The Preparticipation Physical Exam

Jennifer A. Southard, MD, MScSaint Alphonsus Medical Group

Family Medicine and Sports Medicine

NP Idaho Fall ConferenceAugust 24, 2013

ObjectivesDiscuss purpose and timing of PPEsGive Overview of PPEReview 3 key areas: CV, Ortho, NeuroIdentify conditions which warrant further investigation prior to allowing participationDiscuss populations of athletes with special considerationsDiscuss clearing athletes for participation

Purposes of the PPEObjectives of the PPEPrimary Objectives1. Screen for conditions that may be life-threatening or

disabling2. Screen for conditions that may predispose to injury or

illness

Secondary Objectives1. Determine general health2. Serve as an entry point to the healthcare system for

adolescents3. Provide opportunity to initiate discussion on health-

related topics

What the PPE is NOT:PPEs should NOT replace routine health care or comprehensive physicals– The PPE is a screening tool to determine

fitness for athletic participation– The PPE often takes place in a format

which does not allow adequate time for anticipatory guidance

– The PPE often takes place in a format which does not provide adequate privacy to discuss confidential issues

Frequency and Timing of the PPE

Ideally do PPEs 4-6 weeks before athlete’s season to allow for eval/treatment of problemsNFHS: PPE necessary - but leaves to states to mandate & standardizeNCAA recommends & most institutions require annual examsYouth / club sports - no formal requirements

Effectiveness of PPEUnknown as to:Effectiveness of PPE as a screening tool– Lack of efficacy data for PPE – Little effect on morbidity & mortality Ability of PPE to affect outcomes Detect risk for catastrophic events

Is the PPE a good screening tool?Significant burden of disease in populationPreclinical stage is detectable and prevalentEarly detection improves outcome (mortality) with acceptable morbidityScreening tests are acceptable to population, inexpensive, and relatively accurate Effective treatment available for detected disease

Approaches to the PPEHistorically: the HHH exam– Hi, how are ya?– Heart– Hernia

Approaches to the PPEOffice Based: maximizes privacy, allows single examiner to complete entire exam, but inefficient for large groups of people. Recommended methodLocker-Room Approach: allows for one examiner to complete each part of the PPE but is also inefficient for large groups and does not allow for privacyStation-Based: requires multiple examiners, each doing a different part of the exam. Improves efficiency and privacy

The History and Physical

AAFPAAPACSMAMSSMAOSSM

PPE: The HistoryHistory forms are very helpful– athletes and parents should jointly complete a

history form prior to the PPE– Review form: 75% of issues detected through Hx

aloneWeb based history forms may be more convenient for the athletes (ePPE) Preparticipation form recommended by the AAFP, AAP, AMSSM, and AOSSM is available in the Preparticipation Physical Evaluation, 4th ed. 2010.

The Cardiovascular HistoryScreening for conditions that predispose to Sudden Cardiac DeathMost common cause of SCD in US athletes <30 is HCM

AHA GuidelinesCirculation, 2007

Personal History of:– Exertional chest

pain– Syncope/near-

syncope– Excessive fatigue– Prior murmur– Elevated BP

Family history of:– Premature CV

Death– CV disease <50yo– Specific conditions

(ie Marfans, Long QT, HCM, etc)

Maron BJ et al. Circulation 2007;115:1643-1655

AHA GuidelinesA positive finding on >=1 element on history is sufficient to warrant further CV investigationMight include ECG, ECHO, Stress test or referral to cardiology

The Neurologic HistoryAt each PPE, athletes should be asked about previous neurologic problems:– Prior concussions– Previous neck injuries– Previous history of stingers/burners– Seizure history– Current neurologic symptoms

(numbness, tingling, weakness, etc.)– Current learning/emotional problems

Neurologic HistoryConsider baseline neurocognitive studies in athletes who have a history of:– Multiple concussions– School performance problems

– ImPACT testing available to all Boise Public HS students, free, or $15 via STARS

The Musculoskeletal HistoryComplete history of musculoskeletal injuries is important– Operations – Time lost from play– Prior rehabOngoing musculoskeletal complaints – Require a more complete history – Deserve detailed evaluation

Screening for the Female Athlete Triad

All female athletes should be screened for the Female Athlete Triad

WHAT MAKES UP THE FEMALE ATHLETE

TRIAD???

Provider Knowledge 240 health care professionals (physicians, medical

students, physical therapists, athletic trainers and coaches) were surveyed to determine their knowledge and comfort in treating the condition

Results– 48% of physicians, 43% of therapists, 38% of

trainers, 32% of medical students and 8% of coaches could identify all 3 components

– Only 9% of physicians felt comfortable treating the disorder

Troy K, Hoch A, Stavrakos, J. Awareness and comfort in treating the female athlete triad: are we failing our athletes? Wisconsin Medical

Journal. 2006;105(7): 21-24.

Female Athlete Triad History• Not a new entity – various

components have been noted for years

• Defined in 1992 by American College of Sports Medicine

• ACSM developed a Position Statement in 1997• revised statement in 2007

1997 ACSM Position Statement• Syndrome that can

develop in physically active girls and women with three interrelated components:

• Disordered eating• Amenorrhea• Osteoporosis

Otis CL, Drinkwater B, Johnson M, et al. American College of Sports Medicine Position Stand: The female athlete triad. Med Sci Sports

Exerc 1997; 29(5): i-ix.

The Female Athlete Triad Today• 2007 ACSM Definition (Renamed components)

• Disordered Eating• Menstrual Dysfunction• Low Bone Mineral Density (BMD)

• Greater emphasis on the full spectrum of behaviors and conditions within a given disorder.

• The original version focused more on the extreme end point of each disorder.

Beals, K & Meyer, N. Female athlete triad update. Clin Sports Med, 2007;26:69-89.

Who is at Risk?• “Potentially all physically active girls and women

could be at risk for developing 1 or more components of the Triad”

• Sports that emphasize low body weight• Subjective scoring of performance (figure

skating)• Endurance sports (distance running)• Body contour-revealing clothing (track,

cheerleading, volleyball)• Weight categories (wrestling, horse racing)• Emphasis on prepubertal body habitus

(gymnastics)• Male athletes are also at risk for disordered eating

and anorexia nervosa

Prevalence• Disordered Eating: 8% - 62% depending on

population studied. • More prevalent in sports that emphasize lean

physique BUT seen in all sports• Athletes 2.6x more likely than non-athletes to

manifest DE Sx• Burckes-Miller et al: Study 695 NCAA Div I

athletes• 3% met criteria for anorexia nervosa• 21% bulemia

Burckes-Miller ME, Black DR. Male and female college athletes: prevalence of anorexia nervosa and bulimia nervosa. Athl Train J Natl Athl Train Assoc. 1988;23: 137-140.

Prevalence• Menstrual Dysfunction: 6% - 79%

depending on definitions used in study• Prevalence of secondary amenorrhea in

adult female collegiate athletes reported at 14-66% compared to 2-5% of the general population

• Low Bone Mineral Density: 22% - 50% (mainly osteopenia)

Nattiv A, Agostini R, Drinkwater B, Yeager KK. The female athlete triad. The inter-relatedness of disordered eating, amenorrhea, and osteoporosis. Clin Sports Med 1994; 13: 405-18.

Prevalence of the Triad Only 3 studies have examined all 3

disorders using direct measures of BMD in female athletes (DEXA)

The prevalence of all three components simultaneously: 0.4% - 2.2%.

Although prevalence small, presence of any of the three should warrant further provider investigation

Beals, K & Meyer, N. Female athlete triad update. Clin Sports Med, 2007;26:69-89.

Etiology In the 1970’s low body weight or low

body fat was thought to be the primary cause of amenorrhea

Exercise-stress hypothesis Deficit in energy availability

Hypothalamic Dysfunction Disruption of

hypothalamic-pituitary-ovarian axis– Decrease in pulsatile

GnRH disrupts pituitary secretion of LH and FSH

– Disruption of LH and FSH pulsatility shuts down stimulation to the ovary, ceasing production of estradiol

What causes hypothalamic dysfunction?

Deficit in energy availability

Energy Availability Dietary energy intake minus exercise

energy expenditure OR The amount of dietary energy remaining

after exercise training to support physiological processes

Loucks A & Nattiv A. The female athlete triad. Lancet 2005; 366:549-550.

Disordered Eating Includes a wide spectrum of unhealthy

eating behaviors– Skipping meals or limiting calorie intake– Restricting certain foods such as those

high in fat or protein– Binge eating or purging– Diet pills, laxatives, diuretics– Anorexia nervosa– Bulimia nervosa

Disordered Eating May be intentional

or unintentional– Lose a few pounds

before an event– “Inadvertently

failing to balance energy expenditures with adequate energy intake”

2007 ACSM Definition:Menstrual Dysfunction

Includes the full spectrum of menstrual irregularities. Luteal suppression Anovulation Oligomenorrhea Amenorrhea

Primary – redefined by American Society of Reproductive Medicine as absence of menstruation by 15 years of age in girls with secondary sex characteristics

Secondary – absence of 3 consecutive cyclesBeals, K & Meyer, N. Female athlete triad update. Clin Sports

Med, 2007;26:69-89.

Menstrual Dysfunction Prevalence studies

Wide range (2-35%) of prevalence estimates can be explained by methodologic differences among studies differences in athletic populations studied failure to control for OCP use assessment and definition of menstrual

dysfunction Despite differences, menstrual dysfunction is

more prevalent in sports that emphasize leanness

Menstrual dysfunction is NOT a normal part of training!

Beals, K & Meyer, N. Female athlete triad update. Clin Sports Med, 2007;26:69-89.

2007 ACSM Definition: Low Bone Mineral Density

Emphasis has been placed on the full spectrum of bone health. Low bone mass Stress fractures Osteoporosis

Bone strength is characterized by bone mineral content and density as well as quality of bone

Bone quality refers to the process of bone turnover

Beals, K & Meyer, N. Female athlete triad update. Clin Sports Med, 2007;26:69-89.

Bone Health Estrogen suppresses osteoclast activity Female athletes have higher BMD than nonathletic

counterparts UNLESS they have menstrual dysfunction Bone density declines in proportion to the number of

menstrual cycles missed Myburgh and colleagues showed a direct correlation

between time spent amenorrheic and number of stress fractures

Low bone mineral density may be irreversible resulting in a lifetime lower bone density Multiple studies show irreplaceable bone loss after 3

years amenorrhea Risk of stress fractures is two-four fold higher in

athletes with menstrual disturbances compared to those without

Bone Health Females gain more than

50% of skeletal mass during adolescence and reach peak bone mass between 18 and 25 years of age

Young women menstrual dysfunction during these years are at risk for losing 2% of bone mass annually instead of gaining 2-4%

Bone Density Consider DEXA for

the following: Amenorrheic >

one year BMI < 19 Documented

history of stress fracture

Lo B, Hebert C, McClean A. The female athlete triad, no pain, no gain? Clinical Pediatrics 2003; 42(7) 573-580.

How Should Athletes be evaluated for the Triad?

Evaluation Options History Questionnaire (easy and

effective) All

Blood Tests (measure ovarian steroid hormones) High Risk

Dual Energy X-ray Absorptiometry (DEXA) High Risk

History Female Athlete Triad Coalition

Screening Questionnaire (ACSM and IOC):– 12 Questions– Sensitivity 91.5%– Specificity 74.2%– False Positive 25.8 %– False negative 38.5%

Black DR, et al. Physiologic Screening Test for Eating Disorders/Disordered Eating Among Female Collegiate Athletes. Journal of Athletic Training. 2003:38; 4; 286-297.

IHSAA PPE Questions (3/12 similar questions)

When was your first menstrual period?

When was your last menstrual period?

What was the longest time between periods last year?

9 questions not on IHASS PPE Do you worry that you have lost

control over how much you eat? Do you make yourself vomit, use

diuretics or laxatives after you eat? Do you currently or have you ever

suffered from an eating disorder? Do you ever eat in secret? Have you ever had a stress fracture?

9 questions not on IHASS PPE

Are you unhappy with your weight? Are you trying to gain or lose weight? Has anyone recommended you

change your weight or eating habits? Do you limit or carefully control what

you eat?

Laboratory Evaluation CBC, CMP, ESR, Ferritin, VitB12, Folate, UA EKG and/or echocardiogram if abnormal cardiac

exam TSH Pregnancy test for amennorhea LH, FSH to rule out premature ovarian failure Prolactin to rule out pituitary tumor

Consider imaging If hirsutism, free testosterone, DHEA-S, 17-

hydroxy-progesterone to screen for adrenal or ovarian tumors

Progesterone Challenge Medroxyprogesterone 5-10 mg for 5-10 days

Lo B, Hebert C, McClean A. The female athlete triad, no pain, no gain? Clinical Pediatrics 2003; 42(7) 573-580.

Treatment Goal Restore reproductive and metabolic

hormones by increasing energy availability Increase energy intake Reduce energy expenditure

Weight gain of 1-2 kilograms (or 2-3%) or 10% decrease in exercise load in either duration or intensity is often sufficient to reverse reproductive dysfunction!

Loucks A & Nattiv A. The female athlete triad. Lancet 2005; 366:549-550

Treatment Options Educate Correct energy deficit

– Increase calories by 10% per week until target is reached.

– Decrease activity levels to assist in correcting energy deficit.

– Limit weight gain to 1-2 pounds per week

Treatment Options Add Calcium and Vit D supplement Treatment for osteoporosis with

bisphosphonates and calcitonin has not been tested in younger patients, nor patients with female athletic triad

Hormone Therapy No published longitudinal studies available on

long term benefits of HRT to slow or reverse loss of BMD – Longest studies currently available 60 months– Several good studies show irreplaceable bone

loss occurs after three years of amenorrhea Minimal 4-11% BMD increases have been noted

in women with hypothalamic amenorrhea on oral contraceptives– increases in BMD of 6-17% have been seen

with spontaneous reversal of amenorrhea– Increases slow to 3% following year and

plateau at BMD well below normal for ageGoodman, L & Warren, M. The female athlete and menstrual function.

Adolescent and Pediatric Gynecology. 2005;17(5): 466-470.

Hormone Replacement

Retrospective study of amenorrheic runners compared HRT with placebo over 24-30 months Combined estrogen and progesterone Pt’s on HRT showed 3.7% increase in BMD Pt’s in control showed decrease of 2.4% BMD

In women who have not responded to non-pharmacological treatment, initiate therapy with low-dose oral contraceptive to raise estrogen concentrations and prevent further bone loss

Progesterone should be included in any tx regimen to prevent endometrial hyperplasia

Cumming DC. Exercise-associated amenorrhea, low bone density, and estrogen replacement therapy. Arch Intern Med 1996; 156: 2193-5.

Treatment of Eating Disorder Depending on severity SSRI may be

indicated Avoid bupropion because risk of sz TCAs and MAOIs cold be toxic in

underweight pts Consider Cognitive Behavioral

Therapy Consider psychiatric evaluation

Treatment of Eating Disorder

– Recovery rates vary between 23% and 50%, and relapses range from 4% to 27%.

– Even for those who recover, one study indicated that recovery took between four and nearly seven years.

– Depending on the duration of the study, anorexic patients have reported death rates ranging from 4% to 25%.

PREVENTION! Educational programs targeting coaches,

athletes, parents, athletic trainers, school administrators– Currently there is a lack of such

programs Nutrition education

– Emphasis should be placed on concept of food as energy for training and recovery rather than on body weight

Resources NCAA Handbook: “Managing the Female Athlete

Triad” www.ncaa.org/wps/wcm/connect/resources/file/ebad9e4a146e2d0/handbook.pdf

Academy for Eating Disorders: www.aedweb.org International Olympic Committee Position Stand on

the Female Athlete Triad: www.multimedia.olympic.org/pdf/en_report_917.pdf

Female Athlete Triad Coalition: www.femaleathletetriad.org

National Osteoporosis Foundation: www.nof.org National Eating Disorders Association:

www.nationaleatingdisorders.org

Other Important Historical Issues

Respiratory- h/o asthma or allergic problemsInfectious- h/o HBV, HCV, HIV, EBVDerm- Herpes gladiatorum, current rashesHematologic- Sickle Cell, bleeding disordersEndo- diabetesOther- prior heat-related illness, sickle trait

The PhysicalEach PPE should include vitals, examination of HEENT, CV, RESP, ABD, GU (males only), MSK, DERM, and NEURO systemsForms, such as the one published in the Preparticipation Physical Evaluation, 4th ed. , 2010, may be helpful.

The PhysicalGeneral: Attention for excessive height, Marfanoid appearanceVitals: especially important to check BP. Also Ht, Wt, BMI.

Pediatric age and height percentile BP graphsHEENT: Visual acuity, pupils, conjunctivae, lenses, ear exam, oropharyngeal exam

If unable to correct to better than or equal to 20/40 in each eye, need further evaluation and eye protection

RESP: resp effort, wheezes, crackles, etc.ABD: masses, splenomegaly

The PhysicalCV: Auscultation, Femoral/Radial pulses, BP, provocative maneuvers for HCM– Systolic Murmur that increases in

volume/intensity with Valsalva or with going from supine seated

– Murmur of HCM will diminish with squatting or other maneuvers to increase venous return to the heart

Hypertrophic Cardiomyopathy

Further Eval.: CV FindingsFindings requiring further evaluation:– Systolic Murmur that is 3/6 or greater– ANY diastolic murmur– ANY murmur which increases in intensity with

Valsalva– Any FH of SCD or predisposing condition (Long

QT, Marfans, AVRD, HCM) or worrisome personal hx

The Hypertrophic Cardiomyopathy Murmur:– Cres-Decres systolic murmur heard best at LLSB– Increases with maneuvers to decrease venous

return (eg Valsalva, lying to standing) – Decreases with maneuvers to increase VR (ie

squatting)

The PhysicalGU (males only): hernia, mass, undescended testicle. Instruction on TSE Derm: Rashes, lesionsNeurologic: strength testing incorporated into MSK exam; more extensive evaluation required for pts with neurologic complaintsExtremity: arachnodactyly

The PhysicalThe Musculoskeletal Exam:– Asymptomatic pts: General Screening

Exam only– Pts with specific complaints: Gen.

Screening Exam PLUS a joint specific exam

– Sport Specific Exam: consider doing a more complete joint exam for commonly injured joints (Shoulders in swimmers and throwers, Knees in athletes who do cutting maneuvers, etc.)

Beyond the PhysicalAre more tests necessary?

JOHN RUSKIN (1819-1900)

“A thing is worth precisely what it can do for you not what you choose to pay for it”

Beyond the Physical: Screening Labs?

Screening labs are NOT recommended at routine PPE’sSome sport governing bodies require lab tests for performance enhancing substancesNCAA requires sickle trait screeningCaptive adolescents: should we screen for STIs?– Recent paper in J Adol Health found the

following:Males 2.8% + for chlamydia, 0.7% + for gonorrheaFemales 6.5% + for chlamydia, 2.0% + for gonorrhea93.1% of all positives reported NO SYMPTOMS.

Nsuami M et al. J Adolesc Health, 2003, p336-339.

Beyond the Physical: Screening CV Studies?

The Italians:– Since 1982 Italy has screened ALL

athletes with PPE, EKG, as well as Stress tests and ECHO’s for Elite/Olympic athletes

– 2.5% of all athletes screened were disqualified, 51% due to CV probs.

Beyond the Physical: Screening CV Studies?

Baseline rate of SCD prior to initiation of screening protocol was 3.6/100000After initiation of screening, rate of SCD fell to 0.4/100000 (89% reduction)Sounds really compelling for routine use of ECGs, right?

Corrado D et al. JAMA 2006;296(13):1593-1601.

But Italy is not the USA…

Risk of SCD Now Equivalent in Italy and US

2001-2006 Risk of SCD in US is 0.61/100000In Italy, the EXCESS risk from SCD (3.6/100000) was related to ARVDBy doing EKG/ECHO, the risk to Italian athletes is reduced to a comparable risk that exists in the US

Maron BJ et al. Circulation, 2009;119:1085-1092

Beyond the Physical:Screening CV Studies?

Lausanne Recommendations of the European Society of Cardiology, 2006– Similar screening questions to AHA– Similar physical screening exam to AHA– Adds 12-lead ECG after onset of puberty

for all athletesEndorsed by IOC

Beyond the Physical:Screening CV Studies?

AHA recommends against cardiovascular screening of asymptomatic athletes with ECG or Echo Not practical for mass, universal screening – Size of athlete cohort (huge)– Prevalence of disease (low)– Limited resources ($$, personnel)– Absence of physician workforce to interpret

ECG– Potential to create anxiety with False positive

results (morbidity)

Beyond the Physical: Screening CV Studies?

Feinstein et al. in 1993 did 1570 ECHOs on asymptomatic athletes, found no conditions which would preclude competition, at a cost of $500/testEpstein and Maron estimated in 1986 that ECHO alone would prevent 1 death per 200,000 athletes, at a total cost of $100,000,000 per life saved

Beyond the Physical:Screening Neurologic Studies?Currently, the NHL, NFL, many colleges, and increasing numbers of high schools require screening neuropsychological testing for athletes involved in contact/collision sportsPreseason neuropsych testing allows each individual to provide his/her own control for comparison should a head injury occur during the seasonImPACT testing for BPS athletes

Further Eval: Prior Head Trauma

Prior concussion is an independent risk factor increasing risk for subsequent concussionRecurrent concussion increases risk for learning, emotional, and cognitive problemsIn pts with h/o concussion, consider baseline neuropsychological evaluationConsider neuropsych eval in kids with school performance problems (baseline study)

Further Eval: MSK InjuriesFindings of new/recent injuries on PPE deserve appropriate evaluation and treatmentFindings of inadequately rehabilitated injuries on exam should be followed up for several reasons:– Risk of re-injury or injury to others– Risk of long term complications

(arthritis, etc)

Athletes with Special Considerations

Special Populations of Athletes

Athletes with Down’s SyndromeParalympics / Handicapped AthletesAthletes with one-organ or functionally one-organedAthletes s/p transplantAthletes with specific medical problems: bleeding disorders, infectious diseases, etc.

Athlete’s with Trisomy 21Cardiovascular Abnormalities– 50% of children with Down Syndrome have

congenital heart diseaseHypothyroidism– Occurs in 15% of kids with T-21– Should be screened annually

Atlantoaxial Instability– Should be screened for with flex/ext C-spine

films at age 3 years– Required for participation in Special Olympics

or contact sports

The Functionally One-Organed Athlete

Concern is for damage to the “good” organ:– Ophtho: athletes with one eye or whose

best corrected vision is worse than 20/40Recommend appropriate protective equipment

– Renal: athlete’s s/p nephrectomyRecommend appropriate protective equipment

– GU: male’s s/p orchiectomyRecommend appropriate protective equipment

Bottom Line- we are ALL one-organed athletes competing w/ 1 brain, liver, pancreas, etc.

We’ve Got Clearance, Clarence

Clearing Athletes for Participation

3.1% to 13.9% of athletes are initially not cleared pending further evaluation.Ultimately, 0.3% to 1.3% are denied clearanceOptions for Clearance:– Cleared without restriction– Cleared, pending evaluation or treatment of a

specific problem– Disqualified

Letter of clearance/DQ should be reviewed with athlete, athlete should sign release of information form, form should be passed on to coach/trainer

Conditions Which May Require Disqualification

Final ThoughtsThe PPE is an important skill for all providers to be comfortable withThe PPE does not replace routine health care maintenance visitsCV, neurologic, and orthopedic abnormalities may require further evaluation prior to clearanceVast majority of athletes screened will be permitted to participate without restriction

Selected ReferencesKurowski K and S Chandran. The preparticipation athletic evaluation. American Family Physician,May 2000. p2683-98Lyznicki JM et al. Cardiovascular screening of student athletes. American Family Physician,Aug 2000. p765-84Preparticipation Physical Evaluation, 4th ed., 2010Madden CC and M Putukian. The Preparticipation Physical Evaluation, Team Physician’s Handbook, 3rd ed., 2002, pp20-35.Barrett JR et al. The Preparticipation Physical Evaluation, Care of The Young Athlete, 2000. pp. 43-56.Nsuami M et al. Screening for sexually transmitted diseases during preparticipation sports examination of high school adolescents. Journal of Adol Health May 2003, pp 336-339.

Selected ReferencesMaron BJ et al. Cardiovascular Preparticipation Screening of Competitive Athletes. Circulation, Aug 1996, pp850-856.Fuller CM. Cost effectiveness analysis of screening of high school athletes for risk of sudden cardiac death. Medicine and Science in Sports and Exercise, 2000, pp887-890.Corrado D et al. Screening for hypertrophic cardiomyopathy in young athletes. NEJM 6 Aug 1998, pp364-369.Pelliccia A and BJ Maron. Preparticipation cardiovascular evaluation of the competitive athlete: perspectives from the 30 year Italian experience. Am J of Card. 15 April 95, pp827-829.

Selected ReferencesMaron BJ et al. Sudden Deaths in Young Competitive Athletes, Circulation, 2009:119:1085-1092Corrado D et al. Trends in Sudden Cardiovascular Death in Young Competitive Athletes After Implementation of a Preparticipation Screening Program. JAMA 2006;296(13):1593-1601.Maron BJ et al. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes, 2007 Update. Circulation 2007;115:1643-1655Bille K et al. Sudden cardiac death in athletes: the Lausanne recommendations. European Journal of Cardiovascular prevention and rehabilitation. 2006;13:859-875

Thanks!Contact Info: SoutharJ@sarmc.orgSAMG Emerald: 367-41706533 Emerald St., Boise, ID