The Pre-Participation Evaluation of Athletes
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Dr. A. S. Abdulla BSC, MD, LMCC, CCFP©, DipSportMed and
Ms. Faiza Abdulla CDA

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).

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.

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).

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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