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THE PREPARTICIPATION PHYSICAL EVALUATION
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Goal: Screen athletes for injuries, illnesses, and other factors that might place them or others at risk during sports. Should occur 6 weeks prior to starting activity.
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History: Most important and highest-yield part of the preparticipation physical evaluation (PPE). Screen for:
General:
Recent or current illnesses, infections, or fever.
Prior surgeries.
Prior injuries.
Current medications, supplements.
Rapid weight changes (up or down).
Family history:
Heart disease, including hypertrophic or dilated cardiomyopathy, long QT syndrome, Marfan syndrome, arrhythmias.
Sudden death in a family member <50 years of age (hypertrophic cardiomyopathy [HCM] is autosomal dominant).
Cardiovascular:
History of heart murmur, elevated blood pressure, seizure.
Episodes of dizziness, palpitations, chest pain, or syncope/presyncope with exertion, in addition to unexplained syncope/presyncope.
Pulmonary:
Neurologic:
Prior concussion, including any head trauma, loss of consciousness, confusion, memory loss, or headache with exertion.
Gynecologic:
Exam: Evaluate for medical conditions that would prevent or restrict participation, or potentially worsen with participation. Table 17.1 describes the standard components of a PPE.
Studies:
No routine diagnostic testing is recommended (including blood/urine testing).
If history and/or exam is concerning for structural heart disease, arrhythmia, genetic/congenital heart disease, then standard evaluation generally includes a 12-lead ECG, ± stress echocardiography and graded exercise testing. Consider event monitor if history is concerning for arrhythmia. Concerning cardiac findings include:
Systolic murmurs of grade 3/6 or more (concern for atrial stenosis, mitral regurgitation).
Any diastolic murmur (concern for aortic regurgitation, mitral stenosis).
Any murmur that grows louder with ↓ venous return, eg, Valsalva maneuver, standing from squatting to standing (concern for HCM).
An S4 gallop (concern for HCM).
An S3 gallop can be normal in younger patients and in high-output states, such as pregnancy.
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KEY FACT
Because of the risk of splenic injury that occurs with mononucleosis (even in the absence of splenomegaly), sports should be avoided for 21 to 28 days from the start of infection.
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KEY FACT
Recent concussion ↑ risk of recurrence; a patient is most susceptible to recurrent traumatic brain injury in the 7 to 10 days after initial head trauma. Risk of recurrent concussion ↑ with each concussion.
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KEY FACT
An S4 gallop is usually pathologic in younger patients/athletes, and signifies a stiff, noncompliant ventricle and ↑ “atrial kick,” and may be associated with HCM.
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KEY FACT
If a murmur ↑ with the Valsalva maneuver or when the patient stands up from a squatting position (indicating ↓ venous return), worry about HCM.
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KEY FACT
Myocarditis or pericarditis are absolute contraindications to any sport because of the risk of sudden death with exertion, for at least 6 months after diagnosis.
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