Team Medical Coverage

Head, Ears, Eyes, Nose, and Throat

A detailed history of eye disorders, injuries, and the need for corrective or protective eyewear should be obtained. Visual acuity should be assessed via a standard Snellen eye chart. Poor visual acuity is one of the most frequently reported findings on PPEs, and appropriate consultation with a specialist should be facilitated. Athletes whose visual acuity in the poorer eye is worse than 20/40 with optical correction should be classified as being “functionally one-eyed,” and akin to persons missing an eye, they should wear protective eyewear when participating in sports with a high risk for eye injury. Furthermore, they should be restricted from participating in sports that feature intentional harm, such as full-contact martial arts, boxing, and wrestling. A pupillary examination to document baseline anisocoria should be performed for reference in the event of a head injury. Odontogenic pathology such as oral ulcers, gingival atrophy, and decreased enamel may be a sign of an eating disorder.

Cardiovascular System

Sudden cardiac death (SCD) is the most feared complication of sports participation. The annual incidence of SCD in the United States is approximately 1 in 80,000 high school athletes and 1 in 50,000 college athletes. Box 11.1 outlines the most common causes of sudden death in young athletes in the United States. To reduce the risk of SCD during sports participation, the PPE-4 endorses the recommendations made by the 2007 American Heart Association (AHA) consensus statement on preparticipation cardiovascular screening. According to multiple studies, the sensitivity of history taking and a physical examination for detecting cardiac disorders associated with SCD is 20%. The author societies of PPE-4 admit that no outcome-based studies have demonstrated that the PPE is effective for preventing or detecting athletes at risk for SCD. The PPE-4 questions used to evaluate cardiac history (personal and family) are listed in Fig. 11.1 . These questions have been expanded in the PPE-4 to help identify ion channelopathies such as long QT and Wolff-Parkinson-White syndromes.

Current AHA guidelines recommend that the standard 11-point screening guideline and those of the PPE-4 are used by examiners as part of a comprehensive history and physical examination to detect cardiovascular abnormalities for high school and college athletes in the United States. The physical examination recommended by the AHA includes cardiac auscultation for heart murmurs, palpation of radial and femoral pulses to assess for aortic coarctation examination for physical stigmata of Marfan syndrome (MFS), and brachial artery blood pressure taken in the seated position. Cardiac auscultation should be performed with athletes seated and also with Valsalva maneuver and squatting. The murmur related to hypertrophic cardiomyopathy (HCM) will be accentuated by the Valsalva maneuver and decreased with squatting, whereas the murmur related to aortic stenosis would follow the opposite pattern. Soft early systolic murmurs are common in athletes and represent hyperdynamic flow rather than anatomic pathology. Blood pressure measurements should be made with an appropriately sized cuff. All athletes with hypertension require further workup and monitoring. Athletes with stage I hypertension (i.e., the 95th to 99th percentile plus 5 mm Hg in children and 140/90 to 160/100 mm Hg in adults) who do not have heart disease, end-organ damage, or left ventricular hypertrophy should not be restricted, except from sports that may make heavy use of the Valsalva maneuver, such as weightlifting. Athletes with stage II hypertension (i.e., >99th percentile plus 5 mm Hg in children and >160/100 mm Hg in adults) should initially be restricted from all participation pending a thorough workup and control of blood pressure.

Special attention should be directed at excluding MFS (and related connective tissue disorders, such as Ehlers-Danlos and Loeys-Dietz syndromes), which all manifest genetic deficiencies of connective tissue proteins and thereby increase risk of dissection of the aorta and other smaller arteries. Clinical manifestations of MFS may also include the ocular, musculoskeletal, respiratory, neurologic, and integumentary systems ( Box 11.2 ). For the diagnosis of MFS, revised Ghent criteria were published in 2010 and consequently are not referenced in the PPE-4. The revised Ghent criteria have placed more weight on the three cardinal features of MFS : aortic root enlargement, ectopia lentis, and FBN1 mutation to differentiate the manifestations of the cardiovascular, ocular, and skeletal organ systems. In the absence of family history, the presence of both aortic root changes and ectopia lentis are sufficient to make the diagnosis. However, these two features are not easily assessed in the PPE setting, and thus clinicians should be vigilant to identify any possible physical stigmata of MFS, particularly in male athletes taller than 183 cm (6 feet) and female athletes taller than 178 cm (5 feet, 10 inches). Athletes with a family history of MFS or two or more of the aforementioned physical examination findings should be referred for cardiology consultation to comprehensively assess aortic morphology. Given the greater emphasis on ectopia lentis in the revised criteria, a referral to ophthalmology for slit-lamp testing is also prudent.

Significant debate exists regarding noninvasive cardiac screening during the PPE, and although comprehensive coverage of this subject is beyond the scope of this chapter, related controversies are discussed in detail elsewhere in this book. The current AHA guidelines limit the use of electrocardiography (ECG) screening to small cohorts of young people aged 12 to 25 years with suspected cardiovascular pathology based on history and physical examination, provided that close physician supervision and quality control are achieved. The guidelines suggest that limitations of using a 12-lead ECG, including poor sensitivity and specificity, should be anticipated. Otherwise, current guidelines do not agree on systematic inclusion of ECG in preparticipation screening of athletes and nonathletes to identify congenital or other cardiovascular abnormalities. These guidelines are in contradistinction with recommendations of the International Olympic Committee and the European Society of Cardiology (ESC), which recommend the use of a screening ECG during PPEs. Routine ECG screening is supported by Italian data showing a 90% decrease in SCD rate with the inclusion of ECG in PPE cardiovascular screening. The dispute in recommendations among societies is largely based on studies performed in Italy which demonstrated that an ECG had a 77% greater power to detect HCM than did a history and physical examination alone.

There are important sex and race differences in SCD rates that may influence the decision to use the ECG as part of the PPE. It has been shown that there is an increased likelihood of obtaining abnormal ECGs with PPEs of older adolescent males and a decreased likelihood with females. Male athletes have been shown to be at 5 to 6 times greater risk than female athletes for SCD. In addition, the rate of SCD among black athletes has been shown to be 3 to 5 times higher in comparison with all other ethnic groups.

A systematic approach to interpreting screening ECGs as part of the PPE are the Seattle Criteria. These criteria were initially created to balance the sensitivity and specificity of ECG use, while maintaining a practical and concise checklist for physicians to use for ECG interpretation with athletes. The goal of the Seattle Criteria is to aid physicians in distinguishing ECG abnormalities that may be considered normal in athletes from abnormal ECG findings that are concerning for pathology. However, use of the Seattle Criteria has not been shown to decrease morbidity or reduce incidence of SCD among athletes. The Refined Criteria published in 2014 for ECG interpretation have been shown to decrease the occurrence of false-positive and false-negative results. Data suggest that the Refined Criteria outperform the ESC recommendations and Seattle Criteria by reducing false-positive rates of ECG interpretation in black athletes from 40.4% (ESC) and 18.4% (Seattle Criteria) to 11.5%, and in white athletes from 16.2% (ESC) and 7.1% (Seattle Criteria) to 5.3%. These studies suggest that established criteria and standardized guidelines for ECG interpretation are useful to avoid false-positive interpretations and potentially costly and unnecessary additional workup. Recently, the American Medical Society for Sports Medicine (AMSSM) formed a task force to address the need for preparticipation cardiovascular screening in young competitive athletes. Although the AMSSM supported the position that the ECG increases early detection of cardiac disorders associated with SCD, the absence of clear outcome-based research precluded the endorsement of using the ECG as a universal cardiovascular screening strategy. If physicians choose to incorporate routine ECG screening into their PPEs, proficiency in accurate ECG interpretation and access to cardiology resources are of paramount importance to maximize its utility without unnecessary cost escalation. However, the use of ECG as a global cardiovascular preparticipation screening modality in athletes is limited by the low prevalence of SCD in athletes.

A newer area of debate is use of an echocardiogram as part of the routine PPE cardiac screening protocol. It has been demonstrated that ECGs have a higher rate of false-positives as a screening modality in comparison with echocardiogram for detection of causative risk factors for HCM. This is in large part due to the similarities between ECG changes that are physiologic resulting from physical conditioning and the structural and electrical changes found in HCM. The increasing availability of portable ultrasound has led to the development of the Early Screening for Cardiac Abnormalities with Preparticipation Echocardiography (ESCAPE) protocol, which produced accuracy and reliability in diagnosing results indicative of HCM and aortic root dilation. The protocol demonstrated that limited echocardiography measurements by noncardiologists were not statistically different from values obtained from cardiologists trained in echocardiography interpretation. However, as with ECG interpretation, the ability of the team physician, not frequently a cardiologist, to accurately and efficiently interpret echocardiograms is paramount to this modality being as useful as is reported in the literature.

Reducing the incidence of SCD is a noble goal, but clinicians should be aware of the high false-positive rates associated with PPE ECGs, along with high costs, increased use of medical resources, potentially erroneous disqualification of athletes from participation, and the potential for lost “life-years” following needless sedentary lifestyle recommendations. Therefore although controversial, at present there are insufficient data available to promote universal use of screening ECGs or echocardiograms in asymptomatic individuals for detecting cardiovascular disease. A rational decision to include ECG or echocardiography as part of the PPE could conceivably be made in the appropriate setting and with sufficient provider training and resources.

Pulmonary System

It is imperative that athletes be questioned regarding a personal or family history of asthma or exercise-induced bronchoconstriction (affecting 50% to 90% of athletes), asthma-like symptoms and their severity, use of bronchodilators, degree of asthma control, and the use of tobacco or exposure to secondhand smoke. A thorough auscultation of the lung fields should be performed during the PPE. Proper diagnosis may require provocative pulmonary function testing, and in patients with exercise-induced bronchospasm, this is imperative to evaluate for undiagnosed asthma. Because an athlete's symptoms may be related to the environment, these tests may need to be performed in environmental conditions that stimulate symptoms. Athletes who are recovering from an asthma exacerbation and who are actively wheezing must be restricted from sports activity until stabilized. Vocal cord dysfunction should be considered as a potential diagnosis in athletes with asthma-like symptoms who fail to respond to usual bronchodilator therapy. Athletes with stable asthma or exercise-induced bronchoconstriction can usually be cleared to participate in sports, unless they are recovering from a recent asthma exacerbation. It may be indicated for athletes with severe underlying asthma or pulmonary disease to have a rescue inhaler available as a condition for athletic participation.

Gastrointestinal/Genitourinary System

The abdomen should be thoroughly examined for masses, tenderness, rigidity, or enlargement of the liver or spleen. The AMSSM, among other sports medicine professional organizations, recommends that a detailed genitourinary examination should be performed to assess for masses, testicular descent, tenderness, and hernias in male athletes. Liver or spleen enlargement is a contraindication to participation in sports. The athlete with a solitary kidney or testicle may be cleared to participate in contact sports; however, each athlete should be counseled on an individual basis about the harmful consequences of injury, and appropriate protective gear should be mandated during practice and competition. Acute diarrheal illness is a contraindication to participation in sports unless symptoms are mild and the athlete remains well hydrated.

Musculoskeletal System

The musculoskeletal history has a very high sensitivity (92%) for detecting abnormalities, and thus the physician should inquire about current injuries and a history of injuries requiring evaluation, casting, bracing, surgery, or missed participation. Given the high sensitivity of the history, a screening musculoskeletal examination is sufficient but should be supplemented with a more in-depth joint-specific examination when pathology is suspected. Box 11.3 reviews the 11-step general musculoskeletal screening examination. In general, literature suggests that generalized joint laxity, imbalance in strength ratios, excessive foot pronation or supination, level of physical maturity, multidirectional balance, and body mass all may be predictive for risk of injury in the adolescent athlete population. The PPE-4 recommends functional testing with the duck walk and single-leg hop as part of the musculoskeletal examination. These physical examination tests are time-efficient, require no additional equipment, and may help clinicians to effectively assess multiple physical attributes during the PPE.

Clearance for sport participation is determined based on the degree and type of injury or condition, the ability of the injured athlete to compete safely, and the necessities of a given sport. In general, if the athlete has no tenderness to palpation, has normal range of motion (ROM) and normal strength in the affected area, and performs adequately on functional tests, clearance for sport participation can typically be given. Use of protective padding, taping, or bracing may also enable the athlete to participate in sports safely.

Neurologic System

Physicians should inquire about prior concussions or head injuries, seizure disorders, frequent or exertional headaches, problems with recurrent burners or stingers (transient brachial plexopathy), or a prior transient quadriparesis or cervical cord neuropraxia. A positive history demands a thorough neurologic examination, including assessment of cognition, cranial nerves, motor-sensory function, muscle tone, reflexes, coordination testing, and gait evaluation. Athletes who have a history of multiple concussions or who have prolonged postconcussive symptoms should be counseled about risks and encouraged to discuss with their families the potential for harm, although not presently well understood, that may result from repeated concussions. The Sport Concussion Assessment Tool (SCAT), exercise testing such as the Buffalo Concussion Treadmill Test, vestibuloocular system testing such as the Vestibular/Ocular Motor Screening Assessment, vestibulospinal testing such as the Balance Error Scoring System, and neuropsychological testing may increase the sensitivity of detecting residual concussion symptoms. Athletes with persistent symptoms should be disqualified and cleared for participation only after they have successfully completed a graded return-to-sport protocol without recurrence of concussion-related signs or symptoms. Likewise, after sustaining a single stinger, athletes must be asymptomatic with a normal neurologic examination prior to medical clearance, although further diagnostic testing may be necessary for persistent symptoms or recurrent injury. Athletes who have had transient quadriparesis should have an MRI to evaluate for spinal stenosis. For atypical, exercise-related headaches, advanced intracranial imaging may be necessary to evaluate for occult causes of secondary headaches. Although a history of seizures does not preclude athletic participation, sports-specific modifications may be needed, particularly for persons involved in water sports.

Hematologic and Infectious Disease

The risks of transmission of human immunodeficiency virus, hepatitis B, and hepatitis C during routine sports participation are considered minimal, and the presence of these infections is not considered a contraindication to participation. However, guidelines from the National Hemophilia Foundation advise that athletes with bleeding disorders such as hemophilia be restricted from contact or collision sports. In addition, a diagnosis of infectious mononucleosis should preclude all sports participation for the first 3 weeks because of a significantly elevated risk of splenic rupture. Light, noncontact activity may be recommended 3 weeks after diagnosis if the athlete is asymptomatic and without complications. Participation in full-contact sports should be deferred for at least 28 days from the start of symptoms or from clinical diagnosis if the symptom onset date is imprecise. Febrile illness is also a contraindication to participation in sports because of increased susceptibility to heat illness and because it may occasionally accompany conditions such as myocarditis that may make sports participation unsafe.

Sickle cell trait (SCT) is associated with 2% of deaths in National Collegiate Athletic Association (NCAA) football players. Athletes should be questioned about a personal or family history of SCT or sickle cell disease (SCD). Phenotypic expression is varied, and thus medical clearance or exercise modifications should be made on an individual basis. To prevent exertional sickling collapse, athletes with SCT should avoid strenuous activity in extreme heat and high-altitude environments, especially when they are poorly acclimated. Deaths from exertional sickling have reportedly been more common among football players as well. In recognition of these risks, the NCAA in 2010 mandated that all Division I and II athletes be screened for SCT and that the status be established at the time of the PPE ; however, athletes may decline screening. This requirement by the NCAA was extended to Division III competitors as of 2014. If SCT is confirmed with screening, affected athletes are offered counseling on its implications to their health, athletics, and family planning. Debate still exists on universally screening athletes for SCT. Some proponents have estimated that universal screening of NCAA Division I student athletes would save seven lives over 10 years. Based on the available evidence, we recommend that all active individuals be screened for SCT with a 1-time hemoglobin electrophoresis test.

Endocrine System

Persons with types I and II diabetes mellitus can participate in sports without restriction but are encouraged to monitor blood glucose more frequently, maintain a balanced diet, adjust medications appropriately, and hydrate suitably. Education regarding activities with relatively higher risk of cutaneous foot injury such as hiking, rock climbing, or surfing is also recommended. Obese patients should not be discouraged from participating in sports but should receive counseling on lifestyle changes such as dietary and activity modifications, as well as prevention of heat-related illness. Athletes in weight-sensitive sports such as wrestling and boxing, and aesthetic sports such as diving and figure skating are at risk for eating disorders, particularly in females. The female athlete triad consists of disordered eating, amenorrhea, and decreased bone mineral density. A history of stress fractures with prolonged healing in a female athlete should increase clinical suspicion for this treatable yet potentially deadly medical condition. These patients should undergo a multidisciplinary treatment program with further risk stratification before they return to sports. It is recommended that sports medicine professionals include female athlete triad risk assessment in the standard PPE and consider expanding the history to include full menstrual history, reasons for hormonal therapy use, and questions concerning eating disorders and eating irregularities.

Dermatology

Athletes should be asked about a history of dermatologic pathology, with particular attention to highly communicable infections such as herpes or methicillin-resistant Staphylococcus aureus . The athlete should be inspected for evidence of common cutaneous infections such as herpes gladiatorum, tinea gladiatorum, impetigo, molluscum contagiosum, warts, and community-acquired methicillin-resistant S. aureus . Prevention of transmission is critical and may be achieved by covering the infected site, using prophylactic medications as indicated, refraining from sharing personal items, thoroughly cleaning athletic equipment, or ultimately restricting the athlete from participation for a specific period based on the characteristics of the sport, the type of microorganism involved, and governing body guidelines.

Immunizations

Lack of immunizations does not inherently affect sports participation, but many states require them for school enrollment, and thus the PPE provides a good opportunity to discuss vaccinations. Athletes traveling internationally for competition should be aware of local immunization guidelines recommended by the Centers for Disease Control and Prevention.

Medications and Allergies

It is imperative that medical personnel are familiar with regulations established by drug-enforcing agencies such as the World Anti-Doping Agency. Some medications are strictly prohibited, whereas others, such as albuterol, may be used with therapeutic use exemption. Over-the-counter drugs and supplements may contain banned substances and should also be thoroughly reviewed. The PPE provides a good opportunity to address the detrimental effects of illicit drug and alcohol use, particularly in the adolescent population. Medication, food, and environmental allergies should be documented in detail. Specifications should include the name of the allergen, the type of reaction, and whether athletes require an epinephrine autoinjector. Four recommendations for persons with a history of anaphylaxis include:

• 1.

  All medical personnel and athletes with allergies who may potentially require treatment with an epinephrine autoinjector should be trained in how to use it.

• 2.

  All medical kits should be stocked with an epinephrine autoinjector and over-the-counter diphenhydramine.

• 3.

  Athletes with allergies should carry an epinephrine autoinjector in their backpacks, have an additional one in their homes or dormitory rooms, and have over-the-counter diphenhydramine readily available at all times.

• 4.

  An emergency action plan (EAP) should be detailed for athletes with allergies during the PPE.

Heat Illness

Athletes with a history of exertional heat illness (EHI) are at enhanced risk for recurrent heat illness. Such athletes should be educated about preventive measures, including adequate hydration and gradual acclimatization over a period of 10 to 14 days. If possible, use of stimulant and antihistamine medications should be avoided during warm-weather activities. Athletes who use stimulant medications (e.g., for attention-deficit/hyperactivity disorder) and team health care professionals should be informed about the possible deleterious effects of using these medications in hot environments.

The National Athletic Trainers’ Association (NATA) has guidelines for athletes to help mitigate risks involved with EHI. It is recommended that individuals are gradually acclimatized to heat over 7 to 14 days to prevent the risk of EHI. Athletes who are currently sick with any viral infection or fever or have a skin rash should be withheld from participation until the condition is resolved. It is recommended that players have access to fluids at all times. Athletes should consume sodium-containing food or fluids to help replace loss of sodium in sweat and/or urine. Monitoring proper fluid consumption and replacement can help to minimize body mass loss to 2% during activity participation, which should be measured before and after the activity. Athletes should also be encouraged to sleep a minimum of 7 hours per night in a cool environment, eat a balanced diet, and properly hydrate before, during, and after exercise. Of most importance, rest periods should consist of at least 3 hours for food, nutrients, and electrolytes to be properly digested and absorbed before the next practice or game. Cold-water or ice towels should be readily accessible for all patients because immediate whole-body cooling is essential to treat EHI.

Athletes With Special Needs

The PPE-4 includes a chapter that discusses athletes with special needs and a separate form to aid the provider with unique issues affecting this patient population. The history and physical examination should be similar to that used with athletes who do not have special needs but may need to focus on diseases more common in this population such as seizures, hearing loss, vision loss, congenital heart disease, and renal disease. Athletes with Down syndrome should always be assessed for a history of atlantoaxial instability (AAI), and athletes with spinal cord injuries should be asked about difficulties with thermoregulation, autonomic dysreflexia, pressure ulcers, and use of urinary catheterization. The physical examination should focus on the visual, cardiovascular, musculoskeletal, neurologic, and dermatologic systems. Congenital heart disease is present in up to half of all athletes with Down syndrome and may require a cardiology referral for further testing prior to participation in sports.

The neurologic examination in athletes with Down syndrome should include evaluation for symptomatic AAI, which may present with upper motor neuron signs such as spasticity, hyperreflexia, clonus, and clumsiness. Persons with symptomatic AAI should undergo lateral cervical spine flexion and extension plain x-ray views to assess stability. Wheelchair athletes should be evaluated for nerve entrapments, pressure ulcers, and overuse injuries of the shoulders, hands, and wrists.