Details
Sports preparticipation physical exams (or preparticipation physical exams [PPEs]) are clinical exams used to evaluate athletes for injuries, illnesses, or other conditions that might increase the risk of harm to themselves or others when participating in sports.[1][2][3][4] American Medical Society for Sports Medicine: preparticipation physical evaluation history form Opens in new window Although the PPE is often considered a screening tool, it can also be used to evaluate the suitability of athletes with known conditions in order for them to participate in a particular athletic endeavor.
A PPE is a legal or administrative requirement for many competitive athletes in the US.[5] It can be an excellent vehicle for discussing health promotion and maintenance issues with young athletes. However, there is great variability in the way PPEs are performed and little objective data demonstrating that it leads to improved health outcomes.[1]
Adding a screening ECG to a history and physical increases the likelihood of detecting potentially life-threatening cardiovascular conditions, and has been associated with a decrease in the rate of sudden cardiac death in athletes in Italy.[6][7][8][9] However, it is debatable whether implementing standard ECG screening in PPEs across the US would show similar benefit and the debate on augmented cardiac screening continues.[5][10][11][12][13][14][15] There is a growing body of evidence suggesting possible benefit from augmented screening, with a study demonstrating higher rates of ECG abnormalities in young males of black African descent.[16][17][18] Possibly legal and social pressures may result in a change of attitude in the US regarding this issue. However, the costs, ramifications of false positives, and lack of appropriate health system infrastructure to manage the athletes involved make it difficult to apply in the US, and these issues are likely to prevent widespread adoption of an Italian-style program in the near future.[19] The American Heart Association recommendations remain unchanged on this issue. While recognizing the limitations of the standard history and physical PPE, the AHA does not recommend routine augmented screening with ECG or other cardiovascular testing as part of the PPE at present, and instead continues to recommend the 14-point cardiovascular history and physical exam.[1][20][21]
Despite lack of objective data, the PPE may be an excellent vehicle for screening athletes for high-risk behaviors and medical conditions that would otherwise have a profound effect on their lifelong health, if not directly on their short-term athletic performance.
Although estimates vary, studies find that only a small percentage of athletes (<1%) are denied clearance to participate.[22]
The American College of Cardiology has produced a list of key points concerning cardiovascular care of college athletes. American College of Cardiology: cardiovascular care of college student-athletes Opens in new window
The overriding goal of the PPE is to promote and support the health, safety, and well-being of the athlete. According to the PPE Working Group, there are 3 general objectives:[1]
To determine the overall physical and psychological health of the athlete
To detect potentially life-threatening or disabling conditions that may predispose the athlete to illness or injury, including risk of sudden cardiac arrest and other conditions
To serve as an entry point into the healthcare system for those without a medical home or primary care physician.
Each year, an estimated 30 million young athletes under the age of 18 undergo a preparticipation physical exam (PPE) to qualify for sports involvement.[23] It is generally recommended to be performed at least 6 weeks in advance of the athlete beginning sports participation.[24] This allows time for follow-up examinations, diagnostic testing, or completion of a rehabilitation program if required.
The suggested frequency of the PPE varies. The National Collegiate Athletic Association recommends that athletes undergo a comprehensive PPE upon entry into a collegiate athletic program, with additional PPEs only warranted by an updated history or change in health status.[5] For student athletes in secondary education, the PPE Working Group recommends a comprehensive examination upon entry to high school, repeated every 2 years in younger athletes and every 2 to 3 years in older athletes.[1] An annual update should be performed only as needed to address areas of concern and should include measurement of height, weight, and blood pressure, along with a comprehensive history and focused evaluation of any problems that are identified.[1][24]
It has been estimated that a thorough history identifies up to 88% of problems affecting athletes.[1] The PPE Working Group has developed a comprehensive history form designed to identify the issues of greatest concern in the young athlete.[1][25] The form also encourages physicians to consider asking additional questions on more sensitive issues, such as mental health, substance abuse, and high-risk behaviors.[1][25]
In addition to standard history-taking questions, special attention should be given to the personal and family history questions recommended by the American Heart Association (AHA).[26] It is designed (in combination with physical exam elements) to identify underlying cardiovascular disease and those at increased risk for sudden cardiac death:[1]
1. Personal history
Chest pain/discomfort/tightness/pressure related to exertion
Unexplained syncope/near syncope
Excessive and unexplained dyspnea/fatigue or palpitations associated with exercise
Prior recognition of a heart murmur
Elevated systemic blood pressure
Prior restriction from participation in sports
Prior testing for the heart, ordered by a physician.
2. Family history
Premature death (sudden and unexpected, or otherwise) before 50 years of age attributable to heart disease in 1 or more relatives
Disability from heart disease in close relative
Hypertrophic or dilated cardiomyopathy, long QT syndrome or other ion channelopathies, Marfan syndrome, or clinically significant arrhythmias; specific knowledge of genetic cardiac conditions in family members.
More detailed questioning should generally be pursued when history suggests a potential underlying disorder. For example, a female cross-country runner with a history of multiple stress fractures might be sensitively questioned about the possibility of an eating disorder, female athlete triad (common in women competing in sports that emphasize a low body weight; an interaction of amenorrhea, osteoporosis, and disordered eating), and training errors. Sport-specific questioning may also be useful.[27][28] For example, athletes involved with contact sports might be questioned about prior head and neck injuries, and their sequelae. Wrestlers might be asked about current or previous skin infections, such as herpes gladiatorum, tinea, and MRSA infections. Although this approach seems logical, it has not yet been shown to improve outcomes.
Young children and older people require special consideration during a PPE. For young children, emphasis is given to assessing growth and developmental milestones, assessing physical and emotional/psychological maturity, and providing a targeted evaluation and preventive strategy for age-specific problems such as apophysitis and growth-plate injuries.
For older athletes, the evaluation is focused on the risk for coronary artery disease due to age. Postmenopausal women and older men, especially those who have been on prolonged courses of steroids or have other risk factors, need to be evaluated for osteopenia/osteoporosis. Other medical issues associated with aging similarly need to be screened for, such as osteoarthritis, degenerative disk disease, impaired balance, and poor vision and hearing.
A physical exam focuses on assessing overall body morphology (e.g., identifying features of Marfan syndrome), measuring blood pressure, and evaluating the cardiovascular system. Sport-specific orthopedic evaluation should be added to the general orthopedic screen as appropriate. Functional evaluation of proprioception and dynamic stability should be performed in athletes involved in sports such as gymnastics, soccer, or basketball, where suboptimal proprioception is associated with a high risk of injury. A thorough neurologic exam is especially important in athletes involved in contact sports (e.g., football, soccer). Evaluation of lower extremity biomechanics and gait may be useful in athletes who often run and/or jump (e.g., football, basketball, cross-country). It remains to be seen whether or not standardized augmented screening involving ECG or other modalities will prove to be practical on a wide scale in the US.
In expert hands, a thorough physical exam can identify many serious conditions that place the athlete or others at increased risk of harm. The exam may include:
1. Injury identification
The most easily identifiable conditions include orthopedic problems, such as dynamic instability of the shoulders, knees, and ankles. Chronic injuries to the fingers, wrists, feet, and toes are often noticed during a PPE. They may not be limiting the athlete at the time of the examination and so may have gone previously undetected. However, timely diagnosis and proper treatment may have long-term benefits for these injuries (e.g., chronic nonunion of scaphoid fracture, scapholunate instability, or ulnar collateral ligament tear of the first metacarpophalangeal joint).
The examiner should note tell-tale scars, which may indicate previous surgeries or injuries that the athlete may not be aware of or may not wish to disclose.
2. Risk assessment of existing injury
The impact a particular injury may have on an athlete will vary with the sport involved. For example, a basketball forward with an unstable knee due to a torn anterior cruciate ligament is at risk of recurrent instability episodes and further knee damage. However, a crew athlete with the same injury may be able to continue rowing, perhaps with some modifications, without incurring significantly increased risk for further knee damage. Thus, while a comprehensive physical exam is necessary for all athletes, the orthopedic exam should be focused towards the particular demands of the athlete's sport.
3. Cardiac assessment
The AHA recommends that a cardiac PPE physical exam should include:[1][21]
Auscultation for heart murmurs (to be examined both in supine and standing positions)
Simultaneous palpation of radial and femoral pulses to evaluate for aortic coarctation (to detect radiofemoral delay)
Examination for the physical features of Marfan syndrome, which can cause a variety of cardiac abnormalities including mitral valve prolapse, mitral regurgitation, dilation of the aortic root, aortic regurgitation, aortic aneurysm and aortic dissection. Physical features include: arm span greater than height; chest wall deformities; kyphoscoliosis; high-arched palate; hyperextensible joints; murmur of aortic regurgitation; murmur of mitral regurgitation; myopia (nearsightedness); and ectopia lentis (displacement or malposition of the crystalline lens of the eye)
Brachial artery blood pressure measurement (sitting position).
The AHA, while recognizing the limitations of the standard history and physical PPE, does not recommend routine augmented screening with ECG or other cardiovascular testing as part of the PPE at present.[21]
A systolic murmur that increases with Valsalva maneuver and decreases with squatting should make the examiner suspicious of hypertrophic cardiomyopathy.
4. Absence of paired organ
For example: blindness in 1 eye, absent testicle. This may not be highlighted by history taking and needs to be specifically assessed during the physical exam.
5. Dental assessment
This is an extremely important element of a PPE. Many athletes who have not had access to routine dental care and do not practice regular dental hygiene may have serious gingival and periodontal disease. Implications can range from poorly fitting or uncomfortable mouthguards (which may not be worn), and missed practices and games because of pain, to the need for urgent dental procedures due to infection, abscess formation, and other complications.
The PPE is not designed to prevent athletes from participating in sports, but rather to foster safe participation. If the examiner detects evidence of a potentially significant problem during the PPE, the following factors have to be considered.
Does the problem put the athlete or another participant at increased risk for injury, illness, or death? For example, an asymptomatic basketball player is found to have a systolic murmur that increases in intensity with the Valsava maneuver and decreases in intensity with squatting. Hypertrophic cardiomyopathy may be suspected and the athlete should not be cleared without comprehensive expert evaluation and shared discussion of risks.[29] Furthermore, they should not be allowed to train or practice with the team until the diagnostic workup is concluded and a definitive diagnosis obtained.
Can the athlete safely participate if the problem is appropriately treated with medication, rehabilitation, or protective devices? For example, a swimmer with a history of recurrent glenohumeral subluxations might safely participate after a supervised rehab program that improves their dynamic shoulder stability.
Is limited participation safe while treatment is underway? For example, a distance runner recovering from a tibia stress fracture may be able to stay in competitive shape by doing pain-free cross-training, such as deep water pool running and exercise biking.
If the athlete is not cleared for a particular sport, can they be cleared for a different sport? For example, a basketball player found to have hypertrophic cardiomyopathy may be restricted from playing basketball. However, an activity such as golf might still be permissible. Guidelines for clearance for specific sports have been established by the American Academy of Pediatrics Committee on Sports Medicine and Fitness.[3][4]
Most athletes undergoing PPE are cleared for participation, meaning the examiner found no reason why sports participation would put the athlete (or another participant) at unacceptably higher risk of serious injury, illness, or death than their peers.[22] With the limited time and resources available for performing PPEs (especially in a mass-screening setting), determining clearance may not always be easy. This is especially true for the athlete who has a complicated medical or orthopedic history that may require more than one visit for appropriate review and discussion.
Nevertheless, at the end of the PPE a clearance status must be decided. This can be handled in various ways. In the simplest scenario, an athlete is either cleared (i.e., unrestricted athletic participation) or not cleared (i.e., restricted from all athletic participation). Sport-specific clearance can sometimes be useful. For example, an athlete may wish to both play linebacker for his school football team and also run the 100 meter dash on the track. He may have a neck injury that disqualifies him from safely playing football, but may still be cleared for running on the track. Other gradations can be used to make the clearance decision more helpful for both the athlete and the team in question. Any activity limitations must be conveyed to the appropriate athletic trainer, coach, or parent as well as the athlete. If recovery is successfully achieved, the athlete may be given full clearance. In another scenario, an athlete whose medical history needs further evaluation or an athlete undergoing a workup for a possible underlying condition may be deemed cleared pending further evaluation, which allows the athlete, coaching staff, and parents to know that if the evaluation is reassuring, the athlete will likely receive clearance.
It must be understood by all parties that participation in sports always carries some risk of injury, illness, or even death. The risks of serious injury and permanent disability are certainly higher for contact sports such as football. However, the risk of sudden death exists for all athletes. Although sudden cardiac death is more likely to occur in athletes undergoing more strenuous activities, some conditions such as congenital long QT syndrome may trigger lethal arrhythmias even outside of intense athletic activity.
Seizure disorders that are well controlled do not generally preclude athletic activity. However, scuba diving, rock climbing, and hang gliding may be considered exceptions to this rule, as a seizure during one of these activities could prove fatal not only to the athlete but to other participants or spectators. Clearance decisions like these must be considered thoroughly.
Asthma was once considered to be an absolute contraindication to scuba diving. Many experts now feel that a patient with well-controlled mild asthma can safely participate in scuba diving after appropriate evaluation and counseling.[30] Hence, it is important to understand the concept of absolute versus relative contraindications.
It is extremely important that the healthcare provider performing the PPE acts in the best medical interests of the athlete. There may be pressure from the athlete, parents, coaches, or administrators to clear an athlete for participation when it is not medically warranted. An athlete must not be cleared until the physician is satisfied that such clearance is medically appropriate.
An examiner's intention to protect an athlete from harm may conflict with the athlete's perception of their right to participate in sport and accept responsibility for their own health. In the US, the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990 prohibit the exclusion of otherwise qualified athletes from participation in federally funded programs and give legal protection to medically disabled athletes, preventing discrimination against them solely on the basis of their medical condition. The Americans with Disabilities Act: technical assistance manual covering state and local government programs and services Opens in new window
However, court cases such as Knapp versus Northwestern University have established that collegiate athletes can be medically disqualified from sports participation.[31] The case of Larkin versus the Archdiocese of Cincinnati also established that high school athletes do not have the right to participate in interscholastic sports without medical clearance. An examiner who thinks an athlete should be medically excluded from sports participation should ensure that this disqualification is in keeping with the recommendations of the appropriate guidelines.[3] Consultation with appropriate specialists is often advisable and discussion with legal counsel may be necessary.
The need to share important medical information about athletes with their athletic trainers, coaches, or parents needs to be balanced against the need to protect the privacy of the athlete, and the requirement to abide by the Health Insurance Portability and Accountability Act (HIPAA) and the Family Educational Rights and Privacy Act (FERPA) regulations. The clearance status of an athlete may be shared with appropriate team and school staff (e.g., coaching staff, school administrators, athletic trainers). However, release of specific medical information normally requires signed consent.[32] In a public school setting, FERPA regulations take precedence. However, interpretations vary so each examiner should consider how best to comply with the prevailing regulations in their own specific situation. Good Samaritan statutes vary from state to state and may not cover an examiner during the performance of a PPE, even as a volunteer. Every examiner should understand how the laws apply in the state where they perform the PPEs and should ensure they are appropriately covered, whether by state law and/or by malpractice insurance.[32]
Most US states require student athletes to undergo some form of PPE prior to participating in organized athletics. Despite the PPE Working Group's recommendations, there is currently no recognized standard or federal regulation controlling what should (or should not) be done during a PPE. Consequently, there is no standardization of history and physical exam, and no universally agreed standard for determining clearance to participate in sport. However, some specialty associations have published recommendations. American Medical Society for Sports Medicine: preparticipation physical evaluation history form Opens in new window
The American Heart Association (AHA) recommends that all PPEs contain 14 elements designed to screen for potentially serious cardiovascular disease.[26] Research indicates that only a small proportion of competitive scholastic athletic programs across the US fulfill the AHA recommendations. One study found that only 26% of US colleges and universities used PPE forms that included at least 9 of the 12 AHA recommendations, and 24% contained 4 or less.[33] A subsequent study looking at high school PPEs showed that although there had been some improvement in incorporating the AHA recommendations, there was a marked increase in the percentage of schools that allowed nonphysicians (including chiropractors and naturopathic physicians) to perform PPEs.[34] Despite PPE Working Group recommendations that ultimate responsibility for the PPE should be assigned to an MD or DO (Doctor of Osteopathy), some states allow a PPE to be performed by nurse practitioners, physician assistants, athletic trainers, chiropractors, or other healthcare professionals.[1] The style of PPE varies. Some are performed one at a time by a single physician in a traditional office setting. However, many are conducted as mass screenings of large numbers of athletes. This may involve teams of examiners performing a complete evaluation of each athlete they see. Alternatively, an orthopedist may perform the musculoskeletal exam for each athlete, while a primary-care provider performs the medical aspect of the evaluation. Another variation utilizes a multiple station PPE approach: an athlete brings their paperwork to the first station where it is processed by clerical staff; at the next station, the athlete undergoes height, weight, and vision testing; at the following station vital signs are measured; at subsequent stations, individual specialists perform various parts of the exam according to their area of expertise. At the end, the athlete's paperwork is collected by the team physician who synthesizes all the information obtained from the various stations.
To date, no data are available to compare the effectiveness of one style of PPE versus another. Also, there is no universally agreed approach to diagnostic and laboratory testing beyond the standard history and physical, covering tests such as blood and urine analysis, ECG, and echocardiography. This lack of standardization in the US contrasts starkly with how PPEs are handled in other countries. Italy has had a nationally standardized system in place since 1982: all competitive athletes must undergo a comprehensive PPE performed by a specially trained sports medicine physician. The cost of the PPE for athletes under 18 is funded by their national health system, whereas the cost for those over 18 is handled by the athlete or their athletic team.[35] Currently, there are no plans to move to a national standard for the PPE in the US, and there is much controversy surrounding the idea of implementing such a system, especially one that routinely incorporates ECG or other augmented screening.
The ability to evaluate the performance of the PPE as a screening tool is hampered by a paucity of data. A systematic review published in 2003 found that the PPE for athletes does not satisfy the basic requirements for medical screening as described by the US Preventive Services Task Force (USPSTF).[36] Of the few studies that provided otherwise reasonable data, no false positive or false negative rates were presented, making it impossible to evaluate accuracy. Because of this, the authors concluded that providing preparticipation medical screening for athletes is neither supported nor refuted by the current medical literature due to the inadequacies of research data available.[36] Because it is so difficult to evaluate how PPE performs overall, the performance for each objective is considered below.
General objectives of the PPE:
1. To determine overall physical and psychological health of the athlete
Although the majority would probably be considered "healthy", there are a variety of diseases and disorders that afflict seemingly healthy athletes. The PPEs ability to identify these conditions over and above what would be discerned through well-child visits and recommended evaluations for children and adolescents has not been well studied. For young athletes who have not had routine access to high-quality healthcare, the PPE may be their first encounter that could promote health and prevent disease.[37] Conditions such as exercise-induced asthma, eating disorders, and polycystic ovary syndrome (PCOS) and other reproductive/endocrinologic disorders may first be suspected during a PPE, with potentially great benefit to the athlete. Focused screening of high-risk athletes in each of these areas may be beneficial.[38][39] In addition, health promotion and health maintenance can be addressed during the PPE and areas of concern can be explored at follow-up visits or referrals. Still, there is no conclusive data that proves that the PPE can definitively determine general health.[2]
The PPE can serve as a review on general health maintenance issues with the young athlete. Although not all topics can be addressed during each PPE, a detailed history form and targeted questioning by the examiner can screen for issues such as alcohol, tobacco, and drug use; ownership of or access to firearms; sun-protective behavior; use of seatbelts; risk-taking behaviors; safe sex; proper diet; female athlete triad (disordered eating, amenorrhea, and osteoporosis); domestic violence; and depression, anxiety, eating disorders, and other mental health concerns. Athletes with worrisome findings can be evaluated further at a follow-up visit or referred appropriately. While these issues may or may not have a direct bearing on the athlete's suitability to participate in a given sport, the PPE may be the only practical opportunity for the examiner to discuss them with the athlete.[40] If this opportunity is missed, a young athlete who believes they are in good health may not return for further discussion.
The 5th edition of the PPE developed by the American Academy of Pediatrics contains new recommendations and a revised history form, including a validated screening tool on anxiety and depression, as part of an increased focus on identifying and addressing mental health issues in athletes.[1][25][41] While the effectiveness of the PPE in determining overall psychological health is yet to be determined, one study found that most parents believe the PPE is an appropriate setting to discuss mental health and substance abuse issues, suggesting that it could provide a valuable opportunity to identify these issues.[23]
General health maintenance counseling should be performed as indicated and as time allows. The PPE may be the best (and only) time for many young athletes to meet with a health provider to discuss these issues. If as much attention were devoted to critical health maintenance topics (such as teaching the importance of seatbelt use and avoiding excessive alcohol use) as to screening for rare cardiovascular conditions, health benefits for young athletes would be conceivably greater.
2. To detect potentially life-threatening or disabling conditions that may predispose the athlete to illness or injury, including risk of sudden cardiac arrest and other conditions
There are minimal data available to evaluate whether the PPE can detect conditions that could predispose the athlete to illness or injury. Several studies show that musculoskeletal abnormalities are commonly found during PPEs.[42][43][44] However, the sensitivity and specificity of the PPE will clearly vary according to several factors, including:
The severity of the injury or illness. For example, it is hard to miss a severely swollen knee that prevents weight bearing or an illness that causes high fever, tachycardia, and exudative tonsillitis. However, a more subtle injury such as a partial rotator cuff tear, or a mild case of acute infectious mononucleosis, may be easily missed in a PPE setting.
The timing of when the injury occurred. For example, an active stress fracture of the tibia may make the athlete grimace when they are asked to hop on that leg, whereas a healed stress fracture should be asymptomatic.
Honesty and recall of the athlete and/or parent/guardian. If an athlete forgets or chooses not to mention a prior injury, or if a parent or guardian fills out the PPE form and does not indicate the history of an injury, it may never be known to the examiner. This may increase the chance for recurrent injury if the factors leading to the original injury have not been properly addressed and corrected.
The experience and acumen of the examiner. Although objective data is lacking, an experienced sports orthopedist would be expected to have much better accuracy in identifying orthopedic problems than a primary-care provider without specialized orthopedic training. Similarly, a cardiologist would be better able to perform a comprehensive and accurate cardiovascular exam than an orthopedist.
Environmental, logistical, and technical concerns. Even with an experienced cardiologist performing the cardiovascular exam, if the PPE is performed in a noisy training room where only cheap plastic stethoscopes are available and only a few minutes are allotted for the entire encounter, it is likely that the accuracy and quality of the evaluation will diminish. Similarly, the ability of an orthopedist to utilize their diagnostic skills will be compromised if the athletes are not wearing appropriate clothing for the exam and if a proper exam table is not available.
The detection of certain abnormalities during a PPE may have little to no impact on the health of the athlete or their performance. For example, one study of 712 intercollegiate athletes found no correlation between musculoskeletal abnormalities found during a PPE and subsequent injury occurrence.[45]
Data suggest that the risk of sudden cardiac death (SCD) in collegiate athletes is approximately 1:50,000 per year, and may be as high as 1:5200 among male Division I NCAA college basketball players.[46][47] Males are at greater risk of SCD than females, and black athletes have a higher risk than white athletes.[26][48] SCD in young athletes has a male to female ratio of approximately 9:1 at all levels of competition.[26] Many of these athletes have either subtle or no obvious warning signs prior to their death, and other factors such as family history are often unrevealing. Consequently, screening young athletes for the relatively rare causes of SCD can be difficult. A PPE that incorporates only a history and physical exam performs poorly in identifying people at risk. One US-based retrospective study found only 3% of 134 high school and collegiate athletes who experienced athletics-related SCD had been suspected of having a significant cardiovascular problem based on their PPE. Less than 1% of the athletes received an accurate diagnosis, and none of them were barred from competition.[49] The results of the Italian national screening protocol are much different: each competitive athlete undergoes a PPE by a specially trained sports medicine physician, which includes a history, a physical exam, and a 12-lead ECG. Using this protocol, they have documented an 89% reduction in the annual incidence of SCD among screened athletes. This is largely attributed to the ability of the ECG to detect potentially lethal conditions such as hypertrophic cardiomyopathy.[50] A few studies from the US have also documented increased sensitivity for detecting cardiac abnormalities (and possible cost-effectiveness) from performing ECG screening in young athletes.[51][52] However, these studies are observational data only. Furthermore, there are numerous differences between the PPE situations in Italy and the US: the Italian studies involved a specific area in northern Italy where the genetics of the inhabitants likely differ from the majority of Americans. This interpretation is supported by the primary cause of sudden death among the young Italian athletes being arrhythmogenic right ventricular dysplasia (ARVD), an entity rare in the US. However, it is unclear if this difference is due more to genetic factors, the ECG screening program itself (which makes detection of hypertrophic cardiomyopathy much more likely than detection of ARVD), or other reasons.[53]
Furthermore, at the beginning of the Italian national screening program the SCD rate among athletes was significantly higher than in US athletes (3.6/100,000 person-years versus 0.4 deaths/100,000 person-years, p value = 0.001), and by the end of the study period the rate in Italy was still higher than rates seen in the US (0.9/100,000 person-years). In addition, no deaths occurred in the 2% of Italian athletes who were disqualified from sports, whereas 55 deaths (1.9 deaths/100,000 person-years) occurred among those who had undergone the augmented screening and were cleared for participation.[6][7] The exact reasons for these patterns are unclear.
Another important consideration when assessing the fulfillment of PPE objectives is the marked discrepancy between the number of people who have potentially dangerous underlying cardiovascular disorders and those who actually die or suffer morbidity from these disorders. For example, hypertrophic cardiomyopathy (the most common cause of SCD among young athletes in the US) has an estimated prevalence in the community of 1 in 500.[54] In addition, in people who are diagnosed with a potentially life-threatening condition it is worth considering how this will impact on future insurability.
Projected out over 10 million young athletes in the US, it would therefore be expected in 20,000 people, yet there are <100 reported deaths per year due to hypertrophic cardiomyopathy in young athletes. This may be due to the condition having multiple subtypes, not all of which are associated with the same risk of sudden death. It is also possible that some people with less aggressive types of hypertrophic cardiomyopathy may not suffer clinical consequences until they are older, and so data on SCD in young athletes may underestimate the lifetime effects of such a disorder. However, it is also conceivable that if all young athletes with hypertrophic cardiomyopathy were identified with a PPE, a great number who would never have had any adverse cardiac effects from sports participation might be permanently denied that opportunity. The effects of such a diagnosis on the mental and emotional well-being of a patient should be considered, as well as the possibility that the fear of a future cardiac event (which may never happen) could cause many people to avoid an otherwise healthy exercise regimen, paradoxically increasing their risk of premature coronary artery disease. It has been estimated that 200,000 young athletes would have to be screened to detect 1 athlete who would experience SCD.[55] Given the extremely low prevalence of SCD in young athletes, even a screening tool with 99% sensitivity and 99% specificity would only yield a positive predictive value of approximately 0.05%.[56]
Only Israel, Italy, and the US have mandatory national cardiovascular screening for athletes; Japan has this for all citizens. Only Italy and Israel mandate national ECG screening for competitive athletes. Denmark has specifically chosen not to do this, due to perceived low risk. The Canadian Cardiovascular Society/Canadian Heart Rhythm Society Joint Position Statement on the Cardiovascular Screening of Competitive Athletes recommended against the routine performance of an ECG for the initial cardiovascular screening of competitive athletes.[57] Only Italy has documented a decrease in SCD risk with use of ECG screening. Up to 30% to 40% of potentially fatal cardiovascular diseases may have a negative/normal ECG, so false negatives are a real problem (e.g., especially if done too early/too young, prior to the development of the abnormal phenotype in hypertrophic cardiomyopathy).[26]
Associations of the European Society of Cardiology (ESC), the Association for European Paediatric and Congenital Cardiology (AEPC), and the Heart Rhythm Society (HRS) have produced various guidelines for participation in sport in athletes with various cardiovascular disorders. ESC: Recommendations for participation in leisure-time physical activity and competitive sports in patients with arrhythmias and potentially arrhythmogenic conditions: part 1: Supraventricular arrhythmias Opens in new window ESC: Recommendations for participation in competitive and leisure time sport in athletes with cardiomyopathies, myocarditis, and pericarditis Opens in new window ESC and AEPC: Recommendations for participation in competitive sport in adolescent and adult athletes with Congenital Heart Disease Opens in new window HRS: expert consensus statement on arrhythmias in the athlete: evaluation, treatment, and return to play Opens in new window
The American Heart Association (AHA) and the American College of Cardiology (ACC):[26]
Recommend that screening with 12-lead ECGs in association with comprehensive history taking and physical examination may be considered in relatively small cohorts of young healthy people 12 to 25 years of age, not necessarily limited to competitive athletes (e.g., in high schools, colleges/universities, or local communities) to identify or raise suspicion of genetic/congenital and other cardiovascular abnormalities. Close physician involvement and sufficient quality control is mandatory. If undertaken, such initiatives should recognize the known and anticipated limitations of the 12-lead ECG as a population screening test, including the expected frequency of false-positive and false-negative test results, as well as the cost required to support these initiatives over time.
Do not recommend mandatory and universal mass screening with 12-lead ECGs in large general populations of young healthy people 12 to 25 years of age to identify genetic/congenital and other cardiovascular abnormalities for athletes and nonathletes alike.
Do not recommend consideration for large-scale, general population, and universal cardiovascular screening in the age group 12 to 25 years with history taking and physical examination alone.
The American Medical Society for Sports Medicine (AMSSM) 2016 position stand on cardiovascular preparticipation screening in athletes:[58]
The AMSSM similarly notes that the lack of clear outcomes data at this time precludes an algorithmic or universal approach to the decision of adding an ECG to preparticipation screening.
However, it also recognizes the limitations of nonaugmented screening, and it emphasizes the importance of physician autonomy and individualized assessments, weighing the associated risks and potential benefits, in determining the most appropriate screening strategy for a given person.
It further states that no screening strategy provides absolute protection from sudden cardiac arrest or SCD and that, therefore, proper emergency planning and prompt availability of automated external defibrillators during training and competition are critical.
The 2024 HRS consensus statement:[29]
Recommends athletes have periodic preparticipation screening for SCD risk, including at least history and physical exam.
Makes no firm recommendation on use of ECG, acknowledging that it can be complementary and outperform history and physical exam alone in detecting some conditions but is limited by factors such as the need for experienced readers, potential costs, and limited utility for certain conditions and populations.
3. To serve as an entry point into the healthcare system for those without a medical home or primary care physician
The PPE can allow athletes without a medical home the opportunity to access healthcare, however no data are available to evaluate this objective.
1. Augmented cardiovascular testing
In addition to ECG, other modalities have been proposed as a means of screening young athletes for potentially dangerous or fatal conditions. The most popular is limited echocardiography to screen for structural cardiac abnormalities, especially hypertrophic cardiomyopathy, because it is noninvasive, mobile, and can be performed relatively quickly and with reasonable accuracy by an experienced examiner. However, data do not indicate that screening echocardiography in the young athlete population is of demonstrated benefit. In one study, screening with limited 2D echocardiography among 395 university athletes found only 5 cardiovascular abnormalities that required further evaluation. None of the athletes were prohibited from participation.[59] In a subsequent study, 5-minute screening echocardiography for incoming National Collegiate Athletic Association (NCAA) athletes detected 3 athletes (out of a total of 2898 screened over an 8 year period) with cardiac conditions resulting in athletic restriction.[60] Several other studies have shown a similar lack of clinical impact from screening echocardiography.[61][62][63][64][65][66]
Certain cardiac abnormalities do not become phenotypically apparent until later in life. It is therefore possible that one echocardiography screening test of a 12-year-old athlete be interpreted as normal, despite actually having a type of hypertrophic cardiomyopathy that does not express itself morphologically until several years after. The potential danger of such a false negative result should not be underestimated.[21][67]
Despite the relative lack of evidence of benefit, it is possible that screening echocardiography (like screening ECG) may become more commonplace in the future. There are multiple patient advocacy groups that are promoting this type of screening, and several companies are offering screening packages to large numbers of young athletes. The issue of sudden cardiac death in young athletes is highly emotionally charged and replete with medicolegal and political considerations, so the practice may become more widely adopted, if only for a perceived need to keep up with what may come to be considered a community standard.
Changes in recommendations from medical groups in various parts of the world are also occurring. For example, in a 2021 publication, the Asian Pacific Society of Cardiology published a consensus statement advocating resting 12 lead ECG for young, competitive athletes involved in moderate to high intensity (but not low intensity) exercise. However, this intensity-based recommendation was further qualified by the proviso that the following 3 criteria needed to be met:
The screening institution has the capacity for mass ECG screening
The ECG is performed to an acceptable standard; and
The ECG should be interpreted by a trained healthcare professional, with reference to prevailing standards.[68]
Other noninvasive modalities such as stress testing, cardiac MRI/MRA, CT angiography, and electron beam CT can all be useful in the evaluation of an athlete with a suspected cardiovascular disorder. However, none of these techniques have been shown to be cost-effective for mass screening of young athletes.
2. Testicular cancer
The US Preventive Services Task Force (USPSTF) has recommended against screening for testicular cancer with either clinical exam or testicular self-exam. US Preventive Services Task Force: screening for testicular cancer Opens in new window However, performing a testicular and groin exam is an important aspect of a PPE for a male athlete. The exam can identify important issues, such as cryptorchidism, solitary testicle, testicular masses, hernias, and evidence of STIs.
3. Anemia
The usefulness of routine laboratory tests as part of the PPE has not been shown. No screening blood or urine tests are usually indicated for most athletes. However, there are data suggesting that screening for iron deficiency and anemia may be cost-effective in high-risk athletes, such as elite endurance athletes (especially females).[69][70] A comprehensive history including assessment of diet and supplements may help to identify athletes at higher risk of iron deficiency, such as those who do not eat red meat, or female athletes with menorrhagia/metrorrhagia.
4. Sickle cell
Some experts have advocated screening for sickle cell trait in high-risk populations, as it has been associated with an increased risk of rhabdomyolysis and sudden death during periods of intense exertion, especially in extreme environmental conditions.[71] The NCAA has now formally recommended that sickle cell screening should be mandatory for all NCAA division I, II, and III athletes. National Collegiate Athletic Association: sickle cell trait Opens in new window If an athlete can present records showing they have already been tested (which should have been done at birth for all athletes born in the US), this will suffice.
This requirement is the result of a lawsuit, and represents an agreement between the plaintiff (the family of a student athlete whose death was tied to sickle cell trait) and the NCAA. Such universal screening, without regard to risk assessment and with no proof of efficacy or cost-effectiveness, does not seem medically warranted, and there is a lack of consensus between members of the American Medical Society for Sports Medicine regarding the screening policy.[72][73] Yet, it is a legal reality. Whether or not other organizations in the US or around the world will adopt similar screening remains to be seen.
5. Prior concussions
Athletes with a history of prior concussions are at greater risk for accumulating further concussions and future cognitive decline if they continue to participate in contact sports compared with individuals with no history of concussions.[74][75] In athletes at high risk for concussion (contact athletes, athletes with multiple prior head injuries), it seems reasonable to perform a baseline neurologic evaluation, possibly including neuropsychological testing, as part of the PPE.[76] However, there is no evidence to suggest that this strategy leads to improved outcomes.[77] The 2019 American Medical Society for Sports Medicine position statement on concussion recommends that the PPE should include an assessment of any history of concussion or other traumatic brain injury. However, there is no universal consensus on what, if any, neuropsychological testing should be performed for baseline assessment.[78]
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