In the United States, more than 7 million adolescents participate in high school athletics.1 Pediatricians frequently perform sports preparticipation physical evaluations (PPEs) for these young athletes. An important goal of the PPE is to promote sports safety by evaluating young athletes for conditions that increase their chances of sports injury or put them at risk for illness or sudden death.2,3 Most states require PPEs prior to participation in high school sports and some private organizations, such as the Special Olympics, also require PPEs.4 Between 3.2% and 13.9% of athletes require additional evaluation as a result of abnormal findings discovered during the PPE.2 Physicians disqualify 0.3% to 1.3% of athletes who undergo a PPE from athletic participation due to an underlying medical condition.2
The original structure of the PPE more than 40 years ago consisted of limited or no history, evaluating only for heart murmurs and inguinal hernias. In 1992, five organizations (American Academy of Family Physicians, American Academy of Pediatrics [AAP], American Medical Society of Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine) released a preparticipation physical evaluation monograph that provided guidance on performing a more comprehensive screening history and physical examination.5 In 1996, the American Heart Association (AHA) recommended adding questions to the PPE to evaluate for conditions that predispose athletes to sudden cardiac death.6 This article describes the recommended format, timing, and content of the PPE based on the most recent Preparticipation Physical Evaluation Monograph2 and 2014 AHA recommendations,7 with emphasis on cardiovascular screening, musculoskeletal screening, concussion management, and the female athlete triad.
Performing the PPE
How the PPE Differs from the Standard Health Visit
Unlike the PPE, a standard health visit includes administration of vaccines and a more comprehensive preventive health screening (eg, depression questionnaire, lipid levels). Conversely, the PPE includes a focused, systems-based history and physical examination with specific questions and other elements used to identify issues that are known to affect sports participation. For example, knowing if a patient has history or physical examination findings consistent with a methicillin-resistant Staphylococcus aureus (MRSA) skin infection is important for preventing its spread in contact sports such as wrestling. Although an extensive review of systems during a standard health visit should ascertain this information from a patient, asking specifically about any history of MRSA is recommended during the PPE to confirm that no further steps are necessary. Additionally, the PPE also focuses a great deal on the musculoskeletal, cardiac, and neurologic systems, which don't receive the same attentiveness during standard visits.
Most primary care physicians will perform the PPE in an office-based setting. For many adolescents, a required PPE may be their only interaction with a medical provider.2 If this is the case, providers are encouraged to also conduct a standard health supervision visit along with the PPE. “Station-based” PPEs are another method for screening athletes.2 With a station-based evaluation, there are multiple providers set up at one time and each one performs a different part of the PPE. For example, one clinician may review the athlete's entire history with other providers each performing a different portion of the physical examination (Table 1).
Advantages and Disadvantages of the Different Preparticipation Evaluation Settings
Ideally, the PPE should occur at least 6 weeks prior to the first practice of the season to allow for completion of any additional evaluations and/or treatment/rehabilitation before participation. Each state high school athletic association has different rules about how often PPEs are required, ranging from one examination per year to one examination every 3 years with an updated history questionnaire yearly.3 Currently, there are no good data to support one specific PPE schedule over another for middle or high school athletes.2
Over 75% of medical conditions discovered during the PPE are identified by taking a detailed history.2 The 4th edition of the PPE Monograph, published by the AAP, is a consensus statement regarding the recommended content of the PPE history and physical examination.2 The PPE Monograph provides valuable resources for implementation, including a history form with a complete list of questions that can be used to screen athletes for conditions that may limit or preclude sports participation; these questions focus on the cardiovascular, neurologic, and musculoskeletal systems2 (Figure 1). When history questionnaires are used, they should be made available prior to the PPE so the athlete has time to answer questions thoughtfully with assistance from parents or guardians. Physicians should carefully review the history form with athletes; any positive response requires follow-up questions to gather all the details. The answers to key history questions, including those designed to identify increased risk of sudden cardiac death, should be reviewed with athletes and their parents/guardians during the PPE.2,7 Athletes should be asked about what sports they are intending to play as specific medical conditions may have greater significance for a particular sport. For example, an athlete with seizures may be at increased risk of drowning and should not be allowed to swim in an unsupervised pool.8
The American Academy of Pediatrics Monograph Preparticipation Physical Evaluation History Form. Reprinted with permission from the American Academy of Pediatrics.2
A tailored physical examination remains an integral part of the PPE. In addition to providing history questions, the PPE Monograph provides a form that outlines the important elements of the PPE examination (Figure 2). Health care providers should assess height, weight, body mass index (BMI), heart rate, and blood pressure. A patient's BMI can be used as an indicator of a potential eating disorder or to diagnose obesity, both of which have implications for sports and physical activity guidelines.2 Some athletes with hypertension may be at increased risk for complications of an elevated blood pressure during exercise (such as a cerebral vascular accident). Normal blood pressure values for different ages as well as recommendations about when to restrict people from certain levels of competition because of hypertension can be found in the AAPs policy statement: “Athletic Participation by Children and Adolescents Who Have Systemic Hypertension.”9 For example, in athletes age ≥18 years, Stage 2 hypertension is defined as a systolic blood pressure ≥160 mm Hg and/or diastolic blood pressure ≥100 mm Hg. In children younger than age 18 years, Stage 2 hypertension is defined as blood pressure measurements >5 mm Hg above the 99th percentile. Expert consensus states that patients with Stage 2 hypertension should be restricted from sports with a high static component (such as wrestling, weight lifting, or cycling) until their blood pressure is better controlled.9
American Academy of Pediatrics Monograph Preparticipation Physical Evaluation Examination Form. Reprinted with permission from the American Academy of Pediatrics.2
A general examination should be performed to assess for stigmata of genetic conditions, such as Marfan's syndrome, that could potentially place an athlete at higher risk of morbidity/mortality during sport. Deficiencies in vision or hearing could place an athlete at risk for injuries during activity. Visual acuity screening with a Snellen chart and a gross hearing screen (such as a whisper test) should both be performed as well.
The cardiac examination (auscultation of the heart and palpation of pulses in all four extremities) is particularly important as it may reveal signs of structural heart disease that can put an athlete at risk for sudden cardiac death. Auscultation should be performed in two positions (either while squatting and standing or while sitting with and without valsalva maneuver), as this allows for differentiation between a dynamic versus a fixed left ventricular outflow tract obstruction. For example, a person with subaortic stenosis due to hypertrophic cardiomyopathy, the most common cause of sudden cardiac death in young athletes,10 will typically have a systolic ejection murmur heard best at the right upper sternal border that increases in intensity when there is decreased preload (eg, with Valsalva maneuver or going from squatting to standing). Conversely, patients with aortic stenosis have a fixed obstruction of the left ventricular outflow tract, and the murmur will become louder with maneuvers that increase preload. Benign flow murmurs in healthy athletes have been described as soft (1–2/6), early systolic, heard best at the upper sternal boarder, and decrease in intensity with standing.2 Decreased femoral pulses could be a sign of coarctation of the aorta.7
Lung auscultation may show findings consistent with asthma (wheezing, decreased airflow) but if a patient has exercise-induced bronchospasm or vocal cord paralysis he or she likely will have a normal lung examination at rest, thus better identified through a detailed history. The abdominal examination is important in assessing for organomegaly as in the case of splenomegaly in relation to infectious mononucleosis. The genitourinary (GU) examination is not routinely performed in girls; however, in boys the GU examination is recommended to screen for inguinal hernias and testicular masses. The PPE also provides an opportunity to educate boys who are athletes about the benefits of monthly testicular self-examinations. Athletes with a single testicle should use a protective cup for contact sports.11 Other important physical examination details include a dermatologic assessment to look for contagious rashes such as molluscum contagiosum and herpes simplex virus.
A brief musculoskeletal examination screening consists of inspection of the trunk, neck range of motion, shoulder strength and range of motion, elbow and wrist range of motion, clenched fist then spread fingers, lower back flexion and extension, lower extremity inspection, and finally separate “duck,” “heel,” and “toe” walks to assess lower extremity strength. Although this screening examination only has a sensitivity of 50% to diagnose a musculoskeletal condition when used alone, it can be done quickly and does not require advanced musculoskeletal physical examination skills.2 Any abnormality noted in the screening examination or in relation to historical elements should prompt a more detailed and focused physical examination.2 For example, a patient with a recent history of an ankle sprain should have a more complete examination of the foot and ankle.3
A neurologic examination is not required if the history is negative for those concerns and if the musculoskeletal screening is normal. However, if the athlete has a musculoskeletal injury or abnormal finding, a focused neurologic examination of that region should be performed. Importantly, any athlete with a history of concussion should have a full neurologic examination including testing of cognitive function (concentration and memory).
In 2008, the AAP published a clinical report entitled, “Medical Conditions Affecting Sports Participation,”11 as a guide to help physicians make evidence-based decisions when determining if a medical condition requires therapy or treatment before sports participation can be safely allowed, necessitates activity modification, or disqualifies an athlete from some or all sports.11 The PPE monograph also includes guidance regarding clearance for specific injuries and conditions. However, clearance decisions may not always be straight forward as robust data are sometimes not available regarding specific clinical conditions relating to a particular sport. A risk assessment should be made to consider several factors including the sport played, level of competition (such as professional vs recreational league), and advice from experts (eg, sports medicine specialist, cardiologist, or another relevant subspecialist).
Sudden cardiac death (SCD) during sports participation almost always makes headline news; however, it is a rare cause of death in young athletes. Current estimates of SCD incidence in collegiate athletes in the US was found to be about 1 in 44,000.12 The true incidence of SCD in high school athletes is difficult to calculate because, although there are national SCD registries, reporting SCD events is not mandatory. Additionally, estimating participation in sports to obtain denominator data is difficult. Typically, SCD in athletes occurs because of unrecognized heart disease.10 When SCD occurs in a young person perceived to be in peak physical condition, it tends to be a high-profile event that has a powerful effect on the community. Because SCD may be preventable in many cases, screening for conditions that predispose athletes to SCD (Table 2) is an important goal of the PPE.1 However, the prevalence of conditions that place athletes at risk for SCD is relatively low (estimated to be anywhere from 0.1% to 1%),7 which means designing a sound screening tool is challenging.
Examples of Conditions that Place Patients at Risk for Sudden Cardiac Death
The 2014 AHA/American College of Cardiology (ACC) position statement recommended the universal adoption of a 14-element screening tool that includes the combination of 10 history questions and four examination elements,8 all of which are included in the PPE Monograph templates2 (Figure 1). Some of these questions assess for syncope, chest pain, an irregular heartbeat, or excessive shortness of breath with exertion, and other questions attempt to assess for a personal or family history of certain cardiac disorders. A positive answer to these cardiac screening questions should prompt physicians to take an expanded history and consider additional cardiac assessment. For example, when an athlete reports a history of syncope, careful questioning is warranted to help distinguish cardiac causes (eg, structural heart disease or arrhythmia) from less concerning neurocardiogenic syncope. Because there may be some clinical overlap between neurocardiogenic syncope and cardiac conditions that cause syncope, an athlete who experiences syncope during or shortly after exertion should be evaluated for a possible cardiac etiology.13 Decisions about how to perform further evaluation when an athlete has signs or symptoms of possible cardiac disease should be made on a case-by-case basis. Electrocardiogram (ECG) and echocardiogram are typically included as part of this expanded cardiac evaluation. Referral to a cardiologist for further evaluation may be necessary in patients with a history concerning for occult cardiac disease.
There are no large prospective studies examining the sensitivity and specificity of history and physical examination in detecting conditions that predispose a person to SCD. A smaller study demonstrated that the standard PPE has limited ability to detect cardiac conditions. This retrospective analysis of 115 cases of SCD that occurred in trained athletes (age 12–40 years, median of 17) throughout the US from 1985 through 1995 showed that only 3% had suspected cardiovascular disease on their PPE and only one athlete was correctly diagnosed with the condition that caused the SCD.10 Additionally, there are some data showing the AHA/ACC screening questions have at times shown a high rate of false-positive responses.2 As such, there will be some healthy athletes who undergo unnecessary additional testing, which can be costly and cause long delays before clearance to participate, potentially adding significant psychological stress for the athlete and his or her family.
There is considerable debate in the sports medicine community about whether routine screening ECGs should be added to the PPE. The AHA/ACC position statement in 2014 recommended against large-scale ECG screening.8 However, it did state that screening ECGs in certain populations may be appropriate. This decision should be made while considering several factors including the availability of cardiologists with expertise in interpreting ECGs in young athletes and evaluating those with positive ECG findings. The potential harm of subjecting athletes with false-positive testing to additional testing or potential disqualification from sports should also be considered. Further research needs to be performed before definitive recommendations are made for or against universal screening with ECGs as a part of the PPE.
Musculoskeletal injuries are the most common conditions identified during the PPE that preclude athletes from participation in sports.14 A detailed history can identify up to 92% of these conditions.2 Physicians should ask athletes about previous and current injuries including fractures, dislocations, or injuries that caused time away from sport. Clearance to return to sports after a musculoskeletal injury should be based on any limitations and risks that the injury might impose on an athlete. In general, full clearance can be allowed once there is full range of motion of the affected extremity, strength is symmetrical to the uninjured limb, and there is no gross laxity with provocative tests or subjective joint instability. Partial participation may be an option until the patient recovers from an injury. For example, a wrist sprain may prevent a golfer from taking full swings but he or she may be able practice putting. If there are any concerns about whether a musculoskeletal condition would preclude an athlete from competing, a referral to a sports medicine specialist would be warranted.
Sports concussions are common injuries, accounting for approximately 200,000 emergency department visits per year for children and adolescents age ≤19 years.15 If an athlete is experiencing symptoms related to a prior concussion at the time of the PPE he or she should be excluded from sports until symptoms resolve. Asymptomatic athletes with a history of one or more prior concussions and a normal neurologic examination can generally be cleared for sports participation. Over the last decade, there has been a significant increase in concussion rates among high school athletes, likely secondary to increased awareness and reporting.16 Most young people who suffer a concussion will fully recover, have no long-term sequelae, and will be able to continue to participate in contact or collision sports.17 The number of lifetime concussions an athlete has had should be determined as patients who have had previous head injuries are at greater risk for future concussions; however, the decision of whether to withhold an athlete from play and for how long is no longer solely based on the number of prior concussions.2 Physicians should consider withholding or delaying clearance for athletes with multiple, frequent concussions within a short-time interval, particularly when each subsequent concussion has occurred with lesser force or minimal trauma.2 Delaying clearance should also be considered when there is a history of prolonged recovery (longer than 2–3 months). Consultation with a sports medicine specialist can be helpful when deciding whether to withhold clearance based on concussion history.
Some schools, sporting groups, and health care providers will have athletes perform baseline cognitive and balance testing prior to the start of the season. Computerized neuropsychology testing programs that assess visual and verbal memory, processing speed, and reaction time are often used. Baseline testing allows for comparison of pre- and post-head injury performance for an individual who subsequently sustains a concussion. These baseline tests can be helpful in the management of a subsequent concussion, but are not required during a routine PPE.
Female Athlete Triad
The female athlete triad describes the association of decreased energy availability due to an imbalance between caloric intake and expenditure, changes in menstrual function, and decreased bone mineral density.18 Athletes do not need all three components simultaneously to be diagnosed with the triad. Girls and women who participate in sports that value a slim aesthetic (gymnastics, figure skating), have weight classes (rowing), require endurance (cross country runner), or emphasize a small build (flyer in cheerleading) are at higher risk.2,18 Athletes with components of the female athlete triad may be at higher risk for stress fractures, osteoporosis, and possibly cardiovascular disease.18 The PPE can be used to assess for each of the three components. The AAP monograph history questionnaire asks about stress fractures that may be a sign of decreased bone mineral density. It also includes specific questions about weight concerns, dietary restriction of certain foods, and the need or desire to cut weight.2 If there are concerns about the presence of components of the triad based on screening history, an expanded history should be obtained. Patients should be asked if they have a history of an eating disorder or if they engage in excessive exercise, including any training outside of required practice time. Physicians should also ask detailed questions about fracture and menstrual history. Disturbances in menstrual function associated with the female athlete triad can range from anovulation to oligomenorrhea and amenorrhea.
The Female Athlete Triad Coalition created a return-to-play medical risk stratification rubric designed to place athletes into low, moderate, or high risk categories.19 This rubric can be used as a guide for decisions about how much activity an athlete should be allowed to perform based on the severity of each patient's condition at a given time. Education about optimal energy intake to meet expenditure needs for peak performance as well as a discussion about short- and long-term risks associated with the female athlete triad should be discussed. Many of these patients can also benefit from a consultation with a registered dietitian nutritionist with experience treating athletes.
The PPE, including a focused history and physical examination, remains the standard of care for screening athletes for conditions that may interfere with safe sports participation. Although there are still questions about the sensitivity and specificity of the PPE in detecting uncommon, but life-threatening conditions such as SCD, the PPE can identify general medical and musculoskeletal conditions that potentially place an athlete at risk for injuries.2 Universal use of the PPE Monograph is encouraged to standardize the process across providers. This will allow researchers to better evaluate the efficacy of the PPE in diagnosing specific conditions and/or preventing morbidity and mortality in young athletes.
- Centers for Disease Control and Prevention (CDC). Sports-related injuries among high school athletes--United States, 2005–06 school year. MMWR Morb Mortal Wkly Rep. 2006;55(38):1037–1040.
- Bernhardt D, Roberts W, eds. Preparticipation Physical Evaluation. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2010.
- Roberts WO, Löllgen H, Matheson GO, et al. Advancing the preparticipation physical evaluation (PPE). Curr Sports Med Rep. 2014;13(6):395–401. doi:10.1249/JSR.0000000000000100 [CrossRef]
- Caswell SV, Cortes N, Chabolla M, Ambegaonkar JP, Caswell AM, Brenner JS. State-specific differences in school sports preparticipation physical evaluation policies. Pediatrics. 2014;135(1):26–32. doi:10.1542/peds.2014-1451 [CrossRef]
- Lombardo JA, Robinso JB, Smith DM, et al. The preparticipation evaluation. Prim Care. 1991;18(4):777–807.
- Maron BJ, Thompson PD, Puffer JC, et al. Cardivascular preparticipation screening of competitive atheletes. A Statement for Health Professionals From the Sudden Death Committee (Clinical Cardiology) and Congenital Cardiac Defects Committee (Cardiovascular Disease in the Young), American Heart Association. Circulation. 1996;94(4):850–856. doi:10.1161/01.CIR.94.4.850 [CrossRef]
- Maron BJ, Friedman RA, Kligfield P, et al. Assessment of the 12-lead ECG as a screening test for detection of cardiovascular disease in healthy general populations of young people (12–25 years of age): a scientific statement from the American Heart Association and the American College of Cardiology. Circulation. 2014;130(15):1303–1334. doi:10.1161/CIR.0000000000000025 [CrossRef]
- [No authors listed]. Sports and the child with epilepsy. Pediatrics. 1983;72(6):884–885.
- Demorest RA, Washington RL. Athletic participation by children and adolescents who have systemic hypertension. Pediatrics. 2010;125(6):1287–1294. doi:10.1542/peds.2010-0658 [CrossRef]
- Maron 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. doi:10.1001/jama.1996.03540030033028 [CrossRef]
- Rice SGAmerican Academy of Pediatrics Council on Sports Medicine and Fitness. Medical conditions affecting sports participation. Pediatrics. 2008;121(4):841–848. doi:10.1542/peds.2008-0080 [CrossRef]
- Harmon KG, Asif IM, Klossner D, Drezner JA. Incidence of sudden cardiac death in National Collegiate Athletic Association athletes. Circulation. 2011;123(15):1594–1600. doi:10.1161/CIRCULATIONAHA.110.004622 [CrossRef]
- Drezner J, Fudge J, Harmon K, Berger S, Campbell R, Vetter V. Warning symptoms and family history in children and young adults with sudden cardiac arrest. J Am Board Fam Med. 2012;25(4):408–415. doi:10.3122/jabfm.2012.04.110225 [CrossRef]
- Smith J, Laskowski E. The preparticipation physical examination: Mayo Clinic experience with 2,739 examinations. Mayo Clin Proc. 1998;73(5):419–429. doi:10.1016/S0025-6196(11)63723-3 [CrossRef]
- Centers for Disease Control and Prevention. Nonfatal traumatic brain injuries related to sports and recreation activities among persons aged ≤19 Years--United States, 2001–2009. MMWR Morb Mortal Wkly Rep. 2011; 60(39):1337–1342.
- Daneshvar DH, Nowinski CJ, McKee AC, Cantu RC. The epidemiology of sport-related concussion. Clin Sports Med. 2011;30(1):1–17. doi:10.1016/j.csm.2010.08.006 [CrossRef]
- Grool AM, Agilpay M, Momoli F, et al. Association between early participation in phyiscal activity following acute concussion and persistent postconcussive symptoms in children and adolescents. JAMA. 2016;316(23):2504–2514. doi:10.1001/jama.2016.17396 [CrossRef]
- Weiss Kelly AK, Hecht SCouncil on Sports Medicine and Fitness. The female athlete triad. Pediatrics. 2016;138(2). doi:10.1542/peds.2016-0922 [CrossRef].
- De Souza M, Nattiv A, Joy E, et al. 2014 Female Athlete Triad Coalition consensus statement on treatment and return to play of the female athlete triad: 1st International Conference held in San Francisco, CA, May 2012, and 2nd International Conference held in Indianapolis, IN, May 2013. Clin J Sport Med. 2014;24(2):96–119.
Advantages and Disadvantages of the Different Preparticipation Evaluation Settings
||• Usually performed by primary care physician who knows the patient and the family best
||• Not all athletes have a primary care physician to perform an office-based examination
Specialists are often available dur- ing the evaluation and can address specific concerns (such as a cardiologist if an athlete is experiencing syncope)
Can examine large numbers of athletes in a short period
Lack of continuity of care
Often performed in a group setting, which may compromise confidentiality if steps are not taken to ensure privacy
Examples of Conditions that Place Patients at Risk for Sudden Cardiac Death
Coronary artery anomalies
Arrhythmogenic right ventricular cardiomyopathy
Aortic rupture or dissection (usually associated with Marfan syndrome)
Atherosclerotic coronary artery disease
Long QT syndrome
Catecholaminergic polymorphic ventricular tachycardia