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The Preparticipation Physical
Jeffrey Rosenberg MD
Residency Program in Social Medicine
Montefiore Hospital
The Preparticipation Physical
Goal– To prepare for
future preparticipation sports physicals
The Preparticipation Physical
Objectives– Understand the controversies of performing
preparticipation physicals– Review the common causes of Sudden Cardiac
Death – Learn what elements of the history or physical
exam are most important– Review the quick one minute orthopedic exam
Goal of Preparticipation Exam
Maintain the health and safety of athletes and promote safe participation
Not meant to exclude, but rather include safely
Purpose
– Detect conditions that may be life threatening or disabling---HCM, AS, ARVD
– Detect conditions that may predispose to injury--- chronic injury, laxity, subluxation,
– Address legal or insurance requirements
Secondary objectives
Provide primary care?????
Determine general health
Assess fitness level
Counsel on health-related issues
What are the CONS??
Time consumingCostly: J Sch Health 1985 Sep;55(7):270-3 – Study of 763 students; 2.1% needed further eval,
only 2 disqualified; costs $4500 per child
1 in 300,000 athletes/year have SCDRemember: they are screening examinations-most athletes that eventually die while on the field had one
Italian StudyN Engl J Med 1998 Aug 6;339(6):364-9
Prospective study of >30,000 Italians <35 yo, comparing athletes vs. nonathletes for >20 yr
269 deaths < 35yo; 49 in athletes-22% arrhythmogenic right ventricle dysplasia, 18% CAD, 12% anomalous coronary artery, 2% HCM– Non Athletes-7% HCM– HCM detected in 22 athletes-prevented
participation None Died
Evidence Base Review
Clinical Journal of Sports Medicine; May 2004– 639 papers about preparticipation screening and
sudden cardiac death– 25 original research-all type II population based
clinical studies, rest are type III case based opinion studies/position papers
– 5 studies assessed effectiveness of PPE• No randomized control trials exist
Screening Tests ECG
AHA does not recommend ECG Italy requires ECG, Echo, Stress Tests
Human physiologic cardiac adaptation vs pathologic changes-Athletic Heart Vs HCMItalian ECG study vs Echo: 51% sens, 61% specificity, PPV 7%HS Athletes: Sens 65%, Spec 97.4%; ECG picked up 23/33 problems; 2.6% further tested
Sudden Death
Very Rare: 1 per 300,000-500,00 HS athletes/yr1983-1993: Non Traumatic sports related death 126 high school; 34 college. 100 of these are cardiac in originMale 5x > FemaleCongenital Cardiac Anomalies which lead to sudden and fatal arrhythmia
Hypertrophic Cardiomyopathy
Most common cause of sudden cardiac death in young athletes in USA
Mutations in cardiac sarcomere
21% of eventual deaths have prior symptoms: exert CP, Dyspnea, Light headed, Syncope
Italy: 2% of sudden death: stringent screening
Hypertrophic Cardiomyopathy
Asymmetric LV hypertrophyDehydration/decreased preload cause increase outflow obstruction-presyncopal sx.Large muscle mass doesn’t get enough blood->ischemia->arrhythmia
Hypertrophic Cardiomyopathy
Harsh, systolic ejection murmur. Decreases with squatting (increased VR and preload); increases when standing up (decrease VR and preload)
Diagnosis confirmed by ECHO
Idiopathic LVH (10% of deaths):concentric
Congenital Coronary Anomaly
18-20% of sudden cardiac death
Origin from right sinus
31% have previous sx
Stress echo or Cardiac Cath
Marfan’s syndrome
Autosomal Dominant, connective tissue dis. 1:5000; Defect in gene for fibrillin protein
Complicated Diagnosis: Cardiac, Optho, Muskuloskeletal, Skin Involvement. Genetic Testing
Echo: dilated aortic root or MVP w/MR
Contact/Strenuous Sports Contraindicated
Other Causes of Sudden Death
Myocarditis-Absolute Contraindication to physical activity. Viral; >50% coxsachie B– Need 6 months post illness before exertion
Wolff Parkinson White-contraindication until ablated
Long QT syndrome-risk of Torsades de Pointe; familial or from meds
ARVD
Arthymogenic Right Ventricular Dysplasia
Autosomal dominant with variable penetrance
Replacement of cardiac cells with fat or fibrosis predominately in Right Ventricle
Sudden arrhythmia and death
MRI can be useful; Treatment is AICD
History
Most important aspect of PPE to is screen for cardiac symptoms, asthma, review family hx.
Board of Education form doesn’t list all important symptoms
Family History of sudden death <50 yo in 1st degree relative: HCM, Long QT, Congenital coronary anomaly, Arrhythmia
Cardiac Screening Questions:
Dizzy or Syncope during/after exercise
Chest Pain during/after exercise
Tired more quickly than others
Racing of heart or skipped beats
High Blood Pressure/High Cholesterol
Heart Murmur
Cardiac Screening Questions
Family member died before age 50
Recent Mononucleosis/Myocarditis
Has a physician ever limited your participation in sports
Any relatives with cardiomyopathy, Marfan’s syndrome, heart arrhythmia
RED FLAG SYMPTOMS:
Wheezing with exertion: EIB (85% of asthmatics have EIB)
History of Concussion: MTBI causes neuropsychiatric symtoms-headaches, fatigue, memory loss
History
Menstrual History: Primary amenorrhea, or secondary (>3 months): Female Triad
Meds: Albuterol, Theophylline, TCA, Pseudophedrine, stimulants
Anabolic Steroid Usage: 9% HS, 3% JHS
Hypertension
Age Appropriate values most important
Mild to Moderate HTN, no evidence of End-organ damage OK to compete; evidence of End organ damage NOT allowed until treated
Severe HTN NOT allowed until treated
Hypertensive ValuesPediatrics 99:637-678
Age Mild Moderate Severe Very Severe
13-15 135-39
85-89
140-149
90-94
150-159
95-99
>160
>100
16-18 140-149
90-95
150-159
95-99
160-169
100-109
>170
>110
Orthopedic Issues
Previous sports injuries: attention to ankles, knees, shouldersAnkle sprain need full rehabilitation to regain proprioceptionShoulder dislocation may need surgical repair to decrease another incident; rehab for Rotator Cuff SymptomsKnee instability: r/o ACL, Meniscus tear
Physical Findings
Gen:– Obesity, Phenotypic Variation (Marfan's)
Skin: – Impetigo, Molluscum, Herpes, Scabies
Visual Acuity > 20/40
Physical Findings
Pulmonary:– Wheezing
Abdomen:– Organomegaly
GU:– Testicle Exam, teach STE– Single Testicle: Needs Protection
Cardiac Findings
Palpate PMI; S3, S4, midsystolic clickAusculate with pt supine; again standing or Valsalva: – HCM: Murmur incr. with decreased end
diastolic volume: when squatting ->standing; release of Valsalva
– AS: Increases with squatting, decreases with Valsalva
Femoral Pulses
One Minute Orthopedic Exam
Screen for normal range of motion and strength
Orthopedic Issues
Neck:– Previous C-Spine Injury– Stingers: OK as long as symptoms resolve
Back:– Kyphosis, Scoliosis– Range of motion: pain with extension occurs
with stress fractures, spondylolithesis
Orthopedic Issues
Shoulder:– ROM, Instability, RTC strength
Knee:– Lachmans, Valgus/Varus Stress, Q angle
Ankle:– Anterior drawer test