Papers

The preparticipation physical examination for athletics: a systematic review of current recommendations

Peter J Carek, associate professor, Arch Mainous III, professor. 

Department of Family Medicine, Medical University of South Carolina, 9298 Medical Plaza Drive, Charleston, SC 29406

Correspondence to: Peter J Carek
carekpj{at}musc.edu

	Abstract

Top Abstract Introduction Methods Results Discussion Conclusion References

Objective: To examine the medical literature regarding the effectiveness of the preparticipation physical examination (PPE) in satisfying the basic requirements for medical screening.
Design: Medline database (1966 to August 2002) search using the terms "preparticipation physical examination" and "physical examination."
Main outcome measure: The United States Preventive Services Task Force (USPSTF) description of an effective screening test was used to determine whether the studies available provide evidence that the PPE satisfies the basic requirements for medical screening.
Results: 176 articles were identified. The articles did not specify the presence of a randomized control group, nor did they describe subjects who were inappropriately cleared or restricted. Therefore, false-positive and false-negative rates were not presented. As the accuracy of the screening test was not demonstrated, the PPE failed to satisfy one of the major requirements for an effective screening test.
Conclusion: The PPE for athletes does not satisfy the basic requirements for medical screening as described by the USPSTF.

What is already known on this topic The preparticipation physical examination (PPE) is intended to identify medical conditions that may affect safe and effective participation in organized sports The basic structure and format of the PPE has been developed, instituted, and revised based on the recommendations of key opinion leaders and large medical organizations What this study adds The accuracy of the PPE could not be determined from the studies available, and thus the PPE fails to satisfy one of the major requirements for an effective screening test The practice of providing preparticipation medical screening for athletes is neither supported nor refuted by the current medical literature due to the inadequacies of research data available

From BMJ USA 2002;Dec:661

	Introduction

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Though not uniformly implemented in other Western nations, the preparticipation physical examination (PPE) has become the standard of care for more than 6 million high school and college students in the United States as they prepare for athletic participation. In just over three decades this examination has gradually become an integral aspect of the athletic and sports medicine system. During its evolution, the basic structure and format of the PPE has been developed, instituted, and revised, based largely on the recommendations of key opinion leaders and large medical organizations.^1-26 Currently, every state but one requires a medical evaluation before a student is allowed to participate in high school athletics.²⁷ Although the PPE has been adopted by many organizations, its content and utility remain a topic of debate. ^{24 27-36}

Editor's introduction Primary care doctors are often asked to provide medical clearance for high school and college students to participate in athletic activities. This systematic review by family physicians in South Carolina found little evidence of benefit.

The PPE is generally intended to identify medical conditions that may affect safe and effective participation in organized sports. ^{12 19 37} In an expansion of this objective, the American Medical Association (AMA) Group on Science and Technology indicated that every physician should seek to complete two main objectives during the PPE: "1) to identify those athletes who have medical conditions that place them at substantial risk for injury or sudden death and disqualify them from participation or ensure they receive adequate medical treatment before participation and 2) to not disqualify athletes unless there is a compelling medical reason."¹² Similar objectives were presented by the Preparticipation Physical Examination Task Force, a group established by the American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, American Orthopedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine.¹⁹ This group delineated three primary objectives of the PPE: 1) to detect conditions that may predispose to injury, 2) to detect conditions that may be life threatening or disabling, and 3) to meet legal and insurance requirements.

However, the PPE may fulfill other objectives, and these may provide incentives for physicians to participate in the PPE process. In relation to direct patient care, it allows physicians to assess overall physical health and provides an opportunity for preventive medical services. Some physicians may utilize the PPE to provide a community service, build a referral practice, establish a sports medicine center, compile a research database, or educate physicians, therapists, and other paramedical personnel.³⁸

While these potential objectives of the PPE have been extensively presented, they do not constitute formal criteria for the critical evaluation of a medical screening instrument.³⁹ The ability of the PPE to satisfy the basic requirements for screening is unclear. The aim of this systematic review was to examine the medical literature regarding the effectiveness of the PPE in satisfying the basic requirements for medical screening.

	Methods

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To identify studies for possible inclusion, we searched the Medline database (1966 to August 2002) using the terms "preparticipation physical examination" and "physical examination." We also reviewed the bibliographies of identified manuscripts. We screened titles and abstracts (when available) and reviewed relevant articles.

Studies were included if they described the population of athletes screened, provided information regarding clearance, and delineated reasons for additional evaluation or disqualification. In addition, the studies were reviewed for methodological issues, including randomization, presence of a control group, and calculation of sensitivity and false-negative rates (through the detection of individuals with an underlying condition that would restrict participation but was not detected by the PPE).

We adopted the United States Preventive Services Task Force (USPSTF) description of an effective screening test to define the basic requirements for medical screening. Specifically, a screening test must satisfy two major requirements to be considered effective: 1) the test must be able to detect the target condition earlier than would be possible without screening and with sufficient accuracy to avoid producing large numbers of false-positive and false-negative results (accuracy of screening test), and 2) screening for and treating persons with early disease should improve the likelihood of favorable health outcomes (eg, reduced disease-specific morbidity or mortality) compared to treating patients when they present with signs or symptoms of the disease (effectiveness of early detection).³⁹

	Results

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A total of 176 articles were identified. Of these articles, none specified the presence of a randomized control group or described subjects who were inappropriately cleared or restricted. Therefore, false-positive and false-negative rates were not presented. As the accuracy of the screening test could not be determined, the PPE failed to satisfy a major requirement for an effective screening test.

Of the studies found during the Medline search, 11 articles that presented evaluation and clearance results from large screening efforts were selected for further review. ^{38 40-49} From this group, several articles were not used in further discussion as the supporting information regarding the clearance decision could not be interpreted from the data provided. ^{41 44 47}

In general, the studies included in the review used only self-selected samples of the athletic population. Uniformly, athletes could choose either to undergo the PPE as a part of the study or to have a PPE completed by their regular physician. Only one study presented the rate of participation in the described PPE among students who planned to participate in organized athletics.⁴² Furthermore, neither the accuracy of the information provided by athletes nor the physical examination findings of the health care professionals were subject to review for validity. As previous studies have found poor agreement between histories obtained from athletes and parents independently, these issues could possibly affect the results of the studies being reviewed. ^{45 50}

The studies reviewed provided information regarding rates of clearance, clearance with follow-up, and full restriction (table). ^{38 40-49} Further comparison between the studies reviewed and their reported clearance rates could not be completed due to unclear criteria used to determine clearance status in each study.

Another goal of these assessments is to identify individuals with a condition that may be life threatening or disabling. Among the 27 780 student-athletes involved in the studies, one death (from cerebral aneurysm) was reported.⁴³ Because the studies did not include a control group, we did not conduct a comparison of mortality rates between athletes screened and not screened. Further, the studies did not include follow-up of athletes restricted from participation and therefore we could not examine whether restriction resulted in decreased morbidity or mortality.

	Discussion

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Based on the results of this review, scientific evidence is lacking to support the ability of the PPE to satisfy the basic requirements for medical screening. We could not determine the effectiveness of these examinations in detecting physical abnormalities serious enough to limit or restrict athletic participation. The absence of a comparison group, the unknown rate of actual participation of athletes in these examinations, and inconsistent definitions of a physical abnormality serious enough to limit athletic participation contributed to the inability to determine the sensitivity and false-negative rate of the PPE. These values are essential in determining the value of a medical screening tool. Although the AMA Group on Science and Technology reported a rate range for true positives (0/1000 to 12.8/1000) and false positives (11.6/1000 to 79.5/1000),¹² the false-negative rate was not presented nor could it be extrapolated from the results provided.

As recognized by the AMA group, a series of studies has established the effectiveness of the PPE in detecting physical conditions serious enough to limit athletic participation.¹² These conditions may include acute, recurrent, chronic, untreated, or inadequately treated injuries or other medical problems. However, the definition of such conditions, which is based upon expert opinion rather than evidence, is not standardized and varies between studies. ^{19 51} Therefore, these studies have demonstrated only that physicians are able to detect arbitrarily established disqualifying or other medical conditions that may require further evaluation and treatment in an unknown percentage of athletes. Even if specific conditions are identified, the PPE may not predict certain athletic injuries.⁵²

Several studies attempted to provide information regarding other conditions (ie, inflexibility, asymmetric strength, and abnormal mechanics) that may predispose an athlete to injury. ^{43 47 53} For example, several studies found that tight hamstrings and ankle laxity were the most common significant findings resulting in "clearance with follow-up" recommendations by the examining physicians. ^{43 47}

Guidelines for participating in competitive sports from the American Academy of Pediatrics and the Preparticipation Exam Task Force do not specifically address the clearance classification resulting from these frequently identified abnormalities. ^{19 51} The absence of unified recommendations is primarily attributed to several factors: 1) the lack of consensus regarding the threshold of abnormality (eg, the degree of inflexibility that might be considered abnormal), 2) the unavailability of data indicating the predictive value of specific physical abnormalities for injury, and 3) the lack of definitive proof that corrective interventions alter outcome.³⁸ While various degrees of hyperlaxity, muscular tightness, weakness, asymmetry of strength or flexibility, poor endurance, and abnormal foot configuration may predispose an athlete to increased risk of injury during sports competition, the studies have failed to demonstrate conclusively that injuries are prevented by interventions aimed at correcting such abnormalities. ^{3 40 54-60}

A primary objective of the PPE is to identify individuals with a condition that may be life threatening or disabling. An underlying cardiovascular disease has been found to be a significant cause of acute sudden cardiac death in high school and college athletes.⁶¹ These catastrophic events are believed to occur in about 0.5 per 100 000 high school athletes per academic year. ^{62 63}

The practicality and utility of medical screening for athletes at risk of sudden cardiac death are limited by several factors: 1) the apparent low prevalence of relevant cardiovascular lesions (eg, hypertrophic cardiomyopathy, coronary artery anomalies, myocarditis) in the general youth population, 2) the low risk of sudden death even among persons with an unsuspected abnormality, and 3) the large size of the competitive athletic population. ^{12 62} In the studies reviewed, no athlete was restricted from participation based on the finding of hypertrophic cardiomyopathy that had not been previously detected.

In addition, an athlete's history of injury and the degree of rehabilitation may be the best predictor of future orthopedic problems. A musculoskeletal injury is the most common cause for disqualification of an athlete. ^{40 45 49} DuRant et al⁴⁴ found that having previously experienced a knee injury or having undergone knee surgery was significantly associated with the occurrence of knee injuries during subsequent sports seasons of an academic year. Furthermore, Van Mechelen et al⁶⁴ demonstrated that the greatest risk factor for injury is a history of injury. Finally, some evidence exists that athletes who are relatively weak for their level of physical maturation may have an especially high risk of injury.⁶⁵

Several issues limit this review: Additional studies concerning the PPE may exist but were not detected utilizing the search methods described. In addition, other screening tools besides the history and physical were not addressed in the studies reviewed. Routine laboratory studies and other tests used as screening tools in an asymptomatic athletic population are not currently recommended or supported by the medical literature.

	Conclusion

Top Abstract Introduction Methods Results Discussion Conclusion References

The PPE for athletes does not satisfy the basic requirements for medical screening as described by the USPSTF. While current research fails to demonstrate whether the PPE has an effect on the overall morbidity and mortality rates in athletes, other objectives may be fulfilled by these examinations. Furthermore, no harmful effects of these examinations have been reported. The practice of providing preparticipation medical screening for athletes is neither supported nor refuted by the current medical literature due to the inadequacies of research data available.

	Footnotes

Funding: None

Competing interests: None declared

	References

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1.	Runyan DK. The pre-participation examination of the young athlete: defining the essentials. Clin Pediatrics (Phila) 1983; 22: 674-679.
2.	Rice SG. Clearing an athlete for sports participation. J Musculoskel Med 1986; 3: 23-36.
3.	Rowland TW. Preparticipation sports examination of the child and adolescent athlete: changing views of an old ritual. Pediatrician 1986; 13: 3-9[Medline].
4.	McKeag DB. Preparticipation screening of the potential athlete. Clin Sports Med 1989; 8: 373-397[ISI][Medline].
5.	Garrick JG. Orthopedic preparticipation screening examination. Pediatr Clin North Am 1990; 37: 1047-1056[ISI][Medline].
6.	Tanji JL. The preparticipation physical examination for sports. Am Fam Physician 1990; 42: 397-402[ISI][Medline].
7.	Smith DM, Lombardo JA, Robinson JB. The preparticipation evaluation. Prim Care 1991; 18: 777-807[ISI][Medline].
8.	Dyment PG. The orthopedic component of the preparticipation examination. Pediatr Ann 1992; 21: 157[ISI][Medline], 160-162.
9.	Henderson JM. The preparticipation screening evaluation. J Med Assoc Ga 1992; 81: 277-282[Medline].
10.	Johnson MD. Tailoring the preparticipation exam to female athletes. Phys Sportsmed 1992; 20: 61-72.
11.	Nelson MA. Medical exclusion from participation in sports. Pediatr Ann 1992; 21: 149-155[ISI][Medline].
12.	American Medical Association Board of Trustees, Group on Science and Technology. Athletic participation examinations for adolescents. Arch Pediatr Adolesc Med 1994; 148: 93-98[Abstract].
13.	Tanner SM. Preparticipation examination targeted for the female athlete. Clin Sports Med 1994; 13: 337-353[ISI][Medline].
14.	Maron BJ, Thompson PD, Puffer JC, McGrew CA, Strong WB, Douglas PS, et al. Cardiovascular preparticipation screening of competitive athletes. A statement for health professionals from the Sudden Death Committee (clinical cardiology) and Congenital Cardiac Defects committee (cardiovascular disease in the young), American Heart Association. Circulation 1996; 94: 850-856[Free Full Text].
15.	Sanders B, Nemeth WC. Preparticipation physical examinations. J Orthop Sports Phys Ther 1996; 23: 149-163[ISI][Medline].
16.	Bratton RL. Preparticipation screening of children for sports: current recommendations. Sports Med 1997; 24: 300-307[Medline].
17.	Grafe MW, Paul GR, Foster TE. The preparticipation sports examination for high school and college athletes. Clin Sports Med 1997; 16: 570-591.
18.	Hergenroeder AC. The preparticipation sports examination. Ped Clin North Am 1997; 44: 1526-1540.
19.	Smith DM, Kovan JR, Rich BSE, Tanner SM. Preparticipation Physical Evaluation 2nd ed. Minneapolis: McGraw-Hill, 1997:1-46.
20.	Myers A, Sickles T. Preparticipation sports examination. Prim Care 1998; 25: 225-236[ISI][Medline].
21.	NFHS encourages pre-participation physical evaluations [press release]. Kansas City, Mo: National Federation of State High School Associations, November, 1998.
22.	Kurowski K, Chandran S. The preparticipation athletic evaluation. Am Fam Physician 2000; 61: 2696-2698.
23.	Lyznicki JM, Nielsen NH, Schneider JF. Cardiovascular screening of student athletes. Am Fam Physician 2000; 62: 765-774[ISI][Medline].
24.	Metzl JD. The adolescent preparticipation physical examination. Is it helpful? Clin Sports Med 2000; 19: 577-592[CrossRef][ISI][Medline].
25.	Metzl JD. Preparticipation examination of the adolescent athlete: part 1. Pediatr Rev 2001; 22: 199-204[Free Full Text].
26.	National Collegiate Athletic Association. Guideline 1b: Medical evaluations, immunizations, and records. 2001-2002 Sports Medicine Handbook. Available at: http://www.ncaa.org (accessed November 2001).
27.	Glover DW, Maron BJ. Profile of preparticipation cardiovascular screening for high school athletes. JAMA 1998; 279: 1817-1819[Abstract/Free Full Text].
28.	DeHaven KE. The preparticipation physical evaluation of athletes [editorial]. J Musculoskel Med 1986; 3: 7.
29.	Hoekelman RA. The preparticipation sports physical examination [editorial]. Pediatr Ann 1992; 21: 145-146[ISI][Medline].
30.	Strong WB. Preparticipation physical examination. It should be required. Arch Pediatr Adolesc Med 1994; 148: 99-100[ISI][Medline].
31.	Cantwell JD. Preparticipation physical evaluation: getting to the heart of the matter. Med Sci Sports Exerc 1998; 30(10 Suppl): S341-S344[ISI][Medline].
32.	MacAuley D. Does preseason screening for cardiac disease really work?: The British perspective. Med Sci Sports Exerc 1998; 30(10 Suppl): S345-S350[ISI][Medline].
33.	Glover DW, Maron BJ, Matheson GO. The preparticipation physical examination: steps toward consensus and uniformity [commentary]. Phys Sportsmed 1999; 27: 29-34.
34.	McKeag DB, Sallis RE. Factors at play in the athletic preparticipation examination [editorial; comment]. Am Fam Physician 2000; 61: 2617-2618[ISI][Medline].
35.	Pfister GC, Puffer JC, Maron BJ. Preparticipation cardiovascular screening for US collegiate student-athletes. JAMA 2000; 283: 1597-1599[Abstract/Free Full Text].
36.	Reich JD. It won't be me next time: an opinion on preparticipation sports physicals [editorial]. Am Fam Physician 2000; 61: 2618[ISI][Medline], 2620, 2625, 2629.
37.	Cromer BA, McLean SC, Heald FP. Preparticipation sports evaluation. J Adolesc Health 1992; 13: 61S-65S.
38.	Smith J, Laskowski ER. The preparticipation physical examination: Mayo Clinic experience with 2,739 examinations. Mayo Clin Proc 1998; 73: 419-429[ISI][Medline].
39.	United States Preventive Services Task Force. Guide to Clinical Preventive Services. Alexandria: International Medical Publishing, 1996.
40.	Goldberg B, Saraniti A, Witman P, Gavin M, Nicholas JA. Pre-participation sports assessmentan objective evaluation. Pediatrics 1980; 66: 736-745[Abstract/Free Full Text].
41.	Linder CW, DuRant RH, Seklecki RM, Strong WB. Preparticipation health screening of young athletes. Results of 1268 examinations. Am J Sports Med 1981; 9: 187-193[Abstract/Free Full Text].
42.	Tennant Jr FS, Sorenson K, Day CM. Benefits of preparticipation sports examinations. J Fam Pract 1981; 13: 287-288[ISI][Medline].
43.	Thompson TR, Andrish JT, Bergfield JA. A prospective study of preparticipation sports examinations of 2,670 young athletes: Method and results. Cleve Clin Q 1982; 49: 225-233[ISI][Medline].
44.	DuRant R, Seymore C, Linder CW, Jay S. The preparticipation examination of athletes. Comparison of single and multiple examiners. Am J Dis Child 1985; 139: 657-661.
45.	Risser WL, Hoffman HM, Bellah Jr GG. Frequency of preparticipation sports examinations in secondary school athletes: are the University Interscholastic League guidelines appropriate? Tex Med 1985; 81: 35-39.
46.	Magnes SA, Henderson JM, Hunter SC. What limits sports participation: experience with 10,540 athletes. Phys Sportsmed 1992; 20: 143-160.
47.	Briner WW, Farr C. Athlete age and sports physical examination findings. J Fam Pract 1995; 40: 370-375[ISI][Medline].
48.	Rifat SF, Ruffin MT, Gorenflo DW. Disqualifying criteria in preparticipation sports evaluation. J Fam Pract 1995; 41: 42-50[ISI][Medline].
49.	Lively MW. Preparticipation physical examination: a collegiate experience. Clin J Sports Med 1999; 9: 38.
50.	Carek PJ, Futrell MA. Athletes' view of the preparticipation physical examination. Attitudes toward certain health screening questions. Arch Fam Med 1999; 8: 307-312[Abstract/Free Full Text].
51.	American Academy of Pediatrics. Medical conditions affecting sports participation. Pediatrics 2001; 107: 1206-1207.
52.	DuRant RH, Pendergrast RA, Seymore C, Gaillard G, Donner J. Findings from the preparticipation athletic examination and athletic injuries. Am J Dis Child 1992; 146: 85-91[Abstract].
53.	Kibler WB, Chandler TJ, Uhl T, Maddux RE. A musculoskeletal approach to the preparticipation physical examination. Am J Sports Med 1989; 17: 525-531[Abstract/Free Full Text].
54.	Lysens R, Steverlynck A, van den Auweele Y. The predictability of sports injuries. Sports Med 1984; 1: 6-10.
55.	Abbott HG, Kress JB. Preconditioning in the prevention of knee injuries. Arch Phys Med Rehabil 1969; 50: 326-333[Medline].
56.	Goldberg B, Witman PA, Gleim GW, Nicholas JA. Children's sports injuries: are they avoidable? Phys Sportsmed 1979; 7: 93-101.
57.	Goldfuss AJ, Morehouse CA, LeVeau BF. Effect of muscular tension on knee stability. Med Sci Sports 1973; 5: 267-271[ISI][Medline].
58.	Jackson DW, Jarrett H, Bailey D, Kausek J, Swanson S, Powell SW. Injury prediction in the young athlete: a preliminary report. Am J Sports Med 1978; 6: 6-14[Free Full Text].
59.	Micheli LJ. Overuse injuries in children's sports: the growth factor. Orthop Clin North Am 1983; 14: 337-360[ISI][Medline].
60.	Nicholas JA. Injuries in knee ligaments: relationship to looseness and tightness in football players. JAMA 1970; 212: 2236-2239[CrossRef][Medline].
61.	Van Camp SP, Bloor CM, Mueller PO, Cantu RC, Olson HG. Nontraumatic sports death in high school and college athletes. Med Sci Sports Exerc 1995; 27: 641-647[ISI][Medline].
62.	Maron BJ, Shirani J, Poliac LC, Mathenge R, Roberts WC, Mueller FO. Sudden death in young competitive athletes. JAMA 1996; 276: 199-204[Abstract].
63.	Maron BJ, Gohman TE, Aeppli D. Prevalence of sudden cardiac death during competitive sports activities in Minnesota high school athletes. J Am Coll Cardiol 1998; 32: 1881-1884[Abstract/Free Full Text].
64.	Van Mechelen W, Twisk J, Molendijk A, Blom B, Snel J, Kemper HC. Subject-related risk factors for sports injuries: a 1-yr prospective study in young adults. Med Sci Sports 1996; 28: 1171-1179.
65.	Backous DD, Friedl KE, Smith NJ, Parr TJ, Carpine Jr WD. Soccer injuries and their relation to physical maturity. Am J Dis Child 1988; 142: 839-842[Abstract].