The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore...

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