the preparticipation disclosures athletic evaluation sports medicine …andrewsref.org/docs/ft/1040...

5/8/2017

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MICHAEL D. GOODLETT, M.D.,F.A.A.F.P.,

SPORTS MEDICINE TEAM

PHYSICIAN

AUBURN UNIVERSITY

THE PREPARTICIPATION

ATHLETIC EVALUATIONDISCLOSURES

SPORTS MEDICINE CHAIR

EDWARD VIA COLLEGE OF

OSTEOPATHIC MEDICINE – AUBURN

SPECIAL ASSISTANT TO THE

PRESIDENT FOR MEDICAL

EDUCATION, AUBURN UNIVERSITY

HISTORY of the PRE-PARTICIPATION

EXAM (PPE)• Initially suggested Teddy Roosevelt in 1905 due

to sudden deaths seen in football

• Created about 30 years ago, primarily to look at congenital heart disease

• American Heart Association first developed screening guidelines in 2007

• Most recent guidelines form the 2010 PPE 4th

edition monograph

LEARNING OBJECTIVES:

1. Review the guidelines for pre-

participation sports physical

2. Understand the key things to

identify in a medical history for a

patient planning to participate in

athletics

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SCREENING HISTORYTHE PERSONAL AND FAMILY HISTORY OF THE ATHLETE REVEALS 64 TO 78 % OF CONDITIONS THAT COULD PROHIBIT OR ALTER SPORTS PARTICIPATION, MAKING IT A MORE SENSITIVE TOOL THAN THE PHYSICAL EXAMKurowski K, Chandran S, The prepaticpation athletic evaluation Am Fam Physician. 2000; 61(9):2683-2690

• PEARL: ASK WHO FILLED OUT THE FORM (THE ATHLETE OR THE PARENT?)

• PEARL: ASK THE IMPORTANT QUESTIONS AGAIN

PURPOSE of PPE

• PPE purpose is to maximize the health of athletes and their safe

participation in sports, not to disqualify

• > 30 million athletes younger than

18 years receive medical clearance

to participate in sports every year.

RESULTS of PPE

• BJSM 2012: 5.5% of adolescents were deemed ineligible for sports

Mayer F, Bonaventura K, Cassel M, et al. Medical results of preparticipation examination in adolescent athletes. Br J Sports Med. 2012;46(7):524-530

• PEARL:REMEMBER CLASSIFICATION

OF SPORTS, MOST ATHLETES CAN

SAFELY TAKE PART IN SOME TYPE SPORT

Bobsledding/luge,*† field events (throwing), gymnastics,*† martial arts,* sailing, sport climbing, water skiing,*† weight lifting,*† windsurfing*†

Bodybuilding,*† downhill,skiing,*† skateboarding,*†snowboarding,*† wrestling*

Boxing,* canoeing/kayaking, cycling,*† decathlon, rowing, speed skating,*† triathlon*†

Archery, auto racing,*† diving,*† equestrian,*† motorcycling*†

American football,* field events (jumping), figure skating,* rodeoing,*† rugby,* running (sprint), surfing,*† synchronized swimming†

Basketball,* cross-country skiing (skating technique), ice hockey,* lacrosse,* running (middle distance), swimming, team handball

Billiards, bowling, cricket,

curling, golf, riflery

Baseball/softball,* fencing,

table tennis, volleyball

Badminton, cross-country skiing

(classic technique), field hockey,*

orienteering, race walking,

racquetball/ squash, running

(long distance), soccer,* tennis

(<

20

%

MV

C)

(20

%

to

50

%

MV

C)

(>

50

%

MV

C)

†—Increased risk if syncope occurs.

RESULTS of PPE• 13% of athletes required further evaluation

for undiagnosed hypertension, vision problems, nutrition, previous / current

injuries, medical conditions Kurowski K, Chandran S, The prepaticpation athletic evaluation Am Fam Physician. 2000; 61(9):2683-2690

PEARL:BE THOROUGH AND QUICK TO RESOLVE / FOLLOW-UP ISSUES

PEARL: OBTAIN ALL PRIOR MEDICAL RECORDS CONCERNING CLEARANCE ISSUES

ABSOLUTE CONTRADICATIONS

FOR SPORTS PARTICIPATION• ACTIVE MYOCARDITIS OR PERICARDITIS

• ACUTE ENLARGEMENT OF THE SPLEEN OR LIVER

• HYPERTROPHIC CARDIOMYOPATHY

• LONG QT SYNDROME

• EATING DISORDER IN WHICH ATHLETE IS NOT COMPLAINT WITH THERAPY AND FOLLOW-UP, OR WHEN THERE IS EVIDENCE OF DIMINISHED PERFORAMCE OR POTENTIAL INJURY BECAUSE OF THE EATING DISORDER

Kurowski K, Chandran S, The prepaticpation athletic evaluation Am Fam Physician. 2000; 61(9):2683-2690

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CONTRADICATIONS FOR SPORTS

PARTICIPATION• HISTORY OF RECENT CONCUSSION AND

SYYPTOMS OF POSTCONCUSSION SYNDROME (NO CONTACT OR COLLISION SPORTS)

• POORLY CONTROLLED CONVULSIVE DISORDER (NO ARCHERY, RIFERY,SWIMMING, WEIGHT LIFTING OR POWERLIFTING, STRENGTH TRAINING, OR SPORTS INVOLVING HEIGHTS)

• SICKLE CELL DISEASE (NO HIGH-EXERTION, CONTACT, OR COLLISION SPORTS)



PARTICIPATION • RECURRENT EPISODES OF BURNING UPPER-

EXTREMITY PAIN OR WEAKNESS, OR EPISODES OF TRANSIENT QUADRIPLEGIA UNTIL STABILITY OF CERVICAL SPINE CAN BE ASSURED (NO CONTACT OR COLLISION SPORTS)

• SEVERE HYPERTENSION UNTIL CONTROLLED BY THERAPY (STATIC RESISTANCE ACTIVITIES, SUCH AS WEIGHT LIFTING, ARE PARTICULARLY CONTRAINDICATED)



PARTICIPATION

• SUSPECTED CORONARY ARTERY DISEASE UNTIL FULLY EVALUATED (PATIENTS WITH IMPAIRED RESTING LEFT VENTRICULAR

SYSTOLIC FUNCTION LESS THAN 50%, EXERCISE-INDUCED VENTRICULAR DYSHYTHMIAS, OR EXERCISE-INDUCED

ISCHEMIA ON EXERCISE STRESS TESTING ARE AT GREATEST RISK OF SUDDEN DEATH)

Table 1. Contraindications for Sports

Participation

Active myocarditis or pericarditis

Acute enlargement of spleen or liver

Eating disorder in which athlete is not compliant with

therapy and follow-up, or when there is evidence of diminished performance or potential injury because of the

eating disorder

History of recent concussion and symptoms of

postconcussion syndrome (no contact or collision sports)

Hypertrophic cardiomyopathy

Long QT syndrome

Poorly controlled convulsive disorder (no archery, riflery,

swimming, weight lifting or powerlifting, strength training,

or sports involving heights)

Recurrent episodes of burning upper-extremity pain or

weakness, or episodes of transient quadriplegia until

stability of cervical spine can be assured (no contact or

collision sports)

Severe hypertension until controlled by therapy (static

resistance activities, such as weight lifting, are particularly

contraindicated)

Sickle cell disease (no high-exertion, contact, or collision

sports)

Suspected coronary artery disease until fully evaluated

(patients with impaired resting left ventricular systolic

function less than 50%, exercise-induced ventricular

dysrhythmias, or exercise-induced ischemia on exercise

stress testing are at greatest risk of sudden death)

Adapted with permission from Kurowski K, Chandran S. The prepar-

ticipation athletic evaluation. Am Fam Physician. 2000;61(9):2688.

SICKLE CELL • SICKLE CELL DISEASE (NO HIGH-

EXERTION, CONTACT, OR COLLISION

SPORTS)

• SICKLE CELL TRAIT (NO

CONTRAINDICATIONS!!!)

PEARL: SCT IS AN OPPORTUNITY TO

EDUCATE Kurowski K, Chandran S, The prepaticpation athletic evaluation Am Fam Physician. 2000; 61(9):2683-2690

LIMITATIONS of PPE• Lack of data proving it prevents morbidity and

mortality associated with sports participation Bernhardt DT, Roberts WO; American Academy of Pediatrics. PPE: PreparticipationPhysical Evaluation. 4th ed. Elk Grove Villiage, Ill.: American Academy of Pediatrics; 2010

• PPE has not been successful in decreasing

rates of sudden death during sports in young athletes Corrado D, Basso C, Pavel A, Michieli P, Schivon M, Thiene G. Trends in sudden cardiovascular

death in young competitive athletes after implementation of a preparticipation screening program. JAMA

2006;296(14):1593-1601

• AMERICAN HEART ASSOCIATION

guidelines are often not followed or only partial followed

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LIMITATIONS of the PPE • National Federation of State High

School Associations (NFHS)

regards PPE as a prerequisite to

sports but has no authority or ability

to standardize PPE

• Inconsistencies between states (no

national standard)

PREPARTICIPATION PHYSICAL EVALUATION 4th EDITION 2010• Approved by the AAP, AAFP, ACSM,

• American Medical Society for Sports Medicine

• American Orthopedic Society for Sports Medicine

• American Osteopathic Academy of Sports

Medicine

PREPARTICIPATION PHYSICAL EVALUATION 4th EDITION 2010

Primary objectives of the PPE:• Screen for conditions that may

life threatening or disabling

• Screen for predisposing injury or illness. (Example: recurrent injury or obesity).

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PREPARTICIPATION PHYSICAL EVALUATION 4th EDITION 2010

Secondary Objectives:

• Determine general health

• Provide opportunity to

initiate discussion of health

related topics

RECOMMENDATIONS for the

PPE• Preferably performed by the Primary

MD/DO

• Should be performed ideally at least 6

weeks prior to preseason practice

(Allows time for rehabilitation )

• Periodicity is determined by state lawBernhardt DT, Roberts WO; American Academy of Pediatrics. PPE: Preparticipation Physical

Evaluation. 4th ed. Elk Grove Villiage, Ill.: American Academy of Pediatrics; 2010

WHERE SHOULD YOU DO IT• Individual exam / office setting best

allows for privacy and continuity of

careBernhardt DT, Roberts WO; American Academy of Pediatrics. PPE: PreparticipationPhysical Evaluation. 4th ed. Elk Grove Villiage, Ill.: American Academy of Pediatrics; 2010

• Pearl: The ideal situation is in the

office with the physician, the athlete

and their ATC!!

WHERE CAN YOU DO IT• Station approach allows for entire

athletic teams at one time

• Time efficient

• Often utilizes many levels of

providers and specialistsBernhardt DT, Roberts WO; American Academy of Pediatrics. PPE: PreparticipationPhysical Evaluation. 4th ed. Elk Grove Villiage, Ill.: American Academy of Pediatrics; 2010

PEARL:REMEMBER, THE MEDICAL / CV HISTORY IS IMPORTANT!

PEARL:IF YOU CAN NOT HEAR YOUR HEART, YOU CAN NOT

HEAR THE ATHLETE’S HEART!

SCREENING HISTORY• THE HISTORY ALONE MAY UNCOVER

88% OF MEDICAL CONDITIONS AND

67% OF MUSCULOSKETAL PROBLEMS

DURING THE PPE.Diokno,E Rome D. Medical and Orthopedic conditions and sports participation.

Pediatr Clin North Am. 2010;57(3):839-847

• PEARL: ASK WHO FILLED OUT THE FORM (THE ATHLETE OR THE PARENT?)

• PEARL: ASK THE IMPORTANT CV HISTORY QUESTIONS AGAIN

How Should You Do ItHistory

ASK ABOUT

•History of stress fractures or recurrent

injuries

•Ongoing medical conditions

•Use of prescription/non-prescription

drugs/supplements

•History of heat illness

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HOW SHOULD YOU DO ITHistory

ASK ABOUT

• History of allergies/anaphylaxis

• History of asthma or cough with

exercise 10-79% of athletes (high

school, collegiate, Olympic) have

exercise induced asthma

• Recent History of Mono

HOW SHOULD YOU DO ITHistory

ASK ABOUT • History of concussions, head injury or

seizures

• Menstrual history • Screen for the female athlete triad - low

energy availability (disordered eating),

menstrual dysfunction, low bone density for age

HOW SHOULD YOU DO IT

History

ASK ABOUT • History only a single normally paired

organ (example: single kidney)

• History of bleeding disorder

• History of denied or restricted sports

participation by another MD PEARL: MUST PROTECT A SINGLE PAIRED ORGAN

COLLEGE SPECIFIC ASK ABOUT

• ADD / ADHD MEDICATION OR

HISTORY OF DIAGNOSIS

• RE-ASK THE CV HX QUESTIONSPEARL:NCAA DRUG TESTING PENALITY FOR UNDOCUMENTED STIMULANTS POSSIBILITY

ONE YEAR OF ELIGILIBITY LOSTPEARL:NEED PROPER DOCUMENTATION OF ADD/ADHD DIAGNOSIS FOR DRUG TESTING/

POSSIBLE ACADEMIC ACCOMENDATIONS

COLLEGE SPECIFIC ORTHO

ASK ABOUT• PRIOR SURGERY,• PRIOR FRACTURES, STRESS FRACTURES

• PRIOR MRI, CT, BONE SCANS• PRIOR PRP, STEM CELL, “CORTIZONE”

INJECTIONS

• PRIOR CONCUSSIONS, “BURNERS/STINGERS”,LOC

PEARL:ASK ABOUT PRIOR SCHOOLS AND GET THEIR MEDICAL RECORDS

HOW SHOULD YOU DO ITPhysical Exam• Height, Weight, & BMI

• Blood Pressure – 90th-94th% or >120/80 = prehypertension, >95th 3 occasions =

hypertension (further evaluation), >99th%

+ 5mm Hg = severe hypertension (restrict from power lifting, high risk for

catastrophic event)Bernhardt DT, Roberts WO; American Academy of Pediatrics. PPE: PreparticipationPhysical Evaluation. 4th ed. Elk Grove Villiage, Ill.: American Academy of Pediatrics; 2010

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HOW SHOULD YOU DO IT?Physical Exam• Visual Acuity

• Eye protection is recommended by all

athletes the AAP and AAO• Required if best corrected vision in one

is 20/40

• Very High Risk – Contact sports• High Risk – Any sport with a ball, puck,

bat or racquet


Physical Exam• Oral cavity, Nose, Ears

• Cardio Vascular, Lungs,

Abdomen

• GU (Males only)Bernhardt DT, Roberts WO; American Academy of Pediatrics. PPE: PreparticipationPhysical Evaluation. 4th ed. Elk Grove Villiage, Ill.: American Academy of Pediatrics; 2010

HOW SHOULD YOU DO ITPhysical Exam• Musculoskeletal exam is low yield in

asymptomatic athletes

• Look at contour, ROM, stability, symmetry• Follow 2 minute orthopedic exam guidelines • Refer if: joint instability, locking of joints,

weakness, atrophy, recurrent injuryBernhardt DT, Roberts WO; American Academy of Pediatrics. PPE: Preparticipation Physical Evaluation. 4th ed. Elk Grove Villiage, Ill.: American Academy of Pediatrics; 2010

PEARL:DO A MORE THROUGH EXAM ON PREVIOUSLY INJURED

BODY PARTS

HOW SHOULD YOU DO ITAHA Recommendations• Structural cardiac problems leading to fatal

arrhythmias account for >90% of sudden death

in athletes < 30 yr, 36% from hypertrophic cardiomyopathy, 8% from idiopathic LVH, 17% from coronary artery anomalies.

• Annual incidence of sudden cardiac death = 1/100,000 – 1/200,000 high school teens –most are previously asymptomatic

HOW SHOULD YOU DO ITAHA RecommendationsPPE should include:

• Personal and family history

• Exertional chest pain/discomfort • Exertional syncope or near-syncope

• Excessive exertional and unexplained

fatigue• Prior recognition of heart murmur

• Elevated BP

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HOW SHOULD YOU DO ITAHA Recommendations

ASK ABOUT:• Premature death (sudden and unexpected in family)

before 50 yr• Disability from heart disease in a close relative <50

yr• Specific knowledge of certain cardiac conditions in

family members (hypertrophic or dilated cardiomyopathy, long QT syndrome (or other ion channelopathies), Marfan syndrome, clinically important arrthmias

Table 2. American Heart Association Recommendations on Screeningfor Cardiovascular Abnormalities in Competitive Athletes

Personal history

Elevated blood pressure

Excessive dyspnea or fatigue associated with exercise

Exertional chest pain or discomfort

Prior recognition of a heart murmur

Unexplained syncope or near-syncope

Family history

Disability from heart disease in a close relative younger than 50 years

Premature death (sudden and unexpected, or otherwise) before 50 years of age due to heart disease

Specific knowledge of certain cardiac conditions in family members: hypertrophic or dilated cardiomyopathy,

long QT syndrome, Marfan syndrome, or arrhythmias

Physical examination

Brachial artery blood pressure (sitting position)

Femoral pulses to exclude aortic coarctation

Heart murmur*

Physical stigmata of Marfan syndrome

*—Auscultation should be performed in the supine and standing positions (or with the Valsalva maneuver) to identify

murmurs of dynamic left ventricular outflow tract obstruction.

Adapted with permission from Maron BJ, Thompson PD, Ackerman MJ, et al. Recommendations and considerations relatedto preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement

from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism. Circulation. 2007;115(12):1646.

HOW SHOULD YOU DO ITAHA RecommendationsPHYSICAL EXAM • Heart Murmur – cardiac exam includes

auscultation both supine and standing w/

Valsalva to identify murmurs of Left ventricle outflow obstruction (HCM)

• Femoral pulses (to exclude aortic stenosis)

• Physical stigmata of Marfan Syndrome• Brachial artery blood pressure (sitting),

preferably


AHA Recommendations• Screening EKG NOT recommended by

the ACC / AHA in asymptomatic patients during the physical exam Maron BJ, Friedman RA, Kligfield P, et al.

Assessment of the 12-lead electrocardiogram as a screening test for detection of cardiovascular disease in healthy general populations of young people (12-25 years of age): a scientIfic statement froM the American Heart Association and the American College of Cardiology J Am Coll Cardiol 2014;64(14)1479-1514.

• 1 or more positive responses to

cardiovascular screening questions may

be enough to trigger a cardiology referral

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Preparticipation Examination Appendix

Patient stands straight with arms at sides, facing examiner. Normal findings: symmetry of upper and lower extremities and trunk.

Common abnormalities include enlarged acromioclavicular joint, enlarged sternoclavicular joint, asymmetric waist (leg-length difference or scoliosis), swollen knee and swollen ankle

Patient looks at the ceiling, looks at the floor, touches right (and left) ear to shoulder and looks over right (and left) shoulder. Normal findings: patients should be able to touch chin to chest, ears to shoulders and look equally over the shoulders.

Common abnormalities, which include loss of flexion, loss of lateral bending and loss of rotation, may indicate previous neck injury.

Patient stands in front of examiner with arms at side. Examiner tries to hold shoulder down while patient tries to shrug.

Common abnormalities include atrophy or weakness of muscles indicating shoulder, neck or trapezius nerve abnormalities.

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Patient holds arms out from sides horizontally and tries to lift them (while examiner holds arms down). Normal findings: strength should be equal in both arms, and deltoid muscles should be equal in size.

Common abnormalities include loss of strength and wasting of the deltoid muscle.

Patient holds arms out from sides with elbows bent at 90 degrees; patient raises hands vertically as far as they will go. Normal findings: Hands go back equally and at least to upright vertical position.

Common abnormalities: loss of external rotation, which may indicate shoulder problem or old dislocation.

Patient holds arms out from sides, palms up, and completely straightens and bends elbows. Normal findings: motion should be equal on left and right sides.

Common abnormalities, which include loss of extension and loss of flexion, may indicate old elbow injury, dislocation, fractures, etc.

Patient holds arms down at sides with elbows bent at 90 degrees, then twists palms up and down. Normal findings: palms should go from facing the ceiling to facing the floor.

Common abnormalities, which include lack of full supination and full pronation, may indicate an old injury of the forearm, wrist or elbow.

Patient makes a fist, opens the hand and spreads the fingers. Normal findings: fist should be tight and fingers straight when spread.

Common abnormalities, which include a knuckle protruding from the fist and a swollen or crooked finger, may indicate old finger fractures or sprains.

Patient squats on heels, duck-walks four steps and stands up. Normal findings: maneuver is painless, heel-to-buttock distance is equal on left and right sides and knee flexion is equal during the walk.

Common abnormalities include inability to fully flex one knee and inability to stand up without twisting or bending to one side.

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Patient stands up straight with arms at sides (with back to the examiner). Normal findings: symmetry of shoulders, waist, thighs and calves.

Common abnormalities include high shoulder (scoliosis) or low shoulder (muscle loss), prominent rib cage (scoliosis), high hip or asymmetric waist (leg-length difference or scoliosis), and small calf or thigh (weakness from an old injury).

Patient bends forward slowly with knees straight and touches the toes. Normal findings: patient bends forward straightly and smoothly.

Common abnormalities include patient twisting to one side (low back pain) and asymmetric back (scoliosis).

Patient stands on the heels and then rises up on the toes. Normal findings: equal elevation on right and left sides, symmetry of calf muscles.

Common abnormalities include wasting of calf muscles (Achilles injury or old ankle injury).

PPE CASE STUDY17 YO BM

HISTORY OF RIGHT KNEE “MCL SPRAIN” 2 WEEKS PRIOR AT ALL-STAR GAME

HISTORY OF RIGHT TIBIA ORIF FOR “GROWTH

PLATE REPAIR” 09-2011

PE: TTP OVER RIGHT MEDIAL TIBIAL PLATEAU

, RIGHT KNEE OPENS 1+ TO VALGUS STRESS TESTING , 1 CM. LLD ( R<L)

X-RAY SERIES RIGHT KNEE ORDERED,PRIOR MEDICAL RECORDS REQUESTED

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RADIOLOGY REPORT Right Knee

Series: Multiloculated cystic bone

lesion with thin sclerotic margins

abutting the articular surface is most

suggestive of a giant cell tumor.

Aneuromysmal bone cyst and

chondromyxofibroma are also

possibilities. No pathological fracture

is seen at this time.

MRI REPORT Right Knee With and

Without Contrast: Medial aspect of the

proximal right tibia involving the metaphysis

extending into the subchondral bone has a 36 x 37 x 69 mm multiloculated nonaggressive appearing lesion. A giant cell tumor is favored.

Aneurysmal bone is a second most likely consideration. Orthopedic oncology consultation for possible resection is

recommended.

SURGICAL PROCEEDURE

1. Open biopsy, right tibia bone lesion. (Pathology=Simple bone

cyst)2. Curettage and bone grafting of benign cyst of the right proximal

tibia

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GOALS ACCOMPLISHED BY A GOOD PRE-PARTICIPATION PHYSICAL EXAMINATION

• Legal conditions are met for the institution involved

• Conditions that might adversely affect an athlete during sports participation can be identified. These conditions primarily involve

the cardiac and orthopedic systems but are not limited to them

• The overall general health of the athlete can be determined

• A relationship on the part of the athlete has begun with the team physician that will continue during athletic participation

Mckeag, Douglas B., MD, and Robert E. Sallis, MD. "Factors at Play in the Athletic Preparticipation Examination.“American Academy of Family Physicians (2001): n. pag. Web.

GOALS ACCOMPLISHED BY A GOOD PRE-PARTICIPATION PHYSICAL EXAMINATION

• A venue has opened that will enable the athlete to discuss various

nonathletic concerns.

• Appropriate advice and feedback can be given concerning such

areas as nutrition, warm-up, cool down, and proper conditioning

• A network to support health care of that person has been

established or enlarged

• Preventive concerns such as seat belts, drinking, and other high risk

behaviors common to the adolescent age group can be addressed

Mckeag, Douglas B., MD, and Robert E. Sallis, MD. "Factors at Play in the Athletic Preparticipation Examination.“

American Academy of Family Physicians (2001): n. pag. Web.

References“Contact Sports for Young Athletes.” Pediatric Annals May 2010 vol 39, no 5

Maron BJ, Friedman RA, Kligfield P, et al. Assessment of the 12-lead electrocardiogram as a screening test for detection of cardiovascular disease in healthy general populations of young people (12-25 years of age): a scientefic statement fron the American Heart Association and the American College of Cardiology J Am Coll Cardiol 2014;64(14)1479-1514.

Metzl JD “Sports Medicine in the Pediatric Office.” Multimedia Case-Based Text With Video AAP 2008American Academy of Pediatrics. Medical Condition Affecting Sports Participation. Pediatrics 2008; 121:841-8 http://pediatrics.aappublications.org.laneproxy.stanford.edu/content/121/4/841.long

Metzl JD: Preparticipation examinations of the adolescent athlete: part 1 Pediatr Rev June 2001; 22 (6): 199-204 http://pedsinreview.aappublications.org.laneproxy.stanford.edu/cgi/content/full/22/6/199

Metzl JD: Preparticipation examinations of the adolescent athlete: part 2 Pediatr Rev July 2001; 22 (7):227-235 http://pedsinreview.aappublications.org.laneproxy.stanford.edu/cgi/content/full/22/7/227

Peds in Review 2011 the Preparticipation Sports Evaluation http://pedsinreview.aappublications.org.laneproxy.stanford.edu/cgi/content/full/32/5/e53?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=sports+medicine&searchid=1&FIRSTINDEX=0&sportspec=relevance&resourcetype=HWCIT

ReferencesPatel DR, Greydanus DE. Sport Participation by physically and cognitively challenge young athletes. Pediatr Clin North Am. 201;57(3):795-817

Bernhardt DT, Roberts WO; American Academy of Pediatrics. PPE: Preparticipation Physical Evaluation. 4th ed. Elk Grove Villiage, Ill.: American Academy of Pediatrics; 2010

Klossner D; National Collegiate Athletic Association. 2013-14 NCAA Sports Medicine Handbook. 24th

ed. http://www.ncaa.org/sites/default/files/SMHB%20Mental%20Health% 20INterventions.pdf Accessed February 9th,2015


Mirabelli, Mark H., MD, Matthew J. Devine, DO, Jaskaran Singh, MD, and Michael Mendoza, MD. "The Preparticipation Sports Evaluation." American Academy of Family Physicians 92.5 (2015): 371-76. Web.

Maron BJ, Thompson PD, Ackerman MJ, et al. Recommendations and consideration related to

preparticipations screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism. Circulation. 2007; 115(12): 1643-1655

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ReferencesThe Preparticipation Evaluation Monograph. Forth Edition, McGraw-Hill 2010

AAP History/ Physical Exam/ Clearance Forms: http://www.amssm.org/Content/pdf%20files/PPE2010RevisedForm.pdf

Maron BJ, Zipes DP. 36th Bethesda Conference: eligibility recommendations for competitive athletes with cardiovascular abnormalities. J Am Coll Cardiol. 2005:45 (8):1311-1375

Mckeag, Douglas B., MD, and Robert E. Sallis, MD. "Factors at Play in the Athletic Preparticipation Examination.“

American Academy of Family Physicians (2001): n. pag. Web.

Diokno,E Rome D. Medical and Orthopedic conditions and sports participation. Pediatr Clin North Am. 2010;57(3):839-847

Mayer F, Bonaventura K, Cassel M, et al. Medical results of preparticipation examination in adolescent athletes.

Br J Sports Med. 2012;46(7):524-530

Corrado D, Basso C, Pavel A, Michieli P, Schivon M, Thiene G. Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program. JAMA 2006;296(14):1593-1601.

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