The School-Age Preparticipation Examination

By Thomas Souza, DC, DACBSP

The opportunities for chiropractors to provide important musculoskeletal information to athletes are formidable. An estimated 25 million American youths regularly participate in organized sports.¹ Thirty-five states require yearly physicals for high-school sponsored sports, and four other states require a physical, ranging from once only to every three years.² As the coordinator or participant in a sport's pre-participation screening program, the chiropractor is uniquely positioned to determine areas often given cursory evaluation in other settings. This is assuming that the level of knowledge is matched to the task at hand. However, knowledge is often not enough when attempting to coordinate large groups of people through a multi-station process. It is important that the novice examiner become part of a preparticipation exam team to gain an experience level necessary to anticipate and coordinate large group management prior to attempting a primary role.

The specific goals of the examination are to:

determine information which will exclude or modify an individual's performance in a particular sport and possibly refer for future medical evaluation;
determine the musculoskeletal status of an individual compared to the documented requirements for a given sport;
provide feedback to the individual about their general level of health, and more specifically, point out areas in which the individual needs to focus on to better perform the sport or activity, and prevent potential injury;
act as a general health screen which is reproducible, establishing a baseline assessment for future comparison;
meet state or insurance requirements.

The preparticipation evaluation is not intended as a substitute for a full physical. A portion of the examination is intended as a health screen to discover any serious disorders. The primary focus is musculoskeletal. However, for many school-aged children, the sports physical may be the only direct access these children will have.³

A protocol for administration of the examination follows:

Meet with the contact individual at an institution or sporting organization to determine specific needs. The variables which would be discussed include: 1. Which group of individuals is being examined (specific sport or general exam)?

2. Where will the examination be performed?

3. Which type of examination format will better suit the institution based on the numbers of individuals being examined, the facilities for the examination, and the intent of the examination?

Send letters explaining to parents the intent of the examination, who is performing the examination, and an opportunity for the parent to call and ask questions. This letter would include an informed consent section to be signed by the parents.

After the examination is performed, parents and students are given an evaluation summary with a copy sent to the coach and placed in the student's file. The information would include:

vitals and anthropometric measurements (BP, temperature,pulse/respiration rate, height, weight, eyesight and hearing screening);
flexibility, strength, and endurance results with a sex and age matched comparison column;
a summary and recommendation section explaining areas which are below normal and how they may be improved.

The decision to disqualify or modify an individual's participation in a particular sport is based on the American Academy of Pediatrics guidelines.⁴ The format of this decision matrix is to classify sports:

contact/collision (includes boxing, hockey, lacrosse, martial arts, soccer, wrestling, football);
limited contact/impact (includes baseball, basketball, bicycling, diving, high jump, pole vault, gymnastics, volleyball, skiing);
noncontact (three divisions):

strenuous (includes aerobic dancing, crew, fencing, running, swimming, tennis, track, discus, javelin, shot put, weightlifting);
moderately strenuous, (includes badminton, curling, table tennis);
nonstrenuous (includes archery, golf, riflery)

A full list of conditions or disorders is then matched with these categories with a recommendation regarding participation. Absence of a paired organ would, for example, exclude an athlete from a contact sport if it was a kidney, whereas, it may require an eye guard if it was an eye (or functional loss of 20/400). An acute illness with a fever greater than 101 F, a pulse greater than 100, or severe or uncontrolled hypertension may prevent participation in all sporting activities until the illness resolves or is treated. If a parent (or coach) has a concern about the recommendation, they should seek a second opinion with the student's personal physician.

There are no standard legal guidelines in most states. However, based on a screening for serious problems and those problems which may increase chance of injury for a specific sports profile, recommendations should be made. Generally, there are four levels of recommendations:

unrestricted and unconditional: all levels of sports regardless of level of exertion or degree of contact/collision;
approval with restrictions, or pass with conditions or reservations: level of approval allows recommendations with regard to referral for medical evaluation of suspected conditions, restrictions with regard to the level of activity or type of activity (i.e. contact/collision), or recommendations for strengthening/stretching, or requirements for protective gear not usually required in a sport;
fail with reservations or conditions: allows restriction from participation in some sports, however, may allow participation in others (ex. collision vs. non-collision). It would also allow medical consultation to determine whether the failure can be reversed when certain criteria were met (i.e., diabetes patient is under control, asthmatic is properly medicated);
fail: no participation in any sport under any conditions.

Obviously, some of the concerns and restrictions may be transient when the underlying concern is self-resolving or treatable. Exclusion from sports based on the preparticipation physical is extremely rare. Studies have shown a rate between 0.3% and 1.3%.⁵

Dependent on the type of examination, the components of the preparticipation evaluation may vary. The constant components would include:

A General Health Questionnaire

The focus of the examination is to screen for known problems: disease, organ dysfunction (or absence), prior injuries, allergies, current medications, and familial tendencies. There are two tendencies to focus on are, one rare (but catastrophic), the other, common (but often undetected). The first is sudden death, often due to undetected cardiac abnormalities such as hypertrophic cardiomyopathy, which can cause sudden death.

Check for a family history of cardiac disease/death at a young age, and a personal history of syncope or heat intolerance. Marfan's syndrome should also be screened for with family history and on the physical examination.

The second condition is exercise induced bronchospasm. This condition may occur in as many as 15 percent of adolescents. Clues are exertional dyspnea or a complaint of wheezing during or after exercise.

Evaluation of Vitals

Evaluation of anthropometric measurement such as height, weight, body type, body fat composition, and general range of motion.

Medical Evaluation

vision
auscultation of heart and lungs
palpation of abdomen
determination of Tanner staging (direct or indirect) to estimate physiologic maturity (optional)

More specific examination would include testing for:

Strength: use sit-ups or pushups, the squat or one maximum lift bench press (dependent on facilities and type of exam);
Power: use the vertical jump or medicine ball toss;
Anaerobic Endurance: use jumping jacks, 20-yd dash, shuttle run, or hexagon drill;
Aerobic Endurance: using either step test or a timed mile run.
Flexibility: sit and reach test and goniometric measurement.

These may be general examinations or exams focused on target areas based on the specific sport or sports the individual will participate in. Statistically, there are common biomechanical requirements for specific sports and common injury patterns for that sport.⁶ The intent of the preparticipation examination is to focus on these requirements and give suggestions to prevent injury.

The age of the athlete will also influence the focus of concern.⁷ Children 6-10 are more involved in spontaneous play, but becoming increasingly involved in organized sports. The focus of the examination in this group is on scoliosis, congenital anomalies, visual problems, and mesenchymal disorders such as Marfan's. In the young athlete, generally 11-15, the focus shifts to more complex areas such as psychosocial influences. Particular attention is given to questioning regarding sexual activity, drug and alcohol use, and a determination of physical maturity with regard to risk of injury in contact sports.

The most appropriate time for a preparticipation physical is six weeks prior to the season. This usually gives adequate time to further investigate any areas of concern or follow a prescribed program of stretching or strengthening.

Summary of Preparticipation Exam Stations

Station Tests Equipment Needed

Check in * Medical history * Questionnaire & pens

* Blood pressure * BP cuff and stethoscope

* Pulse * Watch

* Height * Scale

* Weight * Scale

* Vision * Eye chart

* Urinalysis * Urine cups & strips

* Body fat measurement * Calipers

Flexibility * Sit and reach * Sit and reach box

* Goniometric joint * Goniometers measure

Strength * Sit-ups * Watch, and mat

* Push-ups or * Mat

* Squats * Squat bench & weights

Power * Vertical jump * Jump flags or chalk/tape measure

* Medicine ball throw * medicine ball & tape measure

Anaerobic endurance * Jumping jacks in 1 min * Watch

* 20-yard dash, or * Tape, tape measure, stopwatch

* Shuttle run, or * Five tennis balls,stopwatch, tape

* Hexagon drill, or * Goniometer, tape, ruler, stopwatch

* Sit-ups in 1 min. * Watch, mat

Aerobic * Step test, or * Metronome, step box, endurance and stopwatch

* Mile run, timed * Stopwatch

General medical * Medical exam. * Standard medical bag evaluation

* Orthopedic neurologic exam * History forms from entry

Checkout * Records review * Forms from previous stations

References

Dyment PC, (ed). Sports Medicine: Health Care for Young Athletes, 2nd ed. Elk Grove Village, IL. American Academy of Pediatrics, 1991.
Feinstein RA, Soileau EJ, Daniel WA. Preparticipation sports physicals, part 1. The station-method examination. Fam Pract Recent 1987; 9: 41-60.
Smith DM. The preparticipation physical examination. Sports Med Arthroscopy Rev, 1995: 3: 84-94.
Swander H (ed). Preparticipation Physical Evaluation. Kansas City, MO. American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, American Orthopedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine, 1992.
Shaffer TE. The adolescent athlete. Ped Clin North Am 1983; 28: 4.
Kibler WB. The Sports Preparticipation Fitness Examination. Champagne, IL: Human Kinetics Books, 1990.
McKeag DB. Preparticipation screening of the potential athlete. Clin Sports Med 1989; 8:373-397.

Thomas Souza, DC, DACBSP
San Jose, California