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Commentary

The Preparticipation Physical Examination

Steps Toward Consensus and Uniformity

David W. Glover, MD; Barry J. Maron, MD; Gordon O. Matheson, MD, PhD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 27 - NO. 8 - AUGUST 1999


In Brief: A few decades ago, the PPE consisted of a question or two and a quick check for heart murmurs and hernias. Today the exam is much more extensive and often includes matters not directly related to sports participation. But the content of the PPE still causes considerable confusion and disagreement, and the exam is seldom used to full advantage to protect the health of young athletes. Physicians should take the lead in forging a consensus on the proper objectives of the exam and developing a standardized PPE form for nationwide use.

No issue in sports medicine causes as much confusion and controversy as the preparticipation physical examination (PPE). As physicians we believe in providing preventive care in its fullest potential and are dedicated to promoting the health and safety of athletes. The PPE meshes these two closely held ideals and provides an element of our professional identity.

Yet there are many questions and practical concerns that at present render the PPE less than ideal. Perhaps chief among these is a lack of standardization in the content of the exam. Adding to the problems are the difficulty of detecting certain conditions that preclude sports participation, the rarity of serious medical conditions in young athletes, the large population of athletes (6 million high school athletes annually), and low reimbursement rates. Therefore, it is timely to stand back and take a look at where we have been, where we are, and where we should go with regard to the PPE.

Evolution of the PPE

The PPE has been in place for decades as an integral part of competitive sports. In fact, of the 51 state high school associations governing interscholastic sports (50 states and the District of Columbia), only one does not officially require a medical evaluation before a student can participate in high school athletics (1). Clearly, it is reasonable to protect the health of athletes by requiring that they undergo a medical examination before they participate in vigorous sports activities that may entail small but real risks.

The first-generation PPE came into existence 30 years ago. This process could be characterized as "the triple H": (1) How are you doing? (2) heart, and (3) hernia. These examinations were focused on detecting functional heart murmurs and asymptomatic hernias. As a consequence, no doubt, many athlete-seasons were lost because of unnecessary disqualification.

The second-generation exam included an additional important question: Have you experienced significant past medical problems? Additional exam components listed on the typical 5-by-7-inch card included a urinalysis, a limited physical exam, and a sports-clearance statement for the physician to sign.

The next major step for the PPE came in 1992, when five organizations (the American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, American Orthopedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine) produced the monograph Preparticipation Physical Evaluation (2). This monograph, which provides a useful form, was produced in an attempt to set a standard for the preparticipation history and physical exam, and it became the third-generation PPE. It was updated in 1996 (3) and has earned widespread acceptance as a guide for the examining professional.

A further step was taken in 1996, when an American Heart Association (AHA) consensus panel developed recommendations specifically concerning cardiovascular screening to be included in the PPE (4). This was a major step forward in that a leading national subspecialty association achieved consensus on specific recommendations to improve the detection of cardiovascular abnormalities during the PPE. However, compliance with the AHA recommendations is spotty, as will be discussed below.

A Variety of Objectives

Much of the difficulty with the PPE is related to the multiple objectives for which it was devised. The PPE forms now in use were developed by several different groups (state high school associations or their sports medicine committees, medical associations, state health departments, state legislatures, state education departments) (1) for purposes pertinent to those groups. Thus, the PPE was hampered from the start by the lack of a clear purpose.

The evaluation process today addresses a variety of objectives. Initially (and perhaps still), one goal of the PPE was to provide liability protection and satisfy insurance regulations for the institutions and sports governing bodies. Another major objective was and is to detect injuries and illnesses that preclude participation in vigorous sports, even though the criteria for identification and the scope of the medical problems are often vague and controversial.

More recently, the PPE was described as an opportunity to detect illnesses and injuries that, while not precluding participation in sports, still require attention and treatment. This objective gained support when it became apparent that for the vast majority of children and adolescents, the PPE is the only health exam received annually. Even more recently, the PPE has been proposed as a primary preventive tool—a way to identify modifiable risk factors (1).

Besides the above, the PPE in its current form addresses several additional objectives: documenting athletic eligibility (in relation to age and grade average), obtaining parental consent for participation and emergency treatment, collecting basic medical data for use in emergencies, and improving the athlete's performance.

Largely because of these multiple origins and objectives, the PPE forms now in use are far from uniform or standardized. A major example is found in the difficulties that remain with implementation of the cardiovascular component of the PPE. It has been clearly shown that the history and physical exam questionnaires used for high school athletes in many cases do not conform with the AHA guidelines (1). Twenty states (40%) either have no approved questionnaire or have forms judged to be inadequate, and no state has a questionnaire that includes all 13 of the AHA-recommended items.

There is even less consensus on the noncardiovascular components of the PPE. Some components of the history and physical exam that have often been included in the PPE (eg, Tanner staging) may not be necessary. Still other areas are generally deemed worthy of consideration (eg, a history of exercise-induced asthma or heat-related illness), but there is no consensus as to what historical information should be obtained or precisely what physical examination should be done.

Where Are We Now?

Despite all these challenges, progress clearly has been made. The first forms produced for use by providers were developed primarily to provide liability protection for the school and required only a physician's signature for clearance. Thus the signed form placed the physician or other health professional in the position of accepting responsibility (liability) for clearing the athlete to participate. Physicians frequently assumed this was the only information needed and complied by simply doing the "triple H" exam and filling out the forms. Thus, legitimacy was conferred on the process despite the lack of any real focus on the detection of diseases.

In contrast, the PPE form in the updated monograph (3) provides a tool for the examiner and helps ensure that information generally held to be useful is gathered before sports participation. Indeed, these forms represent a step forward in promoting the concept of the PPE as an opportunity to improve the health and safety of the athlete. The monograph form is perhaps not the final destination, but is certainly a worthwhile stage on this evolutionary journey.

Still, questions remain. Just what are the objectives of the PPE? Is the exam to identify athletes at risk for catastrophic cardiovascular consequences if they participate in certain sports? Is the PPE to be used as a rare opportunity to discuss risky behaviors, such as steroid or other drug use, smoking, unprotected sex, etc, with adolescents? Is the PPE intended to identify less serious problems that, if corrected, will allow better performance or a reduced risk of injury (eg, exercise-induced asthma or incompletely rehabilitated musculoskeletal injuries)? Ideally, perhaps, the PPE should address all of these purposes.

Certainly, a major goal of the PPE is to identify athletes at risk for cardiovascular catastrophe. This has proved to be difficult at best. The evaluation currently recommended by the AHA, consisting of certain historical information and findings of the cardiovascular exam, has the potential to identify some, but not all, athletes at risk. Indeed, athletes are rarely identified in the PPE as having a serious risk that requires further evaluation. Normal or minor conditions that share some common historical or physical findings with more serious diseases are much more common. Therefore, the examiner can become frustrated with performing seemingly endless exams, while identifying only variants of normal, leading to increased costs, confusion, and worry for athletes, families, and athletic staffs.

The Italian experience has shown that a standard 12-lead electrocardiogram (ECG) will aid in identifying hypertrophic cardiomyopathy (HCM) in athletes at a rate similar to that known for this disease in the general population (5). Therefore, the ECG, a relatively simple test, might well help identify many athletes with HCM, which is the most common cause of sudden death in young athletes (6). Unfortunately, this additional testing would come at considerable cost. Abnormal ECGs, having low specificity, would necessitate a large number of additional and even more expensive tests such as echocardiograms. By increasing the sensitivity of our screening, we would anticipate more false-positives, more testing, and more expense.

To be viable in this era of cost-consciousness and outcome-based evaluations, the PPE should be useful in areas other than athletic disqualification, but this is true to only a limited extent today. An example is the discussion of health issues with adolescents. The exam is a potential opportunity for open-ended discussion of medical issues related only peripherally to athletics. Unfortunately, out of necessity, PPEs are often performed as high-volume station evaluations involving multiple examiners in loud, crowded, nonprivate settings. Confidential one-on-one interaction is very unlikely to occur in these circumstances.

As noted above, the PPE also affords a chance to detect less serious medical problems that are amenable to treatment, but this depends on the interest and expertise of the examiners. For example, the physician who frequently manages individuals with asthma is much more likely to have a high index of suspicion for exercise-induced asthma; the person who has expertise in musculoskeletal injuries is much more likely to identify partially rehabilitated injuries and provide appropriate management strategies to the athlete. Unfortunately, the reality is that the PPE is often performed by physicians who have limited interest and expertise in sports medicine or by nonphysician providers.

Where Are We Going?

Despite these limitations, the PPE has the potential to be an effective means to identify some athletes at risk, help some athletes perform better, and sometimes to enable physicians to interact with adolescents and promote a healthy lifestyle. But for the PPE to better fulfill this potential will require both continuing effort on many fronts and a more systematic strategy than has characterized its development to date.

One endeavor that can serve many of the objectives of the PPE is to increase the amount of historical information available to the examiner, since the history is critical in identifying athletes who may require further, more directed examinations. Using the tools of the information age to focus the PPE is a current thrust at Stanford University. Improving our historical database in some areas of the PPE could be extremely helpful in improving the process. An expanded history with a focused physical exam would seem to fit best into the practical limitations that currently affect the PPE.

Beyond this, efforts to improve the PPE should focus on four main avenues. First, any imperfections in the current PPE monograph form (3) should not at present preclude its widespread acceptance. Second, physicians should carefully define and achieve consensus on the objectives of the PPE and then adopt a standardized exam form for nationwide use. Third, such a standardized exam should be seen as a minimum, not as a perfect procedure that excludes new or expanded formats. Physicians should continue to alter the evaluation process as objective data are collected. Fourth, as a standardized approach to the PPE is adopted, we should consider establishing a national data bank or other mechanism to collectively expand our ability to measure outcomes following the PPE.

Physicians Should Take Control

Our present efforts concerning the PPE should focus on making the process more efficacious. Sports medicine physicians must keep the well-being of the athlete at the center of our attention. For too long in dealing with the PPE, physicians have allowed others to guide this important area of medicine. The exam should not be regarded solely as a legal, bureaucratic, or governmental issue. It is, in fact, a medical issue.

Physicians need to take control. We should not fill out forms that do not represent our standards. We should be assured that organizations governing athletics require the gathering of medical information that we determine to be essential to the safety and well-being of athletes. We should also require that only medical personnel who have appropriate training perform the PPE. This is not a simple process, and it requires the expertise of a physician. The PPE should not be an issue of turf or politics, but only a question of who is best able to perform the exam to permit maximal gain. It is a question of who can best help our athletes to compete safely and optimally. It is a question not merely of accepting legal responsibility, but of assuming moral authority to promote the well-being of those whose trust we hold.

References

  1. Glover DW, Maron BJ: Profile of preparticipation cardiovascular screening for high school athletes. JAMA 192021;279(22):1817-1819
  2. Lombardo JA, Robinson JB, Smith DM, et al: Preparticipation Physical Evaluation, ed 1. Kansas City, MO, American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, American Osteopathic Academy of Sports Medicine, 1992
  3. American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, American Osteopathic Academy of Sports Medicine: Preparticipation Physical Evaluation, ed 2. Minneapolis, New York City, McGraw-Hill Inc, 1996
  4. Maron BJ, Thompson PD, Puffer JC, et al: Cardiovascular preparticipation screening of competitive athletes: a statement for health professionals from the sudden death committee (clinical cardiology) and congenital cardiac defects committee (cardiovascular disease in the young), American Heart Association. Circulation 1996;94(4):850-856
  5. Corrado D, Basso C, Schiavon M, et al: Screening for hypertrophic cardiomyopathy in young athletes. N Engl J Med 192021;339(6):364-369
  6. Maron BJ, Shirani J, Poliac LC, et al: Sudden death in young competitive athletes: clinical, demographic, and pathologic profiles. JAMA 1996;276(3):199-204

To order copies of Preparticipation Physical Evaluation, ed 2, call the American Academy of Family Physicians order department, 1-800-944-0000, or the American Academy of Pediatrics Department of Publications, 1-800-433-9016.

Dr Glover is a practicing family physician with St. Luke's-Shawnee Mission Medical Group of Kansas City, Missouri, and a team physician at Central Missouri State University in Warrensburg; Dr Maron is director of cardiovascular research at the Minneapolis Heart Institute Foundation; and Dr Matheson is editor-in-chief of The Physician and Sportsmedicine and head of the Division of Sports Medicine, Department of Functional Restoration, Stanford University School of Medicine, Stanford, California. Address correspondence to David W. Glover, MD, St Luke's Medical, 407 E Russell, Bldg C, Warrensburg, MO 64093; fax messages to (660) 747-5684; e-mail to [email protected].


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