Robert Sallis, MD Has documented that he has no relevant financial relationships to disclose or COIs to resolve.

Robert Sallis, MD has documented that his presentation will not involve discussion of unapproved or off-label, experimental or investigational use.

Participation Sports Physical

Robert Sallis, MD, FAAFP,FACSMCo-Director; Sports Medicine Fellowship

Department of Family Medicine

Kaiser Permanente Medical Center

Fontana, California, USA

Overview• Review goals and

format of the PPE• Discuss content of the

exam • Clearance and

disqualification• Prevention of exercise

related sudden death

Introduction

• Estimated that well over 2 million physician-hours are spent yearly examining over 12 million youth athletes in the U.S.

• Many have questioned the cost effectiveness of yearly exams.

Risser, et al; 1985

– 2 were disqualified, and 1 had further treatment prior to participating

– 3 significant problems uncovered, at cost of $4,537 per problem

• Looked at 763 PPE’s done on adolescent athletes:– 16 athletes were not cleared.

Mayo Clinic; 1998

• 2,739 PPE’s on HS athletes• 1.9% disqualified; 11.9%

needed more evaluation• Musculoskeletal problems

were most common reason to disqualify (43%), followed by cardiac problems (19%)

Other Studies Have Shown Similar Results

• From .3 to 1.3 % being disqualified.

• From 3.2 to 13.5 % requiring consultation.

PPE Monograph; 2010

Goals of the Pre-Participation Exam

• Detect potentially life threatening or disabling conditions.

• Detect conditions that require treatment of rehab before participating.

• Meet legal or insurance requirements (49 of 50 states require yearly exam).

Goals of the Pre-participation Exam(Continued)

• Determine general health of the athlete.–Answer health related

questions.–Counsel on high risk

behavior.–Assess fitness level and

readiness for sport.

2 Common Formats Used

• Private office:–Records available.–Better continuity.–More privacy.

• Group exam:–Lower cost.–Better communication

with school staff.

Pre-season Mass Screening• This is a screening exam.

– Not meant to replace full exam that should be done by athlete’s personal physician (ideally every 4 years).

– Quick screen to look for pre-existing or new problems.

• Focus on history form completed prior to exam.

• Brief heart and lung exam, with focused musculoskeletal exam.

Frequency and Timing

• Frequency - most states require yearly exams; Every 3-4 yrs with yearly screening updates probably adequate.

• Timing - should occur 4-6 wks before season to allow time to evaluate problems.

Content

• Since exercise primarily stresses the cardiovascular and musculoskeletal systems – these areas need emphasis

• Should begin with a detailed history. • Using a pre-printed form given out prior

to the exam is helpful.• Parents should complete form for

athletes who are minors.

History

• Shown to identify up to 80% of problems affecting participation.

• Ask about pre-existing medical problems or injuries and current state of health.

• Key problems to screen for include cardiac, MSK, asthma, concussions and heat illness.

Cardiovascular Assessment

• Critical history questions:–Have you ever passed

out nearly passed out while exercising?

–Any chest pressure or pain while exercising?

–Any family history of cardiac death before age 35 (50 for adult screen)?

Cardiovascular ExamThe Following Need More Evaluation:

• Heart murmurs which are diastolic or > grade 3 (listen during Valsalva).

• Ectopic beats that worsen with exertion. ? Cocaine use.

• Hypertension – re-check with larger cuff. Avoid high static demand sports if severe.

Musculoskeletal Assessment• Keep in mind the demands

of the sport in which the athlete will compete.

• Evaluate pre-existing or past injuries (knee, shoulder, ankle are high risk to re-injure.

• History shown to ID 92% of musculoskeletal problems.

• “Two minute” orthopedic exam is a useful screen.

Other Important Areas

• Height / weight – eating disorders.• Lungs – wheezing.• Abdomen - organomegaly or masses.• Skin - infectious diseases, acne.• Genitalia - testicular mass or

undescended testicle–Tanner staging no longer recommended.

Pre-season Exam

• Brett Butler• John Kruk

Case Discussion15 yo Wrestler in for PPE

• Rash on neck for few weeks and seems to be spreading.

• Diagnosis? Can he play?– Tinea Corporis (Gladiatorum)– Okay to play if can cover lesions

with gas-permeable dressing and tape

– Must treat for 3 days with topical cream or 2 weeks oral if widespread rash

Screening Tests

• Routine CBC and UA not recommended.

• Routine EKG and echo not recommended.–Not proven cost effective.–Consider only when Hx and

PE support.–Europe using screening EKG

Q2yrs starting age 12-14.

Screening ECG Controversy• Pros

– Relatively cheap and available– Better than H&P alone at diagnosing

causes of SCD– Abnormal in ~80% with cardiomyopathy,

myocarditis, Long QT

• Cons– Athletes Heart changes mimic disease,

so expertise needed– Some potentially fatal heart disease

may not have ECG changes– High false positives; increase expense

and disqualify 2%

Recommended Screeing Tests• Required tests: UA drug screen

(elite athletes), HIV (boxers).• Consider CBC in female

athletes.• Cholesterol testing if family hx

of CAD or hyperlipidemia.• Consider stress EKG in adult

with cardiac risk factors prior to stating exercise program.

• Screen for sickle cell trait in black athletes.

Case Discussion17 yo Football player in for PPE

• Collapsed in practice last year from Heat Stroke. Spent night in hospital; Full recovery.

• Can he play? Precautions?– No exercise x 1 week after

asymptomatic, then gradual return.– Likely increased risk to suffer

another episode.– Close monitoring with cooling

measures.– Ice water immersion.– Heat Tolerance Testing?

Sickle Cell Trait

• About 1 in 10 blacks have trait, while about 1 in 400 have sickle cell disease.

• Usually benign, but can get sickling with strenuous exercise in high heat, humidity or altitude.

• Sickled RBC’s can clog coronary arteries causing arrhythmia.

Davaughn Darling

Case Discussion15 yo Soccer in for PPE

• Suffered head injury in final game last year with 5 min LOC. CT neg and symptoms resolved over few days.

• Can she play? Precautions?– Most important issue is resolution

of symptoms.– Graduated RTP protocol.– How many are too many?– Increased risk for 2nd concussion.– Neuropsych testing controversial.

Return to Play After Concussion• No RTP that day and generally not before 6

days.• Stepwise RTP; advance if no symptoms x 24

hrs; Best case scenario:– Day 1; Rest until asymptomatic (physical and

mental)– Day 2; Light aerobic activity (stationary bike)– Day 3; Sports specific exercise– Day 4; Non-contact training drills (light wt lifting)– Day 5; Full contact practice (after med clearance)– Day 6; Return to competition (game play)

Clearance• Most important and often most

difficult part of the PPE.• Helpful Tools:

–AAP’s recommendations for sports participation.

– “36th Bethesda Conference” recommendations for athletes with cardiovascular problems.

–4th Edition PPE Monograph.• Need to consider several

factors:

Clearance: Factors to Consider

• Does the problem place the athlete at increased risk of injury or illness?

Al ToonNY Jets

Clearance: Factors to Consider

• Is any other participant at risk if the athlete participates?

Magic Johnson

Clearance: Factors to Consider

• Can the athlete safely participate with treatment? (brace, tape, pad)

Carson Palmer

Clearance: Factors to Consider

• Can limited participation be allowed while treatment is being initiated?

Clearance: Factors to Consider• If clearance is denied only for

certain activities, in what activities can the athlete safely participate?

5 Categories of Clearance1. Clearance without restrictions.

2. Cleared, with recommendations for further evaluation or treatment.

3. Not cleared pending further evaluation, treatment or rehab.

4. Not cleared for certain types of sport (contact or strenuous).

5. Not cleared for any sport.– Clearance Form can be helpful.– HIPPA Allows release of this info.

Classification of Sports Contact Sports Non Contact Sports

Contact/Collision

LimitedContact/Impact

Strenuous Moderately Strenuous Nonstrenuous

Boxing Baseball Aerobics Badminton Archery

Field hockey Basketball Crew Curling Golf

Football Bicycling Fencing Table tennis Rifle

Ice hockey Diving Discuss

Lacrosse High Jump Javalin

Martial Arts Gymnastics Shot Put

Rodeo Skating Running

Soccer Skiing Swimming

Wrestling Softball Tennis

Volleyball Track

Squash Wt Lifting

ClearanceThings to Keep in Mind:

• Goal should not be to disqualify, but rather to intervene where needed to allow safe participation.

• Athlete and/or parents have final decision.• Americans With Disabilities Act and

Rehabilitation Act of 73’ prohibit unjustified discrimination.

• Exculpatory Waiver (risk release) may not be protective.

Exercise Related Sudden Death

• Prevention is the only effective strategy.

• The pre-participation exam is the key to prevention.

• Major focus of these exams.

Exercise Related Sudden Death

• Actual incidence is rare:– .2 - .5 per 100,000 adolescents

per year• Cause is usually cardiac:

–Under 30 usually

Structural heart problem.–Over 30 usually CAD.

Hypertrophic Cardiomyopathy• Autosomal dom. disorder causing

asymmetric septal hypertrophy:– Can cause LV outflow obstruction leading to

fatal arrhythmia.• Symptoms: sudden death often first

symptom (80%). May see palpitations, syncope, chest pain, DOE.

• Exam: hi-frequency SEM – louder with Valsalva. S4 common. EKG abnormal in 90%.

• Diagnosis: echo (septum > 15mm).

Hypertrophic Cardiomyopathy

Will KimbleJohn Stewart

Congenital Coronary Artery Anomalies

• Probably the 2nd most common cause of sudden death in sports.

• Symptoms: sudden death is often the first symptom (80%). May see exertional chest pain or syncope.

• Diagnosis: angiogram.

Congenital Coronary Artery Anomalies

• 4 types:–Origin of L. Coronary artery from R.

Sinus of Valsalva.–Single coronary artery.–Origin of coronary artery from

pulmonary artery.–Coronary artery hypoplasia.

“Pistol Pete” Maravich

Pete Maravich1947 – 1988

Pete Maravich1947 – 1988

Marfan’s Syndrome

• Autosomal dominant disorder of connective tissue. Can lead to weakening of aortic wall.

• Need 2 of 4 major features to diagnose:– 1. Family history.– 2. Cardiovascular abnormality.– 3. Musculoskeletal abnormality.– 4. Ocular abnormality.

• Get genetic and cardiology consults if suspected. Need echo to evaluate aorta.

Flo Hymen Died From a Ruptured Aorta in March, 1986.

Marfan’s Syndrome Cases

• Chris Patton• Chris

Weisheit• Vory Billups

Marfan’s Syndrome Screening(Screen All Men >6’ and Women >5’10” With

Echo and Slit Lamp If Any 2 Found)

• Family History• Murmur or Click• Scoliosis• Chest Wall

Deformity

• Arm Span>height• Myopia• Ectopic Lens• Thumb or Wrist

sign

Coronary Artery Disease

• John McSherry• Arthur Ashe

Coronary Artery Disease

• Sergei Grinkov – died at 28.

• Darryl Kile – died at 33.

• Thomas Herrion – died at 23.

Jim FixxAuthor and Marathon Runner

Coronary Artery Disease

• Consider stress EKG prior to exercise program for the following:–Male>45; Female>55–Risk factors: diabetes, hypertension,

family history CAD, high cholesterol–Anyone with exertional chest pain,

syncope or palpitations

Other Cardiac Causes of Sudden Death

• Idiopathic long QT syndrome – sudden death with no structural abnormality (corrected QT interval >440 ms).

• Myocarditis – viral illness followed by progressive CHF sx’s. Coxsackie B (50%).

• Aortic Stenosis – usually CP, syncope or palpitations. Loud murmur.

• Arrythmogenic RV Hypertrophy– fibrosis of RV free wall; Arrythmia. Rare in US.

Screening for Sudden Death

• History is the best tool. Ask about:–Any exercise related syncope, chest

pains or palpitations?–Family history of sudden death or

premature coronary artery disease?–History of heat illness.

PAR-Q

Screening for Sudden Death

• Physical Exam: Marfan’s habitus, murmur

• EKG / CXR: It is reassuring if both are normal

• Stress EKG, Holter, Angiogram done only if indicated by history and PE

Summary

• History is the most important part of these exams (especially as screen for sudden death)

• Focus exam on the cardiovascular and musculoskeletal systems

• Keep in mind it may be the adolescents only contact with a physician

Questions?