Pre-Participation Physical Pre-Participation Physical

ExaminationsExaminationsDr.RAJAT JANGIRDr.RAJAT JANGIR

Consultant Arthroscopy and Orthopedic Consultant Arthroscopy and Orthopedic SurgeonSurgeon

Saket Hospital, MansarovarSaket Hospital, MansarovarAssistant Professor Assistant Professor

Mahatma Gandhi Medical College, JaipurMahatma Gandhi Medical College, Jaipur

Fellowship In Arthroscopy(South Korea)International Olympic Committee Diploma Sports Medicine(UK)Sports Physician RIO Olympic 2016

IPC Medical Code

Fitness to practice a sport46. Prior to engaging in competitive sport, and preferably with regular intervals throughout their athletic career, athletes should undergo pre- participation evaluation....

The International Olympic Committee (IOC) Consensus Statement on Periodic Health

Evaluation of Elite Athleteshttp://www.olympic.org/assets/importednews/documents/en_r eport_1448.pdfBr J Sports Med. 2009 Sep;43(9):631-643.

PPEPPE Goals of the PPEGoals of the PPE

Preparation for the PPEPreparation for the PPE

Medical historyMedical history

Components of the PPEComponents of the PPE

Clearance for participationClearance for participation

Goals of the PPEGoals of the PPE Determine general health and current Determine general health and current immunization statusimmunization status

Establish rapport with participantEstablish rapport with participant

Detect medical conditions that can Detect medical conditions that can predispose one to injury/illness so predispose one to injury/illness so treatment can be continued/initiatedtreatment can be continued/initiated

Identify health risk behaviors that can be Identify health risk behaviors that can be addressed with counselingaddressed with counseling

Goals of the PPEGoals of the PPE Establish baseline parameters for return to Establish baseline parameters for return to play decisionsplay decisions

Assess physical maturityAssess physical maturity

Evaluate physical fitnessEvaluate physical fitness

Make recommendations regarding Make recommendations regarding participation/exerciseparticipation/exercise

Meet legal requirements to athletic Meet legal requirements to athletic participationparticipation

Goals of the PPEGoals of the PPE

Specific focus of PPE varies amongst Specific focus of PPE varies amongst populationspopulations Pre-pubescentPre-pubescent

Undiagnosed congenital abnormalitiesUndiagnosed congenital abnormalities PubescentPubescent

Maturation level, establishing healthy behaviorsMaturation level, establishing healthy behaviors Young adultYoung adult

History of previous injury, sport-specific examHistory of previous injury, sport-specific exam AdultAdult

Overuse conditions predominateOveruse conditions predominate

SUDDEN DEATHSUDDEN DEATH

• Sudden death in athletics can occur from Sudden death in athletics can occur from direct or indirect causesdirect or indirect causes• direct - traumaticdirect - traumatic• indirect - atraumaticindirect - atraumatic

SUDDEN DEATHSUDDEN DEATH

• Most indirect causes are cardiac in origin.Most indirect causes are cardiac in origin.• A very small number of indirect causes of A very small number of indirect causes of

sudden death are noncardiacsudden death are noncardiac• heat strokeheat stroke• CVACVA• pulmonary emboluspulmonary embolus• drug abusedrug abuse

PPE: The HistoryPPE: The HistoryHistory forms are very helpfulHistory forms are very helpful athletes and parents should jointly complete a athletes and parents should jointly complete a

history form prior to the PPEhistory form prior to the PPE Review form: 75% of issues detected through Hx Review form: 75% of issues detected through Hx

alonealoneWeb based history forms may be more Web based history forms may be more convenient for the athletes (ePPE) convenient for the athletes (ePPE) Preparticipation form recommended by the Preparticipation form recommended by the AAFP, AAP, AMSSM, and AOSSM is available in AAFP, AAP, AMSSM, and AOSSM is available in the the Preparticipation Physical Evaluation, 4Preparticipation Physical Evaluation, 4thth ed. ed. 2010.2010.

Preparation for the PPEPreparation for the PPE

No one best/right way to do PPENo one best/right way to do PPE

Influenced by several factorsInfluenced by several factors Level of competitionLevel of competition Availability of personnel and Availability of personnel and facilitiesfacilities

Number of PPE being conductedNumber of PPE being conducted Personal preference/historyPersonal preference/history

Preparation for the PPEPreparation for the PPE

FormatFormat

TimingTiming

FrequencyFrequency

PPE FormatPPE Format

Primary care physician modelPrimary care physician model Enhanced knowledge of medical Enhanced knowledge of medical history, immunization status and history, immunization status and prior injuries that could limit prior injuries that could limit participationparticipation

Generally a more thorough examGenerally a more thorough exam Affords best privacy and better Affords best privacy and better environment for counselingenvironment for counseling

Cost is expensive – insurance?Cost is expensive – insurance?

PPE FormatPPE Format

Group/station modelGroup/station model Good for large number of PPE in Good for large number of PPE in given period of timegiven period of time

Individual personnel responsible Individual personnel responsible for given element of PPE at for given element of PPE at ““stationstation””

Clearance verified by team MD at Clearance verified by team MD at end of PPEend of PPE

Typically free of chargeTypically free of charge

PPE TimingPPE Timing Ideally completed several weeks Ideally completed several weeks prior to initial practiceprior to initial practice

Allows ability to address any Allows ability to address any problems identified on PPE (labs, problems identified on PPE (labs, tests, records) without impeding tests, records) without impeding participation statusparticipation status

Typically done within 1 week prior Typically done within 1 week prior to first scheduled activity – high to first scheduled activity – high schools often over summerschools often over summer

PPE FrequencyPPE Frequency

Entry-level PPE (complete) at Entry-level PPE (complete) at outset of participation for outset of participation for school/organizationschool/organization

Recommended annual re-Recommended annual re-evaluation without complete PPE evaluation without complete PPE unless warrantedunless warranted

Medical HistoryMedical History

Generally accomplished ahead of Generally accomplished ahead of time in yes/no formattime in yes/no format Often a supplemental form for femalesOften a supplemental form for females

For station model, qualified For station model, qualified evaluator must review history and evaluator must review history and red flag potential concerns for red flag potential concerns for further scrutiny/evaluationfurther scrutiny/evaluation

Components of the PPEComponents of the PPE

Vital signsVital signs General medical General medical problemsproblems

CardiovascularCardiovascular Pulmonary Pulmonary MusculoskeletalMusculoskeletal NeurologicNeurologic EyesEyes

Dental Dental Gastrointestinal Gastrointestinal GenitourinaryGenitourinary DermatologicDermatologic Examination for Examination for heat disordersheat disorders

Laboratory testsLaboratory tests

Vital SignsVital Signs

Establishes individualEstablishes individual’’s baseline s baseline parametersparameters Height/weightHeight/weight

Comparison to normative dataComparison to normative data Pulse/respiratory rate (60-100/12-16)Pulse/respiratory rate (60-100/12-16)

Observe quantity and qualityObserve quantity and quality Blood pressure (120/80)Blood pressure (120/80)

Cuff size very importantCuff size very important Body temperature (98.6/37.0)Body temperature (98.6/37.0)

Oral vs. tympanic vs. axillary (rectal)Oral vs. tympanic vs. axillary (rectal)

General Medical General Medical ProblemsProblems

Questions asked regardingQuestions asked regarding Currently being treated for Currently being treated for illness/injuryillness/injury

History of hospitalization or surgeryHistory of hospitalization or surgery History of progressive disease (MS, History of progressive disease (MS, MD, cancer)MD, cancer)

Current use of OTC/Rx medsCurrent use of OTC/Rx meds Allergies to meds, food, environmentAllergies to meds, food, environment

Cardiovascular Cardiovascular ExaminationExamination

Done in quiet area to maximize validityDone in quiet area to maximize validity

Auscultation of heart soundsAuscultation of heart sounds

Questions asked regardingQuestions asked regarding Fainting (syncope), dizziness, SOB, chest pain with Fainting (syncope), dizziness, SOB, chest pain with exertionexertion

Heart palpitations, tachycardia, dysrhythmia, known Heart palpitations, tachycardia, dysrhythmia, known murmurmurmur

Family member with sudden, early cardiac deathFamily member with sudden, early cardiac death

Positive responses to any necessitate referral Positive responses to any necessitate referral to cardiologist for further evaluationto cardiologist for further evaluation

Pulmonary ExaminationPulmonary Examination Done in quiet area to maximize validityDone in quiet area to maximize validity

Auscultation of breath sounds in all Auscultation of breath sounds in all lung lobes – look for symmetrical lung lobes – look for symmetrical movement of diaphragmmovement of diaphragm

Questions asked regardingQuestions asked regarding Excessive coughing during/after activityExcessive coughing during/after activity History of asthma, bronchitis, allergiesHistory of asthma, bronchitis, allergies SOB, unusual breath sounds during/after SOB, unusual breath sounds during/after activityactivity

History of collapsed lung (pneumothorax)History of collapsed lung (pneumothorax)

Musculoskeletal Musculoskeletal ExaminationExamination

Basic exam consists of observation Basic exam consists of observation for symmetry, ROM, strength tests for symmetry, ROM, strength tests for major muscles and specific tests for major muscles and specific tests for previously injured areasfor previously injured areas

Questions asked regardingQuestions asked regarding Focus on history of injury, time frame, Focus on history of injury, time frame, evaluation, treatment and rehabilitationevaluation, treatment and rehabilitation

Use of protective devicesUse of protective devices

Neurologic ExaminationNeurologic Examination Evaluation consists of cranial nerve Evaluation consists of cranial nerve tests including pupil function, tests including pupil function, sensory/motor tests of UE/LE, deep sensory/motor tests of UE/LE, deep tendon reflexestendon reflexes

Questions asked regardingQuestions asked regarding History of head injuriesHistory of head injuries Any previous loss of consciousnessAny previous loss of consciousness Numbness/tingling, loss of motor function in Numbness/tingling, loss of motor function in bodybody

History of seizures, burners/stingersHistory of seizures, burners/stingers

Eye ExaminationEye Examination Visual acuity assessed via Snellen chart, Visual acuity assessed via Snellen chart, both monocularly and binocularly (use both monocularly and binocularly (use corrective lenses)corrective lenses) Emmetropia (20/20 vision)Emmetropia (20/20 vision) Myopia (nearsightedness)Myopia (nearsightedness) Hypermetropia (farsightedness)Hypermetropia (farsightedness)

Questions asked regardingQuestions asked regarding Use of corrective lenses/typeUse of corrective lenses/type Blurring or double visionBlurring or double vision Color blindness, peripheral vision lossColor blindness, peripheral vision loss History of eye trauma, retinal detachmentHistory of eye trauma, retinal detachment

Dental ExaminationDental Examination

Typically done by dentist – not Typically done by dentist – not meant to perform preventative care meant to perform preventative care but to establish pre-existing but to establish pre-existing conditions for liability reasons in conditions for liability reasons in case of dental injurycase of dental injury

Allows opportunity for dental molds Allows opportunity for dental molds to be made for crafting of custom to be made for crafting of custom mouthguardmouthguard

Gastrointestinal Gastrointestinal ExaminationExamination

Evaluation of digestive system, eating habits Evaluation of digestive system, eating habits and nutritionand nutrition Concerns for athletes where image is important to Concerns for athletes where image is important to activityactivity

Evaluation done supine with palpation for Evaluation done supine with palpation for masses or organomegalymasses or organomegaly

Questions regardingQuestions regarding History of heartburn, indigestion, diarrhea or History of heartburn, indigestion, diarrhea or constipationconstipation

Prior history of organ injury (spleen, liver, kidney)Prior history of organ injury (spleen, liver, kidney)

Genitourinary Genitourinary ExaminationExamination

For males, questions asked regardingFor males, questions asked regarding Hernias, testicular torsion, absent or undescended Hernias, testicular torsion, absent or undescended testicletesticle

For females, questions asked regardingFor females, questions asked regarding Menstrual cycle, pregnancyMenstrual cycle, pregnancy

General questions asked regardingGeneral questions asked regarding History of bladder/urinary tract infections, STDsHistory of bladder/urinary tract infections, STDs Absence of one kidneyAbsence of one kidney

Can include urinalysis to look for proteins, Can include urinalysis to look for proteins, blood, sugar and hemoglobin in urineblood, sugar and hemoglobin in urine

Dermatologic Dermatologic ExaminationExamination

Skin evaluated for rashes, lesions, Skin evaluated for rashes, lesions, infections that can be contagious to infections that can be contagious to othersothers Herpes, fungal infections (tinea), Herpes, fungal infections (tinea), impetigo, STDs, acne/treatmentimpetigo, STDs, acne/treatment

Also look at existing blemishes (warts, Also look at existing blemishes (warts, moles, etc.)moles, etc.) Change in appearance (size, color, border, Change in appearance (size, color, border, etc.) in recent pastetc.) in recent past

Examination for Heat Examination for Heat DisordersDisorders

Especially important for activities Especially important for activities taking place under conditions of taking place under conditions of high temperature, high humidity or a high temperature, high humidity or a combination of the twocombination of the two

Questions asked regardingQuestions asked regarding History of heat illness (cramping, History of heat illness (cramping, syncope, exhaustion, stroke)syncope, exhaustion, stroke)

Current meds (diuretics, antihistamines)Current meds (diuretics, antihistamines) Use of caffeinated/alcoholic beveragesUse of caffeinated/alcoholic beverages Nutritional and hydration habitsNutritional and hydration habits

Laboratory TestsLaboratory Tests

Not typical associated with PPE – Not typical associated with PPE – usually due to cost of testing usually due to cost of testing proceduresprocedures

Often used when/if red flags Often used when/if red flags appear during PPEappear during PPE UrinalysisUrinalysis Blood workBlood work ECGECG

Clearance for Clearance for ParticipationParticipation

Conditions to be met to allow clearance Conditions to be met to allow clearance by ME at end of PPEby ME at end of PPE Will condition increase risk of injury to Will condition increase risk of injury to individual or others?individual or others?

Can participation be allowed if meds, rehab Can participation be allowed if meds, rehab or protective bracing/padding is used? If or protective bracing/padding is used? If so, can limited participation be allowed in so, can limited participation be allowed in interim?interim?

If clearance is denied for particular If clearance is denied for particular activity, can other safe activities be activity, can other safe activities be identified and clearance be granted for them?identified and clearance be granted for them?

Clearance for Clearance for ParticipationParticipation

Individuals have right to Individuals have right to participate in any activity participate in any activity regardless of pre-existing medical regardless of pre-existing medical condition/scondition/s

PhysicianPhysician’’s cannot exclude s cannot exclude individual from participation – can individual from participation – can only recommend against participationonly recommend against participation

Conditions that Conditions that Contraindicate Sports Contraindicate Sports

Participation Participation Active myocarditis or pericarditisActive myocarditis or pericarditis

Hypertrophic cardiomyopathy Hypertrophic cardiomyopathy Severe hypertension until Severe hypertension until Poorly controlled convulsive disorder Poorly controlled convulsive disorder

no archery, riflery, swimming, weight lifting no archery, riflery, swimming, weight lifting or power lifting, strength training or sports or power lifting, strength training or sports involving heights)involving heights)

Recurrent episodes of burning upper-Recurrent episodes of burning upper-extremity pain or weakness, or episodes extremity pain or weakness, or episodes of transient quadriplegia until stability of transient quadriplegia until stability of cervical spine can be assured (no of cervical spine can be assured (no contact or collision sports)contact or collision sports)

Conditions that Conditions that Contraindicate Sports Contraindicate Sports

ParticipationParticipation Sickle cell disease (no high-Sickle cell disease (no high-exertion, contact or collision exertion, contact or collision sports) sports)

Eating disorder where athlete is not Eating disorder where athlete is not compliant with therapy and follow-compliant with therapy and follow-up, or where there is evidence of up, or where there is evidence of diminished performance or potential diminished performance or potential injury because of eating disorderinjury because of eating disorder

Acute enlargement of spleen or liver Acute enlargement of spleen or liver