The Pre-participation Evaluation of High School Athletes
The pre-participation evaluation (PPE) of athletes, often called a “sports physical,” is a sign of the beginning of the school year. It is rite of passage for athletes as they start participating at the high school level and is recommended by the NCAA and the NFHS and most state high school associations. While most states require this at some point during high school sports, the timing and frequency of the PPE is variable.
Goal: The goal of the PPE is to identify concerning findings that can lead to injury, worsening an otherwise well-controlled medical problem or identifying a problem that can lead to death during practice and competition.
Timing: The PPE is best done before the season but at a time that allows for further workup of concerning findings as necessary, typically about six weeks before the start of the season. Because some diseases manifest as people get older, it is important to repeat the PPE. The frequency of it being repeated is not standard, so schools should follow their state guidelines.
Components: There are two main elements of the PPE: (1) an assessment of the athlete’s medical history, which includes a family history, and (2) a physical examination.
Medical history: The medical history includes current and past medical and surgical issues, as well as inquiring about the athlete’s family history. This information helps the medical team assign the athlete to a specific risk category and indicates if the athlete needs further testing, for example cardiac testing. This section queries any symptoms that occur during exercise, such as chest pain or shortness of breath, or if the athlete faints or feels like passing out – these are clues that the athlete is harboring a significant cardiac illness. This section also includes questions about a history of concussions, seizures, asthma, clotting problems, sickle cell disease, diabetes and other diseases that would be considered significant to ensure the health and safety of the athlete.
Physical examination: The physical exam is comprehensive, which includes vital signs, vision testing, a detailed cardiac exam, neurologic screening, a comprehensive musculoskeletal exam, and a general medical screen. This type of comprehensive physical examination should be performed for every athlete. Similar to the medical screening exam, this physical exam is done to identify any areas that need further examination as they may indicate a more serious underlying problem. The genitourinary exam, such as testing for hernias, is not routinely indicated for clearance for sports; however, it is indicated if done as a part of a health care maintenance visit.
New to the PPE: There are now questions assessing the mental health of the athlete, as well as questions about sleep, sexual abuse and transgender.
Optimal environment for the PPE: Often the PPE has been done in either a large gymnasium where different stations are set up and athletes can go from station to station and have the different parts of the PPE completed, or it is done in a doctor’s office by a pediatrician, family practice doctor or sports medicine physician. The optimal environment is when the PPE is performed in the medical home by a provider familiar with the athlete’s medical history. Group physicals should be discouraged.
Telemedicine: With the COVID-19 pandemic, telemedicine became an increasingly popular way to interface with the medical profession. Listening to the heart is a very important part of the PPE, and if this cannot be done in the telemedicine environment, then this is not recommended.
Clearance: There are different levels of clearance:
Unconditional clearance: cleared for all sports and levels of participation.
Cleared with recommendation for follow-up.
Not cleared with clearance status to be determined after further evaluation, treatment or rehabilitation.
Not cleared for any sport or level of competition.
While the majority of students are cleared for participation in sports, those athletes who are found to have red flags either in their history or on their physical examination will be held until a more detailed investigation can be completed. To ensure the health and safety of the athlete, clearance does not occur until this workup is complete and all red flags are addressed. Early identification of medical problems and early treatment can prevent more serious injuries and is the goal of the PPE.
The PPE is an essential tool to ensure that athletes can participate in sports without harboring an undiagnosed but potentially lethal condition and to ensure that athletes have appropriately recovered from prior injuries, such as musculoskeletal injuries or concussions. It also allows the medical staff of a team including the physicians and athletic trainers to be appropriately prepared in case of an emergency.
Participation in sports is good for the body but also for the mind and spirit. It provides essential leadership skills to succeed as adults. Participation in sports is an integral part of childhood and screening should be broadly encouraged and screening with the PPE helps to ensure that it is done as safely as possible.
To reference the pre-participation physical evaluation (PPE) form developed by 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 American Osteopathic Academy of Sports Medicine, please visit: www.amssm.org/PPEMono.php.
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