Pediatric Annals

Medical Exclusion From Participation in Sports

Michael A Nelson, MD

Abstract

The importance of participation in sports for adolescents cannot be overemphasteed. It has been demonstrated that adolescents rank failure to make a team in some instances worse than failure to pass in school, separation of parents, or death of a close friend.1 However, the primary responsibility of the physician performing a preparticipation evaluation is to ensure the health and safety of the athlete. Because less than 2% of athletes are disqualified from a specific sport during preparticipation evaluations,2 it is unlikely that a physician will need to make a decision discordant with the goal of the athlete. More often, the athlete needs advice and direction regarding preparation for the season, rehabilitation, or occasionally suggestions for alternative sports.

In 1988, the American Academy of Pediatrics (AAP) published guidelines for Participation in Competitive Sports3 (Tables 1 and 2). These guidelines supersede previous guidelines published by the American Medical Association in 1976. The new guidelines were developed because of advances in medical scienee, modifications of sport rules, and the need for individualization of decision-making regarding participation of athletes with differing degrees of illness and disability.

Classification of sports is based on the inherent degree of contact or collision in a specific sport as well as the potential for inadvertent contact with other players or inanimate objects. For instance, downhill skiing does not inherently involve collision. However, a fall, as all skiers know, can result in collisions of disastrous consequence.

If the physician is forced to make a decision that results in exclusion of an adolescent from a sport, every attempt should be made to reach the decision in cooperation with the athlete, family, and perhaps the coach. When the physician and the athlete as well as the family cannot reach a harmonious decision, some school systems use a waiver system. With such a system, a document should be prepared that carefully explains the medical risks, the procedure used to relay that information to the athlete and the family, their sense of understanding, and that they wish to participate despite potential medical risks. The courts have increasingly ruled that young people have the right to accept medical risks despite disqualification by a physician or health team. Therefore, a waiver system may play an increasingly important role in determining eligibility for participation. Physicians who work as team physicians should be granted absolute and final authority by the institution regarding participation secondary to liability issues.

Table

Hypertensive individuals with target organ involvement (ie, hypertensive retinopathy, renal disease, or polycystic kidneys) should avoid contact collision sports. The risk from trauma in limited contact/collision sports has not been determined, and a decision regarding participation in these sports should be based on discussion with the athlete and the family and their willingness to accept some degree of theoretical risk.

Asthma

Advances in medical care have resulted in exclusion of only the most severe asthmatics from any sport. The majority of individuals with asthma will experience exercise-induced asthma (EIA) as well as 10% of the normal population. The widespread prevalence of this disease should prompt the physician to provide medical care that will allow participation in the sport of the athlete's choice.

Symptoms of dyspnea, shortness of breath, feeling out of shape, or chest pain should raise suspicion of EIA. Subsequently, a therapeutic trial of treatment should be instituted. Exercise stress testing or methacholine challenge is usually not necessary to establish the diagnosis. Only those patients with severe pulmonary disease (ie, forced expiratory volume in 1 second [FEV1J of less than 50% of the predicted) require exercise stress testing to evaluate potential hypoxemia.

Most commonly, medication to prevent EIA includes…

The importance of participation in sports for adolescents cannot be overemphasteed. It has been demonstrated that adolescents rank failure to make a team in some instances worse than failure to pass in school, separation of parents, or death of a close friend.1 However, the primary responsibility of the physician performing a preparticipation evaluation is to ensure the health and safety of the athlete. Because less than 2% of athletes are disqualified from a specific sport during preparticipation evaluations,2 it is unlikely that a physician will need to make a decision discordant with the goal of the athlete. More often, the athlete needs advice and direction regarding preparation for the season, rehabilitation, or occasionally suggestions for alternative sports.

In 1988, the American Academy of Pediatrics (AAP) published guidelines for Participation in Competitive Sports3 (Tables 1 and 2). These guidelines supersede previous guidelines published by the American Medical Association in 1976. The new guidelines were developed because of advances in medical scienee, modifications of sport rules, and the need for individualization of decision-making regarding participation of athletes with differing degrees of illness and disability.

Classification of sports is based on the inherent degree of contact or collision in a specific sport as well as the potential for inadvertent contact with other players or inanimate objects. For instance, downhill skiing does not inherently involve collision. However, a fall, as all skiers know, can result in collisions of disastrous consequence.

If the physician is forced to make a decision that results in exclusion of an adolescent from a sport, every attempt should be made to reach the decision in cooperation with the athlete, family, and perhaps the coach. When the physician and the athlete as well as the family cannot reach a harmonious decision, some school systems use a waiver system. With such a system, a document should be prepared that carefully explains the medical risks, the procedure used to relay that information to the athlete and the family, their sense of understanding, and that they wish to participate despite potential medical risks. The courts have increasingly ruled that young people have the right to accept medical risks despite disqualification by a physician or health team. Therefore, a waiver system may play an increasingly important role in determining eligibility for participation. Physicians who work as team physicians should be granted absolute and final authority by the institution regarding participation secondary to liability issues.

Table

TABLE 1Classification of Sports*

TABLE 1

Classification of Sports*

Regardless of the degree of agreement or disagreement between the physician, athlete, and family, the practitioner's primary responsibility is to render his or her best medical opinion. The health and safety of the athlete is of prime importance relative to the desires of the athlete, family, team or coaches. Readers may wish to use the following in conjunction with the AAP Guidelines in making decisions regarding participation in sports.

PREVIOUS TRAUMA

Virtually all musculoskeletal injuries require individual decision-making, perhaps in conjunction with an orthopedic surgeon, regarding participation. However, for any athlete to qualify for participation at the high school or community youth sport level, there should be complete return of function from previous trauma. The athlete should be able to demonstrate normal strength, endurance, and proprioceptive skills. For instance, a football player recovering from an ankle sprain should demonstrate symmetric strength and endurance in both lower extremities as well as the ability to perform maneuvers similar to those used in practice or competition. The use of supportive prosthetic devices such as an ankle brace is acceptable in accomplishing these tasks.

In the past, development of precise guidelines regarding central nervous system trauma (concussions) and participation in competitive sports has been difficult. In 1990, the Colorado Medical Society published "Guidelines for the Management of Concussion in Sports." These guidelines have been endorsed by the AAP and are available on request from the Colorado Medical Society, PO Box 17550, Denver, CO 80217-0550. The guidelines include a classification scheme for what used to be called "dings" as well as for more serious concussions. In addition, recommendations for future participation are included for the athlete with multiple concussions. A tear-off portion for on-the-field evaluation and recommendations for return to play are also included. A brief summary, extracted from these guidelines, is presented in Table 3. The final decision regarding return to play for the athlete with multiple concussions or a previous injury that required intracranial surgery, in most cases, should involve consultation with a neurosurgeon.

Table

TABLE 2Recommendations for Participation In Competitive Sports'

TABLE 2

Recommendations for Participation In Competitive Sports'

Table

TABLE 2Recommendations for Participation in Competitive Sports*

TABLE 2

Recommendations for Participation in Competitive Sports*

CHRONIC MEDICAL CONDITIONS

Cardiac Diseases

Sudden death among participants in sports is a concern for all physicians who evaluate athletes. A more detailed discussion of this subject is presented in the article, "Sudden Unexpected Death in Sports," by TW. Rowland (pp 189-195). However, it is important to emphasize the importance of the history in evaluating athletes for potential sudden death. Adolescents with a history of exertional dizziness, syncope, chest pain or palpitations, or a family history of sudden unexpected death should receive a thorough cardiovascular evaluation regardless of findings on the physical examination. The evaluation may include a chest x-ray, electrocardiogram, echocardiogram, or exercise stress testing. Individuals with myocarditis, hypertrophic cardiomyopathy, severe aortic stenosis, or anomalous coronary artery disease should be excluded from all but nonstrenuous sports participation.

Hypertension

In children and adolescents, the diagnosis of hypertension should never be made unless elevated blood pressures have been demonstrated with the use of proper technique on at least three separate occasions. Decisions regarding participation should be reassessed at regular intervals, because up to 50% of those with hypertension in adolescence may become normotensive within 2 years without treatment.

Classification of hypertension in children and adolescents is difficult and based on clinical experience and consensus rather than risk data. The AAP guidelines were developed using the mild, moderate, and severe categories of hypertension developed by the 16th Bethesda Conference.4 The National Heart, Lung, and Blood Institute Task Force developed a classification system for children and adolescents using significant (95th to 99th percentiles for age) and severe (>99th percentile for age) categories.5 While this can be confusing to the practitioner, significant hypertension can be considered the equivalent of the mild category in the guidelines published by the 16th Bethesda Conference, while severe hypertension would be inclusive of the moderate and severe categories.

Children with mild (significant) hypertension may participate in all sports. Athletes with moderate or severe hypertension should avoid sports with high static demands such as football, shot putting, or wrestling. Dramatic elevations of blood pressure have been shown to occur during static exercise in both normotensive and hypertensive adolescents. Those with hypertension demonstrate significantly higher blood pressure elevations during these maneuvers. However, there is no evidence linking hypertension with cerebrovascular accidents or sudden death during activities such as weight lifting. The significance of blood pressure elevation during static activity remains unclear; particularly because exercise stress testing has not been shown to predict those athletes at risk for potential cardiovascular injury and thus is of no practical use in evaluating these athletes. Nonetheless, those athletes with severe moderate, severe) hypertension should avoid static activities, at least until good blood pressure control has been established. There is no evidence to indicate a risk from participation in strenuous sports. However, because of limited data, one should be circumspect in recommending participation.

Table

TABLE 3Recommendations Relative to Concussion and Sports Participation*

TABLE 3

Recommendations Relative to Concussion and Sports Participation*

Hypertensive individuals with target organ involvement (ie, hypertensive retinopathy, renal disease, or polycystic kidneys) should avoid contact collision sports. The risk from trauma in limited contact/collision sports has not been determined, and a decision regarding participation in these sports should be based on discussion with the athlete and the family and their willingness to accept some degree of theoretical risk.

Asthma

Advances in medical care have resulted in exclusion of only the most severe asthmatics from any sport. The majority of individuals with asthma will experience exercise-induced asthma (EIA) as well as 10% of the normal population. The widespread prevalence of this disease should prompt the physician to provide medical care that will allow participation in the sport of the athlete's choice.

Symptoms of dyspnea, shortness of breath, feeling out of shape, or chest pain should raise suspicion of EIA. Subsequently, a therapeutic trial of treatment should be instituted. Exercise stress testing or methacholine challenge is usually not necessary to establish the diagnosis. Only those patients with severe pulmonary disease (ie, forced expiratory volume in 1 second [FEV1J of less than 50% of the predicted) require exercise stress testing to evaluate potential hypoxemia.

Most commonly, medication to prevent EIA includes inhaled albuterol or cromolyn prior to exercise. Inhalation of one or both of these medications will prevent the occurrence of EIA for approximately 2 to 4 hours. For those who desire to avoid the use of medication, approximately 50% of episodes can be prevented through the use of short repetitive warm-up drills prior to formal practice or competition. More detailed guidelines are published elsewhere.6

Seizure Disorders

American Academy of Pediatrics recommendations for sports participation for children and adolescents with epilepsy have been published elsewhere.7 These individuals should be excluded from sports where death or a significant injury could occur because of a seizure and include, among others, underwater swimming, high diving, and rope climbing.

Decisions regarding participation in contact/ collision sports should be made on an individual basis and take into consideration seizure type, severity, frequency, etiology, and degree of control. For instance, an athlete who has suffered a seizure because of an electrical injury is unlikely to experience another seizure and could be potentially cleared for participation in all sports. However, an adolescent with poor medication compliance who experiences seizures once or twice a month should probably be excluded from contact/collision sports. Unfortunately, precise definitions of good control are not available. Consequently, decisions regarding participation need to consider all of the factors mentioned above.

ACUTE INFECTIONS

Infectious Mononucleosis

Splenomegaly occurs in approximately 50% of patients with infectious mononucleosis. Unfortunately, there are no clinical guidelines to predict what patients may be at risk for splenic rupture, which occurs in approximately .1% to .2% of patients.8 Virtually all of these cases have involved splenic enlargement at least two to three times the normal size. Ultrasound studies have often demonstrated significant splenomegaly that cannot be recognized clinically and that may persist several weeks after the resolution of clinical symptoms.9 Splenic rupture has not been reported 4 weeks following resolution of clinical symptoms. The significance of splenomegaly persisting beyond this time is unclear.

Participation in contact/collision sports 4 weeks after resolution of symptoms in the absence of splenomegaly demonstrable by ultrasound is considered safe. If splenomegaly is not demonstrable clinically (without ultrasound confirmation) and if the athlete has been asymptomatic at least 4 weeks, the risk of splenic rupture is exceptionally low. If the athlete and the family are counseled about the potential or theoretical risk of splenic rupture and are agreeable, participation in contact/collision sports may be allowed.

Skin Infections

In the sport of wrestling, secondary attack rates of herpes gladiatorum from exposure to an individual with active herpes simplex or zoster range between 20% and 50%.10 Individuals with active lesions should be excluded from wrestling. Generally, it is safe to allow the athlete to participate when there is a pink epithelized base and the crusts have disappeared. Lesions that can be bandaged allow for participation in sports that require less direct contact.

Those athletes with active streptococcal or staphylococcal infection such as impetigo should not participate in contact/collision sports until they have been on appropriate antibiotics and clinical improvement is evident (generally within 48 hours).

ANATOMICAL ABNORMALITIES

Down Syndrome

Currently, Special Olympics programs require radiographic screening for atlantoaxial instability in children with Down syndrome before participation is allowed. The AAP has concurred in this recommendation. However, because of significant questions regarding the appropriateness of cervical spine radiographs as a screening test to identify individuals at risk for catastrophic events, the AAP is currently reassessing its position. It is far more important for the clinician to be familiar with the neurologic symptoms and findings associated with this anomaly because virtually all patients with clinically apparent atlantoaxial instability reported have had neurologic signs or symptoms for a significant period prior to cervical spine dislocation or death. Currently, radiographic screening is required. Those athletes with atlantoaxial separation >4 mm should be excluded from participating in sports associated with a significant risk of head and neck trauma such as soccer, football, and diving.

Hernia

After instruction regarding the symptoms of incarceration, athletes with an inguinal hernia may be allowed to compete during the current sports season in anticipation of surgical repair afterwards. There is no evidence to indicate that sports participation will lead to incarceration.

Absence of fiaired Organs

Baseball participation produces the largest number of significant eye injuries in the 5- to 14-year-old age group.11 However any sport that involves objects moving at high rates of speed, bats, sticks, or racquets as well as those requiring aggressive play (ie, basketball and football) should be considered high-risk sports for eye injuries. While eyewear protection is available for participation in these sports, none is effectively protective for sports such as boxing or full-contact martial arts.

Children and adolescents with a best-corrected vision in one eye of less than 20/50 should be considered functionally one-eyed. Several states revoke driving privileges with a best-corrected vision at this level. Athletes so affected should be required to wear molded, polycarbonate sport frames with 3-mm thick polycarbonate lenses for all sports involving rapidly moving objects, bats, or racquets. For contact/collision sports involving the use of head gear, such polycarbonate frames and lenses should be worn under a cage shield or mask. Functionally one-eyed children and adolescents should not be allowed to participate in sports in which the use of an eye protection device is not possible. A history of a detached retina should prompt consultation with an ophthalmologist before participation in all but nonstrenuous sports is permitted.

The actual incidence of significant renal trauma in contact/collision sports is unknown. However, the consequences of renal trauma in the athlete with a single kidney are extraordinary. Until such time that protective devices such as flak jackets have been shown to offer substantial protection against renal injuries, athletes with a single kidney should be excluded from contact/collision sports.

Athletes with a single testicle can be adequately protected from testicular trauma with the use of a hard-cup athletic supporter. Many young athletes don't like to wear these cups because of the discomfort they cause. However, frankly discussing the consequences of injury (ie, sterility) and requiring the use of a hard cup for participation in sports involving high-speed missiles and in contact/collision sports usually results in compliance by the athlete.

CONCLUSION

The responsible physician should only rarely have to disqualify a young athlete from sports participation. Patients will appreciate the physician who seeks solutions to potential problems in sports rather than simply recommending disqualification. In the future, continued improvement in medical treatment, protective equipment, and changes in sport rules will inevitably lead to even greater participation in sports by children and adolescents with disabilities.

SUGGESTED READING

Committee on Sports Medicine and Fitness, Dyment P, ed. Sports Medicine: Health Cart fur Young Athletes. Elk Grove Village, 111: American Academy of Pediatric*; 1991.

REFERENCES

1. Stevens MB, Smith GN. The preparticipation sports assessment. Family Practice Recertification. 1986;80):68-68.

2. Goldberg B, Saraniti A, Witman P, Gavin M, Nicholas JA. Preparticipation sports assessment: an objective evaluation, Pediatrics. 1980;66:736-745.

3. Committee on Sports Medicine, American Academy of Pediatrics. Recommendations for participation in competitive sports. Pediatrics. 1988;81:737-739.

4. Frolich ED, Lowenthal DT, Miller HS, Pickering T. Strong WB. Task Force IV: systemic arterial hypertension, J Am Coll Cardiol . 1 985;6: 1218-1221.

5. National Heart, Lung, and Blood Institute. Report of the Second Task Force on blood pressure control in children. Pediatrics. 1987;79:1-25.

6. Lemanske RF, Henke KF. Exercise-Induced asthma. In: Gisolfi CV, Lamb DR, eds. flerspectiws in Exercise Science and Spans Medicine: Youth Exercise and Sport. Carmel, Ind: Benchmark Press; 1989:465-511.

7. Committee on Children with Handicaps and Committee on Sports Medicine, American Academy of Pediatrics. Sports and the child with epilepsy. Pediatrics. 1983;72:884-885.

8. McKeag DB, Kinderknecht J. A basketball player with infectious mononucleosis. In: Smith NJ, ed. Common Problems m ftdiatric Sports Medicine. Chicago, 111: Year Book Medical Publishers; 1989:191-203.

9. Primos WA, Landry GL, Scanian KH. The course of splenomegaly in infectious mononucleosis. Am J Dis Child. 1990;144:438-439. Abstract.

10. Belongia EA, Goodman JL, Holland EJ, et al. An outbreak of herpes gladiatorum at a high-school wrestling camp. N Engi/ Med. 1991;13:906-910.

11. Jeffers JB. An ongoing tragedy: pediatric sports-related eye injuries. Seminars in Opnthalmology. 1990;5:216-223.

TABLE 1

Classification of Sports*

TABLE 2

Recommendations for Participation In Competitive Sports'

TABLE 2

Recommendations for Participation in Competitive Sports*

TABLE 3

Recommendations Relative to Concussion and Sports Participation*

10.3928/0090-4481-19920301-05

Sign up to receive

Journal E-contents