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The Preparticipation Examination for the Athlete With Special Needs

Working Group of the Preparticipation Physical Evaluation, 3rd edition: Lori Boyajian-O'Neill, DO; Dennis Cardone, DO; William Dexter, MD; John DiFiori, MD; K. Bert Fields, MD; Deryk Jones, MD; Robert Pallay, MD; Eric Small, MD; Frederick Reed, Jr, MD; William O. Roberts, MD; Randall Wroble, MD; and Phillip Zinni, DO


This article appears as a chapter in the updated and greatly expanded Preparticipation Physical Evaluation, 3rd edition (ISBN 0-07-144636-2). This monograph—published this month by McGraw-Hill—is a joint venture of the American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Copies of the monograph can be ordered toll free at 800-262-4729 or on-line at

Athletes with special needs (physical and intellectual disabilities) represent a growing population of sports participants. Federal legislation mandating equal access and equal opportunity to physical education and sports for persons with special needs as well as extraordinary accomplishments by athletes with special needs have ignited this growth.1

The Americans With Disabilities Act defines a disability as an impairment that limits a major life activity.2 Types of disabilities include cerebral palsy, blindness, deafness, paralysis, mental retardation, and amputation, as well as locomotor disabilities such as arthritis, muscular dystrophy, and multiple sclerosis.

Benefits of Sports

Sports participation for athletes with special needs provides the same benefits as for athletes without special needs: increased exercise endurance, muscle strength, and flexibility; improved cardiovascular function, balance, and motor skills; and psychological benefits, including increased self-esteem, reduced anxiety and depression, and the satisfaction derived from participation and competition. In addition, some benefits from sports participation are unique to the athlete with special needs (table 1).3

TABLE 1. Benefits of Sports Participation Unique to Those With Special Needs (Compared With Inactive Counterparts)

Athletes With Paraplegia
Fewer pressure ulcers
Fewer infections
Lower likelihood of hospitalization

Athletes With Amputations
Improved proprioception
Increased proficiency using prosthetic devices

PPE for Special Needs

The preparticipation examination (PPE) for the athlete with special needs should be similar to that of an athlete without a physical or intellectual disability. In addition, the PPE should address the particular concerns of the athlete with special needs. The healthcare provider should be aware of common problems associated with different disabilities and be able to diagnose abnormalities that may endanger the athlete. Just as important, the healthcare provider should provide support and encourage physical activity.

Athletes with special needs are classified according to the severity of their disability. To promote fairness in competition, athletes with similar degrees of disability compete against one another.

The Special Olympics and the United States Paralympics, a division of the United States Olympic Committee, have organized sports events for athletes with special needs.

Special Olympics is an international organization dedicated to empowering individuals 8 years old and older who have intellectual disabilities to become physically fit through sports training and competition.4 Special Olympics offers year-round training and competition in 26 summer and winter sports.

Special Olympics currently serves more than 1 million people with intellectual disabilities in more than 200 programs in more than 150 countries. In 2000, Special Olympics made a bold commitment to reach 2 million athletes by the end of 2022. This means that more physicians will encounter increasing numbers of Special Olympians who will seek PPEs and sports-related medical and surgical care.

The Special Olympics are arranged at local, state, and international levels, and participation requires a PPE.5 Depending on the state or level of competition, the PPE needs to be performed every 1 to 3 years. Special Olympics World Games, for example, require a PPE to be performed within 12 months of a competition.

United States Paralympics features more than 20 sponsored sports and provides funding and facilities for persons with physical disabilities.6 The Paralympic Games are held every Olympic year and provide competitions for more than 5,000 athletes with physical disabilities in Summer and Winter Games. New technology applied to prosthetic devices allows increasingly more physically impaired athletes to participate at higher levels of competition.

Methods of Evaluation

The office-based PPE is preferred to the station-based or mass screening examination. The decreased mobility of some athletes with special needs makes the station method less practical. The PPE should be performed by a healthcare provider involved in the longitudinal care of the athlete. Specialty consultations are sometimes necessary.

The PPE Medical History

As in the general PPE guidelines, a thorough medical history is essential to an informed participation recommendation. The history form should be completed by the athlete (if possible) and parents or guardian familiar with the athlete's medical history. In addition, a parent or guardian may need to be present at the time of the PPE in order to obtain the most accurate answers to questions. This is especially true for athletes participating in the Special Olympics.

The history should include a detailed summary of previous injuries and illnesses, risk factors for injuries and illnesses, and current medications.

Questions. In addition to the questions asked of an athlete without a physical or intellectual disability, questions in the history of an athlete with a special need should be individualized and address the particular disability. The questions that follow emphasize areas of greatest concern for sports participation:

1. Does the athlete have a history of seizures, hearing loss, or vision loss? Are the seizures controlled? These are common abnormalities seen in Special Olympic athletes.7 Uncontrolled seizures often require a consultation with a neurologist and a delay in clearing the athlete for sports participation.

2. Does the athlete have a history of cardiopulmonary disease? Congenital cardiac disorders, including heart murmurs, ventricular septal defects, and endocardial cushion defects, are more common in persons with Down syndrome.

3. Does the athlete have a history of renal disease or unilateral kidney? Various renal anomalies, such as hypoplasia, dysplasia, and obstruction, are more common in people with Down syndrome.8

4. Does the athlete have a history of atlantoaxial instability? Spontaneous or traumatic subluxation of the cervical spine is a potential risk in athletes with Down syndrome.9

5. Has the athlete had heatstroke or heat exhaustion? Thermoregulation in athletes with spinal cord injuries is impaired because of skeletal muscular paralysis and a loss of autonomic nervous system control. Medications used for pain and bladder dysfunction can interfere with the normal sweat response. Also, athletes who have had a history of heat illness are more prone to again develop the condition.

6. Has the athlete had any fractures or dislocations? Ligamentous laxity and joint hypermobility are prominent features in athletes with Down syndrome.

7. What prosthetic devices or special equipment does the athlete use during sports participation? Healthcare providers need to be aware of an athlete's need for adaptive equipment and regulations concerning their use in different sports.

8. Does the athlete use an indwelling urinary catheter or require intermittent catheterization of the bladder? Athletes with spinal cord injuries or other neurologic disorders often have bladder dysfunction or neurogenic bladders.

9. Does the athlete have a history of pressure sores or ulcers? Athletes who use wheelchairs are prone to pressure ulcers at the sacrum and ischial tuberosities, and athletes who use prostheses are prone to pressure ulcers at prosthesis sites.

10. At what levels of competition has the athlete previously participated?

11. What is the athlete's level of independence for mobility and self-care?

12. What medications is the athlete taking?

13. Is the athlete on a special diet?

14. Does the athlete have a history of autonomic dysreflexia? This is an acute, potentially life-threatening syndrome of excessive, uncontrolled sympathetic output that can occur in athletes with spinal cord injuries at or above the sixth thoracic spinal cord level.10 This reflex may happen spontaneously or may be self-induced ("boosting") by an athlete in an attempt to improve performance.11

Triggers for autonomic dysreflexia include bowel or bladder distension, infections (especially of the urinary tract), sunburn, ingrown toenails, and wearing tight garments.

Signs and symptoms of autonomic dysreflexia include excessively high blood pressure, a pounding headache, sweating above the level of spinal injury, flushed face, and bradycardia.

Boosting is a dangerous performance-enhancing technique that is strictly forbidden by all sports governing bodies. Athletes with spinal cord injuries at T-6 or above sometimes use this technique in an effort to improve cardiopulmonary performance, oxygen utilization, and noradrenaline release. Methods of boosting include occluding one's own urinary catheter and ingesting large amounts of fluids prior to an event to extend the bladder.3

The PPE Physical Examination

The PPE physical examination for the athlete with a special need should include all parts of the examination as for the athlete without a physical or intellectual disability. Particular attention should be given to the visual, cardiovascular, musculoskeletal, neurologic, and dermatologic systems (table 2).

TABLE 2. Findings to Screen for When Performing Physical Examinations on Athletes With Special Needs

Poor visual acuity
Refractive errors

Cardiovascular System
Congenital heart disease

Neurologic System
Peripheral nerve entrapment
   Carpal tunnel syndrome
   Ulnar neuropathy (Guyon's tunnel syndrome)
Inadequate motor control
Inadequate coordination and balance
Impaired hand-to-eye coordination
Muscle weakness
Sensory dysfunction
Atlantoaxial instability
Upper motor neuron and posterior column signs and symptoms

Dermatologic System
Pressure ulcers

Musculoskeletal System
Limited neck range of motion
Decreased flexibility, often with contractures, decreased strength, and
   muscle strength imbalance

In addition to examining the athlete, healthcare providers should thoroughly inspect all prostheses, orthoses, and assistive or adaptive devices to ensure adequate construction for sports participation and proper fit.12

Vision. Eye examinations of Special Olympic athletes reveal a high prevalence of vision abnormalities. A study13 of Special Olympics athletes at the 1995 International Summer Games revealed that almost one third of the athletes had ocular problems. The most common problems identified were poor visual acuity, refractive errors, astigmatism, and strabismus.

Cardiovascular system. Congenital heart disease is present in as many as 50% of athletes with Down syndrome.14 Many of these athletes may require further testing (eg, electrocardiogram, echocardiogram) or clearance from a cardiologist before participating in sports. Decisions for further testing or consultation should follow the same guidelines as for the athlete without a disability.

Neurologic system. Since many athletes with special needs have some form of neurologic deficit, a complete neurologic evaluation should be performed.

Peripheral nerve entrapment syndromes of the upper extremities are common in wheelchair athletes. Two of the most common entrapment syndromes are carpal tunnel syndrome and ulnar neuropathy at the wrist (Guyon's tunnel syndrome). The examiner should look for signs of muscle atrophy and weakness in the hand and sensory deficits following a specific nerve distribution. He or she should perform provocative tests such as Tinel's sign over the median and ulnar nerves in the wrist.

Athletes with cerebral palsy frequently have inadequate motor control and lack adequate coordination and balance for participation in different sports. Hand-to-eye coordination is also impaired. Evaluating these functions will reveal whether sports requiring catching, throwing, and controlling necessary equipment such as floor hockey sticks, rackets, and bats will be difficult or even dangerous to the athlete or other competitors.

Athletes with multiple sclerosis have varying degrees of disability. The examiner should check for ataxia, muscle weakness, fatigue, spasticity, and sensory dysfunction.

Approximately 15% of children with Down syndrome have atlantoaxial instability.15 A very small number of these children develop signs and symptoms of cervical cord myelopathy. The neurologic manifestations of symptomatic atlantoaxial instability include easy fatigue, abnormal gait, incoordination and clumsiness, sensory deficits, spasticity, hyperreflexia, clonus, and other upper motor neuron and posterior column signs and symptoms.

Dermatologic system. Athletes in wheelchairs are especially prone to skin injuries. The upper extremities should be examined for abrasions and blisters caused by friction, shear, and irritation from repeated contact with the wheelchair push rim. Skin wounds can also result from contact with other chairs, wheelchair brakes, or sharp edges of the wheelchair.

The skin over the sacrum and ischial tuberosities should be inspected for pressure ulcers. Athletes in wheelchairs have elevated skin pressures in these regions for prolonged periods during training, competition, and normal daily activity. Sports wheelchairs are designed so that the athlete's knees are at a higher level than the buttocks, a position that leads to increased pressure over the sacrum and ischial tuberosities.1 During sports participation, the combination of skin pressure, shear, and moisture increases the risk for pressure ulcers. Athletes in wheelchairs who have a pressure ulcer should not be cleared for sports participation until there is complete healing of the wound. The chair seat should be modified to decrease the risk of future skin trauma.

Prostheses can cause skin trauma; the prosthesis site should be inspected for abrasions, blisters, rashes, and pressure ulcers. The presence of pressure ulcers precludes participation in sports until the condition has resolved. The prosthesis should be evaluated for proper fit and reconditioned to decrease the risk of future problems. In the skeletally immature athlete, overgrowth of the stump can be a problem leading to breakdown of the overlying skin and soft tissues.11

Genitourinary system. Examination should involve the same evaluation as for athletes without a disability, as well as any external devices used for bladder drainage.

Musculoskeletal system. The musculoskeletal examination of an athlete who uses a wheelchair should include evaluation of the stability, flexibility, and strength of commonly injured sites (eg, shoulder, hand, and wrist) and the trunk.3

Athletes with lower limb amputation and prostheses require a full assessment of the lower back and lower extremities. These are common areas of injury resulting from abnormal forces and motions placed during sports activities.

Musculoskeletal manifestations of atlantoaxial instability in athletes with Down syndrome include limited range of motion of the neck and torticollis or head tilt. Because of hypermobility and ligamentous laxity, athletes with Down syndrome have an increased incidence of hip and knee injuries.14 Examination may reveal signs of instability and weakness.

Athletes with cerebral palsy have decreased musculotendinous flexibility, often with contractures, decreased strength, and muscle strength imbalances—especially of the lower extremities—that vary in severity from mild and nearly imperceptible to very severe and wheelchair bound.1 Overuse injuries, strains, and sprains are common, especially at the hips, knees, ankles, and feet. The PPE should include a thorough examination of these regions.

Functional Assessment

An individualized functional assessment of all athletes with special needs should be part of the PPE. An athlete's overall mobility while using prosthetic, orthotic, assistive, or adaptive devices should be evaluated. Sport-specific tasks should also be incorporated into the evaluation. A physical therapist with expertise in the area can assist with this portion of the evaluation.

Diagnostic Imaging

Athletes with symptomatic atlantoaxial instability should have cervical spine radiographic imaging to assess the extent of the problem. Radiographs of the lateral cervical spine with flexion and extension views assess the space between the posterior aspect of the anterior arch of the atlas and the odontoid.

Even though there is no evidence confirming the value of these radiographs in asymptomatic athletes with Down syndrome and atlantoaxial instability, the Special Olympics requires that athletes with Down syndrome competing in certain sports and events have a radiologic evaluation for atlantoaxial instability. The events for which such a radiologic examination is required are: judo, equestrian sports, gymnastics, diving, pentathlon, butterfly stroke and diving starts in swimming, high jump, Alpine skiing, snowboarding, squat lift, and soccer.16

Determining Clearance

Clearance for sports participation should follow the same principles as for athletes without physical or intellectual disabilities. Healthcare providers need to assess the safety of a given sport for an athlete with special needs. The athlete's medical condition and functional abilities, and the demands of the sport, need to be taken into account.

Athletes with atlantoaxial instability should be restricted from sports that require excessive neck flexion or extension.15 See above (under "Diagnostic Imaging") for a list of those sports.

Pressure sores are common occurrences in athletes using prostheses or wheelchairs.17 Athletes with pressure sores should not be cleared for sports participation until there is complete healing at the involved sites.


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Disclosure information: The authors disclose no significant relationship with any manufacturer of any commercial product mentioned in this particle. No drug is mentioned in this article for an unlabeled use.