Pediatric Annals

EDITORIAL 

A Pediatrician's View: The Preparticipation Sports Physical Examination

Robert A Hoekelman, MD

Abstract

This issue o( Pediatric Annals was prepared by Guest Editor Paul G. Dyment, MD, professor of clinical pediatrics and director of the Student Health Center at Tulane University in New Orleans. It addresses various aspects of sports medicine as they relate to participation in intramural and interscholastic sports by junior and senior high school and college students.

An important aspect of such participation is the assurance that the athlete is physically able to do so without risk of incurring injury or death because of a preexisting medical condition. Parents want this assurance, as do coaches and athletic trainers, who also need to know what the probabilities of such events are and how they might be prevented or managed. School officials want to avoid the legal problems that might arise if students are allowed to participate when they shouldn't. These concerns have led to the performance of millions of preparticipation sports physical examinations annually at great cost to schools and sometimes to parents. All states require that these examinations be done - most annually, but some only on entry to junior high school athletic programs and again on entry to high school programs.1 These are far more reasonable schedules than those in effect not too many years ago when a physical examination was required before each sport season, which would require some athletes to have as many as three or four examinations annually.

The benefits gained from these examinations are few, in that they reveal only 1% to 2% of those examined to have medical conditions considered high-risk for participation in certain sports.1,2 Most of these conditions are known of beforehand and can be detected with a medical history. This should come as no surprise, because the incidence of serious, previously undetected illnesses during the first 2 decades of life is quite low. The yield of abnormal findings (not known to be present beforehand) on routine, periodic physical examinations of presumably well persons in this age group is extremely small - 1.5% in infants during their first year,3 2.5% in preschool children,4 and 4% in primary school children5 and high school children.6 Most important, the abnormalities found in these studies have been for the most part minor and not such a threat to the athlete to preclude participation in sports.

The American Academy of Pediatrics' Committee on Sports Medicine has recommended exclusion from participation in competitive sports on the basis of existing conditions that would create a substantial risk of injury or death.7 These conditions are shown in the table on page 151 of this issue of Pediatric Annals and include atlantoaxial instability, carditis, moderate-tosevere hypertension, moderate-to-severe forms of congenital heart disease, absence of or blindness in one eye, a detached retina, absence of one kidney, an enlarged liver or spleen, certain musculoskeletal disorders, a history of serious head or spinal injury, repeated concussions, prior craniotomy, a poorly controlled convulsive disorder, and severe pulmonary insufficiency.

In many instances, these conditions apply to participation in contact sports only. In many instances, participation can be allowed with a physicians permission. And in almost all instances, these conditions are known to be present prior to a preparticipation sports physical examination. The exceptions to this may be atlantoaxial instability, hypertrophic cardiomyopathy, Marfan syndrome with mitral valve prolapse, idiopathic hypertrophic subaortic stenosis, coronary artery anomalies, and the absence of one kidney. Unfortunately, these conditions are those most likely to be missed on physical examination, even when performed by a neurologist, a cardiologist, or other skilled clinicians. Atlantoaxial instability is diagnosed radiographically (all Down syndrome children, who are more likely than most to have this condition, must…

This issue o( Pediatric Annals was prepared by Guest Editor Paul G. Dyment, MD, professor of clinical pediatrics and director of the Student Health Center at Tulane University in New Orleans. It addresses various aspects of sports medicine as they relate to participation in intramural and interscholastic sports by junior and senior high school and college students.

An important aspect of such participation is the assurance that the athlete is physically able to do so without risk of incurring injury or death because of a preexisting medical condition. Parents want this assurance, as do coaches and athletic trainers, who also need to know what the probabilities of such events are and how they might be prevented or managed. School officials want to avoid the legal problems that might arise if students are allowed to participate when they shouldn't. These concerns have led to the performance of millions of preparticipation sports physical examinations annually at great cost to schools and sometimes to parents. All states require that these examinations be done - most annually, but some only on entry to junior high school athletic programs and again on entry to high school programs.1 These are far more reasonable schedules than those in effect not too many years ago when a physical examination was required before each sport season, which would require some athletes to have as many as three or four examinations annually.

The benefits gained from these examinations are few, in that they reveal only 1% to 2% of those examined to have medical conditions considered high-risk for participation in certain sports.1,2 Most of these conditions are known of beforehand and can be detected with a medical history. This should come as no surprise, because the incidence of serious, previously undetected illnesses during the first 2 decades of life is quite low. The yield of abnormal findings (not known to be present beforehand) on routine, periodic physical examinations of presumably well persons in this age group is extremely small - 1.5% in infants during their first year,3 2.5% in preschool children,4 and 4% in primary school children5 and high school children.6 Most important, the abnormalities found in these studies have been for the most part minor and not such a threat to the athlete to preclude participation in sports.

The American Academy of Pediatrics' Committee on Sports Medicine has recommended exclusion from participation in competitive sports on the basis of existing conditions that would create a substantial risk of injury or death.7 These conditions are shown in the table on page 151 of this issue of Pediatric Annals and include atlantoaxial instability, carditis, moderate-tosevere hypertension, moderate-to-severe forms of congenital heart disease, absence of or blindness in one eye, a detached retina, absence of one kidney, an enlarged liver or spleen, certain musculoskeletal disorders, a history of serious head or spinal injury, repeated concussions, prior craniotomy, a poorly controlled convulsive disorder, and severe pulmonary insufficiency.

In many instances, these conditions apply to participation in contact sports only. In many instances, participation can be allowed with a physicians permission. And in almost all instances, these conditions are known to be present prior to a preparticipation sports physical examination. The exceptions to this may be atlantoaxial instability, hypertrophic cardiomyopathy, Marfan syndrome with mitral valve prolapse, idiopathic hypertrophic subaortic stenosis, coronary artery anomalies, and the absence of one kidney. Unfortunately, these conditions are those most likely to be missed on physical examination, even when performed by a neurologist, a cardiologist, or other skilled clinicians. Atlantoaxial instability is diagnosed radiographically (all Down syndrome children, who are more likely than most to have this condition, must have radiographs of the cervical spine taken prior to their participation in Special Olympic Games events); cardiac anomalies are diagnosed electrocardiographically and echocardiographically (some have advocated that all students engaged in contact or collision sports be screened with an echocardiogram).8 The absence of one kidney requires renal ultrasonography for definitive diagnosis.

It seems clear that preparticipation sports physical examinations, like well-child, pre-day care, pre-Head Start, pre-camp, and annual school physical examinations, are not cost beneficial. Yet, the reasons for doing them will not go away, even though parents allow their children to participate in recreational sports such as tennis, swimming, skiing, skate boarding, and sand-lot baseball, football, and basketball without a prior physical examination. The reasons won't go away, because of parents', coaches', and school officials' fears of severe injury or sudden death occurring on the athletic field. These events will happen even when a preparticipation physical examination is performed, and probably no less often than when one is not.

As pediatricians, we should opt for a pre-junior high and a pre-high school sports participation medical history and physical examination only, the latter consisting of a blood pressure measurement, vision screening, auscultation of the heart and lungs, palpation of the abdomen, and the 2 -minute orthopedic screening examination described by Dyment in his article beginning on page 157 of this issue.9 To do anything more would be unproductive or too expensive, using, for example, radiography, echocardiography, and ultrasonography. To do anything less would be unacceptable to parents, coaches, and school principals.

REFERENCES

1. Risser WL, Hoffman HM, Beliah GG Jr, Green LW. A cost-benefit analysis of preparticipation sports examinations of adolescent athletes. J Sch Health. 1985:55:270273.

2. Thompson TR, Andrtsh JT, Bergfield JA. A prospective study of preparticipation sports examinations among 2670 young athletes: method and results. Cleveland Clinic Quarterly. 1982;49:225-232.

3. Anderson FP. Evaluation of the routine physical examination of infants in the first year of life. Pediatric. 1970;45:950-960,

4. Hoekelman RA, A summer Head Start medical program: implications for change. JAMA. 1972;219:730-733.

5. Yankauer A, Lawrence R. A study of periodic school medical examinations, II: the annual increment of new "defects." Am J Public Health. 1956;46:1553-1562.

6. Kennedy FD. Haveschool-entry medicals had their day? Arch Dis Child. 1988,63:12611263.

7- Committee on Sports Medicine. Recommendations for participation in competitive sports. Pediatrics. 1988;81:737-739.

8. Samples P. Preparticipation exams: are they worth the time and trouble? TAe Physician and Sponsmedkine. 1986;14:180-187.

9. Dyment PG. The orthopedic component of the preparticipation examination. Pediatric Annals. 1992;21:157-162.

10.3928/0090-4481-19920301-04

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