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The Sports Physical. Valerie Robinson D.O. The Goals. The goal of the preparticipation sports physical is to maximize safety of participants. Identify life-threatening medical problems. Identify and treat other medical problems that may interfere with participation. (e.g. asthma, HTN)

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the sports physical

The Sports Physical

Valerie Robinson D.O.

the goals
The Goals
  • The goal of the preparticipation sports physical is to maximize safety of participants.
  • Identify life-threatening medical problems.
  • Identify and treat other medical problems that may interfere with participation. (e.g. asthma, HTN)
  • Identify previous injuries and try to prevent subsequent injuries
  • It does not substitute for a well child check.
the exam
The Exam
  • Most schools require annual physicals
  • Exam 4-6 weeks before sports season starts
  • May be done by the PCP
  • May be done in a station approach at locations set up by the school or local health department
  • Targeted medical hx
  • Targeted family hx
  • Target physical
  • Emphasis on musculoskeletal and cardiovascular
  • Labwork is not necessary
slide4

Given that 30-78% of adolescents have a sports physical in lieu of a well child check, it may be appropriate to take the time to perform a complete check-up as well.

  • If performed in a private office, the physician may ask about drug use, sexual activity, violence, and mental health (e.g. depression or bullying) as part of a comprehensive check-up
the history
The History
  • Medical history
    • Seizure, excess fatigue, shob
  • Injury history
    • Where, when, lingering effects?, LOC
    • Pain, paresthesia, decreased ROM
  • Cardiovascular history
    • HTN, murmur, dyslipidemia, myocarditis, endocarditis, rheumatic fever, syncope, near-syncope, angina, palpitations
  • Family history
    • Especially cardiac or sudden death, Marfan’s, syncope, SIDS
  • Surgical history
  • Medications
  • Immunization history
  • Menstrual history
  • History of weight changes
the physical
The Physical
  • Vitals, BMI
    • Low BMI, bradycardia, hypotension, hypothermia are symptoms of an eating disorder
  • HEENT – need acuity test
    • If corrected acuity <20/40, need protective eyewear
  • Lungs - auscultate
  • Abdomen - splenomegaly
  • Genitals – testes, discuss cup
  • Skin – anything contagious? (herpes, varicella, scabies, tinea corpora, molluscumcontagiosum)
  • Lymphatic – lymphadenopathy, splenomegaly
  • Neuro – cranial nerves, focal defecits
the physical the cardiac exam
The Physical The Cardiac Exam
  • Pulse and BP, right arm while sitting
  • Auscultation done supine and standing
    • Innocent murmur – systolic, decreases when standing
    • Hypertrophic cardiomyopathy – may have no murmur. Systolic, increases when standing and with Valsalva, decreases with squatting
    • Aortic stenosis – ejection murmur, split S2, murmur may radiate to carotids
    • Mitral prolapse – midsystolic click, poss late systolic murmur
  • Locate PMI
  • Asymptomatic bradycardia (40-50 bpm)may be present in fit athletes - does not preclude activity
  • EKG is not recommended for screening purposes
the physical musculoskeletal
The PhysicalMusculoskeletal
  • If hx of injury, pay special attention to area involved
  • Look for asymmetry
  • Look for swelling, bruising, deformities
  • Watch for and ask about pain during exam
  • Test for weakness
  • Look for atrophy and watch for fasciculations
the physical musculoskeletal 2
The PhysicalMusculoskeletal 2
  • Shoulder
    • Full abduction, flexion, external rotation
    • Resisted flexion and abduction, apprehension test
  • Elbow
    • Flexion, extension, supination, pronation
  • Hands
    • Flexion and extension of fingers, grip strength
  • Neck
    • Flexion, extension, rotation, sidebending
the physical musculoskeletal 3
The PhysicalMusculoskeletal 3
  • Back
    • Look for scoliosis, spondylolysis
    • Flexion, extension, rotation
  • Hip
    • Flexion, extension, walk
    • “Duck walk” tests the hip and knee
  • Knee
    • Flexion, extension, walk, “duck walk”
    • Check for Osgood-Schlatter
  • Ankle
    • Hop several times on each foot
tx before participating
Tx Before Participating
  • HTN
  • DM 1 or 2
  • Asthma
  • Exercise-Induced Bronchospasm
    • Dx by H&P. Spirometry or exercise challenge as indicated
  • Eating disorders
    • Treat psych. Cut exercise in half, esp. if 85% of IBW
  • Musculoskeletal injuries
    • Physical rehabilitation
    • Plan for return to activities. “Start low. Go slow.”
relative contraindications
Relative Contraindications
  • Mitral prolapse – May participate UNLESS
    • Hx of syncope
    • Famhx of sudden death d/t prolapse
    • Arrhythmias
    • Moderate or greater mitral regurg
    • Hx of emboli
  • Uncontrolled HTN
  • Fever
sudden death
Sudden Death
  • Sudden death in the young athlete occurs with a prevalence between 1:100,000 and 1:300,000.
  • 90% of deaths are in males, median age 17
  • Causes:
    • Hypertrophic cardiomyopathy
    • Wolff-Parkinson-White – delta waves, SVT
    • Long QT syndrome
    • Aortic stenosis – more common in Marfan’s
    • Commotiocordis – precordial blow disrupts heart rhythm
    • Coronary artery anomalies
    • Right ventricular hypertrophy
    • Myocarditis
    • Aortic rupture
slide18
Refs
  • Albert C Hergenroeder, MD et al. “The preparticipation sports examination in children and adolescents.” UpToDate. Updated July 11, 2012. www.uptodate.com
  • Stephen G. Rice, MD, PhD, MPH et al. “Medical Conditions Affecting Sports Participation.” Pediatrics Vol. 121 No. 4 April 1, 2008 , pp. 841 -848. Retrieved from http://pediatrics.aappublications.org
  • Form: “Preparticipation Physical Evaluation Forms.” American Academy of Pediatrics. http://www.aap.org/en-us/professional-resources/practice-support/Pages/Preparticipation-Physical-Evaluation-Forms.aspx