Beruflich Dokumente
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Preparticipation Examination
OUTCOMES
1. Identify the goals and objectives of a preparticipation
examination (PPE).
2. Design a preparticipation examination.
3. Identify the specic areas in a PPE that should be examined
using a mass station screening process.
4. List follow-up questions to validate information on a medical
history questionnaire.
5. Demonstrate the ability to take vital signs, and identify criteria
used to denote abnormal pulse and blood pressure rates.
6. Identify specic questions that should be asked at the various
stations utilizing a group format to elicit a history of the
athletes physical condition.
7. Explain the importance of completing a physical tness prole
as part of the preparticipation examination.
8. Demonstrate skinfold measurement at the various sites used
to determine body composition.
9. Describe the various stages of maturation using the
Tanner Scale.
10. Contrast the criteria used to categorize hypermobility and
hypomobility.
11. Describe specic methods of measuring strength, power,
speed, cardiovascular endurance, agility, balance, and
reaction time.
12. Identify specic conditions that could exclude an athlete from
participating in physical activity or sport.
19
20
SECTION I
BOX 2.1
Why is it important to do a thorough preparticipation examination? What objectives can be gained by completing the
examination?
Examination Format
The primary care physician usually performs preparticipation examinations. Physically active adults, whether competitive or recreational athletes, depend solely on the primary care physician for medical clearance to participate in
sport. The primary care physician is more knowledgeable
about the athlete and familys medical history, congenital or
developmental deciencies, immunization status, and recent injuries or illnesses that could limit sport participation.
There is a closer examinerathlete relationship, and when
performed in the physicians ofce, a more thorough and
comprehensive exam can be completed. This setting
Chapter 2
TA B L E 2 . 1
Preparticipation Examination
21
High-to-Moderate
High-to-Moderate Dynamic
Boxing*
Crew/rowing
Cross-country skiing
Cycling
Downhill skiing
Fencing
Football
Ice hockey
Rugby
Running (sprint)
Speed skating
Water polo
Wrestling
Badminton
Baseball
Basketball
Field hockey
Lacrosse
Orienteering
Ping-pong
Race walking
Racquetball
Soccer
Squash
Swimming
Tennis
Volleyball
Archery
Auto racing
Diving
Equestrian competition
Field events (jumping)
Field events (throwing)
Gymnastics
Karate or judo
Motorcycling
Rodeoing
Sailing
Ski jumping
Water skiing
Weight lifting
22
SECTION I
This evaluation is only to determine readiness for sports participation. It should not be used as a substitute for regular
health maintenance examinations.
Name
Address
Sport
Age (Yr)
Grade
Phone
Date
Yes
No
4. Have any members of your family under age 50 had a heart attack, had a heart
problem, or died unexpectedly?
6. Are you able to run 1/2 mile (two times around the track) without stopping?
7. Do you:
a. wear glasses or contacts?
b. wear dental bridges, plates, or braces?
8. Have you ever had a heart murmur, high blood pressure, or a heart abnormality?
Figure 2.1. Medical history form. A medical history should be conrmed by the athlete or
parents of minor children to ensure accuracy.
Chapter 2
Preparticipation Examination
23
I hereby state that, to the best of my knowledge, my answers to the above questions are correct.
Date
Signature of athlete
Signature of parent
Part B: Interim Health History
The form should be used during the interval between preparticipation evaluations. Positive responses should prompt
a medical evaluation.
1. Over the next 12 months, I wish to participate in the following sports:
a.
b.
c.
d.
2. Have you missed more than three consecutive days of participation in
usual activities because of any injury this past year?
If yes, please indicate:
a. Site of injury
b. Type of injury
Yes
No
3. Have you missed more than ve consecutive days of participation in usual activities because of an illness, or
have you had a medical illness diagnosed that has not been resolved in the past year?
6. List all medications you are currently taking and what condition the medication is for.
a.
b.
c.
7. Are you worried about any problem or condition at this time?
If yes, please explain:
I hereby state that, to the best of my knowledge, my answers to the above questions are correct.
Date
Signature of athlete
Signature of parent
Figure 2.1. Continued.
demands of sport participation. Utilizing the team physician and
other health care providers in a mass station format is another
valid option for completing a detailed physical examination.
MEDICAL HISTORY
24
SECTION I
Chapter 2
Vital Signs
The PPE should establish the athletes baseline physiologic parameters and vital statistics. Height and weight
should be taken and compared to standard growth charts
for prepubescent adolescents. Information such as pulse
rate, blood pressure, and body temperature may be
recorded at this station by an athletic trainer or other allied health professional (Box 2.2).
Pulse usually is taken at the carotid artery by doubling
the pulse rate during a 30-second time period. However,
to further delineate potential cardiovascular problems,
the pulse should be taken at the radial and femoral arteries to determine whether the heart rate and rhythm are
regular. A weak or nonpalpable femoral artery pulse suggests coarctation of the aorta (8). An irregular pulse raises
suspicion for arrhythmia and requires an electrocardiogram (ECG) evaluation (1).
It is important that a proper cuff size be used when taking blood pressure. The bladder should encircle the midarm and cover two-thirds of the length of the arm. For an
obese arm, use a wide cuff (15 cm). If the arm circumference exceeds 41 cm, use a thigh cuff (18 cm wide). A
pediatric cuff may be indicated for a very thin arm. To
measure blood pressure accurately, the guidelines listed
in Field Strategy 2.1 should be followed. Individuals
with abnormal heart rates or high blood pressure should
BOX 2.2
60 to 100 bpm
60 to 100 bpm (may increase 10
to 15 bpm during pregnancy)
120 to 140 bpm
Can be as low as 50 bpm
Preparticipation Examination
25
Blood pressure
Adults
Children
(age: 10 years)
120/80 mg HG
105/70 mm Hg
26
SECTION I
F I E L D S T R AT E G Y 2 . 1
General Guidelines
No caffeine during the hour prior to the reading; no smoking 30 minutes prior to the
reading.
Take the measurement in a quiet, warm setting.
Subject should sit quietly for 5 minutes with the back supported and the arm
supported at the level of the heart before recording blood pressure.
The air bladder should encircle and cover two-thirds of the length of the arm. If it
does not, place the bladder over the brachial artery. If the bladder is too short,
misleadingly high readings can result.
Manomet: Aneroid gauges should be calibrated every 6 months against a mercury
manometer.
Technique
Inate the bladder quickly to about 200 mm Hg.
Place the stethoscope over the brachial artery in the cubital fossa.
Deate the bladder 3 mm Hg/second and listen for the rst soft beating sounds
(systolic pressure).
As pressure is reduced, the sound becomes louder and more distinct, but gradually
disappears as blood is no longer constricted.
The pressure at which the sound disappears is the diastolic pressure.
If the sounds are weak, ask the patient to raise the arm, open and close the hand 5
to 10 times, and then reinate the bladder quickly.
Record blood pressure, patient position, arm, and cuff size.
Number of Readings and Sites
Take at least two readings, separated by as much time as is practical. If readings
vary by more than 5 mm Hg, take additional readings until two consecutive readings
are close.
If the initial values are elevated, obtain two other sets of readings at least 1 week
apart.
Initially, measure pressure in both arms; if the pressures differ, use the arm with the
higher pressure.
If arm pressure is elevated, take the pressure in one leg (particularly in patients
younger than 30).
Chapter 2
TA B L E 2 . 2
Preparticipation Examination
27
Mild Stage 1
Severe Stage 3
111121
7077
N/A
122129
7085
129
85
1012 years
Systolic
Diastolic
117125
7581
N/A
126133
8289
133
89
1315 years
systolic
Diastolic
124135
7785
N/A
136143
8691
143
91
1618 years
Systolic
Diastolic
127141
8091
N/A
142149
9297
149
97
18 years
Systolic
Diastolic
130
85
140159
9099
160179
100109
180
110
*
Denitions apply to people who are not taking antihypertensive drugs and are not acutely ill. When systolic and diastolic blood pressures fall into
different categories, the higher category should be selected to classify blood pressure status. Blood pressure values are based on the average of two
or more readings taken at each of two or more visits after the initial screening. For adults age 18 and older, optimal blood pressure is 120/80 mm Hg;
high-normal blood pressure is 130139/8589 mm Hg (Sixth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High
Blood Pressure).
Reprinted with permission from the Sixth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood
Pressure, 1997.
Cardiovascular Examination
The cardiovascular examination should be completed in
a quiet area so outside noise does not interfere with auscultation of heart sounds. The physician should check
for cardiac abnormalities to identify those individuals at
risk for sudden death. More than 90% of sudden deaths in
exercise and sports involve the cardiovascular system in
participants younger than 30 years of age; hypertrophic
cardiomyopathy is the leading cause. Questions evaluat-
28
SECTION I
BOX 2.3
Pulmonary Examination
The pulmonary examination may be done in conjunction
with the cardiovascular examination. The physician auscultates for clear breath sounds and watches for symmetric
movement of the diaphragm. A history of coughing spells
or difculty breathing may indicate exercise-induced bronchospasm. Although easily treated, this condition often
goes undetected. In addition, up to 40% of athletes with
environmental allergies or seasonal rhinitis experience
exercise-induced bronchospasm. Up to 80% of asthmatics
are similarly affected. Prolonged symptoms also may indicate possible congenital heart defects, cardiomyopathy,
or valvular dysfunction (5). The ears, nose, and mouth
also may be checked at this exam station. If any hearing
problems are suspected, the athlete should be referred to
a specialist. Questions that should be asked during this
examination include:
1. Have you ever experienced excessive coughing during or after sport participation?
2. Have you ever experienced breathing difculties or
been told you have asthma, bronchitis, or allergies?
3. Have you ever had shortness of breath, or heard
unusual breath sounds during or after sport
participation?
4. Have you ever had a collapsed lung?
If any abnormalities are found (e.g., wheezing,
crackles, rhonchi, rubs, rales, or abnormal inspiratory:
expiratory ratio), appropriate lung function tests may
be ordered. Concerns, such as tuberculosis, uncontrolled asthma, exertional asthma, exercise-induced
bronchospasm, pulmonary insufciency resulting from
a collapsed lung, or chronic bronchial asthma, should
be checked by the physician and discussed with the
athlete (Box 2.4) (12).
Musculoskeletal Examination
The musculoskeletal examination is critical to the sport
participant. A history of previous fractures, strains, tendinitis, sprains, and dislocations may suggest potential
arthritis. Questions should focus on the nature of the
injury, when it occurred, who evaluated it, what the
duration of the treatment and rehabilitation was, and if
surgical intervention was necessary. Information on
wearing special protective equipment may identify
injuries or conditions that might otherwise have gone
Chapter 2
BOX 2.4
Preparticipation Examination
29
Neurologic Examination
The neurologic examination need not be overly complicated. The responses to the questions give a clear indication
Musculoskeletal Examination
Observe:
Postural symmetry: Note unusual swelling or asymmetry of body segments, including
scapular asymmetry, pelvic tilting, and hamstring and calf atrophy.
Back and spine: Place athlete in a forward exed/knee extended position to detect
scoliosis and assess hamstring exibility.
Lower extremities: Note quadriceps symmetry during contraction and relaxation,
genu valgus or varus, pes cavus or pes planus, and excessively pronated or
supinated feet.
Squatting and duck walking assess functional movement of the hip, knee, and ankle.
Heel standing and toe standing assess strength and range of motion in dorsiexion
and plantar exion, respectively.
Assess Resisted:
Cervical exion, extension, lateral exion, and rotation.
Shoulder abduction (shrug) to determine trapezius strength.
Shoulder abduction in the neutral position and in 30 of forward exion (plane of
scapula) with medial (internal) rotation to determine deltoid and supraspinatus
strength, respectively.
Glenohumeral medial and lateral rotation.
Elbow exion and extension.
Wrist exion, extension, pronation, and supination.
Finger exion, extension, abduction, and adduction.
Hip exion, extension, abduction, adduction, and internal and external rotation
Knee exion and extension.
Ankle dorsiexion, plantar exion, inversion, and eversion.
30
SECTION I
BOX 2.5
if the individual is at risk for serious head or nerve injuries. The neurologic history should include questions
on past head injuries, loss of consciousness, amnesia, or
seizures. A history of seizures requires detailed information on frequency, treatment, and whether adequate control has been achieved with prescribed medication. Any
episodes of brachial plexus injuries (burners or stingers)
or pinched nerves should be documented if there is a history of transient paresthesia, loss of sensation, or motor
function anywhere in the body. In addition, if an athlete
has a pre-existing narrow cervical spinal canal, a straightened or reversed cervical lordotic curve, and a history of
using a spear-tackling technique (spear tacklers
spine), the individual should be fully evaluated by a
neurosurgeon. A detailed examination of the neurologic
system, including cervical radiographs, may be warranted
before considering athletic participation. Questions during this exam may include:
TA B L E 2 . 3
I.
Eye Examination
Visual acuity is best tested using the Snellen or common
eye chart (Figure 2.3). The chart tests the individuals
ability to clearly see letters based on a normalized scale.
Emmetropia, or 20/20 vision, indicates that an individual
II.
Optic
III.
Oculomotor
IV.
Trochlear
V.
Trigeminal
VI.
Abducens
VII.
Facial
VIII.
Vestibulocochlear
(acoustic nerve)
IX.
Glossopharyngeal
X.
Vagus
XI.
Accessory
XII.
Hypoglossal
Chapter 2
TA B L E 2 . 4
Preparticipation Examination
Reex
Site of Stimulation
Normal Response
Nerve Segment
Jaw
Mandible
Mouth closure
Cranial nerve V
Biceps
Biceps tendon
Biceps contraction
C5-C6
Brachioradialis
Brachioradialis tendon
Elbow exion
and/or pronation
C5-C6
Triceps
Triceps tendon
Elbow extension
C7-C8
Patellar
Quadriceps tendon
Knee extension
L3-L4
Medial hamstrings
Semimembranosus
tendon
Knee exion
L5-S1
Lateral hamstrings
Knee exion
S1-S2
Tibialis posterior
L4-L5
Achilles
Achilles tendon
Plantar exion
S1-S2
can read the letters on the 20-foot line of the eye chart
when standing 20 feet from the chart, indicating that the
light rays are focused precisely on the retina. Myopia, or
nearsightedness, occurs when the light rays are focused
in front of the retina, making only objects close to the
eyes distinguishable. Hypermetropia, or farsightedness,
occurs when the light rays are focused at a point behind
the retina. Vision should be assessed monocularly (one
eye) and binocularly (both eyes). Individuals who wear
corrective glasses or contact lenses should wear them at
the time of the vision assessment.
However, for sport activities peripheral vision and
depth perception also may be tested. The examiner
should note the presence of involuntary cyclical movement of the eyes (nystagmus). Although it may be normal for the individual, its presence should be documented
in the athletes medical le, especially if the individual
participates in a contact or collision sport and experiences
head trauma during the season. Pupil size should be
noted. Normally, the pupils are equal in size and shape.
However, some individuals may have a congenital slight
BOX 2.6
31
32
SECTION I
Bleeding gums
Lesions in the mouth
Loose or displaced teeth
Loose caps or crowns
Dental appliances in poor condition
Dental Examination
A dental examination is usually done by a dentist. It is
important to determine how many teeth the athlete has
and the last time they were seen by a dentist. This is critical because of potential liability if teeth are avulsed
(knocked out) during sport participation. Questions that
can be asked include:
1. When did you last see a dentist?
2. Have you ever had any problems with your teeth or
gums?
BOX 2.7
Gastrointestinal Examination
This examination involves evaluating the digestive system, eating habits, and nutrition. General questions on
the gastrointestinal system may center on bouts of heartburn, indigestion, diarrhea, or constipation. Questions
that may be asked include:
1. Do you eat regularly and have a balanced diet?
2. Do you skip meals?
3. Are there any food groups that you
predominantly eat?
4. Do you view yourself as too thin, too fat, or just
right?
5. Have you ever tried to control your weight? How
was this done?
6. Have you ever had excessive heartburn or
indigestion?
7. Have you ever had an ulcer or vomited blood?
8. Have you ever been constipated or had diarrhea?
9. Have you ever had mononucleosis or hepatitis?
Any positive responses to the questions should be further investigated (Box 2.9). During the examination, the
athlete should be supine with the lower ribs exposed to
the anterior superior iliac spines (ASIS). The examiner
palpates for tenderness, masses, or organomegaly (enlarged organs) to ensure there is no inammation of the
Chapter 2
BOX 2.9
liver (e.g., hepatitis or enlarged liver) or spleen, especially for individuals involved in contact sports.
In sports in which weight control is particularly important (e.g., gymnastics, ballet, crew, boxing, and wrestling),
it is advisable to investigate the athletes nutritional status
to determine a tendency toward anorexia, bulimia, or disordered eating. This can be completed by having the athlete record his or her food intake for at least 3 days and
have the record analyzed by a nutritionist.
Genitourinary Examination
Information gained at this station varies depending on the
sex of the athlete. For female athletes, a complete menstrual history should be gathered. Any responses related
to oligomenorrhea (long cycles with 35 to 150 days between bleeding) and amenorrhea (no bleeding) should
necessitate further assessment and counseling about the
increased risk of bone demineralization (osteopenia),
stress fractures, and potential osteoporosis. Gynecologic symptoms that may need further evaluation include
dysmenorrhea (painful cramps), lower abdominal pain,
unusual vaginal discharge, pain during urination, and use
of birth control medication. Oral contraceptives may alter
the pH of the vagina and increase the risk of pelvic inammatory disease (PID) and hypertension. Discussion
surrounding the use of birth control also may promote
discussion of safe sexual practices, STDs, and pregnancy.
Common questions that may be asked in this examination include:
1. Have you ever had problems with your kidneys or
genitourinary organs?
2. Have you ever had a kidney or bladder infection?
3. Does it hurt to urinate?
4. Have you ever had an STD? When? What medication
was prescribed?
5. Have you noticed any skin lesions on the genitalia,
or any vaginal or penile discharge?
6. Have you ever been diagnosed as having sugar,
albumin, or blood in the urine?
Preparticipation Examination
33
7. Females: Have you ever been, or are you now pregnant? At what age were you when menarche rst
occurred? How many periods have you had in the
last 6 months? When was your last menstrual period?
What is the usual length of time between periods?
Are the cycles fairly constant or irregular? Do you
have a history of abnormal heavy bleeding (menorrhagia), scant bleeding, or intermittent bleeding?
8. Males: Are you missing a testicle or do you have an
undescended testicle? Have you ever had a history
of testicular pain or a testicular abnormality, such as
a hydrocele or varicocele?
The examiner should check the kidney for costovertebral angle tenderness. Generally, an athlete with one
kidney should be warned of the risks involved in participating in contact sports, especially if the remaining kidney is abnormally positioned or is diseased (5). Males
are given a genital examination looking for hernias; testicular torsion; or an absent, undescended, or atrophied
testicle. Although not necessarily required in the PPE, a
urinalysis should be carried out if diabetes or kidney disease is suspected. Conditions such as albuminuria (protein in the urine), hematuria (blood in the urine), and
hemoglobinuria (hemoglobin in the urine) can indicate
problems with the urogenital system. These conditions
do not preclude activity, but should be evaluated. The
athlete and athletic trainer should be informed of potential dangers caused by these conditions. See Box 2.10
for genitourinary red ags requiring further examination.
Dermatologic Examination
Examination of the skin can identify contagious lesions,
such as herpes simplex (cold sores), molluscum contagiosum, tinea capitis or corporis, furuncles, impetigo, scabies, and secondary syphilis, which can preclude participation in sports. Skin infections that may be contagious to
other participants should be identied and treated. In
contrast, other lesions such as warts, fungal infections,
BOX 2.10
34
SECTION I
BOX 2.11
Laboratory Tests
contact dermatitis, psoriasis, seborrhea, and nevi (birthmarks) require further evaluation but do not necessarily
mean exclusion from participation. Certain medications
used to treat acne may induce sun sensitivity or other organ toxicity. Early treatment can take care of the condition prior to the start of the season. Questions that might
be asked include:
1. Have you ever had problems with acne?
2. Have you ever had any skin rashes, itching, or
scaling in areas covered by clothing, equipment,
or footwear?
3. Do you have any unusual blemishes (e.g., warts
or moles) that have changed in size or color over
the year?
Any skin lesion associated with a contagious disease
or STD should have immediate referral to a physician for
treatment and appropriate counseling. See Box 2.11 for
dermatologic red ags requiring further examination.
Chapter 27 provides more detail and photographs of dermatologic conditions.
BOX 2.12
Cardiac disease
Uncontrolled diabetes
Hypertension
Drug use (e.g., amphetamines, cocaine, hallucinogens, laxatives, or narcotics)
Medications (e.g., anticholinergics, diuretics, antihistamines, or beta blockers)
Excessive muscle cramps in heat
Heat exhaustion
Heat stroke
Chapter 2
It is critical to assess the physical tness status of an athlete prior to the start of physical activity to determine
whether the individual possesses the attributes, skills, and
abilities necessary to meet the demands of the sport. Data
from the examination can identify weaknesses that may
hinder athletic performance or predispose the athlete to
injury, and establishes a baseline of data in the event an
injury does occur. A physical tness prole can assess
body composition; maturation and growth; exibility,
strength, power, and speed; agility, balance, and reaction
time; and cardiovascular endurance. To be effective, the
parameters of the test must be relevant and specic to the
selected sport. The test must be easy to perform, measure, reproduce, and be inexpensive. The test should be
standardized and controlled, and should be repeated during the season to assess improvement. Results should be
explained to the athletes in a meaningful way so they can
understand their signicance (12).
Preparticipation Examination
35
well at higher body fat percentages. Generally, if the percentage of body fat is greater than the upper normal limit
of 14% for males and 17% for females, the individual
should be put on a weight loss program or weight training to increase lean body mass; but this depends on the
activity in which the individual wishes to participate. Additional methods of body composition measurement include girth measurements, bone diameter measurements,
ultrasound measurement, arm radiograph measurement,
and computed tomography (CT) assessment of fat (13).
Flexibility
Flexibility is the total range of motion at a joint that occurs pain-free in each of the planes of motion. In most
cases, less exibility is better than too much. However, in
certain sports (e.g., gymnastics or wrestling) excessive
exibility is a necessity. Several factors can limit exibility and range of motion (Box 2.13).
Flexibility can be measured with a goniometer, exometer, or tape measure. Measurements can be taken to
assess exibility of the hamstrings, quadriceps, gastrocnemius, shoulder, and low back. Hypermobility (laxity in
a joint) should be noted and recorded (Box 2.14). Laxity
in one joint does not necessarily mean hypermobility in
all joints or in all directions, nor does it identify a pathologic state. Total range of motion can be related to genetic makeup or the stresses placed on individual joints.
Loose-jointed individuals tend to do poorly in strength
events and are more susceptible to ligament sprains, dislocations, chronic back pain, disc prolapse, spondylolisthesis, pes planus (at feet), joint effusion, and tendinitis
(12). If strength and endurance are not at the appropriate
level in hypermobile individuals, the joints cannot be
36
SECTION I
F I E L D S T R AT E G Y 2 . 3
Skinfold Site
Description
Abdominal
Triceps
Biceps
Vertical fold; on the anterior aspect of the arm over the belly of the
biceps muscle, 1 cm
Chest/Pectoral
Medial calf
Vertical fold; at the maximum circumference of the calf on the midline of its medial border
Midaxillary
Subscapular
Suprailiac
Diagonal fold; in line with the natural angle of the iliac crest taken
in the anterior axillary line immediately superior to the iliac crest
Thigh
General Guidelines
All measurements should be made on the right side of the body.
The caliper should be placed 1 cm away from the thumb and forenger,
perpendicular to the skinfold, and halfway between the crest and base of the fold.
The pinch should be maintained while reading the caliper.
Wait only 1 to 2 seconds before reading caliper.
Take duplicate measures at each site and retest if measurements are not within 1 to
2 mm.
Rotate through measurement sites or allow time for skin to regain normal texture
and thickness before retesting.
supported and may become unstable and subject to injury. These individuals should avoid further stretching
exercises, and support the joint through proper positioning, balance, and strengthening programs.
In contrast, tight-jointed or hypomobile individuals
tend to be more susceptible to muscle strains, nerve
pinch syndromes, and overstress tendinitis. If a person is
hypomobile, mobilization or manipulation of the affected
joint in the direction of tightness may be helpful. Tight
supporting structures should be stretched and active
exercises used to maintain the restored range of motion.
It is important that these individuals retrain their kinesthetic sense so that the acquired range of motion can be
maintained or improved (12).
Chapter 2
Stage
1
Stage
2
Stage
3
Preparticipation Examination
Stage
4
37
Stage
5
Figure 2.4. Tanner Scale of Maturity. This scale measures breast and pubic hair development in girls and genital and pubic hair development in boys to determine the appropriate stage of maturity.
BOX 2.13
Bony block
Joint adhesions
Muscle tightness
Tight skin or an inelastic, dense scar tissue
Muscle bulk
Swelling
Pain
Presence of fat or other soft tissues that block normal motion
Gender (women tend to be more exible than
men)
Dominant limb tends to be less mobile than the
nondominant limb
Age (exibility decreases with age)
Race (Native Americans are more mobile than
blacks, who are more mobile than whites)
Genetic makeup
Cardiovascular Endurance
Cardiovascular endurance, commonly called aerobic capacity, is the bodys ability to sustain submaximal exercise
over an extended period, and depends on the efciency
of the pulmonary and cardiovascular systems. Several
tests may be used. The actual selection of tests should be
dependent on the specic demands of the sport. The
Harvard step test is commonly used in a physical tness
BOX 2.14
Hypermobile Traits
Passive opposition of the thumb can reach the
exor aspect of the forearm
Passive hyperextension of the ngers so they lie
parallel with the extensor aspect of the forearm
Ability to hyperextend the elbow at least 10
Ability to hyperextend the knee at least 10
Excessive passive dorsiexion of the ankle and
eversion of the foot
38
SECTION I
Chapter 2
TA B L E 2 . 5
Preparticipation Examination
Condition
May Participate?
Qualied yes
Explanation: Athlete needs evaluation to assess risk of spinal cord injury during sports participation.
Bleeding disorder
Qualied yes
No
Qualied yes
Explanation: Those with signicant essential (unexplained) hypertension should avoid weight and
power lifting, body building, and strength training. Those with secondary hypertension (hypertension
caused by a previously identied disease) or severe essential hypertension, need evaluation.
Congenital heart disease (structural heart defects present at birth)
Qualied yes
Explanation: Those with mild forms may participate fully; those with moderate or severe forms, or
who have undergone surgery, need evaluation.
Dysrhythmia (irregular heart rhythm)
Qualied yes
Explanation: Athlete needs evaluation because some types require therapy or make certain sports
dangerous, or both.
Mitral valve prolapse (abnormal heart valve)
Qualied yes
Qualied yes
Explanation: If the murmur is innocent (does not indicate heart disease), full participation is permitted.
Otherwise the athlete needs evaluation (see congenital heart disease and mitral valve prolapse).
Cerebral palsy
Explanation: Athlete needs evaluation.
Diabetes mellitus
Qualied yes
Yes
Explanation: All sports can be played with proper attention to diet, hydration, and insulin therapy.
Particular attention is needed for activities that last 30 minutes or more.
Diarrhea
Qualied no
Explanation: Unless disease is mild, no participation is permitted, because diarrhea may increase the risk
of dehydration and heat illness. See fever.
Eating disorders
Qualied yes
Anorexia nervosa
Bulimia nervosa
Explanation:These patients need both medical and psychiatric assessment before participation.
Eye
Qualied yes
No
Explanation: Fever can increase cardiopulmonary effort, reduce maximum exercise capacity, make heat
(Continued)
39
40
SECTION I
TA B L E 2 . 5
Condition
May Participate?
illness more likely, and increase orthostatic hypotension during exercise. Fever may rarely accompany
myocarditis or other infections that may make exercise dangerous.
Heat illness, history of
Qualied yes
Explanation: Because of the increased likelihood of recurrence, the athlete needs individual assessment to
determine the presence of predisposing conditions and to arrange a prevention strategy.
HIV infection
Yes
Explanation: Because of the apparent minimal risk to others, all sports may be played that the state of
health allows. In all athletes, skin lesions should be properly covered, and athletic personnel should use
universal precautions when handling blood or body uids with visible blood.
Kidney: absence of one
Qualied yes
Explanation: Athlete needs individual assessment for contact/collision and limited contact sports.
Liver: enlarged
Qualied yes
Explanation: If the liver is acutely enlarged, participation should be avoided because of risk of rupture. If
the liver is chronically enlarged, individual assessment is needed before collision/contact or limited
contact sports are played.
Malignancy
Qualied yes
Qualied yes
Qualied yes
Explanation: Athlete needs individual assessment for collision/contact or limited contact sports, and
also for noncontact sports if there are decits in judgment or cognition. Recent research supports a
conservative approach to management of concussion.
Convulsive disorder, well controlled
Yes
Qualied yes
Explanation: Athlete needs individual assessment for collision/contact or limited contact sports.
Avoid the following noncontact sports: archery, riery, swimming, weight or power lifting, strength
straining, or sports involving heights. In these sports, occurrence of a convulsion may be a risk to self
or others.
Obesity
Qualied yes
Explanation: Because of the risk of heat illness, obese persons need careful acclimatization and hydration.
Organ transplant recipient
Yes
Yes
Qualied yes
Explanation: Athlete needs individual assessment, but generally all sports may be played if
oxygenation remains satisfactory during a graded exercise test. Patients with cystic brosis need
acclimatization and good hydration to reduce the risk of heat illness.
Asthma
Yes
Explanation: With proper medication and education, only athletes with the most severe asthma have to
modify their participation.
Acute upper respiratory infection
Explanation: Upper respiratory obstruction may affect pulmonary function. Athlete needs individual
assessment for all but mild disease. See fever above.
Qualied yes
(Continued)
Chapter 2
TA B L E 2 . 5
Preparticipation Examination
41
Condition
May Participate?
Qualied yes
Explanation: Athlete needs individual assessment. In general, if status of the illness permits, all but high
exertion, collision/contact sports may be played. Overheating, dehydration, and chilling must be avoided.
Sickle cell trait
Yes
Explanation: It is unlikely that individuals with sickle cell trait (AS) have an increased risk of sudden death
or other medical problems during athletic participation except under the most extreme conditions of heat,
humidity, and possibly increased altitude. These individuals, like all athletes, should be carefully conditioned,
acclimatized, and hydrated to reduce any possible risk.
Skin: boil, herpes simplex, impetigo, scabies, molluscum contagiosum
Qualied yes
Explanation: While the patient is contagious, participation in gymnastics with mats, martial arts, wrestling,
or other contact/collision or limited contact sports is not allowed. Herpes simplex virus probably is not
transmitted via mats.
Spleen: enlarged
Qualied yes
Explanation: Patients with acutely enlarged spleens should avoid all sports because of risk of rupture.
Those with chronically enlarged spleens need individual assessment before playing contact/collision or
limited contact sports.
Testicle: absent or undescended
Yes
Summary
1. The basic objective of the preparticipation examination is to determine the general health and tness
level of a physically active individual to ensure safe
athletic participation.
2. A medical history questionnaire should be completed prior to the examination, and then validated
for accuracy during the actual examination.
3. The physical examination involves assessing the
vital signs; general medical conditions; and cardiovascular, pulmonary, musculoskeletal, neurologic,
gastrointestinal, genitourinary, and dermatologic
systems. In addition, the eyes and teeth should be
evaluated, and athletes at risk for heat-related illness
should be identied.
4. The physical tness of the athlete should be
assessed by measuring body composition, maturation,
flexibility, strength, power, speed, agility, balance,
reaction time, and cardiovascular endurance.
5. At the conclusion of the examination, the physician
must ask:
Will the abnormality increase the risk of injury to
the athlete or other participants?
Can participation be allowed if medication, rehabilitation, or protective bracing or padding is
used? If so, can limited participation be allowed
in the interim?
References
1. Madden CC, Putukian M. The preparticipation physical evaluation. In:
The Team Physicians Handbook. Edited by Mellion MB, Walsh M,
Madden C, Putukian M, Shelton GL. Philadelphia: Hanley & Belfus,
2002.
2. Sanders B, Nemeth WC. Preparticipation physical examination. JOSPT
1996;23(2):144163.
3. Kibler WB. The preparticipation examination. In: ACSMs handbook
for the team physician. Edited by Kibler WB. Baltimore: Williams &
Wilkins, 1996.
4. Kligman EW, Jewitt MJ, Crowell DL. Recommending exercise to
healthy older adults: The preparticipation evaluation and exercise prescription. Phys Sportsmed 1999;27(11):4262.
5. Bergfeld J, Lombardo JA, Nelson M. Pre-participation physical examination. Chicago: Joint publication by the American Academy of Family Physicians, the American Academy of Pediatrics, the American
Medical Society for Sports Medicine, and the American Osteopathic
Academy of Sports Medicine, 1992.
6. Hunter SC. Preparticipation physical examination. In: Orthopedic
Knowledge Update: Sports Medicine. Edited by Grifn LY. Rosemont,
IL: American Academy of Orthopaedic Surgeons, 1994.
7. Johnson MD. Tailoring the preparticipation exam to female athletes.
Phys Sportsmed 1992;20(7):6172.
8. Seto CK. Preparticipation cardiovascular screening. Clin Sports Med
2003;22(1):2235.
9. Bickley LS, Szilagyi PG. Bates Guide to Physical Examination and
History Taking. Baltimore: Lippincott Williams & Wilkins, 2003.
42
SECTION I
14. Tanner JM. Growth of Adolescence. Oxford, England: Blackwell Scientic, 1962.
15. American Academy of Pediatrics Committee on Sports Medicine and
Fitness: Medical conditions affecting sports participation. Pediatrics
1994;94:757760.