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Determining Clearance During the Preparticipation Evaluation

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—recently published 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 online at

Determining clearance is an important and sometimes difficult decision. Studies of the preparticipation evaluation (PPE) show that 3.1% to 13.9% of athletes require further evaluation before a final clearance status can be determined.1-11

The initial clearance status for an athlete can be divided into 4 categories:

  • Cleared without restriction;
  • Cleared, with recommendations for further evaluation or treatment (eg, "recheck blood pressure in 1 month");
  • Not cleared—clearance status to be reconsidered after completion of further evaluation, treatment, or rehabilitation; and
  • Not cleared for certain types of sports or for all sports.

Clearance Considerations

It must be reemphasized that the PPE is not intended to discourage or prevent participation in competitive sports. All athletes deserve a diligent and thorough assessment of any issues that could lead to denial of participation. Should such an evaluation result in restriction from participation in the sport of choice, the physician must consider alternative forms of participation. The decision to restrict participation may prevent an individual from reaping the many health benefits of regular physical exercise and may cause significant psychological consequences. One study12 emphasized the importance of participation by pointing out that adolescents rank failure to make a team worse than the death of a close friend, failure to pass a grade in school, and separation of parents.

When an abnormality or condition is found that may limit an athlete's participation or predispose him or her to further injury, the physician must consider the following questions:

  • Does the problem place the athlete at increased risk for injury or illness?
  • Is another participant at risk for injury or illness because of the problem?
  • Can the athlete safely participate with treatment (such as medication, rehabilitation, bracing, or padding)?
  • Can limited participation be allowed while treatment is being completed?
  • If clearance is denied only for certain sports or sport categories, in what activities can the athlete safely participate?

When a potentially disqualifying issue is identified during the PPE, clearance for a particular sport should be considered based on a review of the pertinent current literature. Examples include guidelines established by the American Academy of Pediatrics (AAP) Committee on Sports Medicine and Fitness (tables 21, 22, and 23 in the monograph) and the 26th Bethesda Conference guidelines on cardiovascular abnormalities.13,14 These recommendations classify sports according to the degree of contact and the level of dynamic and static stress.

Contact categories (see table 21 in the monograph) are based on the potential for injury from collision. High-impact contact-collision sports, such as football and ice hockey, have a higher risk of serious injury than do noncontact sports, such as golf.

Distinctions based on strenuousness (see table 22 in the monograph) are particularly relevant for athletes with cardiovascular or pulmonary disease. Static exercise causes a pressure load, whereas dynamic exercise causes a volume load on the left ventricle.15

In all cases, the physician's judgment is essential in applying these recommendations to a specific patient.

It is the opinion of the author societies that clearance status is best determined when the PPE is conducted using the single-physician examiner model. Should the PPE be performed with multiple examiners, clearance should be determined by a physician who has reviewed the entire history and physical exam. In any PPE format, clearance is best determined by a physician who is familiar with the demands of the activities, the limitations that result from various problems, and the current medical literature on what affects safe participation. The physician may also decide on follow-up and further workup for a specific problem found during the PPE, whether or not it affects participation. The physician determining clearance should refer to the relevant recommendations needed to establish the clearance status of the athlete or seek appropriate consultation as needed.

No matter which type of PPE format is used, it is extremely important to ensure complete understanding by the athletes and parent(s) of any restrictions, necessary workup and treatment, and any alternative activities in which the athlete may participate. While athletic trainers, coaches, and school administrators can be informed of the general participation status of the athlete, confidentiality must be maintained. The dissemination of any medical information must be done in accordance with federal laws concerning privacy of medical records.

Using a clearance form separate from the history and physical examination form is suggested to provide the parents and school with a copy of clearance decisions and follow-up recommendations while protecting the confidentiality of athletes' history and physical findings. Alternatively, this form may be used just for athletes who are not fully cleared.

In some cases, the school or organization may have a designated team physician who was not part of the PPE process. In such situations, it may be appropriate for the physician who performed the PPE to seek permission from the student-athlete and parent(s) to communicate to the team physician any ongoing problems that could affect safe participation.

Occasionally, an athlete will wish to participate despite medical recommendations to the contrary. In such cases, it is critical that the athlete, parent(s) or guardian(s), coach, and school or program administrators all understand the degree of risk in participation and the potential long-term consequences of participation.

Medication and Supplement Use

During the PPE, physicians may often be asked questions regarding the use of medications and supplements, or they may identify athletes who have been using substances for performance enhancement. Such individuals should be counseled regarding the safety and effectiveness of such agents, as well as issues related to drug testing.

Competitors need to be aware of the names and dosages of any drugs and supplements they are taking, as well as the policies that affect them. Recent studies show that supplements may contain substances that are not listed on the label that are banned by various sports organizations, and that the amount of the substances that are listed may vary considerably.16 Athletes who are subject to drug testing by a sport organization are responsible for the content of any substance they ingest. A positive test that results from using a product without knowing its contents, or a product whose contents are inaccurately labeled, may nonetheless result in sanctions. With respect to drug testing, athletes should therefore be advised that those who use such products do so at their own risk.

Sports medicine physicians should be familiar with the drug testing guidelines relevant to their institution. In addition, athletes may be competing for multiple organizations with varying drug-testing regulations. Physicians should therefore be cognizant of this when counseling athletes and when prescribing medications. Any physician prescribing medication to an athlete subject to drug testing should ensure that it is not a banned substance. If a medication needed to treat a condition is on the banned list and no alternative is available, the sport organization should be contacted to determine if approval for use of the medication can be obtained. Up-to-date information regarding drug testing and banned substances may be obtained from the following sources:

  • NCAA Sports Medicine Handbook and Drug Testing Program Book: Can be ordered via the Web ( or by phone (888-388-9748); the Web site provides printable files of these publications, including the banned drug list.
  • United States Anti-Doping Agency: Provides a drug reference hotline: 800-233-0393; additional information, including banned substance lists and printable reference material, can be obtained at

Acute Illness

On occasion, the physician performing the PPE may encounter an athlete experiencing an acute illness. Because the PPE is performed in advance of the sports season, denial of participation because of an acute illness does not generally occur. However, the ability of the athlete to safely participate in training and conditioning may be affected until the illness has resolved.

When such a situation occurs, clearance should be based on individual assessment. Factors to consider include the risk of the illness worsening as a result of participation and the potential for spreading the disease to others. The author societies recommend restriction of participation for athletes with a febrile illness and those with ongoing fluid losses due to gastrointestinal illnesses. Limiting activity in such patients is important in preventing complications such as dehydration, thermoregulatory problems, and viral myocarditis—although the latter is rare.

Bloodborne Pathogens: HIV and Hepatitis

The bloodborne pathogens of greatest concern in sports are human immunodeficiency virus (HIV) and the hepatitis B and C viruses (HBV and HCV). All can be transmitted through parenteral exposure to blood and blood products, contamination of open wounds or mucous membranes with infected blood, sexual contact, and perinatal spread from an infected mother to her baby. Body piercing and tattoos may also present some risk of contracting HIV, HCV, and HBV. Further, the sharing of needles during the use of injectable anabolic steroids has been reported to result in HIV transmission and may increase the risk of contracting HBV and HCV.17,18

Although HIV is present in tears, sweat, urine, sputum, vomitus, saliva, and respiratory droplets, only blood is recognized as a threat in the athletic setting. HIV transmission during sports has not been documented. One published report19 described a suspected case in an Italian soccer player. However, this report was poorly documented and has not been accepted as a transmission related to sport. Transmission of HIV has never been shown to occur in the NFL. The risk of transmission has been estimated to be less than 1 occurrence per 85 million games.20

Although HBV is more concentrated in blood and more easily transmitted than HIV among healthcare workers, HBV transmission in sports is rare.21 There have been 2 reports of HBV transmission during sports.22,23 In the United States, the practice of routine HBV immunization further reduces the risk of transmission.

HCV was recognized as a cause of non-A, non-B hepatitis in 1988.24 The risk of transmission of HCV to healthcare workers exposed to infected blood is intermediate to HIV and HBV.21,24 Transmission of HCV via exposure during sports participation has not been documented.

Thus, the risk of transmitting HIV, HBV, and HCV in sports is not zero, but, because it is so uncommon, it has not been quantifiable.25 Sports that involve close body contact for sustained periods (such as wrestling) are considered to present a relatively higher risk of transmission. Nonetheless, the risk is considered minimal.21,25,26

Since HIV, HBV, and HCV appear to present minimal risk to others, the NCAA, AAP, American Medical Society for Sports Medicine, and American Academy of Sports Medicine do not view the presence of such infections alone as a reason for exclusion from participation.21,25,26 Asymptomatic individuals may participate in sports under the guidance and ongoing monitoring of a knowledgeable physician. Clinical signs and symptoms should be evaluated in relation to the demands of the sport. The type of athletic activity, the health risks of participation, intensity of training, and risk of transmission to others all need to be considered. Changes in the affected athlete's health status mandate reevaluation of the participation level. Finally, confidentiality of the health status of the individual must be maintained.

Cardiovascular Abnormalities

Clearance guidelines for cardiovascular conditions in young athletes have been established by considering which conditions may be exacerbated by physical activity and which predispose an athlete to sudden cardiac death. The guidelines established by the 26th Bethesda Conference14 cover the major cardiac abnormalities seen in athletes, including hypertension, arrhythmias, congenital heart disease, acquired valvular disease, ischemic heart disease, and the cardiomyopathies. It is recommended that any physician who is determining clearance for an athlete with a cardiovascular condition consult this reference, as well as more recent recommendations cited below. If any doubts remain about the cardiovascular condition after thorough evaluation by the athlete's personal physician, the athlete should not be cleared until evaluation by a cardiologist has been completed. Summaries for selected common cardiac conditions follow.

Hypertension. Elevated blood pressure is one of the most common abnormalities found during the PPE.2,4,10,11 Care should be taken to ensure accurate blood pressure measurement according to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7).27 In particular, appropriately sized blood pressure cuffs should be available during screening to obtain accurate readings.

Previous recommendations concerning the participation status of athletes with hypertension were based on the 26th Bethesda Conference report.14 The following recommendations reflect an update that takes into consideration the most recent blood pressure classification guidelines for children and adults (see tables 16 and 17 in the monograph).27,28

Athletes 18 years old and older who are identified during the PPE as having a blood pressure reading classified as prehypertension or stage 1 hypertension according to the JNC 7, and who have no evidence of target-organ damage, may compete in all categories of sports. Such individuals should be under the care of a physician and receive regular monitoring of their blood pressure.

Those who are found to have stage 2 hypertension (systolic blood pressure ≥ 160 mm Hg or diastolic blood pressure ≥ 100 mm Hg), or who have findings of end-organ damage, should not be allowed to participate in any competitive sport until their blood pressure is further evaluated and treated, at which time eligibility for participation can be reevaluated. Cardiovascular conditioning activities may be considered in such cases on an individual basis.

For those younger than 18, normative blood pressures have been established based on age, gender, and height.28 Children and adolescents with a blood pressure measurement greater than the 99th percentile for age, gender, and height—or who have evidence of end-organ damage—are managed similarly to adults with stage 2 hypertension as described above. Those with a blood pressure measurement above the 90th percentile but less than the 99th percentile, and who do not have findings of target-organ damage, may participate while undergoing additional assessment and treatment.

Therefore, unless: (1) hypertension first noted at the PPE is at the stage 2 level in an adult or greater than the 99th percentile for children, (2) there is a concern that end-organ damage exists, or (3) a secondary cause of hypertension is suspected, the athlete may be cleared for competition while undergoing further evaluation.

Benign functional murmurs. These are commonly found during the PPE but do not preclude participation in sports. Mitral valve prolapse should not result in restriction from participation in high-intensity competitive sports unless accompanied by 1 of the following: (1) history of syncope due to arrhythmia, (2) family history of sudden death attributed to mitral valve prolapse, (3) prior embolic event, (4) arrhythmia (eg, supraventricular arrhythmias) worsened by exercise, or (5) moderate-to-marked mitral regurgitation. If any of these criteria apply, participation in low-intensity sports may be considered on an individual basis.

Hypertrophic cardiomyopathy. Athletes with an unequivocal diagnosis of HCM—the most common cause of sudden death in young athletes in the United States29—should not be allowed to participate in competitive sports, with the possible exception of low-intensity sports as defined by the 26th Bethesda Conference. Though some nationally known athletes have been allowed to engage in high-dynamic sports, risk stratification for athletes with HCM is especially difficult because of the extreme conditions that can occur with high-intensity training and competition. In addition, recent data suggest that removal of athletes with HCM from competitive sports may reduce the risk for sudden cardiac death.30

Advances in the treatment of HCM have included the use of implantable cardioverter defibrillators (ICDs) to prevent death. ICD placement is currently recommended for secondary prevention of sudden cardiac death in those with a prior cardiac arrest or sustained, spontaneous ventricular tachycardia.31 ICD use is also considered in the primary prevention of sudden cardiac death for those deemed at high risk because of multiple clinical risk factors or a single major risk factor (eg, family history of sudden death from HCM). However, there is no published literature regarding the use of ICDs for primary prevention in HCM patients considered at low risk who are then exposed to the rigors of competitive sports. The American College of Cardiology/European Society of Cardiology clinical expert consensus document on HCM reviewed these recent developments in HCM and supports the recommendation that individuals with HCM should avoid exposure to most competitive sports.31

Arrhythmias. Although a detailed discussion of arrhythmias is beyond the scope of this monograph, recommendations for clearance of athletes are covered in the 26th Bethesda Conference guidelines and the more recent Expert Consensus Conference on Arrhythmias in the Athlete of the North American Society of Pacing and Electrophysiology.14,32

Dermatologic Disorders

The presence of any open wound or infectious skin condition that cannot be protected in order to prevent exposure to other athletes warrants exclusion from competition.33 Examples include herpes simplex, scabies, louse infestation, molluscum contagiosum, tinea corporis, impetigo, and furuncles or carbuncles. In particular, herpes gladiatorum and tinea corporis gladiatorum are notoriously problematic.

Denying clearance is especially important in sports in which close physical contact occurs, such as wrestling, rugby, and martial arts, and in sports in which equipment, such as baseball helmets, is shared. Recent studies suggest that prompt identification and treatment of infected athletes is essential to prevent the spread of the infection to teammates and competitors.34 Participation may be resumed when the condition has been adequately treated and is no longer contagious. For athletes with recurrent herpes gladiatorum, nucleoside analogues (eg, acyclovir, famciclovir, or valacyclovir) are effective in preventing recurrence and are therefore recommended.35

Outbreaks of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) skin infections have recently been described among competitive athletes.36,37 Since any open skin lesion is a potential site for the development of CA-MRSA, skin wounds identified during the PPE (or at any time) should be promptly treated and covered. Athletes should be reminded to avoid sharing of personal items, including towels and razors. Athletes with CA-MRSA should be treated with appropriate antibiotics. They may return to play when the infection is clinically controlled as determined by the treating physician and the wound is able to be adequately covered.

The specific requirements for return to participation for wrestlers with skin infections can be obtained from the NFHS and the NCAA.38,39

Diabetes Mellitus

It is important that those with a history of type 1 or type 2 diabetes mellitus be carefully screened for signs of complications that could affect participation status, including: cardiovascular disease (hypertension and coronary artery disease), peripheral vascular disease, retinopathy, nephropathy, neuropathy (peripheral and autonomic), and gastrointestinal problems (gastroparesis).40-42

For patients with coronary artery disease or peripheral vascular disease, an appropriate level of activity should be determined by the treating primary physician or specialist. In patients with retinopathy, strenuous exercise can cause retinal detachment or vitreal hemorrhage. The American Diabetes Association recommends that activities that significantly elevate blood pressure, such as weight lifting, be avoided in those with moderate or severe nonproliferative retinopathy.42 These activities, and also high-impact activities (eg, jogging), should also be avoided by those with proliferative retinopathy.

There are little data on how strenuous exercise affects diabetic nephropathy, though the presence of this complication may limit exercise capacity. Highly strenuous activities should most likely be restricted, though each case should be managed on an individual basis.42

Those with peripheral neuropathy can injure their feet during exercise. Because of this, it is recommended that their activities be limited to those that do not cause repetitive impact to the feet (eg, bicycling and swimming).42

Patients with autonomic neuropathy must be screened for coronary artery disease. They can have difficulty exercising in hot or cold environments due to thermoregulatory dysfunction. Postural hypotension may also occur. The activity level of these individuals may therefore be significantly limited. The examining physician may indicate which activities are acceptable on a case-by-case basis.

Diabetic gastroparesis can affect fluid and electrolyte absorption and thus may limit safe participation in strenuous activities, prolonged activities, or activities performed in warm environments.

Because of the risk of hypoglycemia during exercise, sports such as rock climbing, skydiving, and scuba diving are considered high risk for diabetic individuals.43 Solo endurance activities (eg, ultramarathons, cycling, open-water swimming) may make it difficult to have proper support available for diabetic athletes to ensure safe participation. And motor sports present a potential risk to other competitors. Although the use of insulin pumps may reduce the frequency of hypoglycemia in those with type 1 diabetes and are now being used by athletes, such activities remain high risk.44

Those with diabetes who are free of complications and who are in good blood glucose control should not be restricted from participation in sports that do not present a high risk. Furthermore, the increasing use of intensive insulin therapy and insulin pumps has given athletes who have diabetes greater ability in adjusting insulin dosing to suit their activities. Although a complete discussion of the management of diabetes in athletes is beyond the scope of this document, the American Diabetes Association provides the following general guidelines for regulating blood glucose in athletes with type 1 diabetes42:

1. Metabolic control before exercise.

  • Avoid exercise if fasting glucose levels are greater than 250 mg/dL and ketosis is present or if glucose levels are greater than 300 mg/dL, irrespective of whether ketosis is present.
  • Ingest added carbohydrate if glucose levels are less than 100 mg/dL.

2. Blood glucose monitoring before and after exercise.

  • Identify when changes in insulin or food intake are necessary.
  • Learn the glycemic response to different exercise conditions.

3. Food intake.

  • Consume added carbohydrate as needed to avoid hypoglycemia.
  • Carbohydrate-based foods should be readily available during and after exercise.

In addition, the athlete with diabetes should be well instructed on maintaining adequate hydration, using proper footwear, and monitoring the feet for skin trauma. All these patients should wear a diabetes identification bracelet or shoe tag.

Disordered Eating and the Female Athlete Triad

When disordered eating alone or the female athlete triad (interrelated disordered eating, amenorrhea, and osteopenia or osteoporosis) is suspected, evaluation and treatment, using a multidisciplinary approach, is warranted.45 In addition, recent research has emphasized the role of inadequate energy availability in the development of oligomenorrhea or amenorrhea and osteopenia or osteoporosis in athletes.46-48 That is, individuals who do not display disordered eating behavior of psychological origin may develop oligomenorrhea or amenorrhea or have lower bone mineral density simply due to inadequate caloric intake. Athletes may be reluctant to undergo treatment, but their cooperation is imperative. It must be stressed to coaches and athletes that inadequate caloric intake or disordered eating behaviors may impair athletic performance and predispose the athlete to injury, particularly stress fractures.48

Athletic participation should be restricted when there is evidence of compromised performance or when disordered eating or the female athlete triad has threatened the athlete's health in such a way that continued participation could cause injury or deterioration of the athlete's health status.

Eye Disorders and Abnormal Vision

The potential for loss of vision because of injury is always a concern in sports. Although it is difficult to quantify the relative risk of eye injury for a specific sport, some sports such as basketball, baseball, softball, ice hockey, field hockey, and lacrosse are classified as high risk because of the number of eye injuries reported and the potential for eye impact sufficient to cause injury.49 Table 1 provides the eye injury risk classification for a variety of sports.

TABLE 1. Categories of Sports-Related Eye-Injury Risk to the Unprotected Player

High Risk
Small, fast projectiles
  Air rifle
  BB gun
Hard projectiles, "sticks," close contact
  Hockey (field and ice)
  Lacrosse (men's and women's)
Intentional injury
  Full-contact martial arts

Moderate Risk
Water polo

Low Risk
Noncontact martial arts
Skiing (snow and water)

Eye Safe
Track and field*

*Javelin and discus have a small but definite potential for injury. However, good field supervision can reduce the extremely low risk of injury to nearly negligible.

Adapted with permission from: Vinger PF: A practical guide for sports eye protection. Phys Sportmed 2000;28(6):49-69.

Because protective devices exist that can significantly reduce the risk of eye injury, it is important that all athletes and their parent(s) are made aware of the types of eye protection available and the risks of the particular sport. It is essential to consider eye protection for athletes whose vision is already impaired in 1 eye. A visual acuity of 20/40 or better in at least 1 eye is considered to provide good vision. An individual is deemed functionally 1-eyed if the loss of the better eye would result in a significant change in lifestyle. Consequently, athletes with best corrected vision in 1 eye of less than 20/40 should be considered functionally 1-eyed.50

Sports in which eye protection cannot be effectively worn are contraindicated for functionally 1-eyed athletes. Athletes who are functionally 1-eyed and who participate in sports that carry a high risk of eye injury may be individually evaluated and allowed to participate if they wear appropriate protective eyewear (table 25 in the monograph).

The athlete, his or her parent(s) or guardian(s), the coach, and school administrators, if necessary, must understand: (1) the serious long-term consequences if injury to the better eye were to occur, (2) the level of protection available for the better eye, and (3) the degree of risk of injury—with and without protection—to the better eye. Treatments for injuries that can typically occur in the desired activity should also be discussed.

If, after this discussion, the functionally 1-eyed athlete still wishes to participate in a given sport, he or she must wear appropriate protective eyewear during participation.

Athletes with eye conditions, including a high degree of myopia, surgical aphakia, retinal detachment, and a history of eye surgery, injury, or infection, may be at increased risk for eye injury.51 Such individuals should be referred to an ophthalmologist for complete evaluation and clearance.

Finally, abnormal visual acuity is among the most frequently reported findings during the PPE.2,6,9,11 Athletes who are identified as having abnormal visual acuity at the time of the PPE should be evaluated and treated by an eyecare professional.

Gynecologic Disorders and Pregnancy

Because ovarian injury is so unlikely in sports, no restrictions are necessary for female athletes with only 1 ovary. Athletes with menstrual disorders should receive a complete evaluation by a physician. Such individuals should also be screened for signs of disordered eating and a history of stress fractures.45,47,48 A nutritional evaluation to assess the adequacy of caloric intake relative to the athlete's energy expenditure should be considered.46-48 Athletes with oligomenorrhea or amenorrhea usually may be cleared while undergoing further evaluation. If pregnancy is suspected, clearance for contact-collision or strenuous sports participation should be withheld pending either a negative pregnancy test or clearance by the clinician who is following the pregnancy. The need for routine gynecologic care in an asymptomatic individual (eg, Pap smear) is not a reason to deny or delay clearance.

Heat Illness (Recurrent)

The athlete with a history of heat illness may be at risk for recurrent heat illness.52,53 Because these athletes may have unique characteristics that affect their ability to acclimate to hot environments, they need further assessment to determine the presence of predisposing conditions and to arrange a prevention strategy. Meticulous monitoring of the training environment, gradual acclimatization, and the gradual introduction of vapor-barrier equipment can help to reduce the risk. Tracking individual fluid losses, and proper fluid and electrolyte replacement, are essential to preventing cumulative dehydration. Recurrent heat illness may also be due to a medical condition, such as obesity or febrile illness; medications, such as antihistamines, antidepressants, psychomotor stimulants; or poor physical conditioning.54

The presence of sickle cell trait should be considered in athletes with a history of heat illness, because such individuals may be at greater risk for heat illness, including heatstroke, and may be at risk for sickling during exertion in the heat or at altitude.55-59 It is plausible that, in individuals with sickle cell trait, dehydration—due to an inability to fully concentrate the urine—increases the risk of heat illness. However, confusion exists between sickling collapse and heatstroke. It appears that some deaths attributed to heatstroke may actually have been due to sickling.55,59

Although clearance need not be denied to athletes with a history of heat illness, a specific prevention strategy should be implemented. Athletes with sickle cell trait, even if they have no history of heat illness, should receive specific counseling regarding the prevention of sickling during exertion. Athletes with a documented history of heatstroke or heat-related rhabdomyolysis also merit further investigation. Clearance for these athletes should be individualized.

Hepatomegaly and Splenomegaly

Organomegaly is a cause for concern if there is increased risk of damage to the organ or malfunction of a vital organ. The underlying cause must also be determined.

Acute hepatomegaly may signal the presence of infection (eg, hepatitis, infectious mononucleosis [mono]) or malignant disease (eg, hepatocellular carcinoma, lymphoma). A liver that is enlarged beyond the bony protection of the rib cage is at risk of injury. Even though the incidence of hepatic rupture among patients with acute hepatomegaly is low, participation in all sports should be avoided. Full activity may be resumed after resolution of hepatomegaly.

An athlete who has acute splenomegaly should not participate in sports. This situation is most frequently encountered in the athlete diagnosed with infectious mono. Athletes with the condition should be restricted from participation because of the rare, but serious, complication of splenic rupture.60,61 Furthermore, because splenic rupture in mono can occur in the absence of trauma, athletes should be restricted from all forms of sports-related activity.60,61 Determining when it is safe to return the athlete recovering from mono to sports is based on the resolution of clinical symptoms and the risk for splenic rupture.

Once symptoms have resolved, the decision to resume activity is difficult, since there are no prospective studies available that have assessed the spleen. The greatest risk for splenic rupture in those with infectious mono is within the first 21 days of illness in those with splenic enlargement.60 Splenic rupture very rarely occurs beyond 28 days, but it has been reported.62

Complicating the return-to-play decision is that, although acute splenomegaly commonly develops, the physical examination cannot be relied on to determine its presence.63 Serial ultrasound examination of the spleen in these patients, however, indicates that spleen size appears to normalize within 28 days.63 Based on these data, athletes with mono should be restricted from all sports-related activities for the first 21 days of illness. (If the date of symptom onset is not known, the date of the diagnosis should be used as the starting point.) If the patient is asymptomatic by day 21, light activities can be undertaken for the 4th week, with full participation resumed at week 5. Some clinicians employ serial ultrasound measurements as an additional tool in determining return to play. However, it may be difficult to determine when the spleen size has normalized, because parameters for spleen size based on gender, height, weight, and ethnicity have not yet been established and may vary considerably among individuals.64

For individuals with chronic hepatomegaly or splenomegaly, participation in sports should be assessed individually and decisions made based on the degree of enlargement and the associated disease state.

Inguinal Hernia

An athlete with an asymptomatic inguinal hernia may participate in all sports. Symptomatic inguinal hernias may limit an athlete's ability to participate and may be affected by activity. Such symptomatic cases invariably require treatment at some time and should be evaluated individually.

Kidney Abnormalities

Because of the potential for kidney injuries ranging from contusion to complete rupture, special consideration should be given when determining clearance for an athlete who has a single functioning kidney. Some, but not all, experts believe that if the kidney is pelvic, iliac, or multicystic, or shows evidence of hydronephrosis or ureteropelvic junction abnormalities, the athlete should not participate in contact-collision sports. The consequences of the loss of a single functioning kidney (eg, transplantation or dialysis) may be severe enough to warrant disqualification from these sports, even though the risk is small.65 Evaluation by a urologist or nephrologist is recommended.

If the athlete chooses to play in a sport that may place a solitary kidney at increased risk for damage, a full explanation should be given to the athlete, his or her parent(s) or guardian(s), and the coaches. The explanation should include available protection (eg, flak jacket), potential serious long-term consequences, and treatment of injuries if they occur.

Musculoskeletal Disorders

Determining clearance for athletes who have musculoskeletal injuries or disorders requires assessing both short- and long-term risks and benefits, considering carefully the general questions on page 30. Clearance for participation must be based on the degree and type of injury, the ability of the injured athlete to compete safely, and the requirements of a given sport. Participation may be possible in activities that do not directly affect the injured site (eg, a wrist sprain might prevent a gymnast from full training, but not a runner). Therefore, the physician should also determine which strength and conditioning activities are appropriate during the recovery period so that the athlete is able to maintain some level of fitness.

Protective padding, taping, or bracing may be designed to provide the athlete a safe means to compete. The types of protective splinting or bracing permitted in competition vary by the sport and the rules of the sport organization or league. If the examining physician is not certain of the rules concerning safe participation with protective devices, consultation with a sports medicine specialist is suggested. The final decision on what type of protective padding or bracing to use may rest with the on-site officials. In such situations, a change in the original type of protection recommended by the sports medicine staff could be deemed necessary by the official. Any alteration required by the official should be evaluated to ensure that it provides the necessary protection for the injury.

Referral to a consultant is warranted when the examiner is uncertain of the athlete's ability to participate because of the injury. In any case, physicians who initiated the treatment of an injury that was present at the time of the PPE should be included in the clearance decision. Reevaluation is required after rehabilitation.

Review of every musculoskeletal problem is beyond the scope of this monograph, but selected problems deserve mention:

Sprains, subluxations, and dislocations. Before clearance is given, sprains, subluxations, and dislocations should be examined and the following ruled out:

  • Effusion, swelling, or other signs of inflammation;
  • Decreased range of motion of the affected joint;
  • Strength less than 85% to 90% of the uninjured side or insufficient for the desired activity;
  • Ligamentous instability of the affected joint; and
  • Loss or alteration of sport-specific functional ability (ie, inability to complete pain-free functional activity at 100% effort). For example, a football defensive back who is rehabilitating a lateral ankle sprain could be assessed with back-pedaling and side-to-side movements.

If any of these findings are abnormal, further treatment will be needed to allow for return to play. Referral, if necessary, to a physician familiar with the sport-specific requirements and injury assessment is recommended. Ultimately, the decision for clearance is based on the examiner's clinical judgment and may be withheld until further evaluation and completion of prescribed treatment or rehabilitation. Further evaluation and appropriate consultation is warranted if uncertainty about clearance persists.

Strains or muscle contusions. Before clearance is given, strains or muscle contusions should be examined and the following ruled out:

  • Decreased range of motion of joints controlled by the muscle;
  • Strength less than 85% to 90% of the uninjured side or insufficient for the desired activity; and
  • Loss or alteration of sport-specific functional ability.

Treatment and clearance decisions parallel those for sprains, subluxations, and dislocations (page 38).

Overuse injuries. Overuse or overload injuries are caused by repetitive microtrauma. Examples include stress fractures, Achilles tendonopathy, medial and lateral epicondylitis, plantar fasciitis, patellofemoral pain syndrome, rotator cuff tendonopathy, and impingement syndrome. Clearance decisions are generally based on criteria similar to those for acute sprains or strains.

Fractures. Clearance of an athlete with a fracture should be determined by the treating physician. The location and type of fracture, risk of reinjury or complications, and the effect of treatment should be considered. The possibility of protecting the fracture with a cast or splint during participation should be considered if the risk of worsening the injury is believed to be negligible. Also, in making clearance decisions, the physician should be aware of specific rules relevant to the athlete's sport regarding use of padded and unpadded materials on the extremities. Contacting a league representative or referral to a sports medicine specialist is warranted if the examiner or treating physician is unfamiliar with options regarding protective devices.

Developmental conditions. Any history or physical findings of spinal deformity (eg, scoliosis, spondylolysis, or spondylolisthesis) require a more thorough evaluation than is generally provided in the PPE. Follow-up with the athlete's primary care physician, sports medicine specialist, or spine specialist is recommended should questions arise. Spondylolysis and spondylolisthesis should be evaluated individually on the basis of symptoms, physical limitations, and imaging findings. Because of the risk of progressive slippage, spondylolysis or spondylolisthesis may require follow-up imaging. Generally, athletes with spinal deformities need not be excluded from play. However, activities may need to be modified based on clinical symptoms and the extent of the abnormality.

Clearing athletes who have apophysitis of the tibial tubercle (Osgood-Schlatter disease), calcaneus (Sever's disease), ileum, or ischium follows similar criteria as for overuse injuries and acute strains. If there are any questions concerning clearance, sports medicine consultation is suggested.

Neurologic Disorders

Careful assessment of the neurologic history is important in determining clearance for athletes who have a history of concussion or other head injury, burners or stingers, or seizure disorders.

Concussion. The most common serious head injury in contact-collision sports is the cerebral concussion, also termed mild traumatic brain injury. An estimated 300,000 such injuries occur annually in the United States.66

Although the definition of concussion is not universally agreed upon, the First International Symposium on Concussion in Sport recently defined concussion as a complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces.67

This consensus group described several characteristic features that further enhance the definition67:

  • Concussion may be caused either by a direct blow to the head, face, neck, or by a blow elsewhere on the body with an "impulsive" force transmitted to the head. Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously.
  • Concussion may result in neuropathologic changes, but the acute clinical symptoms largely reflect a functional disturbance rather than structural injury.
  • Concussion results in a graded set of clinical syndromes that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course.
  • Concussion is typically associated with grossly normal structural neuroimaging studies.

There are multiple concussion classification and management protocols in the literature, based primarily on clinical experience and expert opinion.68 The complexity of concussion and the lack of large outcome studies have hampered the development of evidenced-based management recommendations. Recent studies using symptom checklists and neuropsychological testing have begun to describe the natural history of sports-related concussion.69,70 Such studies demonstrate the importance of the monitoring of clinical symptoms and the potential value of neuropsychological testing in concussion management.68,69,71 Furthermore, athletes with a history of concussion appear to be at higher risk of future concussion, and those with a history of multiple concussions may suffer long-term sequelae.71-73

Athletes at the PPE who report a history of a recent concussion should be individually assessed to ensure symptom resolution and to determine an appropriate level of activity. Symptomatic individuals should not be cleared for participation. Any physician determining return to play following a concussion should be familiar with the current literature and commonly referenced clinical recommendations. Because of the present lack of evidenced-based guidelines, such decisions ultimately are made based on the clinical judgment of the physician.

Those with a history of concussion who have been asymptomatic should be educated on the signs and symptoms of concussion and encouraged to report the occurrence of such symptoms. Baseline neuropsychological testing may be considered in athletes with a history of concussion to provide an additional tool in the management of future concussions. The role of baseline neuropsychological testing for participants with no history of concussion who are competing in high-risk sports such as football, soccer, and ice hockey is an area of emerging research.74-76

"Second impact syndrome." A rare but catastrophic entity has been described in which diffuse cerebral edema develops after head trauma. This injury has been reported primarily in children and teenagers, and at times has occurred after minimal head trauma.

The mechanism of injury is thought to involve disruption of cerebral vascular autoregulation, with resultant brain swelling and increased intracranial pressure causing high morbidity and mortality. It has been proposed that this syndrome is precipitated by head trauma that occurs when symptoms of a prior concussion or head injury are still present or by repeated concussions and has therefore been termed second impact syndrome.77,78 However, it has recently been questioned whether this injury occurs as a result of previous head trauma or simply occurs due to a single impact.79

Burners and stingers. Athletes who have had an episode of transient neurapraxia affecting an upper extremity, commonly termed a "burner" or "stinger," may be cleared for all sports if they are asymptomatic and their physical examination is normal. Athletes with a history of recurrent episodes or persisting symptoms following a single episode require evaluation with cervical spine radiographs and additional imaging to rule out a predisposing condition such as cervical disk disease, foraminal stenosis, or cervical spinal stenosis.

Transient quadriparesis. Athletes with a history of transient quadriparesis (sometimes referred to as cervical spinal cord neurapraxia) should be evaluated by a spine subspecialist. Those who have had an episode of transient quadriparesis and who have findings of ligamentous instability, cord injury or edema, or prolonged symptoms should be excluded from participation in contact sports.80,81 For all other athletes with a history of transient quadriparesis, including those with congenital or acquired cervical spinal stenosis, return to play is controversial.80-83

Seizure disorder. Athletes with a treated and controlled seizure disorder can participate in nearly all sports. Sports or activities that entail high risk (eg, gymnastics on high apparatus, high diving, skydiving, motor sports, rock climbing) should be avoided.84,85 When athletes have poorly controlled seizures, clearance should be deferred for contact-collision, limited-contact, and potentially hazardous noncontact sports, such as archery, riflery, swimming, weight lifting or power lifting, strength training, or sports involving heights.13 In the interim, while medications are adjusted and seizure control is improving, athletes may participate in noncontact sports that do not involve risk to themselves or others. In the rare instance that athletic activity precipitates an athlete's seizures, clearance should be denied and the athlete referred to a neurologist.


Childhood obesity has reached epidemic proportions.86 Physicians performing the PPE will undoubtedly encounter athletes who are obese, and concerns may arise as to whether to clear them. Although individuals with obesity may have associated conditions (eg, hypertension, exercise-induced asthma [EIA,] susceptibility to heat injury, diabetes, slipped capital femoral epiphysis), there is no reason to exclude them from sports participation because of their weight alone.

In fact, once underlying causes of obesity have been ruled out (eg, thyroid deficiency), every effort should be made to encourage some type of sports participation. Such athletes, however, should receive counseling on specific strategies to prevent heat-related illnesses. Any associated medical conditions must be appropriately treated and monitored.

Physical Maturity Status

Concerns may arise regarding clearance of an adolescent who is relatively delayed in physical maturation or underweight and who seeks to participate in competitive sports. There is no medical reason to exclude such an individual from sports participation unless a coexisting condition warrants exclusion.

Pulmonary Disorders

The most prevalent pulmonary problem in athletes is exercise-induced bronchoconstriction (EIB). The term EIB is usually used in referring to those who have symptoms (eg, shortness of breath, wheezing, chest tightness, cough) that occur during or after exercise and who do not have a history of asthma.87 EIA refers to patients with a diagnosis of asthma who have exercise-related symptoms. The prevalence of EIB is highest among those who compete in cold-weather sports.88

Arriving at a diagnosis of EIB can be difficult, especially since self-reported symptoms poorly predict the condition.89 During the PPE, physicians should evaluate athletes who report symptoms consistent with EIB. In addition, those who report EIB should have their records reviewed to ensure that an accurate diagnosis was made. It is important to determine that the exercise-associated symptoms are not simply the most apparent manifestation of chronic asthma. Therefore, spirometry to document the patient's forced expiratory volume in 1 second (FEV1) should be performed.

For those with a history consistent with EIB and a normal FEV1 on spirometry, a presumptive diagnosis of EIB may be made, and a therapeutic trial of medication can be instituted, along with instructions for a preexercise warm-up. The medication most often used is a beta-agonist taken by inhalation. It is important for the clinician to ensure that the athlete is using the inhaler correctly.

Provocational testing is necessary to confirm the diagnosis of EIB when it is in doubt or for those in whom a therapeutic trial does not improve function. Challenge testing may also be necessary to establish documentation for medication use in national and international competitions. The type of challenge test that best diagnoses EIB has not been established. Examples include field-based exercise testing, laboratory-based exercise testing, methacholine challenge testing, eucapnic voluntary hyperventilation, and osmotic challenge tests.87

Finally, it is rarely necessary to withhold an athlete with EIB or chronic asthma from participation in sports, although appropriate treatment is necessary to ensure optimal performance. Athletes whose PPE findings are suggestive of EIB or asthma may participate while being treated and monitored by a physician as their evaluation is being completed.

Testicular Disorders

The incidence of testicular injury in sports is extremely low.90 An individual with a single testicle may be cleared for participation, with the use of a protective cup for higher-risk sports.13 However, the athlete with a solitary testicle who wishes to participate in contact-collision sports must be informed that there is a risk of injury and loss of the testicle. Although wearing a protective cup may reduce the incidence of injury, it does not guarantee complete protection. Protective cups can be cumbersome and uncomfortable, and some athletes prefer not to wear them. However, with a thorough explanation of the potential benefits and availability of more comfortable cups, many athletes will choose to wear protection to decrease their risk of injury. In addition, the athlete with a solitary testicle who chooses to compete in sports should be informed of the option of sperm banking to preserve fertility and its associated costs should an injury to the testicle occur.

If an athlete has an undescended testicle that has not been thoroughly evaluated, the examining physician should refer him for evaluation and inform him of the increased risk of testicular cancer associated with this condition. Clearance determination for an athlete who has an undescended testicle is similar to that for an athlete with a single testicle.

For references, please see the monograph, Preparticipation Physical Evaluation, 3rd edition. To order, call 800-262-4729 or visit

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.