What is the first thing you should do when assessing an injured patient athlete?

Continuing Education Activity

Evaluation of a patient for participation in sporting activities has a traditional role in ensuring their health before enduring the effects and stresses of that particular sport. This form of patient evaluation has been used by both professional as well as amateur athletes, hence having a variable level of comprehensiveness. Many sports associations and leagues require a health exam, documentation, and paperwork from health care providers to certify that the subjects are healthy and ready for their sport of choice. Patients will undergo an assessment that includes personal medical history, family medical history, history of supplemental or enhancer drug use, a physical examination, and potential diagnostic tests. This activity reviews the fundamental components of a medical evaluation by the interprofessional team for an athlete and how these evaluations can be optimized to ensure that patients are medically safe, to a certain degree, for their choice of sporting activity.

Objectives:

• Summarize the history that should be evaluated in a prospective athlete.

• Identify the physical exam features in a prospective athlete that would prohibit sports participation.

• Review the indications for various diagnostic tests that should be considered in a prospective athlete.

• Outline how the interprofessional team can work together to screen and educate patients on safe sports participation.

Access free multiple choice questions on this topic.

Introduction

Evaluation of a patient for participation in sporting activities has a traditional role in ensuring their health is optimized before enduring the effects and stresses of that particular sport. This form of patient evaluation has been used by both professional as well as amateur athletes, hence having a variable level of comprehensiveness. Many sports associations and leagues require a documented physical exam from a physician to certify that the athlete is in good health. Patients will undergo an assessment that includes personal medical history, family medical history, medication use, a physical examination, and potential diagnostic tests.

The medical history evaluates potential existing medical illnesses, which include cardiac illness, musculoskeletal disease, history of neurological illness, respiratory disease, bleeding disorders, and psychiatric illness. Similarly, the family history is evaluated for any conditions that might have been inherited but are asymptomatic or not yet recognized. The physical examination assesses for optimal neurological and musculoskeletal health as well as evaluation of cardiovascular function.[1] Diagnostic tests may include blood tests and electrocardiograms (ECGs). The purpose is to assess organ health and to assess cardiac structure and function. Abnormal findings during the history and physical examination or ECG may prompt further diagnostic tests and evaluations.[2] 

Function

The primary purpose of a sports participation evaluation is to assess for underlying medical pathology while also ensuring that the athlete is in optimal health. Athletes are asked about symptoms they are experiencing during times of physical exertion and at rest.  

Key Symptoms and Medical History In Athletes

Cardiac

• Syncope

• Presyncope

• Dizziness

• Dyspnea

• Chest pain

• Shortness of breath

• Seizures

Respiratory

• Dyspnea

• Pain with breathing

• History of Asthma 

Neurological

• Headaches

• Seizures

Musculoskeletal

• Excessive joint pain

• Limited range of motion in extremities

• Hypermobility

• Chronic low back pain

• History of fractures or past injuries 

• History of muscular tears

• Back or neck pain

Hematologic

• Excessive bleeding

• Clotting disorder(s)

• Immunosuppression

Psychiatric

• Depression

• History of suicidal ideation

• History of manic phases

• Eating disorders and nutritional status

General

• Previous exclusion from sports

• Previous injuries 

• Complications and sequelae from past events 

Family Medical History 

• Sudden unexpected death

• History of undiagnosed syncope

• History of unexpected drowning

• Familial heart diseases

• Muscular dystrophies  

Cardiac-related symptoms that occur during rest and/or exertion are of particular concern due to the risk of sudden cardiac death. However, other probable etiologies should also be considered.[3] Given that congenital heart disease is inherited, it is important to assess the family medical history for possible undiagnosed heart disease.[4] 

Physical Examination

The physical examination focuses on the cardiovascular, respiratory, musculoskeletal, and neurological systems. The patient is checked for a regular heart rhythm, the possible presence of murmurs, and the existence of an S3 or S4 sound upon auscultation. The presence of heaves, lifts, or thrills is also evaluated. The respiratory exam is used to ensure that the athlete does not have asthma or, if they do, that it is well controlled. Furthermore, the musculoskeletal examination serves the purpose of assessing connective tissue health. Certain conditions, such as Ehlers Danlos, may also be suspected.

It is essential for athletes who engage in contact sports, given the potential risk of damage to their connective tissues. Contact sports are also a concern in those with histories of neurological disease. Lastly, a focused psychiatric assessment is an important aspect of examining an athlete. Psychiatric illnesses might interfere with the dynamics of teamwork and participation. Some psychiatric conditions may be exacerbated by the mental and physical stress of competitive sports. Also, the athlete's performance may not be optimal if mental illness is present.[5] In addition, eating disorders may exist within certain athlete populations, especially those who compete within certain weight classes.

Supplement and Drug Use

A thorough medical examination of an athlete must include an assessment of any supplements and drugs the athlete uses. Health and nutritional supplements are commonly used within the athletic communities. Certain supplements may contain ingredients that pose a health risk to the athlete and are banned for use by the World Anti-Doping Agency (WADA). Also, certain supplements, such as specific stimulants, may be legal for use but pose a long-term cumulative health risk when used in repetitive high doses. Beyond the use of supplements, performance-enhancing drugs (PEDs) and recreational drugs are both cause for concern in athletes. PEDs are highly sport-specific, with the most commonly used ones categorized as anabolic agents and stimulants. Anabolic drugs are further classified as anabolic-androgenic steroids (AAS), peptide hormones, and other newer drugs.

An example of a new class of drugs that have become popular is selective androgen receptor modulators (SARMs), which are potentially harmful and banned by the WADA. Conversely, some common anabolic agents include testosterone, trenbolone, methandrostenolone, stanozolol, oxandrolone, oxymetholone, nandrolone, and many other anabolic steroids. Recreational drug use is also of concern in athletes, given their health risks and interference with their function and drug testing during sporting activities. Lastly, prescribed medications should always be evaluated, given their potential for causing an athlete to fail a drug test or to affect their performance.[6] 

Electrocardiogram

There are a variety of written opinions regarding the use of the ECG to screen athletes for cardiac defects. The decision to undergo testing may be shared between the physician and the patient. It is critical to distinguish between abnormal ECG findings within the general population and normal findings in athletes. ECGs in athletes should be assessed for accessory pathways, short PR intervals, long or short QT intervals, epsilon waves, T wave inversions, excessive premature ventricular contractions, and any significant pathologic signs. Normal ECG findings in athletes include bradycardia, sinus arrhythmia, ventricular enlargement, and first-degree atrioventricular block. Additional diagnostic testing and unnecessary treatments can be reduced significantly by distinguishing between benign and pathologic findings.[7]   

Issues of Concern

A significant issue surrounding sports pre-participation physical examinations is the potential for unnecessary diagnostic testing. The tests may reveal false-positive findings and lead to further invasive testing, which may cause harm and anxiety to the patient. The physician must assess each athlete on a case-by-case basis to ensure unnecessary testing and treatment are minimized. 

On the issue of PED use, many users may not directly reveal to their physicians that they use PEDs. It is imperative to thoroughly assess supplement and drug use in athletes so that the athlete's health risks can be accurately evaluated. 

Clinical Significance

Athletes who experience potential cardiac symptoms, especially episodes of syncope, may be at risk of sudden cardiac death. However, the differential diagnosis for syncope in athletes should always include vasovagal events, heatstroke, dehydration, and blunt trauma. An optimal sports participation evaluation will reassure the athlete that they are not at risk of sudden cardiac death or any predictable severe injury while participating.   

Cardiac Conditions Associated With Sudden Death In Athletes

• Hypertrophic Obstructive Cardiomyopathy - this is the most common cause of sudden death in young athletes, according to some authors[8][9][10]

• Coronary Artery Anomaly - the second most common cause of sudden death in young athletes 

• Coronary Artery Disease - is the most common overall cause of death in athletes due to its relatively high prevalence among older athletes[11]

• Arrhythmias such as ventricular tachycardia - The most common cause of sudden death cited by some authors[12][11]

• Left Ventricular Hypertrophy - can also occur due to anabolic and peptide steroid use

• Anabolic Steroid Induced Cardiac Disease[13]

• Arrhythmogenic Right Ventricular Dysplasia 

• Dilated Cardiomyopathy

• Left Ventricular Noncompaction

• Congenital Long QT Syndrome

• Short QT Syndrome

• Brugada Syndrome

• Wolff Parkinson White Syndrome

• Catecholaminergic Polymorphic Ventricular Tachycardia

• Early Repolarization Syndrome

• Myocarditis

• Commotio Cordis

Beyond assessing the risk of sudden death, the risk of general harm to the athlete should be considered in the context of their medical history and sport of choice. 

• Concussion history - Given the risk of neurological harm and chronic traumatic encephalopathy in contact sports

• Rheumatologic disease - Given the forced stress induced upon an already damaged soft tissue 

• Orthopedic injuries - Ensuring optimal recovery of prior injuries before returning to competitive sports

• Hematologic disorders - May lead to internal organ bleeding or significant blood loss in the event of a laceration 

PEDs and Associated Health Risks

• Anabolic steroids induce a broad range of symptoms and illnesses, which may increase the long-term risk of early mortality

• Peptide hormones may lead to cardiac structural changes that are tied to cardiac arrest and increase the risk of cancers

• Stimulants can lead to long-term cardiovascular damage and increase the risk of both benign and dangerous arrhythmias[14]

Other Issues

Overall goals of preparticipation evaluation are to identify medical problems and treat them before initiating the activity. This includes the identification and treatment of conditions that might interfere with performance and cause damage or injury. In doing so, the evaluation hopes to maximize the participation of the athlete but minimize the potential dangers and complications. Many leagues and clubs ask for preparticipation evaluation 6 to 8 weeks before the start day to have enough time to do additional testing, if required. Many of them also ask for a yearly re-evaluation if there is a change in the level of participation. 

Chances of sudden cardiac death are minimal in the overall population, but 1 in 100,000 young athletes per year is considered at risk.[15] Other potential complications are not so common. Most of the time, the benefit of exercise outweighs the risks associated with it, regardless of the baseline fitness of the athlete or the type and intensity of the sport played. 

Enhancing Healthcare Team Outcomes

Health care workers should take an interprofessional team-based approach to ensure that athletes participate safely in sports.  Primary care clinicians, including PAs and nurse practitioners, can provide optimal screening for their athletic patients and ensure they do not have any significant medical issues. Pharmacists also play a significant role as educators, assisting the clinical team, especially in the era of supplements. Unnecessary use of nutritional and health supplements can be avoided if an athlete is thoroughly educated and has ready access to a pharmacist. Nurses can perform parts of the examination, take patient history, and answer any questions patients or parents may have about the examination, both before and after. An interprofessional team approach will result in the best outcomes. [Level 5]

Review Questions

References

Lick D, Abdel-Aty K, Diaz D, Dulku J, Lochub S, Mir K, Ricketts R. Preparticipation Sports Physicals: A Comparison of Single Provider and Station-Based Models. Clin J Sport Med. 2018 Nov;28(6):530-532. [PubMed: 28708703]

Lehman PJ, Carl RL. The Preparticipation Physical Evaluation. Pediatr Ann. 2017 Mar 01;46(3):e85-e92. [PubMed: 28287681]

Pigolkin YI, Shilova MA, Zakharov SN, Sereda AP, Zholinskiy AV, Kruglova IV, Shigeev SV. [The sudden death among the young persons under effect of the different forms of physical loads]. Sud Med Ekspert. 2019;62(1):50-55. [PubMed: 30724895]

Ison HE, Ware SM, Schwantes-An TH, Freeze S, Elmore L, Spoonamore KG. The impact of cardiovascular genetic counseling on patient empowerment. J Genet Couns. 2019 Jun;28(3):570-577. [PubMed: 30680842]

Roberts WO, Löllgen H, Matheson GO, Royalty AB, Meeuwisse WH, Levine B, Hutchinson MR, Coleman N, Benjamin HJ, Spataro A, Debruyne A, Bachl N, Pigozzi F., American College of Sports Medicine (ACSM). Fédération Internationale du Médicine du Sport (FIMS). Advancing the preparticipation physical evaluation: an ACSM and FIMS joint consensus statement. Clin J Sport Med. 2014 Nov;24(6):442-7. [PubMed: 25347259]

Horwitz H, Andersen JT, Dalhoff KP. Health consequences of androgenic anabolic steroid use. J Intern Med. 2019 Mar;285(3):333-340. [PubMed: 30460728]

Basu J, Malhotra A. Interpreting the Athlete's ECG: Current State and Future Perspectives. Curr Treat Options Cardiovasc Med. 2018 Nov 19;20(12):104. [PMC free article: PMC6244896] [PubMed: 30456469]

van Driel B, Asselbergs FW, de Boer RA, van Rossum AC, van Tintelen JP, van der Velden J, Michels M. [Hypertrophic cardiomyopathy]. Ned Tijdschr Geneeskd. 2019 Feb 07;163 [PubMed: 30730688]

Maron BJ, Shirani J, Poliac LC, Mathenge R, Roberts WC, Mueller FO. Sudden death in young competitive athletes. Clinical, demographic, and pathological profiles. JAMA. 1996 Jul 17;276(3):199-204. [PubMed: 8667563]

Finocchiaro G, Papadakis M, Robertus JL, Dhutia H, Steriotis AK, Tome M, Mellor G, Merghani A, Malhotra A, Behr E, Sharma S, Sheppard MN. Etiology of Sudden Death in Sports: Insights From a United Kingdom Regional Registry. J Am Coll Cardiol. 2016 May 10;67(18):2108-2115. [PubMed: 27151341]

Eckart RE, Shry EA, Burke AP, McNear JA, Appel DA, Castillo-Rojas LM, Avedissian L, Pearse LA, Potter RN, Tremaine L, Gentlesk PJ, Huffer L, Reich SS, Stevenson WG., Department of Defense Cardiovascular Death Registry Group. Sudden death in young adults: an autopsy-based series of a population undergoing active surveillance. J Am Coll Cardiol. 2011 Sep 13;58(12):1254-61. [PubMed: 21903060]

Corrado D, Basso C, Schiavon M, Thiene G. Screening for hypertrophic cardiomyopathy in young athletes. N Engl J Med. 1998 Aug 06;339(6):364-9. [PubMed: 9691102]

Chistiakov DA, Myasoedova VA, Melnichenko AA, Grechko AV, Orekhov AN. Role of androgens in cardiovascular pathology. Vasc Health Risk Manag. 2018;14:283-290. [PMC free article: PMC6198881] [PubMed: 30410343]

Farzam K, Richards JR. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): May 1, 2022. Premature Ventricular Contraction. [PubMed: 30422584]

Landry CH, Allan KS, Connelly KA, Cunningham K, Morrison LJ, Dorian P., Rescu Investigators. Sudden Cardiac Arrest during Participation in Competitive Sports. N Engl J Med. 2017 Nov 16;377(20):1943-1953. [PMC free article: PMC5726886] [PubMed: 29141175]

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