The Pre-Participation Sports Examination Jeffrey A. Zlotnick, MD CAQ FAAFP DABFP Family & Sports Medicine Asst. Clinical Professor Family and Primary Care

The Pre-Participation Sports Examination Jeffrey A. Zlotnick, MD CAQ FAAFP DABFP Family & Sports Medicine Asst. Clinical Professor Family and Primary Care Sports Medicine Rutgers - Robert Wood Johnson Medical School Rutgers - New Jersey Medical School Philadelphia College of Osteopathic Medicine Medical Consultant Healthy Athletes Initiative Special Olympics New Jersey New Jersey Academy of Family Physicians

Jeffrey A. Zlotnick, MD CAQ New Jersey Academy of Family Physicians The Pre-Participation Exam Primary Goal is the Health and Safety of the athlete Objective is to be INCLUSIVE, not to try to exclude participation NOT a substitute for the regular health examinations by the Primary Care Physician

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Primary Objectives Detect conditions that may limit participation Atlanto-axial instability in Downs Heart murmurs: Innocent vs. HCM Detect conditions that may lead to injury Lack of physical conditioning, weak muscles Poor exercise tolerance, heat intolerance High amount of major joint problems ex; Miserable Misalignment Syndrome Meet legal and insurance requirements

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Secondary Objectives Assess the general health of the athlete May be the ONLY opportunity you will have to see this patient & go into issues such as immunizations, substance abuse, birth control Counsel the athlete on health related issues Assess growth & development Tanner staging can be helpful where less mature athlete is playing against a more mature athlete: HIGH risk for injury in contact sports (Exam can be embarrassing) Assess fitness level & performance Help identify weaknesses that may increase chances of injury ex; Swimmers with weak pectoral muscles

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Timing Best done at a MINIMUM of SIX weeks prior to the start of practices Gives time to identify & correct problems that were noted on the exam

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Frequency Vary from before each season to every few years (few is variable) Optional: short interval history and go after specific changes or problems Once yearly is the most popular

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Methods Private office by Primary Care Physician Multi-station exam with different providers of various types (physicians, nurses, PAs) Each type has its advantages and disadvantages In-school physical Currently not in NJ to get athletes to have a Medical Home. However, there are exceptions

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Private Office Advantages PCP knows the PMHx, the FHx, Immunizations Less likely to overlook problems Young athlete will be more willing to discuss sensitive issues with a known person Easier/Less embarrassing to do GU exam (if indicated) Less chance that abnormalities found will be overlooked and not followed up on

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Private Office Disadvantages Many athletes dont have a PCP Limited time for appointments: Time consuming Varying levels of knowledge and interest in sport specific problems Must be well versed in Sports-specific demands Greater cost: Many cant afford Higher income athletes will tend to go to different specialists for each problem found Tendency for poor communication between the PCP and the school athletic staff Many un-indicated disallowed athletes

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Multi-Station Advantages Cost-effective and easy to screen large numbers of athletes Specialized personnel at each station Usually 5-6 stations Good communication with the school athletic staff since the Coach & ATs are usually part of the team

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Multi-Station Disadvantages Requires a large amount of space Hurried, noisy, with minimal privacy Difficult for GU exam, Heart murmurs Continuity of care easily lost, problems noted are NOT followed up upon Lack of communication with parents Particular consultant may put unreasonable demands on an athlete Varying level of training of school physicians

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Multi-Station Required Station Sign-in, Ht/Wt, Vital signs, Vision History review, Physical (medical, orthopedic, & neurological) assessment/clearance Personnel Coach, Trainer, Nurse, volunteer Physician

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Multi-Station Optional Station Specific orthopedic exam Flexibility Body composition Strength Speed, agility, power, endurance, balance Personnel Physician Trainer or therapist Physiologist Trainer, coach, therapist, physiologist Trainer, coach, physiologist

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians MEDICAL HISTORY IS KEY!! Statistics show that a good history will identify 63-74% of medical problems! Anecdotally information from the athlete agrees with the parents less than half of the time! Medicine & Science in Sports & Exercise: Volume 31(12) December 1999p 1727

Key Questions Need to be asked or put on a questionnaire that is reviewed

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Ever been treated in a hospital or had surgery? Important to know number and severity of Traumatic Brain Injuries (concussions) Determine if certain medical conditions are under control enough to allow or limit participation Diabetes, Asthma Has enough time been allowed to heal and rehabilitate from surgery?

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Taking any Rxs, OTCs, Drugs? History of Rxs important to assess control Diabetes, Asthma Does the athlete require any emergency drugs that the coach/AT will need to know about AND how to use them! Get information on birth control measures, menstrual history Amenorrhea in women athletes can lead to a high risk of stress fractures (Female Athletic Triad) Good way to introduce talk on STDs

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Taking any Rxs, OTCs, Drugs 2 Get information on OTC use as athletes tend to abuse these: OTC asthma, decongestants, diet pills can cause increased heart rate and arrhythmia's NSAIDs can cause increased bleeding, renal damage Laxatives (wrestlers) can cause electrolyte abnormalities Try to get history of illicit drug use Alcohol, tobacco, marijuana, steroids

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Allergies? Drugs Know what can and CANT be given in case of an emergency Bees, Insects - important in outdoor sports Need to carry an EpiPen?

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Skin Problems, Rashes? Mainly looking for herpes, scabies, lice, molluscum contagiosum Impetigo, herpes and others can be spread by mats, helmets, towels Acne and other atopic conditions can be exacerbated by clothing or equipment

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians History of Head Injury, LOC, Seizure, Burners or Stingers? Seizure history (epilepsy?) LOC & HA Hx important to determine ability to resist Traumatic Brain Injury & risk for Second Impact Syndrome Burners/stingers are Brachial plexus injuries Usually resolve but are occasionally permanent Cervical cord neuropraxia w/ transient quadriplegia: Rare! Associated w/ cervical stenosis, congenital fusions, cervical instability, disc problems

ANY History of Recurrent burners/stingers, or transient quadriplegia? NEED Cervical spine films BEFORE being allowed to participate!

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Concussion? 1.6 to 3.8 million sports-related TBIs occur each year Concussion accounts for 6-10% of all sport related injuries Higher risk among high school athletes in contact sports Langlois, 2006 TBI can be cumulative Cognitive Function (Punch Drunk) Memory Ability to learn Reaction time Increased risk of Second Impact Syndrome Primarily younger (pre-adolescent) athletes

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Heat or muscle cramps? History of dizziness or passing out during activities in the heat Determines ability to tolerate heat or prolonged events Marathons

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Difficulty Breathing? During or after activity? Seasonal: allergies vs. asthma Also could be cardiac HCM Valvular disease Arrhythmia's

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Special Equipment/Braces? Inspect for fit & function Risk to other players?

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Problems with Eyes/Glasses? Is athlete single-eyed Less than 20/50 as best in one eye Hx of orbital fractures

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Sprains / Strains / Fractures / Dislocations? Need to determine need for rehabilitation PRIOR to being allowed to participate

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Other Questions Medical problem or injury since last evaluation (periodic exam) Immunizations up to date? Td, Hep B, MMR, Meningitis Women: 1st menses, last menses, Longest time between menses Family use of tobacco, alcohol, street drugs How about yourself??

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Most Important Questions Ever passed out or became significantly dizzy during/after exercise? Ever have chest pain during/after exercise? Do you tire more quickly than your peers? Hx of increased BP, heart murmur? Hx of heart racing/skipping beats? FHx of sudden death before age 50? Hx of concussion (Traumatic Brain Injury)

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Keep in mind: 90% of sudden death in athletes

Key Components of the Physical Exam

Height & Weight Compare to growth charts for age/sex Body fat: male 5-10%, female 12-15% Very thin: Ask about diet, weight loss, body image (r/o anorexia, bulimia) Optional: Body composition: Skin fold calipers easiest Electronic scales Total immersion more accurate Good time to discuss weight in athletes where weight is important Wrestling, Ice Skating, Gymnastics

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Eyes Absence of 1 eye or vision >20/50 in the best eye: AVOID COLLISION SPORTS! Anisicoria: slight/baseline is normal and should be noted (1-2mm) Large difference needs neurological workup first!

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Cardiovascular BP: Use correct size cuff!! The strongest risk factor for primary hypertension in children is elevated body mass index. The USPSTF found inadequate evidence on the diagnostic accuracy of screening for primary hypertension. The USPSTF also found inadequate evidence on the effectiveness of treatment and the harms of screening or treatment. http://www.uspreventiveservicestaskforce.org/ Check pulses: Symmetrical femoral and radial pulse is a good screen for Coarctation of the aorta Murmurs: deep inspiration, valsalva, squatting Innocent, Mitral valve prolapse, Hypertrophic cardiomyopathy, Aortic sclerosis Arrhythmia: EKG to evaluate 24 hour monitor

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Neurological Baseline testing: Neuropsych testing Memory, Cognitive function Ability to learn Orientation VERY useful if athlete receives TBI Presence of post-concussive symptoms More accurate for determining return to play Can demonstrate loss of baseline function

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Practice Recommendation Anyone with traumatic brain injury and a recorded Glasgow Coma Scale of 13 or less at any stage after the first 30 minutes OR who received a CT scan of the head as part of their initial assessment should be routinely followed up with, as a minimum, a written booklet about managing the effects of traumatic brain injury and a phone call in the first week after the injury Approved Source: National Guideline Clearinghouse Website: http://www.guideline.gov/summary/summary.aspx?doc_id=10281&nbr= 005397&string=concussion Level of Evidence: B - A well-designed, nonrandomized clinical trial. A non- quantitative systematic review with appropriate search strategies and well-substantiated conclusions

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Other Lungs: look for symmetry of movement, listen for wheezes/rubs Abdomen: check for organomegaly, tenderness, rigidity Skin: check for rashes. growths

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Practice Recommendation In a population of stable asthmatics short acting beta- agonists, mast cell stabilizers, or anti-cholinergics will provide a significant protective effect against exercise- induced broncho-constriction with few adverse effects Approved source: Cochrane Database Website: http://www.cochrane.org/reviews/en/ab002307.html Strength of Evidence: Twenty-four trials (518 participants) conducted in 13 countries between 1976 and 1998 were included. All drugs were effective at attenuating the exercise-induced bronchoconstriction response but to varying degrees even within the same individual. Compared to anti-cholinergic agents, mast cell stabilizers were somewhat more effective at attenuating bronchoconstriction

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Genito-Urinary Male: Hernia (?) Testes both descended Single: should counsel about collision sports Female: Pelvic not necessary part of basic exam Do w/ Hx of severe menstrual irregularities, primary or secondary amenorrhea Both: Maturity & development (self rating?)

Musculo-Skeletal Need to assess major muscle groups and joints via a screening exam Follow up closely on any abnormalities noted -Decreased ROM, function - Hyper-flexibility

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Laboratory Testing Traditionally: UA dip for protein/glucose Non-pathologic proteinuria VERY common U-glucose NOT reliable & unproven in large studies for DM screening Same for CBC, Hct, Fe, Ferritin Cardiovascular screening (EKG, Echo) under investigation for cost-effectiveness Screen only those at risk or positive findings Vol 61, No 1 | January 2012 | The Journal of Family Practice

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians MOST IMPORTANT PART! Determining Clearance MOST IMPORTANT PART! 1 Does the problem put the athlete at greater risk for injury? 2 Is the athlete a risk to other players? 3 Can the athlete safely participate with treatment, rehabilitation, medicine, bracing or padding? 4 Can limited participation be allowed? 5 If clearance is denied, are there other activities that the athlete can safely participate in?

Clearance is based on AAP Committee on Sports Medicine Recommendations for Participation in Competitive Sports Based upon the amount of contact/collision and intensity of exercise

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Contact Non-Contact

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Some Specifics

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Acute Illness Individual assessment Generally accepted to limit activity during fever URIs and strenuous activity (re: cycling) can cause significant impact on the immune system

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Cardiovascular Abnormalities May Dispose to Sudden Death! Mild Hypertension: No restrictions Moderate to Severe: need assessment and possible treatment Benign functional murmurs: No restriction Mild Mitral valve prolapse: No restriction

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians MVP with: PMHx of syncope Chest pain/tightness increased w/ activity FHx of sudden death Moderate to Severe regurgitation REASSESS! HIGH RISK! Oxford Journals Medicine European Heart Journal Volume 26, Issue 14 Pp. 1422-1445 Oxford JournalsMedicineEuropean Heart JournalVolume 26, Issue 14 Oxford JournalsMedicineEuropean Heart JournalVolume 26, Issue 14

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Hypertrophic Cardiomyopathy (HCM, IHSS) Most common cause of sudden death in athletes Usually find: Marked LVH (***Need to differentiate from normal LVH in conditioned athletes) Significant L outflow obstruction & Arrhythmia's Both increased by activity PMHx of syncope or FHx of sudden death in a young relative May participate in LOW intensity activities

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Symptoms HCM Most are ASYMPTOMATIC until Sudden Cardiac Death (can be the 1 st symptom) Symptoms with activity: Chest pain Shortness of breath Lightedness Dizziness Loss of consciousness Children often do not show signs of HCM After puberty

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Basketball Star's Sudden Death Brings Awareness of Deadly Heart Disease By Dan O'Donnell Story Created: Mar 7, 2011 Story Updated: Mar 8, 2011 MILWAUKEE - The shockwaves from high school basketball star Wes Leonard's sudden death last week have reverberated from Fennville, Mich. across the nation. An autopsy revealed that Leonard suffered cardiac arrest brought on by dilated cardiomyopathy (DCM), a condition more commonly referred to as an "enlarged heart."

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Incidence HCM 0.2% to 0.5% of the general population All types of HCM (Obstructive vs Non- obstructive) Appears in all racial groups Sarcomeres (contractile elements) in the heart replicate causing heart muscle cells to increase in size Results in the thickening of the heart muscle Typically an autosomal dominant trait 50% chance of passing trait

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Veneto Italy Study Claim 89% reduction in SCD by screening ALL athletes with ECG in the PPE Actual numbers: 84 of 12,880 (0.65%) screened had any significant ECG abnormalities Study was done between 1979-2001 11 of that 84 (0.09% of the 12,880) had significant pathology US athlete population alone is ~15 million New findings higher familial incidence of HCM in Veneto Italy population Pediatrics in Review November 2006; 27:418-424; doi:10.1542/pir.27-11-418 European Heart Journal (2011) 32, 983990 doi:10.1093/eurheartj/ehq428 Peliccia et al, N Eng J Med 2008 V358(2) pp152-61

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Cardiovascular Risks ALL Causes SCD per year in healthy patients 1 / 133,000 Men 1 / 769,000 Women AMI w/in 1 hour of exercise 2-10% 2.1 10x higher than in sedentary patients SCD 6-164x greater than sedentary patients Recommend higher level of screening in high risk patients Circulation 2007: Exercise and Acute CV Events: Placing Risks Into Perspective

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Who Should Be Screened for SCD Low risk: Men

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Visual Impairment Considered + if singled-eyed or best vision in one eye >20/50 NO effective eye protection for Martial arts, Boxing, Wrestling >>>>Disallow! High risk: Football, Baseball, Racquetball Eye guards exist but protection is limited

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Practice Recommendation Functionally 1-eyed athletes and those who have had an eye injury or surgery must not participate in boxing or full-contact martial arts. (Eye protection is not practical in boxing or wrestling and is not allowed in full-contact martial arts.) Approved Source: National Guideline Clearinghouse Website: http://www.guideline.gov/summary/summary.aspx?doc_id=4861&nbr= 3502&ss=6&xl=999 Strength of Evidence: Although the evidence for each recommendation is not specifically stated the evidence is drawn from reports from American National Standards Institute. Occupational and educational personal eye and face protection devices. Washington (DC): American National Standards Institute; 2003 and American Society for Testing and Materials. Annual book of ASTM standards: Vol 15.07. Sports equipment; safety and traction for footwear; amusement rides; consumer products. West Conshohocken (PA): American Society for Testing and Materials; 2003.

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Kidney/Renal Incidence of renal trauma is 5-25%, but is mostly mild Other injuries more common that renal Solitary kidney: Pelvic, Iliac, Multicystic, Hydronephrotic, Uteropelvic jct abns >>> No Collision Sports! Normal position: Counsel and sign consent Pediatrics Vol. 118 No. 3 September 1, 2006 pp. 1019 -1027

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Hepato/Splenomegaly Liver: determine primary cause (ex: mono) OK to return once organ reduces size Spleen: Acute splenomegaly associated w/ HIGH risk rupture with Minimal provocation! Chronic splenomegaly: need to assess and treat individually

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Hernia: Only remove if symptomatic Gyn: No restriction w/ single ovary Do look for menstrual irregularities Female athletic triad (Amenorrhea, anorexia, osteoporosis) Testicular: Single may play all sports: CUP! Undescended testes more serious Increased risk of Ca Sickle Cell: (more later) Trait: No restrictions altitudes ">

Hearing Impairment Tend not to consider themselves disabled Subculture of society Variations: Mild: threshold 27-40 dB Profound: threshold > 90 dB Behavioral disorders 2 0 communication challenges No related physical disabilities except due to lack of experience with certain activities

Seizures Common in athletes with developmental disabilities Familiarity with meds & side effects Attention span & cognitive impairment Decreased potential for seizures w/ exercise Metabolic acidosis due to lactate buildup & incomplete respiratory compensation Decreased pH Stabilizes neuromembranes Good control must be obtained prior to participation in activities Be prepared as with ALL athletes

Insulin Dependant Diabetes Need to monitor glucose: 30 min before activity Immediately before activity Every 30-45 min during activity Ideal pre-exercise range is 120-180 mg/dl > 200 mg/dl: Postpone & take extra insulin to get glucose levels down 1 st Exercise with elevated glucose will cause levels to RISE further which can lead to increased diuresis, dehydration, and keto-acidosis

Insulin Adjustments Moderate exercise: AM activity reduce Reg by 25% PM activity reduce Reg by 25% as well as NPH or Long Acting Strenuous or Long Term: AM activity reduce Reg by 50% PM activity reduce Reg by 50% as well as NPH or Long Acting Insulin pumps or Lantus: as above Liberal hydration < 1hr: water alone OK > 1hr: think Na+ replacement (Sport drinks: remember they contain CHO!!)

Complications Autonomic dysfunction Avoid power lifting 2 0 bradycardia & syncope Increased hot & cold intolerance Hyperglycemia: treat & watch for KA Hypoglycemia Tremors, sweating, palpitations, pallor, hunger Long acting CHOs, glucagon Late onset hypoglycemia: 6-28 hrs later Replace glycogen w/in 1 hr of activity Avoid activity near intermediate insulin peaks Use long-acting to avoid peaks Watch for Neuro-glypenic Syndrome

Parental Concerns Some athletes non-verbal Cannot describe problems Some will hide problems Not unlike other athletes Older athletes may demonstrate adolescent behavior & significant psychiatric problems Some have parents/caregivers in their 70s Some problems may be related to parental & caregiver burn-out

Some problems out of scope of practice for Family Physicians: Dental disease Complex Cardiac problems Advanced Orthopedic problems Ophthalmic problems Need to establish referral network of physicians comfortable & willing to care for SO athletes Parental Concerns

Coaches need to be made aware of what medical problems athletes have and what medications they are on Side effects SO PPE form needs to be revised to include major medical problems Currently form does not include this

Parental Concerns Podiatric problems: difficulty finding good athletic shoes that fit Pes planus Toenail fungus Tinea & groin abscesses Orthostatic hypotension

Parents Biggest Concern The athlete is NOT seen in isolation, but rather within the family network

Conclusion Be aware of special needs but remember that Common problems are common! Take the usual precautions as outlined Participation is critical for these athletes Self esteem Enhances physical development Requires a multidisciplinary approach Physicians, nurses, athletic trainers, coaches PTs & OTs Most important: the Athlete

Some Pictures From MedFest 1: Before We Start

Registration

Vitals

History Review

Heart & Lung

Orthopedic

Questions? Jeffrey A. Zlotnick, MD, CAQ, FAAFP [email protected] New Jersey Academy of Family Physicians www.njafp.org 224 West State St., Trenton, NJ 08608 Phone: 609-394-1711 ~ Fax: 609-394-7712 or Exec. Vice President: Ray J. Saputelli, MBA, CAE [email protected] Deputy Exec. Vice President: Theresa J Barrett, PhD, CMP, CAE [email protected] Office Manager & Membership Services: Candida Taylor [email protected]

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians Questions

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The Pre-Participation Sports Examination Jeffrey A. Zlotnick, MD CAQ FAAFP DABFP Family & Sports Medicine Asst. Clinical Professor Family and Primary Care