Sports Participation Evaluation


Article Author:
Khashayar Farzam


Article Editor:
Hossein Akhondi


Editors In Chief:
Dustin Constant
Donald Kushner


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
6/29/2019 2:32:58 PM

Introduction

Evaluation of a patient for participation in sporting activities has a traditional role in ensuring their health before enduring the effects and stresses of that particular sport. This form of patient evaluation has been used in both professional as well as amateur athletes; hence having a variable level of comprehensiveness. Many sports associations and leagues require a health exam, documentation, and paperwork from physicians and other health care providers to certify that the subjects are healthy and ready for their sport of choice. Patients will undergo an assessment which includes personal medical history, family medical history, history of supplemental or enhancer drug use, a physical examination, and potential diagnostic tests.

The medical history evaluates potential existing medical illnesses which include cardiac illness, musculoskeletal disease, history of neurological illness, respiratory disease, bleeding disorders, and psychiatric illness. Similarly, the family history is made to evaluate for any diseases that might have been inherited but are asymptomatic or have not yet recognized. The physical examination assesses for optimal neurological and musculoskeletal health as well as evaluation of the cardiovascular function.[1] Diagnostic tests which may be performed include blood tests and electrocardiograms (ECGs). The purpose is to assess organ health and to assess cardiac structure and function. Abnormal findings during the history and physical examination or ECG may prompt further diagnostic tests and evaluations.[2] 

The purpose of this activity is to review the fundamental components of a medical evaluation for an athlete and how these evaluations can be optimized to ensure that our subject is medically safe, within a certain degree, for their choice of sporting activity.  

Function

The primary purpose of a sports' participation evaluation is assessing for underlying medical pathology while also ensuring that the athlete is in optimal health. Athletes are asked about symptoms they are experiencing during times of physical exertion and at rest.  

Key Symptoms and Medical History In Athletes

Cardiac

  • Syncope
  • Presyncope
  • Dizziness
  • Dyspnea
  • Chest pain
  • Seizures

Respiratory

  • Dyspnea
  • Pain with breathing
  • History of Asthma 

Neurological

  • Headaches
  • Seizures

Musculoskeletal

  • Excessive joint pain
  • Limited range of motion in extremities
  • Chronic low back pain
  • History of fractures or past injuries 
  • History of muscular tears
  • Back or neck pain

Hematologic

  • Excessive bleeding
  • Clotting disorder(s)
  • Immunosuppression

Psychiatric

  • Depression
  • History of suicidal ideation
  • History of manic phases
  • Eating disorders and nutritional status

General

  • Previous exclusion from sports
  • Previous injuries 
  • Complications and sequelae from past events 

Family Medical History 

  • Sudden unexpected death
  • History of undiagnosed syncope
  • History of unexpected drowning
  • Familial heart diseases
  • Muscular dystrophies  

Cardiac-related symptoms that occur during rest and exertion are of particular concern due to the risk of sudden cardiac death. However, other probable etiologies should also be considered.[3] Given that congenital heart disease is inherited, it is important to assess the family medical history for possible undiagnosed heart disease.[4] 

Physical Examination

The physical examination focuses on the cardiovascular, respiratory, musculoskeletal, and neurological systems. The patient is checked for regular heart rhythm, the possible presence of murmurs and the existence of an S3 or S4 sound upon auscultation. The presence of heaves, lifts or thrills is also evaluated. The respiratory exam is used to ensure that the athlete does not have asthma or if they do, it is well controlled. Furthermore, the musculoskeletal examination serves the purpose of assessing muscle strength, joint, and extremity health.  It is especially important for athletes engaging in contact sports given the potential risk of damage to their connective tissues. Contact sports are also a concern in those with histories of the neurological disease. Lastly, psychiatric assessment is an important aspect of examining an athlete. Psychiatric illnesses might interfere with the dynamics of teamwork and participation. Some psychiatric illnesses may be exacerbated by the mental and physical stress of competitive sports. Also, the athlete's performance may not be optimal if mental illness is present.[5]

Supplement and Drug Use

A thorough medical examination of an athlete must include assessment of any supplements and drugs the athlete uses. Health and nutritional supplements are commonly used within the general population that are frequently used within the athletic communities. Certain supplements may contain ingredients that pose a health risk to the athlete and are banned for use by the World Anti Doping Agency (WADA). Also, certain supplements such as specific stimulants may be legal for use but pose a long-term cumulative health risk when used in repetitive high doses. Beyond the use of supplements, performance-enhancing drugs (PEDs) and recreational drugs are both cause for concern in athletes. PEDs are highly sport-specific, with the most commonly used ones being categorized into anabolic agents and stimulants. Anabolic drugs are further categorized into anabolic-androgenic steroids (AAS), peptide hormones and other newer drugs. An example of a new class of drugs which have become popular is selective androgen receptor modulators (SARMs); which are potentially harmful and banned by the WADA. Recreational drug use is also of concern in athletes given their health risks and interference with their function and drug testing during sporting activities. Lastly, prescribed medications should always be evaluated given their potential for causing an athlete to fail a drug test or to affect his/her performance.[6] 

Electrocardiogram

There are a variety of written opinions regarding the use of the ECG to screen athletes for cardiac defects. The decision to undergo testing may be a shared decision between the physician and the patient. It is critical to distinguish between abnormal ECG findings within the general population and normal findings in athletes. ECGs in athletes should be assessed for accessory pathways, short PR intervals, long or short QT intervals, epsilon waves, T wave inversions, excessive premature ventricular contractions, and any significant pathologic signs. Normal ECG findings in athletes include bradycardia, sinus arrhythmia, ventricular enlargement, and first-degree atrioventricular block. Additional diagnostic testing and trial treatments can be reduced significantly by distinguishing between benign and pathologic findings.[7]   

Issues of Concern

A significant issue surrounding sports pre-participation physical examinations is the potential for unnecessary diagnostic testing. The tests may reveal false positive findings and lead to further invasive testing which causes superfluous harm and anxiety to the patient. It is crucial for the physician to assess each athlete on a case by case basis to ensure unnecessary testing and treatment is minimized. 

On the issue of PED use, many users may not directly reveal to their physicians that they use PEDs. It is imperative to thoroughly assess supplement and drug use in athletes so that the athlete's health risks can be accurately evaluated. 

Clinical Significance

Athletes who experience potential cardiac symptoms, especially episodes of syncope, may be at risk of sudden cardiac death. However, the differential diagnosis for syncope in athletes should always include vasovagal events, heat stroke, dehydration, and blunt trauma. An optimal sports participation evaluation will reassure the athlete that they are not at risk of sudden cardiac death or any predictable severe injury while participating.   

Cardiac Conditions Associated With Sudden Death In Athletes

  • Hypertrophic Obstructive Cardiomyopathy - the most common cause of sudden death in young athletes by some authors [8][9] [10]
  • Coronary Artery Anomaly - the second most common cause of sudden death in young athletes 
  • Coronary Artery Disease - the most common overall cause of death in athletes due to its relatively high prevalence among older athletes [11]
  • Arrhythmias such as ventricular tachycardia - The most common cause of sudden death cited by some authors [12][11]
  • Left Ventricular Hypertrophy - can also occur due to anabolic and peptide steroid use
  • Anabolic Steroid Induced Cardiac Disease[13]
  • Arrhythmogenic Right Ventricular Dysplasia 
  • Dilated Cardiomyopathy
  • Left Ventricular Noncompaction
  • Congenital Long QT Syndrome
  • Short QT Syndrome
  • Brugada Syndrome
  • Wolff Parkinson White Syndrome
  • Catecholaminergic Polymorphic Ventricular Tachycardia
  • Early Repolarization Syndrome
  • Myocarditis
  • Commotio Cordis

Beyond assessing for the risk of sudden death, the risk of general harm to the athlete should be considered in the context of their medical history and sport of choice. 

  • Concussion history - Given the risk of neurological harm and chronic traumatic encephalopathy in contact sports
  • Rheumatologic disease - Given the forced stress induced upon an already damaged soft tissue 
  • Orthopedic injuries - Ensuring optimal recovery of prior injuries before returning to competitive sports
  • Hematologic disorders - May lead to internal organ bleeding or significant blood loss in the event of a laceration 

PEDs and Associated Health Risks

  • Anabolic steroids induce a broad range of symptoms and illnesses which may increase the long-term risk of early mortality
  • Peptide hormones may lead to cardiac structural changes that are tied to cardiac arrest and increase the risk of cancers
  • Stimulants can lead to long-term cardiovascular damage and increase the risk of both benign and dangerous arrhythmias[14]

Other Issues

Overall goals of preparticipation evaluation are to identify medical problems and treat them before initiation of the activity, identify and treat conditions that might interfere with performance and cause damage or injury, maximize the participation but minimize the potential dangers and complications. Many leagues and clubs ask for preparticipation evaluation 6-8 weeks before start day to have enough time available to do additional testing, if required. Many of them also ask for a yearly repeat of the evaluation and re-evaluation if there is a change in the level of participation. 

Chances of sudden cardiac death are minimal (1 in 100,000 young athletes per year). [15]Other potential complications are not so common. Most of the time the benefit of exercise outweigh the risks associated with it, regardless, baseline fitness of the athlete together with the type and intensity of the sport played, determine the overall risk. 

Enhancing Healthcare Team Outcomes

Health care workers should take an interdisciplinary team-based approach to ensure that athletes participate safely in sports.  Primary care physicians and nurse practitioners can provide optimal screening for their athletic patients and ensure they do not have any significant medical issues. Pharmacists also play a significant role as educators, especially in the era of supplements. Unnecessary use of nutritional and health supplements can be avoided if an athlete is thoroughly educated and has ready access to a pharmacist. 


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Sports Participation Evaluation - Questions

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A 17-year-old male patient presents with fatigue and ongoing sore throat. Rapid flu test and rapid strep tests are negative. Given the most likely etiology, which of the following symptoms would disqualify him temporarily from contact sports?



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Which of the following is not an absolute contraindication to contact sports?



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Which of the following is false regarding football injuries?



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A 16-year-old male presents for advice on how to "bulk up" for football. Which of the following is the best advice?



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A 15-year-old high school student is visiting for an evaluation before joining a local basketball team. He is overweight and gets short of breath with moderate exercise, but there is no chest pain, syncope, or dizziness. He gets better after a little rest. There is no family history of cardiac death or pathology. His vitals are within the normal range, and physical exam of heart, lungs, musculoskeletal system are without abnormal findings. What should be recommended to this patient?



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Sports Participation Evaluation - References

References

Lick D,Abdel-Aty K,Diaz D,Dulku J,Lochub S,Mir K,Ricketts R, Preparticipation Sports Physicals: A Comparison of Single Provider and Station-Based Models. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine. 2018 Nov;     [PubMed]
Lehman PJ,Carl RL, The Preparticipation Physical Evaluation. Pediatric annals. 2017 Mar 1;     [PubMed]
Pigolkin YI,Shilova MA,Zakharov SN,Sereda AP,Zholinskiy AV,Kruglova IV,Shigeev SV, [The sudden death among the young persons under effect of the different forms of physical loads]. Sudebno-meditsinskaia ekspertiza. 2019;     [PubMed]
Ison HE,Ware SM,Schwantes-An TH,Freeze S,Elmore L,Spoonamore KG, The impact of cardiovascular genetic counseling on patient empowerment. Journal of genetic counseling. 2019 Jan 24;     [PubMed]
Roberts WO,Löllgen H,Matheson GO,Royalty AB,Meeuwisse WH,Levine B,Hutchinson MR,Coleman N,Benjamin HJ,Spataro A,Debruyne A,Bachl N,Pigozzi F, Advancing the preparticipation physical evaluation: an ACSM and FIMS joint consensus statement. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine. 2014 Nov;     [PubMed]
Horwitz H,Andersen JT,Dalhoff KP, Health consequences of androgenic anabolic steroid use. Journal of internal medicine. 2018 Nov 20;     [PubMed]
Basu J,Malhotra A, Interpreting the Athlete's ECG: Current State and Future Perspectives. Current treatment options in cardiovascular medicine. 2018 Nov 19;     [PubMed]
van Driel B,Asselbergs FW,de Boer RA,van Rossum AC,van Tintelen JP,van der Velden J,Michels M, [Hypertrophic cardiomyopathy]. Nederlands tijdschrift voor geneeskunde. 2019 Feb 7;     [PubMed]
Chistiakov DA,Myasoedova VA,Melnichenko AA,Grechko AV,Orekhov AN, Role of androgens in cardiovascular pathology. Vascular health and risk management. 2018;     [PubMed]
Farzam K,Richards JR, Rhythm, Premature Ventricular Contraction (PVC) 2018 Jan;     [PubMed]
Maron BJ,Shirani J,Poliac LC,Mathenge R,Roberts WC,Mueller FO, Sudden death in young competitive athletes. Clinical, demographic, and pathological profiles. JAMA. 1996 Jul 17     [PubMed]
Finocchiaro G,Papadakis M,Robertus JL,Dhutia H,Steriotis AK,Tome M,Mellor G,Merghani A,Malhotra A,Behr E,Sharma S,Sheppard MN, Etiology of Sudden Death in Sports: Insights From a United Kingdom Regional Registry. Journal of the American College of Cardiology. 2016 May 10     [PubMed]
Eckart RE,Shry EA,Burke AP,McNear JA,Appel DA,Castillo-Rojas LM,Avedissian L,Pearse LA,Potter RN,Tremaine L,Gentlesk PJ,Huffer L,Reich SS,Stevenson WG, Sudden death in young adults: an autopsy-based series of a population undergoing active surveillance. Journal of the American College of Cardiology. 2011 Sep 13     [PubMed]
Corrado D,Basso C,Schiavon M,Thiene G, Screening for hypertrophic cardiomyopathy in young athletes. The New England journal of medicine. 1998 Aug 6     [PubMed]
Landry CH,Allan KS,Connelly KA,Cunningham K,Morrison LJ,Dorian P, Sudden Cardiac Arrest during Participation in Competitive Sports. The New England journal of medicine. 2017 Nov 16     [PubMed]

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