The Preparticipation Examination - Position Stand

Kerry C Dollaway, PT, DPT; Joel Paul PhD, Marlon Melville PhD, Terry Ali MBBS, FRCS, DM

July 22nd 2020

The preparticipation examination (PPE) consists of a group of tests performed on athletes interested in pursuing sport prior to participation. The fundamental objectives of it are to minimize short and long-term risks associated with sport participation, and to maximize the health status of athletes. Although the tests are performed before taking part in sport, it is conducted annually thereafter to safeguard the wellbeing of the athlete.

Objectives of the PPE

The preparticipation examination aims to:

• identify medical conditions that may predispose  athletes to injury or sudden death
• clear  individuals from  participating  in sport without restriction
• clear  individuals from  specific sports and prohibit them from participating in others
• clear  individuals only after  they’ve received further medical testing
• bar individuals from  participating  until medical treatment is obtained
•  bar individuals before  serious medical issues are  identified
• meet legal and insurance requirements (Carek & Mainous, 2002)

Components of the PPE

There are two main areas of the PPE

• Health Status Information
• Fitness or Performance Tests

Health Status information

Health status information (HSI) is the most critical aspect of the PPE; it can reveal 64-78% of a participant’s medical condition. HIS provides a bevy of historical data to determine the athlete’s suitability before participating in sport. To glean this information, the validated and reliable questionnaire Medical History Questionnaire (MHQ) is utilized. By itself, the MHQ gathers information on the medical history of the participant and hisher immediate family. It is more sensitive than the physical exam utilized as part of the health status information. (Kurowski & Chandran, 2000).

As part of the health status information, the physical examination is completed after the MHQ. All major organs are examined in this physical exam; these include neurological, cardiovascular, respiratory, urogenital, integumentary, musculoskeletal, and digestive systems. Additionally, Body Mass Index, blood pressure and pulse rate that signal underlying cardiac issues are examined. Further, visual acuity important in kinetic performance is taken during the physical examination test.

Fitness or Performance Testing

Fitness test are only performed if the athlete successfully passes the health status information. This tests can be used prescriptively for exercise prescription and performance enhancement. During this examination, there are three significant population.

1. Male athletes over the age of 45 and females athletes over the age of 55 since they are in the high risk category for heart disease. Graded exercise tests should be used to evaluate individuals in this category (Heart attack - Symptoms and causes, 2020). Those over 50 years old or those with other diseases such as diabetes mellitus and or hypertension will require special investigations e.g. blood tests, Stress ECG’s etc.
2. The female athlete, since increased Quadriceps (Q) angles at the knee and hip can place them at increased risk for lower extremity injuries. Athletes with a Q angle greater than or equal to 20 degrees were at greater risk for injury and had greater time lost due to injury (Rauhet al., 2007). Females are also at risk of developing the Female Triad, a cluster of interrelated disorders including disordered eating habits, amenorrhea and reduced bone mineral density which collectively increases the risk of injury, especially stress fractures and mortality (Rumball & Lebrun, 2005).  This will require specialist psychiatric assessment.
3. The athlete below the age of 17 years old since their major organ systems has not yet developed. This age group is at a higher risk of sudden cardiac death and growth plate injuries.

Other than these classification of significant persons, the Fitness and Performance tests may include flexibility, balance, body composition, muscular strength and aerobic endurance

PPE Usage in Trinidad and Tobago

There’s a dearth of data related to the use of PPE in Trinidad and Tobago. However, a recent survey of 274 elite and emerging athletes revealed no athlete used a full PPE test (Dollaway et al, 2019). Of these 274, approximately 16.4% completed some components of the PPE; while only 19.7% completed a Doctor Physical Examination, Additionally, approximately 63.8% completed a performance or fitness test, 44% never had a Physical Examination prior to beginning sport, and 36.13% did not undergo fitness or performance testing.

Recommendations

• The PPE should be used as a prerequisite to participating in sport in Trinidad and Tobago.
• Stakeholders including the Ministry of Education, Ministry of Sport, Trinidad and Tobago Olympic Committee and National Sporting Organizations should devise a policy to ensure that PPEs are performed on all athletes before they engage in sport.
• Tertiary level institutions together with the Trinidad and Tobago Olympic Committee should develop educational courses to train and certify persons to become PPE assessors.
• Regulatory bodies should be involved to ensure persons administering the PPEs are qualified and competent in carrying out the assessment.
• A standardised PPE form should be created for use in schools, clubs and national sporting organizations.
• legislation should be developed to mitigate against potential injuries due to lack of PPE examination

References

Basso, C., Rizzo, S., Carturan, E., Pilichou, K., & Thiene, G. (2020). Cardiac arrest at rest and during sport activity: Causes and prevention. European Heart Journal Supplements, 22(Supplement_E), E20-E24. https://doi.org/10.1093/eurheartj/suaa052

Carek, P. J., & Mainous III, A. (2002). The preparticipation physical examination for athletics: A systematic review of current recommendations. BMJ USA, 2, 661-664. https://doi.org/10.1136/bmjusa.02120003

Clark, J., Betz, B., Borders, L., Kuehn-Himmler, A., Hasselfeld, K., & Divine, J. (2020). Vision training and reaction training for Improving performance and reducing injury risk in athletes. Journal of Sports and Performance Vision, 2(1). https://doi:10.22374/jspv.v2i1.4

Comstock, R. D., Knox, C., Yard, E. E., & Gilchrist, J. (2006). Sports-related injuries among high school athletes - United States, 2005-06 school year. The Journal of the American Medical Association, 296(22), 2673-2674.

Dollaway, K. C., Melville, M., & Paul, J. (2019). Preparticipation examination usage in Trinidad and Tobago. Unpublished manuscript.
Harmon, K. G., & Wilson, M. G. (2020). Sudden Cardiac Death in Athletes: Incidence, Causes and Prevention Strategies. Textbook of Sports and Exercise Cardiology, 73-94. https://doi:10.1007/978-3-030-35374-2_5

Heart attack - Symptoms and causes. (2020). Mayo Clinic.  https://www.mayoclinic.org/diseases-conditions/heart-attack/symptoms-causes/syc-20373106

Kurowski, K., & Chandran, S. (2000). The preparticipation athletic evaluation. American Family Physician, 61(9), 2683-2698. https://www.aafp.org/afp/2000/0501/p2683.html

Rauh, M. J., Koepsell, T. D., Rivara, F. P., Rice, S. G., & Margherita, A. J. (2007). Quadriceps angle and risk of injury among high school cross-country runners. Journal of Orthopaedic & Sports Physical Therapy, 37(12), 725-733. https://doi:10.2519/jospt.2007.2453

Rumball, J. S., & Lebrun, C. M. (2005). Use of the preparticipation physical examination form to screen for the female athlete triad in Canadian interuniversity sport universities. Clinical Journal of Sport Medicine, 15(5), 320-325. https://doi: 10.1097/01.jsm.0000179136.69598.37

Thomas, M., Haas, T. S., Doerer, J. J., Hodges, J. S., Aicher, B. O., Garberich, R. F., Mueller, F. O., Cantu, R. C., & Maron, B. J.. (2011). Epidemiology of sudden death in young, competitive athletes due to blunt trauma. Pediatrics, 128(1) e1-e8. https://doi.org/10.1542/peds.2010-2743