Considerations for the Pre-Sports Evaluation in Primary Care

Athletes of all ages and levels may be required to undergo a preparticipation physical evaluation (PPE) before being allowed to participate fully in structured athletics. PPEs primarily function to ensure the health and wellness of athletes prior to sports participation, particularly to avoid exacerbation of a condition that could result in morbidity or mortality. PPEs can be a time to offer anticipatory guidance geared toward healthy living and athletics, provide a health check-in for those not otherwise required to have a yearly well visit, and meet jurisdictional and/or organizational requirements.The conduct of the PPE has been detailed in a monograph, which reviews the purpose of the PPE, recommended location and frequency, notable historical and physical exam points, considerations for special populations, potential need for additional testing, and a clearance determination. The monograph was developed as a collaboration of the American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and the American Osteopathic Academy of Sports Medicine. The fifth and most recent edition of the monograph was released in 2019 and includes updates to improve care for athlete mental health and gender identity. A supplement, with information about an athlete’s COVID-19 history and vaccine status, was also released during the coronavirus disease 2019 pandemic.The logistics of conducting PPEs has been well prescribed. It is recommended that the PPE occur at the primary care provider’s office, providing continuity and, likely, a more complete evaluation. Station-based PPEs offer less privacy and a lower likelihood of an ongoing patient-provider relationship. PPEs should, thus, be conducted as part of routine wellness care whenever possible. Many jurisdictions and organizations also require a PPE on a regular timeframe, often, but not always, annually.Providers completing a PPE should ensure appropriate documentation, including their clearance determination and any follow-up that might be needed. It can be helpful to utilize the standardized PPE documents for patient care (Table 1), although many providers use what is available in their electronic health record, in addition to the documents that meet jurisdictional and/or organization requirements. When considering documentation, providers should also consider their coding. If a PPE is performed at a well visit, it is recommended to include the sports physical diagnosis code, which could be helpful for future evaluation of the utility of the PPE and its components. As a complete sports physical is a separate service, it is acceptable to bill for this service at the same time as the well visit. Different insurances have different requirements for billing for this service. Be sure to check with the insurance carriers affiliated with your medical practice.An accurate and thorough medical history has been shown to identify roughly 75% of issues that affect sports participation. The history should be obtained from both the patient and guardian, as studies have shown poor correlation between patient and guardian medical history reporting. Performing a separate history with the patient can also be an opportunity to discuss private psychosocial issues (eg, mood, safety, drug use) that are important to both sports participation and adolescent wellness care.The medical history should review the patient’s general health, current medical conditions, medications, supplements, allergies, and any past sports restrictions, medical and musculoskeletal (MSK). Other areas of import include mental health, menstrual health, sickle cell history, and weight/nutrition concerns. These questions can help uncover other potential concerns in male and female athletes, such as relative energy deficiency in sport.Particular attention should be paid to personal and family cardiac health, as sudden cardiac death is the leading cause of death during sports participation for young athletes and results from underlying cardiac disease. Electrocardiograms (ECGs) are commonly used in European countries as part of evaluation; however, in the United States, given the current evidence, the cost, and issues with access to ECGs and cardiologists, the current recommendation is to test only those with abnormal cardiac screening (by history and exam).The physical examination includes vital signs, a general medical exam, a focused cardiac exam (including auscultation for murmurs in positions that decrease preload, like standing or performing the Valsalva maneuver, and that increase preload, like squatting, to evaluate for hypertrophic cardiomyopathy), and a comprehensive MSK exam. This MSK exam, which can be completed in under 2 minutes, checks overall range of motion, strength, and brief functional testing. Other recommended MSK functional movement testing includes the double-leg squat test, single-leg squat test, and drop jump test. Based on the history, a focused exam of a previously injured joint may also be required. The most common abnormalities found during the physical examination are elevated blood pressure and visual acuity issues.Athletes with certain medical conditions warrant particular consideration. For example, absence or nonfunction of one organ of a pair may affect clearance for sports that put the remaining organ of the pair at risk and may require additional protective equipment. Patients with glasses who are playing sports with a high risk of eye injury (eg, baseball, hockey) should wear polycarbonate lenses.Sickle cell trait (SCT) can put athletes at risk for exertional sickling. Self-reporting by the athlete or guardian for SCT can be inconsistent; verifying the sickle cell test results from the newborn metabolic screen or obtaining a new sickle cell test may be required for collegiate sports participation.Athletes with genetic disorders, like trisomy 21 and hemophilias, may require additional pre-sports testing and/or treatment. Similarly, athletes with physical and/or intellectual disabilities would benefit from a multidisciplinary approach with their specialists and other care team members to determine eligibility for their sport of choice. A supplemental form for athletes with disabilities is also available (Supplemental Material).Generally, additional diagnostic testing is ancillary to a PPE. The need for any additional tests should be based on history and exam findings. For example, an athlete with a fever, sore throat, cervical lymphadenopathy, and abdominal pain might have mononucleosis. In such cases, laboratory testing for mononucleosis would be helpful for diagnosis and subsequent counseling on temporary athletic avoidance if indicated. Radiographs are not typically necessary for PPEs without abnormal findings.Referrals can also lead to additional testing. Common specialties and the reasons for referrals based on PPE findings include the following: Cardiology: loud murmur, syncope, hypertensionPulmonology: exercise-induced bronchospasm unresponsive to regular therapiesNeurology: seizures, headaches with exerciseNeurosurgery: bilateral burners/stingers (transient bilateral neurapraxia)Nephrology: hypertensionOphthalmology: monocular vision statusOnce the history and exam are complete, an assessment can be made. Occasionally, some questions may remain. What if there is a historical risk factor for sports participation that has not recurred? It can be helpful to determine how remote the risk-contributing event or issue was. Has the level of play stayed the same since that event or issue occurred without a recurrence? When in doubt, it is prudent to investigate further with testing and/or referral. The same approach is recommended in cases of intermittent or mildly abnormal findings on history or exam.Clearance determinations are not always dichotomized into full participation or no participation. Some athletes may be cleared without restrictions, but others may be cleared with restrictions (to certain sports or activities) or cleared only after being evaluated by a specialist.PPEs aim to ensure the safe and successful participation of all our young athletes. They should occur regularly and be conducted with a systematic and comprehensive method. Concerns should be addressed early. Clearance decisions may not be all or none. Consider limited participation to avoid complete restriction whenever possible.Comment: During my high school swimming career, my PPEs were conducted assembly-line fashion by my health maintenance organization. On one evening each year, I could show up without an appointment and move through stations to have my sports physical form completed piecemeal. Times have changed, and the PPE monograph now stresses that exams should occur individually in a physician’s office, in recognition of the fact that PPEs serve an important secondary function of bringing athletes in for preventive services that they might otherwise miss. This is particularly true for adolescents who, on average, play more organized sports and miss more recommended checkups than younger children. To make the most of this extra, mandated contact between athletes and health care providers, front office staff should be instructed to determine whether students are due or overdue for health maintenance exams and if so, convert requested PPE appointments into appointments for full checkups. Even when a checkup is not warranted, it is still advisable for health care providers to assess for and order recommended vaccinations at PPEs. Finally, given the high prevalence of mental health issues among all children, including athletes, a thorough PPE would not be complete without screening for anxiety and depression. These days, children can get their PPE from pharmacy retail clinics. While this may be convenient for some families, retail clinics do not deliver the same level of continuous, coordinated, and comprehensive care to athletes that primary care providers are well prepared to deliver.Linda Y. Fu, MD, MSAssociate Editor, In Brief