For many adolescents, participation in sports is vitally important. During the 1994-1995 school year, approximately 5.8 million high school students were involved in organized athletics.1 The preparticipation athletic examination (PAE) offers the opportunity to assess the young athlete's readiness to compete safely and effectively. This article reviews the purpose, content, and conduct of these specialized examinations.
WHY SHOULD PAEs BE PERFORMEDT
Traditionally, the PAE has been envisioned as a focused health assessment designed to detect conditions that may compromise the athlete's ability to compete safely and effectively. Specifically, one hopes to identify those athletes at risk of injury or sudden death or those with an underlying medical condition that may affect participation. Since 22% to 39% of high school athletes sustain a significant injury2'3 and as many as 20% of such injuries may be preventable,4 the value of identifying those at risk is obvious. In contrast to injury, sudden death in athletes fortunately is uncommon; between 1983 and 1993, 126 nontraumatic deaths among high school athletes were identified by the National Center for Catastrophic Sports Injury Research (overall annual death rate 4.68/1 million athletes).5 Although rare, the devastating nature of a sudden unexpected death warrants efforts at prevention. How well the PAE identifies athletes at risk for injury and sudden death is a vital issue that will be discussed later. A second, albeit less noble, reason for performing PArIs is to comply with state or local requirements. A survey of state high school athletic associations conducted in 1985 found that 35 of 45 states responding required annual PAEs.6
Recently, some experts have suggested that the mission of PAEs should be enlarged to incorporate an assessment of medical and psychosocial issues that are important but not relevant to athletic participation.7'8 The arguments in favor of such change are several. First, from 33% to 89% of parents and athletes state that they plan to use the PAE as their only contact with a health-care provider.7'9 For this group of young people, the PAE may be the only opportunity to address health issues unrelated to sports participation. Second, since some adolescents lack an identified medical provider, their only access to care may be the PAE. Schicor and Beck,10 for example, found that 64% of student-athletes in Hartford, Connecticut, undergoing school-sponsored PAEs viewed this as their only means of obtaining health care. Third, some parents harbor misconceptions regarding the purpose of PAEs, believing that these examinations perform a broader function than simply assessing readiness for athletic participation. In a survey of 381 parents of high school athletes receiving PAEs, one third believed that the PAE should evaluate health problems unrelated to athletics, one in five thought that the PAE should incorporate health screening procedures (eg, vision and hearing testing, etc), and one in six believed that PAE visits should address social or behavioral issues.8 Owing to such misconceptions, parents or guardians may be less likely to schedule an independent visit for comprehensive health care. Although these arguments are compelling, some believe that such changes alter the purpose of these examinations and, in the case of largegroup examinations, may be costly and logistically difficult to implement.
WHEN SHOULD THE PAE BE PERFORMED?
To permit adequate opportunity for further evaluation and treatment of medical or orthopedic problems, the PAE is best conducted at least 6 to 8 weeks before the season begins. From a practical perspective, however, if PAEs are to be performed in a large groupformat, it often is desirable to schedule examination sessions near the close of a school year, rather than during the summer when student-athletes are on vacation and may be difficult to contact.
HOW OFTEN SHOULD PAEs BE PERFORMED?
Typically, PAEs have been conducted annually, and most states have requirements to this effect.6 Many authorities believe, however, that complete evaluations are needed only when a student-athlete is beginning a new school, sport, or higher level of competition iU and that annual assessments can be limited to a review of the interim history and a limited, directed examination. Although diminishing the frequency with which complete PAEs are conducted is medically sound and cost effective, this strategy might limit availability of care for those adolescents who use the examination as their only source of ongoing health maintenance. If the mission of PAEs was expanded, however, the schedule of visits described above would assure access to care and interface well with recently proposed Guidelines for Adolescent Preventive Services (GAPS). 1^ GAPS advises, for example, complete health assessments during early age 1 1 to 14 years), middle (age 15 to 17 years), and late (age 18 to 21 years) adolescence with an annual review of social and behavioral risk factors.12
HOW SHOULD THE PAE BE CONDUCTED?
Various approaches to the conduct of PAEs exist. An evaluation conducted by the athlete's primary care provider offers several advantages. This clinician is likely to be familiar with the athlete's personal and family history and to have established a relationship with the athlete. In addition, in an office setting, the elements of the PAE may be incorporated into a comprehensive health assessment. Finally, the primary care provider is most likely to assure appropriate evaluation, monitoring, and care for identified problems. Unfortunately, not all athletes have an identified provider, the cost of in-office examinations may be comparatively high, and some physicians may not be knowledgable about sports medicine issues or may be limited in their ability to detect musculoskeletal disorders.
Frequently, PAEs are conducted on large groups of athletes who circulate through a series of stations where individual components of the assessment are completed, including:
* a review of the history,
* measurement of height and weight,
* measurement of blood pressure,
* assessment of visual acuity,
* examination of the eyes, mouth, and skin,
* examination of the heart and lungs,
* examination of the genitalia (males),
* examination of the musculoskeletal system, and
* a final review of the findings of the PAE and determination of clearance to participate.
Since these multiple-station format PAEs permit the evaluation of large numbers of athletes efficiently and, often are performed by interested volunteers, the cost to the athlete typically is low. In addition, involvement of specialized personnel may enhance the identification of important issues- DuRant and colleagues13 found that the multiple-station PAE was more likely than an examination by an individual physician to detect musculoskeletal abnormalities of the spine and lower extremities and to result in referral of diese athletes for additional evaluation. The presence of expert providers may permit the assessment of additional areas, including nutritional status, fitness, and body composition. Finally, because school personnel, including coaches, usually are involved in the planning and conduct of these PAEs, communication with the medical staff is facilitated.
Due to their focused nature and goal of examining large numbers of athletes, however, multiple-station examinations generally do not permit the evaluation of medical OT social issues unrelated to sports participation. For those athletes whose only contact with a health-care provider is through the PAE, important health concerns may not be addressed. Furthermore, conducting such large-group examinations is logistically complex, requiring considerable preparation and organization along with the commitment of multiple providers and the availability of an appropriate facility. A significant challenge in large-group examinations is to ensure effective communication with both the athlete's parents and identified provider, particularly when a problem is identified that requires additional investigation or immediately disqualifies the student-athlete from participation.
The final type of PAE is that in which a single provider sequentially examines à large number of athletes. This "assembly line" model is cost effective and relatively efficient14 but tends to emphasize the examination to the relative exclusion of the history.13 Like multiple-station examinations, it does not allow for the investigation of other important medical or social issues and does not ensure continuity of care.
The athlete's personal and family history and review of systems can detect 64% to 78% of conditions that might adversely affect safe participation.9'15 Collection of data can be facilitated by distributing a questionnaire that is completed by the athlete and parents in advance of the examination. Although numerous questionnaires have been developed, each contains certain key elements. One such instrument formulated by the Committee on Sports Medicine of the American Academy of Pediatrics (AAP) is included as an Appendix. The form has three sections, an initial history (Part A), an interim history to be conducted annually (Part B), and a focused examination (Part C).4 Although the rationale for many of the questions posed is obvious, for others it may not be immediately apparent and will be discussed here.
* Question I , a-f: Does the athlete have a significant underlying health problem? Asking if the athlete has experienced an illness that required hospitalization or surgery, lasted longer than 1 week, caused them to miss practice or a game, or was considered chronic will identify most important conditions that may affect competition and require special attention (eg, asthma, diabetes mellitus, a seizure disorder, etc). A history of anaphylactic reactions following insect stings suggests the need for specialized evaluation or desensitization,16 and allows the athlete and physician to prepare for future emergencies by assuring the availability of appropriate medications (eg, epinephrine or diphenhydramine) at all practices and games.
* Question 2, a-e: Has the athlete experienced a significant injury? Among young athletes, injuries, particularly those involving the lower extremity, often represent an exacerbation of preexisting problems.13, The importance of the history in detecting orthopedic problems and therefore athletes at risk is underscored by the results of a study conducted by Gómez and colleagues.18 Among 259 athletes receiving PAEs, 120 significant injuries were detected, of which 91.5% were identified by the history alone.
* Question 3: Does the athlete use any medications? The use of medications may serve as a clue to the presence of an underlying condition that otherwise may have gone undetected. In addition, the intake of certain medications (eg, antícholinergics, betablockers, decongestants, and diuretics) may predispose the athlete to heat exhaustion or heat stroke. Depending on the setting used for the PAE and the confidentiality it allows, athletes may be questioned about the use of ergogenic aids (eg, nutritional supplements, anabolic steroids, etc), agents designed to control weight (eg, laxatives, diuretics, or stimulants), or other substances.
* Questions 4, 5a, and 8: Is there a family history of early cardiovascular disease? Has the athlete experienced syncope, near-syncope, or chest pain during exercise! Does the athlete have a heart murmur, hypertension, or a heart abnormality? The majority of nontraumattc sudden deaths in young athletes are the result of cardiac disease, including hypertrophie cardiomyopathy, coronary artery anomalies, myocarditis, dysrhythmia, aortic rupture in individuals with Marfan syndrome, dilated cardiomyopathy, and premature atherosclerosis.5'19'20 The questions posed are designed to identify athletes at risk for sudden death; however, it may be difficult to achieve this goal since in most such events there is no prior awareness of heart disease.19'20
Although syncope shortly following exercise may be the result of relatively benign conditions, including extreme exertion or heat-related illness, syncope during strenuous activity should be taken seriously since it may indicate the presence of a coronary artery anomaly, dysrhythmia, or aortic stenosis. Chest pain with exercise may indicate the presence of hypertrophie cardiomyopathy, valvular abnormalities, coronary insufficiency, or Marfan syndrome. A family history of sudden cardiac death prior to age 35 years suggests disorders that may be transmitted in an autosomal dominant fashion (eg, hypertrophie cardiomyopathy, Marfan syndrome, familial hyperlipidemia, and the Romano- Ward form of the prolonged QT syndrome).
* Question 5b: Has the athlete ever suffered a concussion? Athletes who have suffered a concussion should be questioned regarding the nature and severity of the injury, what evaluation was performed, and what recommendations were offered.21 If the concussion occurred recently, the possibility of a "second impact syndrome," in which diffuse brain swelling occurs, mandates that an appropriate assessment be performed and that complete recovery occurs before the athlete returns to play.22 Those athletes who have sustained multiple concussions as a consequence of participation in contact sports merit evaluation by a neurologist or neurosurgeon.
* Question 9: Is the athlete missing a paired organ (eg, eye , testis , kidney) ? The absence of a paired organ raises concern about potential injury to the remaining organ during participation in certain sports. This issue will be discussed later.
* Question 12, a-b: Menstrual history. A menstrual history, including age at menarche, frequency of menses, and episodes of amenorrhea, is useful to assesss any adverse effect of physical activity on menstrual function and may serve as a clue to the presence of eating disorders.
* Has the athlete experienced a heat-related illness? Although heat-related illness is not addressed in the AAP questionnaire, athletes should be asked about the occurrence of frequent muscle cramps, inordinate weakness, or near-syncope during exercise in hot weather. For those affected, possible precipitating factors (eg, medications) should be sought and advice regarding prevention offered (eg, allowing acclimatization, taking appropriate amounts of fluid, scheduling training times during cooler times of the day, etc).
THE PHYSICAL EXAMINATION
In conjunction with the history, the physical examination is designed to detect conditions that compromise safe participation. When large-group, multiple -station examinations are being performed, athletes should be advised to dress in shorts and a T-shirt to facilitate a thorough examination. Essential elements of the assessment include measurement of height, weight, heart rate, blood pressure, and visual acuity; and examination of the eyes, ears, nose, mouth and throat, neck, heart, lungs, abdomen, skin, genitalia, and musculoske letal system (Appendix). Selected portions of this examination will be discussed in detail.
Blood pressure should be measured in the right arm with the athlete seated. It is vitally important to have several cuff sizes available (eg, child, adult, large adult, and thigh). Relying solely on the standard adult cuff may result in falsely elevated blood pressures in athletes who are muscular or overweight.
Beyond assessing visual acuity, the eyes are examined for anisocoria that is usually physiologic. Recognizing this variation is important for athletes who later sustain a head injury.
Since the majority of nontraumatic deaths in young athletes are the result of occult cardiovascular disease,5'20 examination of the heart is an essential component of the PAE. Hypertrophie cardiomyopathy often is associated with a systolic murmur that, in contrast to benign murmurs, increases in intensity with standing and during the straining phase of the Valsalva maneuver, and decreases with squatting. Although aortic dilation cannot be diagnosed clinically, individuals at risk are those with Marfan syndrome, characterized by tall stature, myopia or ectopia lentis, arachnodactyly, etc. Unfortunately, however, other conditions responsible for sudden death, including coronary artery abnormalities, dysrhythmias, dilated cardiomyopathy, and premature atherosclerosis, may go unrecognized despite a careful clinical examination.
The limitations of the PAE in detecting athletes at risk for sudden cardiac death is illustrated by the results of a recent study by Maronetal.20 Among 115 athletes who experienced sudden cardiac death, only 4 (3%) were identified by the standard PAE.20 Disturbingly, this evaluation failed to identify 47 of the 48 individuals who died as the result of hypertrophic cardiomyopathy, the most common cause of sudden cardiac death in athletes.20 Although noninvasive testing could enhance the recognition of athletes at risk, the American Heart Association recently stated that the rarity of sudden cardiac death and issues of cost and practicality made it "not prudent" to recommend the use of electrocardiography, echocardiography, or graded exercise testing in the routine evaluation of young or older athletes.2*
The athlete with an enlarged liver or spleen is at risk for traumatic rupture during contact sports. In those with infectious mononucleosis, however, spontaneous splenic rupture during strenuous noncontact activities also may occur. Therefore, the finding of hepatomegaly or splenomegaly precludes participation pending evaluation.
In males, examination of the genitalia is performed to detect the absence or atrophy of a testis. In addition, an assessment of the level of sexual maturity is useful to identify and counsel athletes who, by virtue of their relative immaturity, possess less muscular development than their peers and may be at increased risk for injury in contact/collision sports.24 The examination also offers the opportunity to rapidly assess other potential abnormalities that do not directly impact athletic participation, including inguinal hernia, varicocele, or testicular mass, and to review the rationale and methods of testicular self-examination. For purposes of the PAE, examination of the genitalia in females is useful to assess the level of sexual maturity as reflected by breast development. Although this component of the evaluation, as well as breast examination and instruction in self-examination techniques, is easily accomplished when the PAE is conducted in the provider's office, the lack of privacy and chaperons generally preclude such an assessment during large-group, multiple-station examinations.
Active impetigo, tinea corporis, scabies, molluscum contagiosum, and herpes simplex virus infection preclude participation in contact sports that involve close physical contact (eg, wrestling, martial arts, or gymnastics with mats). If the lesions can be covered effectively or when healing has occurred, the athlete may return to competition.
The musculoskeletal system often is assessed using the "2-minute" orthopedic examination (Table 1). If abnormalities are detected or if an athlete has a history of a prior injury, the area in question is examined more thoroughly. Although the "2-minute" examination is rapid, cost effective, and noninvasi ve,25 concerns have been raised about its efficacy in detecting abnormalities and predicting injury. In a study of 259 athletes with 120 significant recent injuries, the "2minute" orthopedic examination had a sensitivity of 50.8%, specificity of 97.5%, positive predictive value of 40.9%, and negative predictive value of 98.3%. l8 Since most of the injuries identified involved the shoulder, knee, and ankle regions, the authors suggested that the diagnostic sensitivity of the screening examination could be increased by incorporating a more thorough evaluation of these high-risk areas.18
Based on available data, routine laboratory studies are not recommended as part of the PAE.21'26 Although the performance of a ferritin level, iron studies, or complete blood cell count may reveal iron insufficiency or anemia, particularly among female athletes, it is rare that such findings would impact participation. Similarly, the urinalysis, long included in sports physicals, is not useful in identifying renal pathology in otherwise healthy individuals.21 Furthermore, it is not uncommon to detect some degree of proteinuria that, while almost always benign in etiology, prompts an unnecesary and costly evaluation. These laboratory studies, while not recommended for inclusion in the PAE, may be valuable components of a more comprehensive health assessment.
CLEARANCE FOR PARTICIPATION
At the conclusion of the PAE, the physician will possess the information necessary to determine whether the athlete may be cleared for participation or requires further evaluation. Although a discussion of exclusion from sports is beyond the scope of this article, a few areas deserve mention. To assist the physician in reaching a decision regarding clearance, the AAP has developed recommendations for participation in competitive sports based on the characteristics of the sport (eg, level of contact and exertion involved) (Tables 2 and 3) and the nature of the underlying health problem (Table 4)-27
Fortunately, most athletes are healthy; approximately 98% of those examined eventually receive clearance to participate.9'28,29 If a significant problem is identified during the PAE, the clinician first must determine if the athlete can continue to participate during the period of evaluation and treatment or if immediate exclusion is necessary. The problem should be discussed with the athlete and documented clearly in writing for the parents. For all but the most trivial problems, however, it is wise to discuss the problem with the athlete's parents personally or by telephone. Communication with the athlete's coach about the problem and any limitations is also valuable.
The '2-Minute' Orthopedic Examination
Since sports participation is often viewed as an integral part of the adolescent's life, any decision regarding exclusion from competition should be made only after careful consideration. If an athlete's medical status precludes participation in certain sports (eg, those involving contact), involvement in other more appropriate activités can be explored. Although the athlete is almost certain to experience disappointment at being unable to participate in a chosen sport, over time it may be possible to redirect his or her interests to other activities.
Mild elevations of blood pressure are not a reason for exclusion from any form of sports participation. In contrast, moderate to severe hypertension requires evaluation and an individualized approach to involvement in athletics. For advice in this area, clinicians may wish to consult a pediatrie cardiologist or review "The Report of the Second Task Force on Blood Pressure Control in Children - 1987,30 and the recently published update on this report."31 Athletes with suspicious cardiac findings should have clearance to play deferred pending evaluation. Although guidelines for medical eligibility fot competition by athletes with heart disease have been developed,32 it is prudent to discuss issues of participation and in what types of sports with their cardiologist prior to providing clearance.
Classification of Sports by Contact*
Classification of Sports by Strenuousness*
Medical Conditions and Sports Participation*
Medical Conditions and Sports Participation*
Absence of a Paired Organ
Absence or significant impairment of an eye, kidney, or testis raises concern about damage to the remaining organ during athletic participation. If an athlete with an absent paired organ wishes to participate in a sport that places the remaining organ at risk, the physician should review with the athlete and parents the potential consequences of this decision and what protective measures are available. If the athlete wishes to play and the parents support this decision, it is prudent to request that they sign a document that states that they are aware of and accept the risks associated with athletic participation. This waiver may provide the physician and school with some protection against liability, and assistance in its preparation can be provided by the school's attorney.
For the athlete with an absent or nonfunctioning eye, participation in football, baseball, handball, tennis, or squash places the remaining eye at risk. In most cases, however, protection can be offered by wearing eye guards with lenses approved by the American Society for Testing and Materials.27,33 Athletes with prior ocular injuries (eg, a detached retina) should be referred to their ophthalmologist for a final decision regarding clearance.27 The concern in an athlete with a single kidney is the potential for serious renal injury that, although rare, could occur while playing a contact/collision sport. For this reason, participation in sports such as football generally is not recommended. This is of particular importance if the remaining kidney is known to be ectopically located, where it is at greater risk for injury, or is abnormal in structure or function. The testes are at some risk, albeit low, for trauma that may occur in contact or limited contact sports. Although participation in these sports is not contraindicated for the athlete with a single testis, the use of a protective cup is advised.
Sickle Cell Trait
Most experts believe that sickle cell trait does not pose a significant problem for athletic participation.27,34 Some concern exists, however, that individuals widS this hemoglobin may be at increased risk of exertional rhabdomyolysis, heat stroke, and unexplained cardiac death. Studies of military recruits entering basic training between 1977 and 1981 revealed a 20-fold increase in sudden death among African- American males who had sickle cell trait.34 Coincident with efforts to prevent exertional heat illness, the mortality rate among recruits with sickle cell trait declined, approaching that of individuals with normal hemoglobin. Although available data do not support limiting athletic participation by those with sickle cell trait, it is prudent that these individuals avoid heat illness through careful conditioning and acclimatization, adjustment of training schedules during hot and humid weather, and appropriate hydration.27,34
The PAE is a specialized health assessment that functions relatively well as a screening device for orthopedic or medical problems that may affect an athlete's ability to compete safely and effectively. Nevertheless, certain challenges to the philosophy and conduct of sports physicals exist. First, an issue of some controversy is whether the focus of PAEs should be enlarged to provide more comprehensive care for the large number of young people who lack access to health care and for whom the PAE is their only regular contact with a health-care provider. Second, recent information suggests that modifications of the PAE may be indicated. Although the current evaluation is able to identify a majority of athletes at risk for musculoskeletal injury, the diagnostic sensitivity of the "2-minute" orthopedic examination might be enhanced by incorporating a detailed evaluation of the knee, ankle, and shoulder. Additionally, and perhaps most vexing, is whether the PAE can be altered to enhance the detection of young athletes at risk for sudden nontraumatic death.
1. National Federation of Stale High School Associations. 1995 High School Atfiferics Parudfaaan Survey. Kansas City, Mo: National Federation of Stare High School Associations; 1992.
2. McLam LG, Reynolds S. Sports injuries in a high school. Pediatrics. 1 989:84:446-450.
3. Oarrick JG, Requa RK. Injuries in high school sports. Pediatría. 1978Í 1:465-469.
4. Greydanus DE. Pediatrics and the teenage athlete. The sports specific physical exam· inarion. Adolescent Heabh Update. 1990;2:1-5.
5. Van Camp SP, Bloor CM, Mueller FO, Canni RC, Oison HG. Nontraumatic sports death in high school and college athletes. Med Sd Sforo EuCTc. 1995:27:641 -647.
6. Feinstein RA, Soileau EJ, Daniel WAJr. A national survey of ptepaiticipation physical examination requirements. The Physician and Sports Medicine. 1988; 16:5 1 -59.
7. Risser WL. HofFman HM, Bellah GGJr, Green LW. A cost-benefit analysis of preparticipation sports examination of adolescent athletes. } Sch Health. 1985;55:270-273.
8. Krowchuk DR Krowchuk HV, Hunter DM. et al. Parents' knowledge of the purposes and content of preparticiparion physical examinations. Arch Pedina Adolísc Med. 1995:149:653-657.
9. Goldberg B, Saraniti A. Witman P. Gavin M, Nicholas JA. Pre-parricipatlon sports assessment - an objective évaluation. Pediatrici. 1980:66:736-745.
10. Schicot A, Beck A. School-based follow up care for sports physicals, ] Sdì Health. 1988;58:200-Z02.
11. McKeag DE Preparricipation screening of the potential athlete. CIm Sports Mei l989;8:373-397.
12. Elster AB, Kuznets NJ. AMA Giudelme fot Adolesoiu fWnwe Services (GAPS). Baltimore, Md: Williams and Wilkins; 1994.
13. DuRant RH, Seymore C. Linder CW, Jay S. The preparticipation examination of athletes. AmJ Dû Chíü 1985:139*57-661.
1 4. Group on Science and Technology, American Medical Association. Athletic prcpattkipation examinations for adolescents. Report of the Board of Trustees. Ardi Pediatr Aootesc MeA 1994:148:93-98.
15. Risset WL. Hoffman HM, Bellah GG Jr. Frequency of prepartkipation sports examinations in secondary school athletes: are the University lnlenchoiastic League guidelines appropriate! Tex Med. 1985:81:35-39.
16. Reisman RE Insect stings. N Enj>i J Med. 1994:331:523-527.
17. Lysens R. Steverlynck A, van den Auweele Y, et al. The predictability of sports injuries. Sporn Mid. 1984:1:6-10.
18. Gomei JE, Landry GL. Bernhardt DT. Critical evaluation of the 2-minute orthopedic screening examination. Am J Dis ChM 1993:147:1109-1113.
19. Marón BJ, Roberts WC, McAHister HA. Rasing DR, Epstein SE. Sudden death in young athletes. Oculaoon. 1980:62:218-229.
20. Marón BJ. Shirani J. Poliac LC, Mathenge R, Roberts WC. Mueller FO. Sudden death in young competitive athletes. Clinical, demographic, and pathological profiles. JAMA. 1996:276:199-204.
2 1 . Preparticipation Physical Evaluation Task Force. PrefertofiaBon Physical Evaluation. 2nd ed. Minneapolis, Minn: The Physician and Sporrsmedicine; 1997.
22. Kelly JP, Nichols JS, Filley CM, Lillehei KO, Rubinstein D, Kleinschmidt-DeMasters BtC Concussion in sports. Guidelines for the prevention of catastrophic outcome. JAMA. 1991:266:2867-2869.
23. Matón BJ, Thompson PD, Puffer JC. et al. Cardiovascular preparticipation screening of competitive athletes. Circulation. 1996:94:850-856.
24. Gatrick JG. Epidemiology of sport: injuries in the pediatrie athlete, in: Sullivan JA, Grana WA. eds. T)M Pediatrie Athlete. Part Ridge. Ill: American Academy of Othopaedk Surgeons: 1990123-132.
25. DuRant RH, Pendergrast RA, Seymore C, Gaillard G. Dormer J. Findings from the prepaitic ipation athletic examination and athletic injuries. Am J Du Child. 1992:146:85-91.
26. Committee on Sports Medicine, American Academy of Pediatrics. Sports Medicine: Health Care for Young Athletes. 2nd ed. Elk Grove Village, 111: American Academy of Pediatrics; 1991.
27. Committee on Sports Medicine and Fitness, American Academy of Pediatrics. Medical conditions affecting sports participation. Pediatrics. 1994;94:757-760.
28. Linder CW, DuRant RH, Seklecki RM. Strong WB. Preparticipation health screening of young athletes. Results of 1268 examinations. AmJ Sports Mai 1981:9:187191.
29. Thompson TR, Andrish JT, Bergfeld JA. A prospective study of preparticipation sports examinations of 2670 young athletes: method and results. Clew Clin Q. 1982:49:225-233.
30. Task Force on Blood Pressure Control in Children of the National Heart, Lung and Blood Institute. Report of the Second Task Force on Blood Pressure Control in Children- 1987. Pediatria. 1987:79:1-25,
31 . National High Blood Pressure Education Program Working Group on Hypertension Control in Children and Adolescents. Update on the 1987 Task Force Report on High Blood Pressure in Children and Adolescents: A Working Group Report from the National High Blood Pressure Education Program. Pediatrics. 1996:98:49-225.
32. Mitchell JH1 Marón BJ1 Epstein SE Sixteenth Bethesda Conference: cardiovascular abnormalities in the athlete: recommendations regarding eligibility for competition. JAmCollCardioL 1985 ;6; 11 86- 1232.
33. American Academy of Pediatrics Committee on Sports Medicine and Fitness and American Academy of Ophthalmology Committee on Eye Safety and Sports Ophthalmology. Protective eyeweat for young athletes. Pediatrics. 1996;98:3 11-313.
34. Kark JA. Ward FT. Exercise and hemoglobin S. Semin Henioid. 1994:31:181-225.
The '2-Minute' Orthopedic Examination
Classification of Sports by Contact*
Classification of Sports by Strenuousness*
Medical Conditions and Sports Participation*
Medical Conditions and Sports Participation*