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J. Bryan Mann, MD, FAAP (316) 978-5735 Mann@chp.twsu.edu. Preparticipation Physical evaluation (PPE) Preparticipation Athletic Examination Sports physical. The P.P.E.

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the p p e
J. Bryan Mann, MD, FAAP

(316) 978-5735

Mann@chp.twsu.edu

Preparticipation Physical evaluation (PPE)

Preparticipation Athletic Examination

Sports physical

The P.P.E.
slide2

Sports ParticipationAAP: Committee on Sports Medicine and Fitness and Committee on School Health. Organized Sports for Children and Preadolescents. Pediatrics. 2001. 107;6:1459-1462

There is no consensus as to the overall value of organized sports for preadolescents.

The younger the participant, the greater the concern about safety and benefits.

Basic motor skills do not develop sooner simply as a result of introducing them to children at an earlier age.

The shift from child-oriented goals to adult-oriented goals can further negate positive aspects of organized sports.

slide3

Intensive Training AAP: Committee on Sports Medicine and Fitness. Intensive Training and Sports Specialization in Young Athletes. Pediatrics. 2000. Volume 106: pp 154-157

  • Research supports the recommendation that child athletes avoid early sports specialization.
  • Those who participate in a variety of sports and specialize only after reaching the age of puberty tend to be more consistent performers, have fewer injuries, and adhere to sports play longer than those who specialize early.
preparticipation physical evaluation ppe
Preparticipation Physical Evaluation (PPE)
  • Recommendations for PPE exist and are based on consensus of the literature (AAP, AAFP, AAOSSM)
  • Primary Goals of PPE:
    • Detect conditions that may cause injury
    • Detect conditions that may be life-threatening
    • Meet legal/insurance requirements
ppe goals
PPE Goals
  • Identify conditions that may interfere with participation
  • Identify conditions that may be exacerbated by participation
  • Help select an appropriate sport or the child’s particular abilities and physical maturity
ppe goals7
PPE Goals
  • Poorly conditioned children
  • Children with muscle or joint weakness (usually related to recent injury)
  • Immature children (physically)
  • Previously unsuspected disease
slide8
PPE

1% of children undergoing PPE’s have conditions that might limit sports participation and are generally discovered through the history.

sports the numbers
Sports - The Numbers
  • 30 million American children annually participate in sports (7 million adolescents)
  • Majority of sports examinations are ineffective in determining potential health problems
  • 80% of pediatric population will have no other health care during the year
  • Majority of adolescents and their parents regard the PPE as sufficient annual health examination.
ppe utility
PPE - Utility
  • Value of PPE remains unproven
    • Screening of a healthy population is somewhat dubious
    • 35 of 7 million adolescents participants are at risk of sudden death
    • $4,537.00/athlete identified with any significant medical condition
  • Only “proven” utility is the recognition of “at risk” participants from poorly rehabilitated or recent orthopedic injuries
  • Ideally, incorporate health maintenance exam, anticipatory guidance, with the PPE
morbidity and mortality
Morbidity and Mortality
  • 6,000,000 cases of adolescent STD’s/year
  • 1,000,000 pregnancies/year to < 19 yrs
    • 500,000 live births
  • 15,000- 18,000 adolescent MVA deaths/year
  • 6,000 young adult homicides/year
  • 5,000 adolescent suicides/year
slide13
Locker room method

Station method

Individual office-based method

PPE
ppe history
PPE-History

1. Significant underlying health conditions

Surgical

Hospitalization

Duration > one week

2. Sustained a significant injury

3. Use of medication(s)

Ergogenic aids, substance abuse

4. Medical allergies/Anaphylaxis

5. Tetanus/Immunizations

ppe history15
PPE-History

6.Cardiovascular disease?

Syncope, dizziness, or chest pain with exercise

Hear murmur or hypertension?

Sudden cardiac death before age 35 yrs

7. Concussion?

8. Exercise tolerance

9. Corrective lenses/dental appliances

10. Missing a paired organ?

11. Menstrual history

12. Heat-related illness

px what s important
Px – What’s Important?
  • Musculoskeletal exam
    • 10% of males examined will have an orthopedic abnormality, usually minor
    • 92% will be detected by history alone
    • “Two minute” orthopedic examination
ppe laboratory
PPE – Laboratory?
  • Generally thought to be unnecessary as screening tools
    • Hematocrit
    • UA
    • Body fat measurement
    • Aerobic capacity
physical exam
Physical Exam
  • Ht
  • Wt
  • BP
  • Visual acuity
  • CV exam
  • Palpation of the abdomen
  • GU exam (males)
  • Screening musculoskeletal exam
obesity
Obesity
  • Obesity - excess of body fat relative to lean body mass
  • Third National Health and Nutrition Examination Survey (NTHANES III):
    • 33% of adult Americans are obese
    • 25% of children and adolescents are either “overweight” or “highly at risk”
expert committee on obesity
Obesity:

> 95%tile BMI for age and sex

“At risk” for obesity

85-95%tile or age and sex

BMI tables are available from the CDC: http://www.cdc.gov/growthcharts/

Expert Committee on Obesity
expert committee on obesity recommendations
Expert Committee on Obesity - Recommendations
  • Weight maintenance (slowing of excessive weight gain) for:
    • Children 2-7 years with “at risk” BMI
    • BMI > 95% and no complications of obesity
    • > 7 yrs < 95% and no complications
  • Weight Loss:
    • > 2 yrs and BMI > 95% and complications of obesity
    • > 7 yrs with a BMI > 85% and a secondary health complication
ppe cv exam
PPE - CV Exam
  • Evaluate peripheral pulses, murmurs, BP
  • BP > 135/85 (in adolescence) should prompt concern and repeat exams
  • 3/6 systolic and all diastolic murmurs should be referred
    • IHSS apical murmur that increases with Valsalva maneuver and intensifies with standing
  • Femoral pulses in coarctation
  • Marfan’s syndrome habitus
slide24
“Youth who have severe hypertension need to be restricted from competitive sports and highly static (isometric) activities until their hypertension is under adequate control and they have no evidence of target organ damage.”HypertensionAAP: Athletic Participation by Children and Adolescents Who Have Systemic Hypertension. Pediatrics. 1997.99;4:637-638.
sudden death cardiac
Cardiomyopathy

Hypertropic cardiomyopathy*

Congenital heart disease

Anomalous left or hypoplastic coronary artery

Aortic rupture

Cardiac Arryhthmias

Prolonged QT syndrome* (Romano-Ward)

WPW

Sudden Death - Cardiac
marfan syndrome
Tall and skinny

Long, narrow face

High arched palate

Pectus deformity

Long fingers and toes

Hyperflexible

Myopia/lentis ectopia

Family hx of early, sudden death

Marfan syndrome
abdomen and genitalia
Hepatomegaly

Splenomegaly

IM return to play one month after onset of illness and no splenic enlargement

Absence or atrophy of testicles

Tanner staging

Inguinal hernia

Varicolcele

Testicular mass

Abdomen and Genitalia
varicocele
Most common scrotal mass

15% of teenagers have a varicoceles

Usually asymptomatic

“Bag of worms”

Controversy as to therapy

Surgical repair:

Large varicocele and testicle not growing normally

Left testis 3 ml smaller than right

- 2 SD for testicular size

Bilateral or symptomatic varicoles

Pain

Varicocele
sexual maturity
“Preadolescents and adolescents should avoid competitive weight lifting, power lifting, body building, and maximal lifts until they reach physical and skeletal maturity.”

- AAP:Strength Training by Children and Adolescents. Pediatrics. 2001.107;6:1470-1472

Caution with Tanner stage < 3 in collision sports.

Sexual Maturity
slide31
Skin
  • Active impetigo
  • Tinea corporis
  • Scabies
  • Molluscum contagiosum
  • Herpes simplex
ppe musculoskeletal
PPE - Musculoskeletal
  • Majority of all abnormalities identified
  • “two-minute” musculoskeletal examination
    • Garrick – 1977
    • 14 screening positions
    • Specificity of 97.5%
orthopedic screening exam garrick
1. Acromioclavicular joint/general habitus

2. Cervical spine motion

3. Trapezius strength

4. Deltoid strength

5. Shoulder motion

6. Elbow motion

7. Elbow and wrist motion

8. Hand/finger deformity

9. Symmetry/effusion

10/12. LE symmetry/strength

11. Lower back

12. Scoliosis

13. Knee effusion

14. Calf symmetry/strength

Orthopedic Screening Exam (Garrick)
adolescent scoliosis
Adolescent Scoliosis
  • Lateral curvature of the spine
  • Usually not painful
  • Most common spinal deformity in the 10-16 year
  • 30% will have a family history
scolisosis adam s forward bend test
Knees fully extended

Hands to side

Bends forward to a horizontal position

Document asymmetry with a scoliometer

7 degrees on

scoliometer = 20 degrees on x-ray

Scolisosis - Adam’s Forward Bend Test
adolescent ppe anticipatory guidance
Immunizations

Tetanus

Varicella

Hepatitis B

Meningococcemia

Behavioral/

Psychosocial screen

Testicular/Breast self-exam

Discussion of:

Androgenic agents

“Natural” agents

DHEA

Creatine

Female athlete “triad”

Adolescent PPE - Anticipatory Guidance
slide38

Participation - Medical Conditions AAP: Committee on Sports Medicine and Fitness. Medical Conditions Affecting Sports Participation (RE0046). Pediatrics. 2001. 107:5:1205-1209.

  • Who should and should not participate in a particular sport?
  • What, if any, modifications are necessary?
  • Risk of injury related to any conditions present
slide39

Participation - Medical Conditions AAP: Committee on Sports Medicine and Fitness. Medical Conditions Affecting Sports Participation (RE0046). Pediatrics.2001. 107:5:1205-1209.

  • Sports are categorized into three categories by degree of contact
    • Collision
    • Limited Contact
    • Noncontact
  • Assessment of various medical conditions:
    • Risk of injury
    • Risk of adversely affecting the medical condition
slide42
When an athlete's family disregards medical advice against participation, the physician should ask all parents or guardians to sign a written informed consent statement indicating that they have been advised of the potential dangers of participation and that they understand them. The physician should also document, with the child's signature, that the child athlete also understands the risks of participation.”

- AAP: Committee on Sports Medicine and Fitness. Medical Conditions Affecting Sports Participation (RE0046). Pediatrics. 2001. 107:5:1205-1209.

adolescent female sports
Adolescent Female - Sports
  • 1972 = 1:27
  • 2000 = 1:3
  • Injury rates are similar between male and female adolescents in the same sport except:
    • “Female Athlete Triad”
    • Stress fractures
    • ACL injuries
female athlete triad
Eating disorder or

Disordered eating

Less severe and more subtle than true eating disorders

fasting

vomiting

food restriction

diet pills/laxatives

Amenorrhea

Osteoporosis

Risk factors:

Highly structured life

Social isolation

Lack of support system

Family hx of eating disorders

Female Athlete Triad
amenorrhea definitions
Amenorrhea - Definitions
  • Primary amenorrhea:
    • No menses by age 16 years
    • No menses 4.5 years after onset of breast development
  • Secondary amenorrhea:
    • Absence of at least 3-6 menstrual cycles in a female that has begun menstruation
slide46

Female Athlete Triad AAP: Committee on Sports Medicine and Fitness. Medical Concerns in the Female Athlete. Pediatrics.2000. 106;3610-613

  • 3-60% will have amenorrhea vs. 2-5% in adult women
  • Normal weight athletes usually don’t have menstrual problems
  • Disordered eating may occur in 15-65% of all female athletes
  • Disordered eating should be considered in adolescent amenorrhea
disordered eating amenorrhea
Disordered Eating - Amenorrhea

Decreased calories

“Energy” drain

Hypothalamic dysfunction

Decreased estrogen production

Amenorrhea

Decreased BMD

female athlete amenorrhea
Female Athlete - Amenorrhea
  • Athletes with amenorrhea have lower bone mineral density (BMD)
  • Bone mass maybe unrecoverable after resumption of menses
  • Complete exam is necessary for any adolescent with primary or secondary amenorrhea
amenorrhea treatment
Amenorrhea - Treatment
  • Decrease training
  • Attempt to increase weight/height to 10%
  • Calcium intake
  • Addressing any eating disorders
  • Premarin/OCT?
stress fractures
3.5X more common in female athletes (vs. male athletes)

“Load” exceeds bodies attempts at skeletal repair

More common in tibia, femur and pelvis

Pain with activity initially, later pain at rest

Risk factors:

Smoker

Asian

Corticosteroids

Female Athlete

Amenorrhea

Family history

Stress Fractures
stress fracture
Stress Fracture
  • Plain radiographs may miss a stress fracture
  • Bone scan is the “gold standard”
  • Conservative treatment for 6-12 weeks
references
References
  • Callahan, L.R. The Evolution of the Female Athlete: Progress and Problems. Pediatric Annals. 2000. 29;149-155.
  • Berul, C. Cardiac Evaluation of the Young Athlete. Pediatric Annals. 2000. 29;162-165.
  • AAP and AAOS. Care of the Young Athlete. 2000. ISBN 1-58110-050-7
  • Menses and the Pediatrician: The Pediatricians Role in the Development of Adolescent Girls. Pediatric Annals. 1997. Volume 26, Number 2, Supplement.
  • Metzel, J. ed., Sports Medicine in the Pediatric Office. Pediatric Annals. 2000. 29:139-188.
  • Killiam, J.T., et. al. Current Concepts in Adolescent Scoliosis. Pediatric Annals. 1999. 28:755-761.
  • American Academy of Pediatrics. Preparticipation Physcial Evaluation. 2nd Ed. 1997
  • Sarah E. Barlow and William H. Dietz. Obesity Evaluation and Treatment: Expert Committee Recommendations. Pediatrics. 1998; 102: e29.
references53
References
  • AAP:Committee on Sports Medicine and Fitness. Medical Concerns in the Female Athlete. Pediatrics. 2000. 106;3: 610-613
  • American Academy of Pediatrics: Committee on Sports Medicine and Fitness. Medical Conditions Affecting Sports Participation (RE0046). Pediatrics. 2001. Volume 107;5: pp 1205-1209.
  • American Academy of Pediatrics: Committee on Sports Medicine and Fitness and Committee on School Health. Organized Sports for Children and Preadolescents (RE0052). Pediatrics. Volume 107, Number 6: pp 1459-1462
  • Krowchuk, D.P. The Preparticipation Athletic Examination: A Closer Look. Pediatric Annals. 26;1:37-47
  • AAP: Committee on Sports Medicine and Fitness. Medical Concerns in the Female Athlete. Pediatrics.2000. 106;3610-613.
  • Adelman an Joffe. The Adolescent Male Genital examination: What’s Normal and What’s Not. Contemporary Pediatrics. 1999.
  • AAP:Strength Training by Children and Adolescents. Pediatrics.2001. 107;6:1470-1472
  • Perriello,V. ajd Barth, J. Sports Concussion: Coming to the Right Conclusion. Contemporary Pediatrics. 2000.