral Medical Problems Questions asked regardingQuestions asked regarding

Currently being treated for illness/injuryCurrently being treated for illness/injury History of hospitalization or surgeryHistory of hospitalization or surgery History of progressive disease (MS, MD, History of progressive disease (MS, MD,

cancer)cancer) Current use of OTC/Rx medsCurrent use of OTC/Rx meds Allergies to meds, food, environmentAllergies to meds, food, environment

Cardiovascular ExaminationCardiovascular Examination Done in quiet area to maximize validityDone in quiet area to maximize validity

Auscultation of heart soundsAuscultation of heart sounds

Questions asked regardingQuestions asked regarding Fainting (syncope), dizziness, SOB, chest pain with exertionFainting (syncope), dizziness, SOB, chest pain with exertion Heart palpitations, tachycardia, dysrhythmia, known Heart palpitations, tachycardia, dysrhythmia, known

murmurmurmur Family member with sudden, early cardiac deathFamily member with sudden, early cardiac death

Positive responses to any necessitate referral to Positive responses to any necessitate referral to cardiologist for further evaluationcardiologist for further evaluation

Pulmonary ExaminationPulmonary Examination Done in quiet area to maximize validityDone in quiet area to maximize validity

Auscultation of breath sounds in all lung Auscultation of breath sounds in all lung lobes – look for symmetrical movement of lobes – look for symmetrical movement of diaphragmdiaphragm

Questions asked regardingQuestions asked regarding Excessive coughing during/after activityExcessive coughing during/after activity History of asthma, EIA, bronchitis, allergiesHistory of asthma, EIA, bronchitis, allergies SOB, unusual breath sounds during/after activitySOB, unusual breath sounds during/after activity History of collapsed lung (pneumothorax)History of collapsed lung (pneumothorax)

Musculoskeletal Musculoskeletal ExaminationExamination

Basic exam consists of observation for Basic exam consists of observation for symmetry, ROM, strength tests for major symmetry, ROM, strength tests for major muscles and specific tests for previously muscles and specific tests for previously injured areasinjured areas

Questions asked regardingQuestions asked regarding Focus on history of injury, time frame, Focus on history of injury, time frame,

evaluation, treatment and rehabilitationevaluation, treatment and rehabilitation Use of protective devicesUse of protective devices

Neurologic ExaminationNeurologic Examination Evaluation consists of cranial nerve tests Evaluation consists of cranial nerve tests

including pupil function, sensory/motor including pupil function, sensory/motor tests of UE/LE, deep tendon reflexestests of UE/LE, deep tendon reflexes

Questions asked regardingQuestions asked regarding History of head injuriesHistory of head injuries Any previous loss of consciousnessAny previous loss of consciousness Numbness/tingling, loss of motor function in Numbness/tingling, loss of motor function in

bodybody History of seizures, burners/stingersHistory of seizures, burners/stingers

Eye ExaminationEye Examination Visual acuity assessed via Snellen chart, both Visual acuity assessed via Snellen chart, both

monocularly and binocularly (use corrective lenses)monocularly and binocularly (use corrective lenses) Emmetropia (20/20 vision)Emmetropia (20/20 vision) Myopia (nearsightedness)Myopia (nearsightedness) Hypermetropia (farsightedness)Hypermetropia (farsightedness)

Questions asked regardingQuestions asked regarding Use of corrective lenses/typeUse of corrective lenses/type Blurring or double visionBlurring or double vision Color blindness, peripheral vision lossColor blindness, peripheral vision loss History of eye trauma, retinal detachmentHistory of eye trauma, retinal detachment

Dental ExaminationDental Examination Typically done by dentist – not meant Typically done by dentist – not meant

to perform preventative care but to to perform preventative care but to establish pre-existing conditions for establish pre-existing conditions for liability reasons in case of dental injuryliability reasons in case of dental injury

Allows opportunity for dental molds to Allows opportunity for dental molds to be made for crafting of custom be made for crafting of custom mouthguardmouthguard

Gastrointestinal Gastrointestinal ExaminationExamination

Evaluation of digestive system, eating habits and Evaluation of digestive system, eating habits and nutritionnutrition Concerns for athletes where image is important to activityConcerns for athletes where image is important to activity

Evaluation done supine with palpation for masses Evaluation done supine with palpation for masses or organomegalyor organomegaly

Questions regardingQuestions regarding History of heartburn, indigestion, diarrhea or constipationHistory of heartburn, indigestion, diarrhea or constipation Prior history of organ injury (spleen, liver, kidney)Prior history of organ injury (spleen, liver, kidney)

Genitourinary ExaminationGenitourinary Examination For males, questions asked regardingFor males, questions asked regarding

Hernias, testicular torsion, absent or undescended testicleHernias, testicular torsion, absent or undescended testicle

For females, questions asked regardingFor females, questions asked regarding Menstrual cycle, pregnancyMenstrual cycle, pregnancy

General questions asked regardingGeneral questions asked regarding History of bladder/urinary tract infections, STDsHistory of bladder/urinary tract infections, STDs Absence of one kidneyAbsence of one kidney

Can include urinalysis to look for proteins, blood, Can include urinalysis to look for proteins, blood, sugar and hemoglobin in urinesugar and hemoglobin in urine

Dermatologic ExaminationDermatologic Examination Skin evaluated for rashes, lesions, Skin evaluated for rashes, lesions,

infections that can be contagious to othersinfections that can be contagious to others Herpes, fungal infections (tinea), impetigo, Herpes, fungal infections (tinea), impetigo,

STDs, acne/treatmentSTDs, acne/treatment

Also look at existing blemishes (warts, Also look at existing blemishes (warts, moles, etc.)moles, etc.) Change in appearance (size, color, border, etc.) Change in appearance (size, color, border, etc.)

in recent pastin recent past

Examination for Heat Examination for Heat DisordersDisorders

Especially important for activities taking Especially important for activities taking place under conditions of high place under conditions of high temperature, high humidity or a temperature, high humidity or a combination of the twocombination of the two

Questions asked regardingQuestions asked regarding History of heat illness (cramping, syncope, History of heat illness (cramping, syncope,

exhaustion, stroke)exhaustion, stroke) Current meds (diuretics, antihistamines)Current meds (diuretics, antihistamines) Use of caffeinated/alcoholic beveragesUse of caffeinated/alcoholic beverages Nutritional and hydration habitsNutritional and hydration habits

Laboratory TestsLaboratory Tests Not typical associated with PPE – Not typical associated with PPE –

usually due to cost of testing usually due to cost of testing proceduresprocedures

Often used when/if red flags appear Often used when/if red flags appear during PPEduring PPE UrinalysisUrinalysis Blood workBlood work ECGECG

Clearance for ParticipationClearance for Participation Conditions to be met to allow clearance by Conditions to be met to allow clearance by

ME at end of PPEME at end of PPE Will condition increase risk of injury to Will condition increase risk of injury to

individual or others?individual or others? Can participation be allowed if meds, rehab or Can participation be allowed if meds, rehab or

protective bracing/padding is used? If so, can protective bracing/padding is used? If so, can limited participation be allowed in interim?limited participation be allowed in interim?

If clearance is denied for particular activity, If clearance is denied for particular activity, can other safe activities be identified and can other safe activities be identified and clearance be granted for them?clearance be granted for them?

Clearance for ParticipationClearance for Participation Individuals have right to participate in any Individuals have right to participate in any

activity regardless of pre-existing medical activity regardless of pre-existing medical condition/scondition/s

Physician’s cannot exclude individual from Physician’s cannot exclude individual from participation – can only recommend participation – can only recommend against participationagainst participation

Often use exculpatory waiver to identify Often use exculpatory waiver to identify and acknowledge assumption of riskand acknowledge assumption of risk

Clearance for ParticipationClearance for Participation Examples of recommended disqualifying Examples of recommended disqualifying

conditions (American Academy of Pediatrics)conditions (American Academy of Pediatrics) Atlantoaxial instabilityAtlantoaxial instability Aortic disordersAortic disorders Convulsive disordersConvulsive disorders Serious bleeding tendenciesSerious bleeding tendencies Absence of paired organ for contact activitiesAbsence of paired organ for contact activities Repeated concussionsRepeated concussions Uncontrolled diabetesUncontrolled diabetes