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Dr.
A. S. Abdulla BSC, MD, LMCC, CCFP©,
DipSportMed and
Ms. Faiza Abdulla CDA
Fahad Alanezi,
MD
Department of Pediatrics
Al-Jahra Hospital, Kuwait
PO Box 4026, Z. code 01753
Tel: 965-4577213 Mob: 9659846919
Fax: 965-5640975, E-mail:
fdh529@hotmail.com
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ABSTRACT
The pre-participation
evaluation of the athlete deals with
the epidemiological group with which
most physicians do not have the opportunity
to deal, that is the "healthy"
and physically active population between
age 10 and 30. Even though the likelihood
of significant medical conditions
being found in this group is relatively
uncommon, it is not rare. Specifically
speaking the concern is exercise-related
sudden death and significant musculo-skeletal
disability, but also issues of increased
likelihood of injuries, alcohol and
drug abuse, suicide, mood disorders,
pregnancy, and sexually transmitted
diseases are also key to the appropriate
evaluation and counseling of this
group (1-4).
The intent of this article to present
a synthesized pre-participation evaluation
that identifies medical conditions
that may limit participation, predispose
to injury or illness, evaluate risky
behaviors, counsel on health-related
issues, and ideally evaluate fitness
level and performance. This will include
a focused history, physical examination,
and the appropriate indications for
laboratory testing. We will also discuss
those medical conditions that might
disqualify an athlete from specific
athletic participation.
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The
first question is an attempt to deal with
current infections, illnesses, and medical
conditions that require active medical management.
Examples of these include diabetes and asthma.
The next few questions deal with those conditions
that may play a factor in the future health
of the athlete or may require further evaluation.
Particular attention is paid to musculo-skeletal
conditions that may not have completely
resolved or are recurrent. Musculo-skeletal
conditions are the most common disqualifiers
for athletic participation (5). Examples
of this include recurrent patellar subluxation
or incompletely treated shoulder dislocation.
Family history is an opportunity to screen
for premature death, disabling cardiovascular
disease, or genetic abnormalities like Marfan
syndrome or hypertrophic cardiomyopathy.
Medications and substance abuse provides
clues on ongoing medical conditions, their
management, the patient¢s compliance,
their understanding of drugs and their effect
on sport, and the opportunity to discuss
nutritional supplements. Nutrition and fitness
evaluation is an excellent chance to educate
and provide preventative health information.
Immunization records¢ importance is
obvious. And finally, the review of systems
includes screening questions for cardiac,
respiratory, neurological, muscular, gynecological,
and dermatological problems.
A special note is made
at this juncture regarding problems more
prevalent with female athletes. Screening
questions are included to uncover the female
athletic triad of amenorrhoea, eating disorders,
and osteoporosis. Female athletes are considerably
more prone to stress fractures (6). Also,
patello-femoral syndrome, anterior cruciate
ligament injuries, foot disorders, and mitral
valve prolapse is more common in female
athletes (7).
| PRE-PARTICIPATION
PHYSICAL EXAMINATION |
Important issues will
be highlighted only. Blood pressure should
be evaluated in relation to the patient¢s
age, height and weight (please refer to
appropriate norms). Visual acuity and field
testing is important. Cardiovascular examination
should focus on conduction abnormalities,
valvular abnormalities, and signs of hypertrophic
cardiomyopathy. This may signal further
laboratory evaluation (see below). Respiratory
evaluation should note signs of asthma,
but remember exercise-induced asthma will
not be evident at rest. Abdominal evaluation
should look for organomegaly. There should
be a check for hernias even though they
are not disqualifiers. The musculoskeletal
evaluation should focus on those areas of
previous injury and rehabilitation. This
is the most critical section and may prompt
further evaluation since it is the most
frequent disqualifier. Finally, a skin check
should look for those conditions that are
infectious and can temporarily prevent participation
in sports with direct skin-to-skin contact
like wrestling. Examples of skin conditions
include herpes, impetigo, and tinea corporis
(1-5).
Krowchuk reviewed the
use of pre-participation laboratory tests
in 1997 and recommended that urinalysis,
complete blood counts, and serum ferritin
levels have poor yields in asymptomatic
and healthy patients and that these tests
do not affect participation significantly
to warrant their expense (8). Routine screening
electocardiograms (EKG) is not recommended
by the American Heart Association (9), however
in selective individuals it can be quite
useful (1-5). Those individuals with "red-flagged"
family and personal history or physical
signs would be served well to have an EKG.
Those individuals that have signs and symptoms
associated with Marfan syndrome or congenital
or acquired heart disease may be better
served with an echocardiography study and/or
exercise stress testing (10). Common sense
will determine further evaluation of incompletely
rehabilitated musculo-skeletal conditions.
| SPECIFIC
MEDICAL CONDITONS AND SPORTS |
EYE CONDITIONS
The main issue here is
those athletes that have only one functioning
eye with better than 20/40 corrected vision,
should be evaluated by an ophthalmologist.
As well, it would be pertinent to have protective
eyewear in those sports that allow, them
such as basketball, and contraindicate involvement
in sports with projectiles and collision,
like shooting or boxing (15).
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CARDIOVACULAR CONDITIONS
Hypertrophic cardiomyopathy
contraindicates sports participation, especially
highly resistive activities like weight
lifting. A complete evaluation by a cardiologist
or a sports medicine specialist is required.
The presenting symptomatology includes exertional
dyspnoea, angina, palpitations, and syncope.
Signs include hypertension, and mid-systolic
ejection murmur. An abnormal EKG shows left
ventricular hypertrophy, and Q waves in
the inferior and anterior leads. Critical
factors include severe hypertension, ventricular
tachyarrhythmias, and suspected coronary
artery disease (1-5, 11).
Mitral valve prolapse
(MVP) is not absolutely contraindicated,
but does require further evaluation by a
cardiologist or sports medicine specialist.
It is the most common cause of mitral regurgitation
in young adults. It can also coexist with
tricuspid valve prolapse in about one third
of individuals. Common presenting symptoms
include cardiac palpitations and chest pain.
On examination, there is often an individual
with low blood pressure, low body weight,
pectus excavatum, joint laxity, and a mid-systolic
click that may be followed by a late systolic
murmur. The EKG can be normal or may show
inverted T waves in the inferior leads.
Critical factors include symptomatic dysrrhythmias
and mitral regurgitation (1-5, 12).
Congenital aortic valvular
stenosis is not absolutely contraindicated,
but does require evaluation by a cardiologist
or sports medicine specialist. The valve
is usually bicuspid. Males predominate and
typically present with exertional syncope.
The precordial exam shows a harsh systolic
murmur with radiation to the carotid arteries.
A click and thrill are often found. Critical
factors include dysrrhythmias and (pre)
syncopal episodes (1-5).
Congenital long QT syndrome
is a hereditary ventricular repolarization
abnormality. The most common presentations
include cardiac arrest, seizures, and syncope
related to high exertional circumstances
like marathons. An EKG with a corrected
QT for heart rate greater than 0.50 seconds
and perhaps a double humped T wave or negative
U waves help make the diagnosis. Women have
the greatest incidence of cardiac events
with this abnormality especially at heart
rates greater than 100bpm (1-5, 13).
Marfan syndrome is an
autosomal dominant condition with an equal
male to female ratio. There are, classically,
blue sclera, arachnodactyly, arm span greater
than height, and aortic root dilatation
leading to aortic insufficiency. Auscultation
reveals a diastolic blowing murmur, and
water hammer pulse (rapidly disappearing).
The EKG reflects left ventricular enlargement.
Critical factors include aortic aneurismal
dissection and rupture (1-5,14).
MUSCULOSKELETAL CONDITIONS
As we have mentioned
earlier, this is the most common category
that leads to restriction from sport (5).
The most common joints include the knee
and the ankle (16). The athlete must be
able to use the joint in all aspects of
the sport with which he is intending involvement.
As well, there should be no effusion, full
range of motion and at least 80 percent
of normal strength in the effected joint
(1-5).
CONVULSIVE DISORDERS
There are no contraindications
to involvement in sport (even contact sports)
with well-controlled convulsive disorders.
However, if the sport involves high risk
like climbing or scuba diving, a consultation
with a neurologist or sports medicine specialist
should be considered. Athletes with poorly
controlled seizures, frequent occurrences,
bizarre forms of psychomotor epilepsy, or
unusual post convulsive states, should be
withheld from collision, contact or projectile
sports like weight-lifting (17).
HEAD AND NECK
Concussions have been
the topic of controversy for many years
(18). Recently, the Canadian Academy of
Sports Medicine is working on a census statement
on return to play after concussion. As best
as my present awareness allows they have
suggested that the symptoms of concussion,
that is headache, dizziness, amnesia, decreased
alertness, nausea, mental difficulty, sensory
changes, and visual disturbances, should
be resolved for at least a week and not
evident during activity for full clearance.
The persistence of some of these symptoms
is denoted as "post-concussion syndrome"
and this is a contraindication to return
to play. The reasoning behind this is the
propensity to have a fatal second impact
while recovering from the first concussion,
leading to significant brain damage (19).
Subsequent concussions require neurologic
or sports medicine specialist consultation.
"Burners" or
"Stingers" are related to brachial
plexus pulling or cervical nerve root impingement.
To return to sport after these injuries
requires full range of motion of the neck
and freedom from radicular pain (20).
SPECIAL CIRCUMSTANCES
Exercise-induced asthma
requires pre-participation beta agonist
prophylaxis and does not disqualify the
athlete from any sport (1-5).
Heat-related illness
requires appropriate counseling and the
avoidance of extreme temperatures and adequate
hydration (1-5).
Sickle cell trait has
no contraindications to any sport, but does
require counseling regarding adequate hydration
and acclimatization to various altitudes
(17). Sickle cell disease is contraindicated
from collision and contact sports (17).
Acute infection is generally
contraindicated from all sports (1-5).
We have discussed those
medical conditions that might disqualify
an athlete from specific athletic participation.
We have also included a focused history
and physical examination through a well-developed
screening form. With this knowledge, it
will be easier to identify those medical
conditions that may limit participation,
predispose to injury or illness, evaluate
risky behaviors, and counsel on health-related
issues.
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