National Athletic Trainers’ Association Position Statement: Preparticipation Physical Examinations and Disqualifying Conditions
National Athletic Trainers’ Association Position Statement: Preparticipation Physical Examinations and Disqualifying Conditions
Authors
Kevin M. Conley, PhD, ATC (Chair)
Delmas J. Bolin, MD, PhD, FACSM
Peter J. Carek, MD, MS
Jeff G. Konin, PhD, PT, ATC, FNATA, FACSM
Timothy L. Neal, MS, ATC
Danielle Violette, MA, ATC
Affiliations: University of Pittsburgh, Via College of Osteopathic Medicine– Virginia Campus, Medical University of South Carolina, University of South Florida, Syracuse University, The Washington Hospital
Objective
To provide athletic trainers and sports medicine professionals with evidence-based recommendations for both the content and the administration of the preparticipation physical examination (PPE).
To emphasize considerations for assessing safe athletic participation and identifying potentially disqualifying medical conditions or those requiring specialized management.
Background on PPE Efficacy
The PPE has been a standard component of sports medicine for nearly 40 years.
Despite its long-standing use, significant debate exists regarding its clinical efficacy due to:
A distinct lack of standardization across different states and organizations.
Inconsistent information gathered by various practitioners.
Variations in the expertise of the examiners performing the screenings.
The rise in sports participation, coupled with highly publicized cases of sudden death in athletics, has necessitated a more rigorous, standardized process to protect athlete welfare.
Clinical Recommendations and Evidence Grading
Recommendations are graded based on the Strength of Recommendation Taxonomy (SORT):
Evidence Category A: Recommendation based on consistent, good-quality patient-oriented evidence.
Evidence Category B: Recommendation based on inconsistent or limited-quality patient-oriented evidence.
Evidence Category C: Recommendation based on consensus, usual practice, opinion, or case series.
Introduction and Epidemiology
Participation in organized US athletics has seen a steady rise:
7.6 million high school students participated in 2010--2011, up from 7.1 million in 2005--2006.
444,077 NCAA student-athletes participated in 2010--2011, up from 393,509 in 2005--2006.
Etiology of Sudden Death in Athletes
Sudden deaths are frequently attributed to:
Cardiovascular Issues: Congenital or acquired malformations (e.g., Hypertrophic Cardiomyopathy), particularly among male football and basketball players.
Non-Cardiac Causes: Exertional heat stroke, cerebral aneurysms, acute asthma, commotio cordis, and complications related to sickle cell trait (SCT).
Objectives Defined by the AMA
According to the American Medical Association (AMA), the primary objectives are:
Identify athletes at high risk for life-threatening conditions to either disqualify them or treat them before they participate.
Avoid the unnecessary disqualification of athletes without evidence-based medical reasons.
Historical Context and Evolving Standards
Primary Objectives:
Detection of life-threatening or disabling conditions.
Identification of conditions predisposing the athlete to injury.
Fulfillment of legal, insurance, and administrative requirements.
Secondary Objectives: Documentation of eligibility, obtaining parental consent, and assessing fitness for performance improvement.
Medical and Family History: The Diagnostic Gold Standard
Medical history is the most sensitive component of the PPE, identifying approximately 75\% of problems affecting participation.
AHA Screening: Specifically focus on the American Heart Association (AHA) 12-point cardiovascular screening guidelines.
Accuracy Concerns: Self-reported histories often lack precision; clinicians must cross-reference history with parents or previous records where possible (Strength: C).
Physical Examination Components
1. General Health Screening
Vital Signs: Measuring height, weight, and blood pressure (identifying hypertension or growth abnormalities) (Strength: C).
Visual Acuity: Screening for vision deficits that may require corrective lenses or protective eyewear.
2. Cardiovascular Screening
Auscultation: Should occur in both standing and supine positions. Specific maneuvers (e.g., Valsalva) help differentiate benign murmurs from those associated with Hypertrophic Cardiomyopathy (Strength: C).
Advanced Testing: Non-invasive tests like ECG or Echocardiography should only be ordered if red flags appear in the personal or family history (Strength: B).
3. Neurological and Musculoskeletal Screening
Neurologic: Required if there is a history of concussion, recurrent headaches, or spinal cord injuries (e.g., "stingers/burners").
Orthopaedic: A complete musculoskeletal exam is mandatory for any athlete with a history of major injury or current symptoms (Strength: A).
Specific Medical Conditions
Diabetes Mellitus: Focus on checking HbA1c levels, reviewing insulin delivery methods, and establishing an emergency action plan for hypoglycemia.
Sickle Cell Trait (SCT): Confirm the athlete's status. If positive, provide education on the risks of exertional sickling and implement modified conditioning programs during high-heat or high-altitude training.
Disordered Eating: Use screening tools like the Female Athlete Triad screening questions to identify risks for low energy availability and bone density issues.
Administration and Clearance
Timing: The PPE should be conducted 4 to 6 weeks before the season begins. This window allows for further diagnostic testing, specialist referrals, or rehabilitation of existing injuries.
Frequency: A complete exam is required at the entry of each new level of participation (e.g., moving from middle school to high school, or high school to college).
Confidentiality: All records must comply with HIPAA and FERPA regulations.
Clearance Categories:
Cleared for all sports without restriction.
Cleared for all sports with recommendations for further evaluation/treatment.
Not cleared for any/certain sports until further evaluation.
Disqualified.