Preparticipation Orthopedic Screening Evaluation

8/10/2019 Preparticipation Orthopedic Screening Evaluation

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Preparticipation Orthopedic Screening Evaluation[Thematic Issue]

Garrick, James G. MD

From the Department of Pediatrics, Universit of !a"ifornia#$anFrancisco, $an Francisco, !%.%ccepted March &''(.)eprints* Dr. James G. Garrick, !enter for $ports Medicine, +'' de,$an Francisco -e#mai"* JGGarrick mac.com/.Abstract

012ective* To revie3 evidence#1ased support for the preparticipationorthopedic eva"uation.

Data $ources4Methods* %rtic"es 3ere revie3ed that dea"t 3ith thesensitivit , specificit , and predictive va"ue of the components of thestandardi5ed preparticipation orthopedic eva"uation. In addition,studies descri1in6 muscu"oske"eta" conditions4findin6s predictive offuture in2uries 3ere sou6ht throu6h a Pu1Med search.

)esu"ts* The sensitivit of the eva"uation 7uestionnaire appears to 1eade7uate, e8ceedin6 +'9 in some studies. There is "itt"e or nopu1"ished information documentin6 that the ph sica" e8amination -:/approaches the 7uestionnaire in either sensitivit or specificit or -&/identifies e"ements of va"ue 1ased on their association 3ith futurein2uries or rein2uries. There are no readi" discerni1"e e"ements even inan e8panded e8amination that are documented as 1ein6 predictive offuture pro1"ems.

!onc"usions* The current 7uestionnaire and e8amination appear tofu"fi"" ade7uate" 1oth "e6a" and institutiona" re7uirements.Practitioners shou"d 1e a3are of the a1sence of data "inkin6 virtua""an of the findin6s on the e8amination to either an increase or adecrease in the "ike"ihood of future in2uries. There is no evidence thatincreasin6 the scope of the e8amination 3ou"d enhance its predictive

va"ue.


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The ori6ina" preseason orthopedic screenin6 e8amination, descri1ed in:+;;, : had < ma2or purposes* -:/ it 3ou"d fu"fi"" the institution=s "e6a"and insurance re7uirements, -&/ it 3ou"d assure the coaches that teammem1ers 3ou"d start the season 3ith some common "eve" of hea"thand fitness, ->/ it 3ou"d provide the medica" team 3ith the opportunit

to discover treata1"e conditions that mi6ht interfere 3ith or 1e3orsened 1 ath"etic participation, -(/ it mi6ht aid inpredictin64preventin6 future in2uries, and -


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3ou"d re7uire a su1stantia"" hi6her "eve" of kno3"ed6e and ski"" on thepart of the e8aminer, makin6 the task impractica", especia"" at thehi6h schoo" and outh sports "eve"s.

In 6enera", a positive response from the histor , re6ard"ess of ho3

comprehensive the form is, 3i"" in itse"f neither prec"ude nor de"aapprova" for participation. This decision rests 3ith the findin6s from adirected e8amination.

o3ever, none 3ou"d ar6ue that the histor portion of the eva"uation,even thou6h far from perfect, is the most va"ua1"e too" fordocumentin6 previous in2uries and muscu"oske"eta" pro1"ems. Indeed,virtua"" ever investi6ator has found that the preparticipation historis much more "ike" to unearth previous in2uries than the actua"ph sica" e8amination. 0ne of the more comprehensive studies ofefficac of the eva"uation p"aces the sensitivit of the histor at +:. 9Afar a1ove the


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"ike"ihood of su1se7uent in2ur . Pu1Med searches of the termsweakness or strength a6ainst the common" in2ured anatomic re6ions-for e8amp"e, knee, ank"e, thi6h, and shou"der/ revea"ed 1ut a sin6"ecitation that su66ested 3eakness as a predictor of future in2ur Ainthis case, adductor 3eakness in ice hocke p"a ers. The search fai"ed

to revea" an other investi6ation that identified a specific a1norma"itof stren6th or motion that 3as associated 3ith an increased in2urrate. There 3ere, ho3ever, man artic"es descri1in6 the 3eaknessaccompan in6 various in2uries.

There are indeed tests for specific in2uries that are 1oth sensitive andspecific. In their meta#ana" sis of tests common" used in anorthopedic e8amination of the knee, Ma"an6a et a" ; pointed out that,for e8amp"e, the Eachman and pivot shift tests often reachedsensitivities e8ceedin6 +'9. %side from the fact that the performanceof these tests re7uires an e8perienced e8aminer, the predictive va"ueof a positive test remains e"usive.

The :(#point e8amination presented in the Preparticipation Ph sica"Bva"uation & appears to have 3ithstood the test of time - Fi6. : /. Threema2or studies >, ,+ e8aminin6 the efficac of the ori6ina" screen mahave p"a ed some ro"e in the addition of the h pere8tension step tothe "um1ar spine e8amination and the interna" rotation step in theshou"der e8amination. Kased on their comparison of the screen 3ith acomprehensive orthopedic e8amination, Gome5 et a" > a"so su66estaddin6 a test for supraspinatus stren6th and a d namic stren6th test

-1a"ancin6 on : foot/ in the ank"e se7uence.
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$I%U E &' %ener a lm

Idea"" , a screenin6 e8amination 3ou"d 1e hi6h in sensitivit , "eavin6specificit to the directed e8amination. Unfortunate" , the studiesdescri1ed revea"ed overa"" sensitivities rare" approachin6


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a1norma"itiesN for in2ur , and ->/ the "ack definitive proof thatcorrective interventions a"ter outcome. ?e have 1een una1"e to findan evidence contrar to the a1ove statements.

There does appear to 1e a1undant evidence that man anatomic

re6ions, once in2ured, have an increased "ike"ihood of future in2ur .These re6ions inc"ude the knee, ank"e, and shou"der. Unfortunate" , theactua" reason for the propensit to future in2uries has escapeddetection. Prec"udin6 ath"etic participation 1ased simp" on thepresence of a previous in2ur , even thou6h the ath"ete ma 1e more"ike" to sustain a future simi"ar in2ur , is not a rea"istic approach.

Performin6 a muscu"oske"eta" e8amination is a chi""in6 e8perience forthe nonorthopedist 3ith "itt"e sports medicine e8perienceAthe verindividua" for 3hom the screenin6 e8amination 3as desi6ned. From thestandpoint of muscu"oske"eta" fami"iarit , the e8amination must p"a tothe "east common denominator. %n e8amination that is 1ased on visua"o1servations re"ieves the e8aminer of the necessit of ac7uirin6 ne3ski""s re7uired to perform the tests so common in orthopedice8aminations. Indeed, the current" used and approved e8amination isessentia"" a test of s mmetr . & The e8aminer need not kno3 ho3 1i6a 7uadriceps musc"e shou"d 1e 1ut rather 3hether it is simi"ar to thecontra"atera" side. Eike3ise, one need not kno3 the norma" ran6e ofmotion of the shou"der 1ut rather on" that 1oth sides are e7ua".

CO#CLUSIO#S

The Preparticipation Ph sica" Bva"uation has served as the approvedeva"uation since :++&. )evised in :++;, it has remained unchan6edsince that time. %"thou6h investi6ators have 7uestioned 1oth its uti"itand accurac , no one has offered an a"ternative appropriate for those3ho 3i"" actua"" 1e performin6 the e8amination. %1sentdocumentation of conditions tru" predictive of future in2uries, thecreation of a 1etter eva"uation is un"ike" .

E$E E#CES

:. Garrick JG, )e7ua )O. In2uries in hi6h schoo" sports. Pediatrics .:+; :*( < ( +. (ibliographic Lin)s Librar* Holdings [!onte8t Eink]

&. %merican %cadem of Fami" Ph sicians, %merican %cadem of Pediatrics,%merican Medica" $ociet for $ports Medicine, %merican 0rthopaedic $ocietfor $ports Medicine, %merican 0steopathic %cadem of $ports Medicine.
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Preparticipation Ph sica" Bva"uation. &nd ed. Minneapo"is* The Ph sician and$portsmedicine :++;. [!onte8t Eink]

>. Gome5 JB, Eandr GE, Kernhardt DT. !ritica" eva"uation of the minuteorthopedic screenin6 e8amination. Sports Med . :++> :(;*::'+ :::>.[!onte8t Eink]

(. Go"d1er6 K, $araniti %, ?itman P, et a". Preparticipation sports assessmentAan o12ective eva"uation. Pediatrics . :+ ' *;> ;(*>< (&. (ibliographic Lin)s Librar* Holdings [!onte8t Eink]

The Pu1Med search 3as focused on citations 3ith the ke 3ords ineither the tit"e or a1stract. The ke 3ord strin6s 3ere, H3eakness %@Dknee in2uries -n Q /, H3eakness %@D ank"e in2uries -n Q >/,

H3eakness %@D ank"e sprains -n Q ::/, H3eakness %@D shou"derin2uries -n Q ; /, H3eakness %@D in2ur prevention -n Q & /, and

Hin2ur prevention %@D ran6e of motion. Date ran6es 3ere from :+

to Fe1ruar &''(. [!onte8t Eink]

Oe 3ords* preparticipation orthopedic screenin6 eva"uation evidence1ased orthopedic screenin6 eva"uation
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Preparticipation Orthopedic Screening Evaluation