The Pre-Participation Evaluation (PPE): Summertime Emergency, Clearance for Sports or Opportunity for Adolescent Health
- Describe the importance of screening ALL children and adolescents prior to sports participation or general exercise
- Know that all screening tests are not endorsed for general use at this time
- Recognize that use of a standardized history form to be completed by parents or guardians allows for an efficient history that can be incorporated into routine health supervision visits
General pediatricians, family medicine physicians and primary care providers who see young athletes are faced with a common summertime emergency – signing pre-participation waivers for middle and high school students. Before the practitioner becomes dismayed about one more athlete or family waiting until the last minute to make their annual athletic physical, keep in mind that this may be the only opportunity these children will have to establish a medical home or update their immunizations.
When considering the pre-participation evaluation (PPE), bear in mind the following case scenarios and determine who should undergo screening similar to what is being advocated for all high school athletes.
Case 1: A 15-year-old male is otherwise healthy and has no cardiac family history. He has had one episode of lightheadedness while running cross country last fall. His father has high cholesterol and high blood pressure.
Case 2: A 10-year-old girl who does not participate in any organized sports. She enjoys playing at recess with friends and likes to play a variety of active games after school. On exam, all is normal but her BMI is > 95 percentile.
Case 3: A 13-year-old female soccer player who participates on her club ice hockey team and middle school recreational soccer team. She is completely healthy, has a negative family history and a normal physical exam.
A monograph which thoroughly reviews all of the issues related to the PPE was published by the American Academy of Pediatrics in 2010 and co-written and endorsed by the American Academy of Pediatrics, American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine1. The purpose and objectives of the PPE vary depending on the viewpoint or intent of the beholder – parent, athlete, primary care provider, sponsoring institution or organization. The monograph clearly states the overall purpose of the PPE is to facilitate and encourage safe participation, not to exclude athletes from participation2. The parent may view this screening as a way of safeguarding the health of their child – making sure their child is not going to get injured or even possibly die while playing a sport. Clinicians aim to provide primary care (including immunizations), screen for medical conditions which may lead to injury or sudden death, and provide anticipatory guidance (see Figure 1). Institutions such as high school athletic associations seek to limit liability for injuries, risk of sudden death or illness which may be caused or exacerbated by participation in sports. The clinician, in facing all of these different expectations, may be overwhelmed.
Figure 1: Aims of the PPE
In facing this challenge, the practitioner may want to consider the PPE as routine part of every health supervision visit for all children and adolescents starting at five years of age. Using the standard PPE history and physical form, the clinic visit is still relatively efficient and the practitioner is more likely to meet the goals of all parties. If we as providers are encouraged to promote wellness and physical activity for all children and adolescents, it makes sense to screen all of them for the same conditions that may be exacerbated by physical activity similar to what we do for high school and college athletes who need to cleared for liability purposes.
The Medical History
The history portion of the PPE should be standardized to guarantee that all children and adolescents are undergoing a similar evaluation. The history form for the 2010 PPE Monograph is accessible at http://www2.aap.org/sections/sportsmedicine/PPEAbout.cfm. It is critical that a parent or guardian assist the patient in completing this portion of the history. In studies of high school students completing PPE history forms, only between 20-40% of the forms were consistent with parental report on similar history forms.3,4
The cardiac portion of the PPE is critical to complete when screening for the common “silent” conditions associated with sudden cardiac death in sport. A standardized form allows the practitioner to cover a uniform set of questions, which is important in screening for cardiac conditions. At the college level, a study looking at 625 universities demonstrated that only 25% of the institutions routinely completed an adequate cardiovascular screening. This emphasizes the need for uniform guidelines when looking for cardiac conditions5. The family history may not be obvious. Therefore, the writing group added and expanded some of the questions including those related to family history of unwitnessed motor vehicle accidents, drowning or near drowning and sudden infant death syndrome all of which may be associated with cardiac conditions.
The musculoskeletal and concussion history is the next most important part of the screening. Identifying athletes who have sustained injuries that may require a more thorough evaluation prior to being cleared for participation is the most effective way of avoiding consequences from returning an orthopedically or neurologically impaired athlete to participation prematurely. Many athletes do not recognize symptoms that are associated with a concussion. Similar to other components of the history form, more in-depth questioning is necessary when an athlete reports a positive history.
The Physical Exam
The PPE physical exam should be fairly consistent with the standard physical exam performed as part of the routine health supervision visit. Hypertension is one of the most common abnormalities discovered on physical exam during the PPE. Athletes with mild to moderate hypertension (>95 to 98% tile for age, sex and height) require a thorough evaluation but should be encouraged to exercise as part of their overall treatment plan.
Athletes who require corrective lenses should be advised to wear protective lenses for contact sports participation. Functionally one-eyed (corrected vision is worse than 20/40 in one eye) athletes should wear American Society for Testing and Materials approved protective eyewear6.
Sudden cardiac death related to playing sports is usually associated with a cardiac condition that is easily detected on physical exam; therefore, a complete cardiac exam should be performed. Auscultation in both the supine and seated positions to detect subtle heart murmurs, palpation of the point of maximum impulse, and palpation of femoral pulses should be included in the physical examination of every patient presenting for a health supervision visit and is no different for the athlete.
A focused musculoskeletal exam is dictated by the history of previous injury. The “two-minute” orthopedic exam is not a thorough or sensitive screening exam when used as a screening tool in detecting injuries7. Therefore, a history of a previous injury should lead the practitioner to perform an exam of the injured area.
When considering screening tests (EKG, ECHO, sickle cell screening for sickle cell trait), similar to any mass screening test, the test must be sensitive, change the long-term outcome on a population basis, and be cost effective. In addition, if the goal is to make exercise safe for all, these screening tests should not just be for athletes, but should encompass the whole population. There is significant controversy regarding the effectiveness of EKG, ECHO and sickle cell testing that is beyond the scope of this article. All of this is highlighted in the 2010 PPE Monograph and in a recent review of all of the controversies by a NHLBI working group8. At this time, there is insufficient evidence to support any screening test beyond the history and physical exam in the PPE.
As stated in the 2010 monograph, the preparticipation physical evaluation (PPE) is ideally done as a part of routine health screening examinations by an athlete’s primary physician and should be considered a part of the preventive health examination for all children and adolescents to encourage safe physical activity of any kind on a regular basis. Although not an ideal screening evaluation which meets all of the objectives of all vested parties, members of the PPE writing group and their respective organizations continue to feel that the PPE as it presently stands offers the best opportunity to screen athletes for important medical and musculoskeletal conditions, provide routine primary care including immunizations, and establish a medical home for most children and adolescents.
In the future, EKG and echocardiograms may be part of routine screening for all children and adolescents. However, at this time, there is not enough research to support the routine use of these tests.
When considering the cases outlined at the beginning, it has hopefully become obvious that all of these athletes – whether it is elite high school soccer player, the club hockey player, or the couch potato/video game addict who needs to be encouraged to exercise -- all deserve the same screening to safeguard against preventable conditions which could potentially be made worse by sport or physical activity.
- American Academy of Pediatrics. Preparticipation Physical Evaluation 4th Edition found at http://www2.aap.org/sections/sportsmedicine/PPEAbout.cfm. 2010
- American Academy of Pediatrics. Preparticipation Physical Evaluation 4th Edition found athttp://www2.aap.org/sections/sportsmedicine/PPEAbout.cfm. 2010
- Risser WL, Hoffman HM, Bellah GG Jr. Tex Med. 1985;81(7):35-39
- Carek PJ, Futrell M, Hueston WJ. The preparticipation physical examination history: who has the correct answers? Clin J Sport Med. 1999;9(3):124-128
- Pfister GC, Puffer JC, Maron BJ. Preparticipation cardiovascular screening for US collegiate student-athletes. JAMA. 2000;283:1597-1599
- American Academy of Pediatrics Committee on Sports Medicine and Fitness. Protective eyewear for young athletes. Pediatrics. 2004;113:619-622
- Gomez JE, Landry GL, Bernhardt DT. Critical evaluation of the 2-minute orthopedic screening examination. Am J Dis Child. 1993;147(10):1109-13
- Kaltman JR, Thompson PD, Lantos J, et al. Screening for sudden cardiac death in the young. Circulation. 2011;123:1911-1918