Pediatric Annals

The Orthopedic Component of the Preparticipation Examination

Paul G Dyment, MD

Abstract

Some recent titles of medical journal articles concerning the preparticipation sports physical examination indicate this time-honored ritual may be just that, a ritual rather than a meaningful health'care encounter. "A Cost-Benefit Analysis of Preparticipation Sports Examination of Adolescent Athletics,"1 "Preparticipation Sports Examination of the Child and Athlete: Changing Views of an Old Ritual,"2 and "Preparticipation Exams: Are They Worth the Time and Trouble?"3 are articles that have appeared in the medical literature in the past 6 years, and they illustrate the ferment regarding the usefulness of this examination as it is usually performed.

Many, if not most, primary care physicians have little conviction that these examinations are very effective in preventing either athletic injuries or a medical catastrophe such as sudden unexpected death on the playing field. The traditional medically oriented history and physical examination (emphasizing such things as auscultation of the heart and checking for an inguinal hernia) results in only about 1% of participants having an abnormality detected that either needs further study or modification of some kind in sports participation. Those abnormalities requiring further testing generally turn out to be such things as clinically insignificant amounts of proteinuria, a situation so commonly occurring that the American Academy of Pediatrics no longer recommends that a urinalysis be done as part of the preparticipation examination.4 Other commonly detected "abnormalities" are an innocent heart murmur, or mild and transient hypertension, neither of which should affect an athlete's participation in sports activities. With the odds of detecting something abnormal being only one in a hundred, it is no wonder that physicians view sports examinations as being of little importance and are only too willing to just do a cursory examination.

MEDICAL HISTORY

As with most of medicine, the history is at least as important as the physical examination. Regrettably, the "sports physical" performed in July before one athletic season is deemed by most schools to be valid for at least the rest of the year. This makes little sense, as a girl could well sprain her ankle during field hockey season in the fall, then try-out for basketball in November with an incompletely rehabilitated ankle injury, and there would be no system in place to ensure that her ankle sprain had healed enough to be subjected to another vigorous athletic season without significant risk of reinjury. Schools should riierefore require an interim history prior to each athletic season that will question whether there have been any recent athletic injuries; if injuries have occurred, then a physical examination by a physician should be required.

THE 2-MINUTE MUSCULOSKELETAL EXAMINATION

This component of the physical examination is designed to identify those acquired musculoskeletal abnormalities, as well as the rarely occurring congenital abnormalities, either of which might affect the athlete's performance or might be worsened by participation in sports. It should be considered a screening examination, and if an abnormality is detected, then a directed orthopedic examination of that area is performed. For example, if assuming a squatting position during the musculoskeletal examination causes the athlete to wince with discomfort in the knee, then a complete knee examination should be performed.

Method

The athlete should stand in front of the physician. Figures 1 through 12 provide the instructions die physician should give to the athlete, illustrate most of the movements, and list the normal findings as well as common abnormalities that may be present.

Abnormalities

Generalized joint "laxity" used to be considered a risk-factor for injuries, but this is no longer the case and athletes with hypermobile joints do not require any special attention to prevent injuries. However, if there is excessive joint laxity or…

Some recent titles of medical journal articles concerning the preparticipation sports physical examination indicate this time-honored ritual may be just that, a ritual rather than a meaningful health'care encounter. "A Cost-Benefit Analysis of Preparticipation Sports Examination of Adolescent Athletics,"1 "Preparticipation Sports Examination of the Child and Athlete: Changing Views of an Old Ritual,"2 and "Preparticipation Exams: Are They Worth the Time and Trouble?"3 are articles that have appeared in the medical literature in the past 6 years, and they illustrate the ferment regarding the usefulness of this examination as it is usually performed.

Many, if not most, primary care physicians have little conviction that these examinations are very effective in preventing either athletic injuries or a medical catastrophe such as sudden unexpected death on the playing field. The traditional medically oriented history and physical examination (emphasizing such things as auscultation of the heart and checking for an inguinal hernia) results in only about 1% of participants having an abnormality detected that either needs further study or modification of some kind in sports participation. Those abnormalities requiring further testing generally turn out to be such things as clinically insignificant amounts of proteinuria, a situation so commonly occurring that the American Academy of Pediatrics no longer recommends that a urinalysis be done as part of the preparticipation examination.4 Other commonly detected "abnormalities" are an innocent heart murmur, or mild and transient hypertension, neither of which should affect an athlete's participation in sports activities. With the odds of detecting something abnormal being only one in a hundred, it is no wonder that physicians view sports examinations as being of little importance and are only too willing to just do a cursory examination.

Figure 1. Instructions: Have patients stand straight with their arms at their sides (facing the examiner). Normal Findings: Symmetry of upper and lower extremities and trunk. Common Abnormalities: 1) enlarged acromioclavicular joint, 2) enlarged sternoclavicular joint, 3) asymmetrical waist (leg length difference or scoliosis), 4) swollen knee, and 5) swollen ankle. Figure 2. Instructions: Have patients look at the ceiling; look at the floor; touch their right (left) ear to their shoulder; look over their right (left) shoulder. Normal Findings: Patients should be able to touch their chin to their chest, their ears to their shoulders, and look equally over their shoulders. Common Abnormalities: 1 ) loss of flexion, Z) loss of lateral bending, and 3) Loss of rotation may indicate previous neck injury. Figure 3. Instructions: Have patients shrug their shoulders (while the examiner holds patients down). Normal Findings: Trapezius muscles appear equal; left and right sides exhibit equal strength. Common Abnormalities: 1) Loss of strength and 2) loss of muscle bulk may indicate neck or shoulder problem.

Figure 1. Instructions: Have patients stand straight with their arms at their sides (facing the examiner). Normal Findings: Symmetry of upper and lower extremities and trunk. Common Abnormalities: 1) enlarged acromioclavicular joint, 2) enlarged sternoclavicular joint, 3) asymmetrical waist (leg length difference or scoliosis), 4) swollen knee, and 5) swollen ankle. Figure 2. Instructions: Have patients look at the ceiling; look at the floor; touch their right (left) ear to their shoulder; look over their right (left) shoulder. Normal Findings: Patients should be able to touch their chin to their chest, their ears to their shoulders, and look equally over their shoulders. Common Abnormalities: 1 ) loss of flexion, Z) loss of lateral bending, and 3) Loss of rotation may indicate previous neck injury. Figure 3. Instructions: Have patients shrug their shoulders (while the examiner holds patients down). Normal Findings: Trapezius muscles appear equal; left and right sides exhibit equal strength. Common Abnormalities: 1) Loss of strength and 2) loss of muscle bulk may indicate neck or shoulder problem.

Figure 4. Instructions: Have patients hold their arms out from their sides horizontally and lift (while the examiner holds arms down). Normal Findings: Strength should be equal and deltoid muscles should be equal in size. Common Abnormalities: 1) loss of strength and 2) wasting of deltoid muscle. Figure 5. Instructions: Have patients hold arms out from their sides with their elbows bent (90°); have patients raise hands back vertically as far as they will go. Normal Findings: Hands go back equally and at least to upright vertical position. Common Abnormalities: Loss of external rotation may indicate shoulder problem or old dislocation. Figure 6. Instructions: Have patients hold their arms out from their sides, palms up; have patients completely straighten and bend their elbows. Normal Findings: Motion should be equal left and right. Common Abnormalities: 1) loss of extension and 2) loss of flexion may indicate old elbow injury, old dislocation, fractures, etc).

Figure 4. Instructions: Have patients hold their arms out from their sides horizontally and lift (while the examiner holds arms down). Normal Findings: Strength should be equal and deltoid muscles should be equal in size. Common Abnormalities: 1) loss of strength and 2) wasting of deltoid muscle. Figure 5. Instructions: Have patients hold arms out from their sides with their elbows bent (90°); have patients raise hands back vertically as far as they will go. Normal Findings: Hands go back equally and at least to upright vertical position. Common Abnormalities: Loss of external rotation may indicate shoulder problem or old dislocation. Figure 6. Instructions: Have patients hold their arms out from their sides, palms up; have patients completely straighten and bend their elbows. Normal Findings: Motion should be equal left and right. Common Abnormalities: 1) loss of extension and 2) loss of flexion may indicate old elbow injury, old dislocation, fractures, etc).

However, this 1% incidence rate for abnormalities can be increased to over 10% if a 2-minute examination of the musculoskeletal system is also performed.5 The musculoskeletal examination is designed to detect the residua of incompletely healed or rehabilitated sports injuries, which are of importance because most sports injuries are reinjuries.

Figure 7. Instructions: Have patients hold their arms down at their sides with their elbows bent (90°); have patients twist their palms up and down. Normal Findings: Palms should go from facing ceiling to facing floor. Common Abnormalities: 1) lack of full supination and 2) lack of full pronation may indicate old forearm, wrist, or elbow injury. Figure 8. Instructions: Have patients make a fist, open their hand, and spread their fingers. Normal Findings: Fist should be tight and fingers straight when spread. Common Abnormalities: 1) protruding knuckle from fist and 2) swollen and/or crooked finger may indicate old finger fractures or sprains). Figure 9. Instructions: Have patients squat on their heels, duck-walk four steps, and then stand up. Normal Findings: Maneuver is painless; heel to buttock distance is equal left and right; knee flexion is equal during walk. Common Abnormalities: 1) inability to fully flex one knee and 2) inability to stand up without twisting or bending to one side.

Figure 7. Instructions: Have patients hold their arms down at their sides with their elbows bent (90°); have patients twist their palms up and down. Normal Findings: Palms should go from facing ceiling to facing floor. Common Abnormalities: 1) lack of full supination and 2) lack of full pronation may indicate old forearm, wrist, or elbow injury. Figure 8. Instructions: Have patients make a fist, open their hand, and spread their fingers. Normal Findings: Fist should be tight and fingers straight when spread. Common Abnormalities: 1) protruding knuckle from fist and 2) swollen and/or crooked finger may indicate old finger fractures or sprains). Figure 9. Instructions: Have patients squat on their heels, duck-walk four steps, and then stand up. Normal Findings: Maneuver is painless; heel to buttock distance is equal left and right; knee flexion is equal during walk. Common Abnormalities: 1) inability to fully flex one knee and 2) inability to stand up without twisting or bending to one side.

Figure 10. Instructions: Have patients stand up straight with their arms at their sides (with their backs to the examiner). Normal Findings: Symmetry of shoulders, waist, thighs, and calves. Common Abnormalities: 1) High shoulder (scoliosis) or low shoulder (muscle loss), 2) prominent rib cage (scoliosis), 3) high hip or asymmetrical waist (leg length difference or scoliosis), and 4) small calf or thigh (weakness from old injury). Figure 11. Instructions: Have patients bend forward slowly with their knees straight and then touch their toes. Normal Findings: patient bends forward straightly and smoothly. Common Abnormalities: 1) twists to side (low back pain) and 2) back is asymmetrical (scoliosis). Figure 12. Instructions: Have patients stand on their heels and then stand on their toes. Normal Findings: Equal elevation right and left; symmetry of calf muscles. Common Abnormalities: Wasting of calf muscles (Achules injury or old ankle injury). (Figures 1 through 12 are reprinted with permission from For the Practitioner: Orthopedic Screening Examination for Participation in Sports. Copyright ©1987, Ross Laboratories.)

Figure 10. Instructions: Have patients stand up straight with their arms at their sides (with their backs to the examiner). Normal Findings: Symmetry of shoulders, waist, thighs, and calves. Common Abnormalities: 1) High shoulder (scoliosis) or low shoulder (muscle loss), 2) prominent rib cage (scoliosis), 3) high hip or asymmetrical waist (leg length difference or scoliosis), and 4) small calf or thigh (weakness from old injury). Figure 11. Instructions: Have patients bend forward slowly with their knees straight and then touch their toes. Normal Findings: patient bends forward straightly and smoothly. Common Abnormalities: 1) twists to side (low back pain) and 2) back is asymmetrical (scoliosis). Figure 12. Instructions: Have patients stand on their heels and then stand on their toes. Normal Findings: Equal elevation right and left; symmetry of calf muscles. Common Abnormalities: Wasting of calf muscles (Achules injury or old ankle injury). (Figures 1 through 12 are reprinted with permission from For the Practitioner: Orthopedic Screening Examination for Participation in Sports. Copyright ©1987, Ross Laboratories.)

MEDICAL HISTORY

As with most of medicine, the history is at least as important as the physical examination. Regrettably, the "sports physical" performed in July before one athletic season is deemed by most schools to be valid for at least the rest of the year. This makes little sense, as a girl could well sprain her ankle during field hockey season in the fall, then try-out for basketball in November with an incompletely rehabilitated ankle injury, and there would be no system in place to ensure that her ankle sprain had healed enough to be subjected to another vigorous athletic season without significant risk of reinjury. Schools should riierefore require an interim history prior to each athletic season that will question whether there have been any recent athletic injuries; if injuries have occurred, then a physical examination by a physician should be required.

THE 2-MINUTE MUSCULOSKELETAL EXAMINATION

This component of the physical examination is designed to identify those acquired musculoskeletal abnormalities, as well as the rarely occurring congenital abnormalities, either of which might affect the athlete's performance or might be worsened by participation in sports. It should be considered a screening examination, and if an abnormality is detected, then a directed orthopedic examination of that area is performed. For example, if assuming a squatting position during the musculoskeletal examination causes the athlete to wince with discomfort in the knee, then a complete knee examination should be performed.

Method

The athlete should stand in front of the physician. Figures 1 through 12 provide the instructions die physician should give to the athlete, illustrate most of the movements, and list the normal findings as well as common abnormalities that may be present.

Abnormalities

Generalized joint "laxity" used to be considered a risk-factor for injuries, but this is no longer the case and athletes with hypermobile joints do not require any special attention to prevent injuries. However, if there is excessive joint laxity or instability at one joint resulting from a previous ligamentous injury, then reinjury or even posttraumatic osteoarthritis are possible consequences. Muscle-strengthening exercises involving that joint are therefore indicated, and consideration should be given to recommending supportive braces. An example would be an incompletely rehabilitated ankle sprain causing pain when the athlete "duck- walks," or perhaps, the athlete just has a history of recurrent ankle sprains. In either case, ankle-strengthening exercises would be recommended, as well as an ankle brace to be worn whenever the athlete is physically active (such as the Swede-O ankle stabilizer,* a laced-up type of brace that resists inversion and eversión and can be worn with regular or athletic shoes).

Most musculoskeletal abnormalities detected will be either muscle or ligament weaknesses remaining from incompletely rehabilitated injuries such as an ankle sprain or overuse syndromes such as "swimmer's shoulder" or patellofemoral syndrome (chondromalacia patella).

What does a pediatrician do once an abnormality has been detected? Few of us are trained in rehabilitative exercises, so a referral to a certified athletic trainer or a physiotherapist experienced in sports injuries will be necessary. Generally, the athlete should still be allowed to participate during that season. It takes 3 to 6 weeks for exercises to become effective, and this is why the preparticipation examination should be performed at least 6 weeks before the beginning of the playing season.

If pediatricians include the "2-minute orthopedic examination" in all of their sports physical examinations, the increased number of abnormalities detected would make the physician view these preparticipation examinations as productive and worthwhile.

REFERENCES

1. Risset WL, Hoffman HM, Bellah OG1 et al. A cost-benefit analysis of preparticipation sports examinations of adolescent athletes. J School Health. 1985;55:270-273.

2. Rowland TW. Preparticipation sports examination of the child and adolescent athlete: changing views of an old ritual. Pediatrician. 1986;13:3-9.

3. Samples R Preparticipation exams: are they worth the time and trouble ' Physician and Sportsmedicme. 1986;14:180-187.

4. The preparticipation examination. In: Dyment PG, ed. Sports Mediane." Health Care of the Young Athlete, 2nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 1991:49.

5. Thompson TR, Andrish JT, Bergfeld JA. A prospective study of preparticipation sports examinations of 2670 young athletes: method and results. Cleue Clin Q. 1982;49:225-233.

10.3928/0090-4481-19920301-06

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