PRE PARTICIPATION EXAMINATION I Dr.RAJAT JANGIR JAIPUR
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PRE PARTICIPATION EXAMINATION I Dr.RAJAT JANGIR JAIPUR
1. Pre-Participation Physical ExaminationsPre-Participation Physical Examinations
Dr.RAJAT JANGIRDr.RAJAT JANGIR
Consultant Arthroscopy and Orthopedic SurgeonConsultant Arthroscopy and Orthopedic Surgeon
Saket Hospital, MansarovarSaket Hospital, Mansarovar
Assistant ProfessorAssistant Professor
Mahatma Gandhi Medical College, JaipurMahatma Gandhi Medical College, Jaipur
Fellowship In Arthroscopy(South Korea)
International Olympic Committee Diploma Sports Medicine(UK)
Sports Physician RIO Olympic 2016
2. IPC Medical Code
Fitness to practice a
sport
46. Prior to engaging in
competitive sport, and
preferably with regular
intervals throughout their
athletic career, athletes
should undergo pre-
participation evaluation....
3. The International Olympic Committee (IOC)
Consensus Statement on Periodic Health
Evaluation of Elite Athletes
http://www.olympic.org/assets/importednews/documents/en_r
eport_1448.pdf
Br J Sports Med. 2009 Sep;43(9):631-643.
4. PPEPPE
Goals of the PPEGoals of the PPE
Preparation for the PPEPreparation for the PPE
Medical historyMedical history
Components of the PPEComponents of the PPE
Clearance for participationClearance for participation
5. Goals of the PPEGoals of the PPE
Determine general health and current immunizationDetermine general health and current immunization
statusstatus
Establish rapport with participantEstablish rapport with participant
Detect medical conditions that can predispose one toDetect medical conditions that can predispose one to
injury/illness so treatment can be continued/initiatedinjury/illness so treatment can be continued/initiated
Identify health risk behaviors that can be addressed withIdentify health risk behaviors that can be addressed with
counselingcounseling
6. Goals of the PPEGoals of the PPE
Establish baseline parameters for return to playEstablish baseline parameters for return to play
decisionsdecisions
Assess physical maturityAssess physical maturity
Evaluate physical fitnessEvaluate physical fitness
Make recommendations regarding participation/exerciseMake recommendations regarding participation/exercise
Meet legal requirements to athletic participationMeet legal requirements to athletic participation
7. Goals of the PPEGoals of the PPE
Specific focus of PPE varies amongstSpecific focus of PPE varies amongst
populationspopulations
Pre-pubescentPre-pubescent
Undiagnosed congenital abnormalitiesUndiagnosed congenital abnormalities
PubescentPubescent
Maturation level, establishing healthy behaviorsMaturation level, establishing healthy behaviors
Young adultYoung adult
History of previous injury, sport-specific examHistory of previous injury, sport-specific exam
AdultAdult
Overuse conditions predominateOveruse conditions predominate
8. SUDDEN DEATHSUDDEN DEATH
• Sudden death in athletics can occur fromSudden death in athletics can occur from
direct or indirect causesdirect or indirect causes
• direct - traumaticdirect - traumatic
• indirect - atraumaticindirect - atraumatic
9. SUDDEN DEATHSUDDEN DEATH
• Most indirect causes are cardiac in origin.Most indirect causes are cardiac in origin.
• A very small number of indirect causes ofA very small number of indirect causes of
sudden death are noncardiacsudden death are noncardiac
• heat strokeheat stroke
• CVACVA
• pulmonary emboluspulmonary embolus
• drug abusedrug abuse
10. PPE: The HistoryPPE: The History
History forms are very helpfulHistory forms are very helpful
athletes and parents should jointly complete a history formathletes and parents should jointly complete a history form
prior to the PPEprior to the PPE
Review form: 75% of issues detected through Hx aloneReview form: 75% of issues detected through Hx alone
Web based history forms may be more convenient forWeb based history forms may be more convenient for
the athletes (ePPE)the athletes (ePPE)
Preparticipation form recommended by the AAFP,Preparticipation form recommended by the AAFP,
AAP, AMSSM, and AOSSM is available in theAAP, AMSSM, and AOSSM is available in the
Preparticipation Physical Evaluation, 4Preparticipation Physical Evaluation, 4thth
ed. 2010.ed. 2010.
11.
12. Preparation for the PPEPreparation for the PPE
No one best/right way to do PPENo one best/right way to do PPE
Influenced by several factorsInfluenced by several factors
Level of competitionLevel of competition
Availability of personnel and facilitiesAvailability of personnel and facilities
Number of PPE being conductedNumber of PPE being conducted
Personal preference/historyPersonal preference/history
13. Preparation for the PPEPreparation for the PPE
FormatFormat
TimingTiming
FrequencyFrequency
14. PPE FormatPPE Format
Primary care physician modelPrimary care physician model
Enhanced knowledge of medical history,Enhanced knowledge of medical history,
immunization status and prior injuries thatimmunization status and prior injuries that
could limit participationcould limit participation
Generally a more thorough examGenerally a more thorough exam
Affords best privacy and better environmentAffords best privacy and better environment
for counselingfor counseling
Cost is expensive – insurance?Cost is expensive – insurance?
15. PPE FormatPPE Format
Group/station modelGroup/station model
Good for large number of PPE in given periodGood for large number of PPE in given period
of timeof time
Individual personnel responsible for givenIndividual personnel responsible for given
element of PPE atelement of PPE at ““stationstation””
Clearance verified by team MD at end of PPEClearance verified by team MD at end of PPE
Typically free of chargeTypically free of charge
16. PPE TimingPPE Timing
Ideally completed several weeks prior to initialIdeally completed several weeks prior to initial
practicepractice
Allows ability to address any problems identifiedAllows ability to address any problems identified
on PPE (labs, tests, records) without impedingon PPE (labs, tests, records) without impeding
participation statusparticipation status
Typically done within 1 week prior to firstTypically done within 1 week prior to first
scheduled activity – high schools often overscheduled activity – high schools often over
summersummer
17. PPE FrequencyPPE Frequency
Entry-level PPE (complete) at outset ofEntry-level PPE (complete) at outset of
participation for school/organizationparticipation for school/organization
Recommended annual re-evaluationRecommended annual re-evaluation
without complete PPE unless warrantedwithout complete PPE unless warranted
18. Medical HistoryMedical History
Generally accomplished ahead of time inGenerally accomplished ahead of time in
yes/no formatyes/no format
Often a supplemental form for femalesOften a supplemental form for females
For station model, qualified evaluator mustFor station model, qualified evaluator must
review history and red flag potentialreview history and red flag potential
concerns for further scrutiny/evaluationconcerns for further scrutiny/evaluation
19. Components of the PPEComponents of the PPE
Vital signsVital signs
General medicalGeneral medical
problemsproblems
CardiovascularCardiovascular
PulmonaryPulmonary
MusculoskeletalMusculoskeletal
NeurologicNeurologic
EyesEyes
DentalDental
GastrointestinalGastrointestinal
GenitourinaryGenitourinary
DermatologicDermatologic
Examination for heatExamination for heat
disordersdisorders
Laboratory testsLaboratory tests
20. Vital SignsVital Signs
Establishes individualEstablishes individual’’s baseline parameterss baseline parameters
Height/weightHeight/weight
Comparison to normative dataComparison to normative data
Pulse/respiratory rate (60-100/12-16)Pulse/respiratory rate (60-100/12-16)
Observe quantity and qualityObserve quantity and quality
Blood pressure (120/80)Blood pressure (120/80)
Cuff size very importantCuff size very important
Body temperature (98.6/37.0)Body temperature (98.6/37.0)
Oral vs. tympanic vs. axillary (rectal)Oral vs. tympanic vs. axillary (rectal)
21. General Medical ProblemsGeneral Medical Problems
Questions asked regardingQuestions asked regarding
Currently being treated for illness/injuryCurrently being treated for illness/injury
History of hospitalization or surgeryHistory of hospitalization or surgery
History of progressive disease (MS, MD,History of progressive disease (MS, MD,
cancer)cancer)
Current use of OTC/Rx medsCurrent use of OTC/Rx meds
Allergies to meds, food, environmentAllergies to meds, food, environment
22. Cardiovascular ExaminationCardiovascular Examination
Done in quiet area to maximize validityDone in quiet area to maximize validity
Auscultation of heart soundsAuscultation of heart sounds
Questions asked regardingQuestions asked regarding
Fainting (syncope), dizziness, SOB, chest pain with exertionFainting (syncope), dizziness, SOB, chest pain with exertion
Heart palpitations, tachycardia, dysrhythmia, known murmurHeart palpitations, tachycardia, dysrhythmia, known murmur
Family member with sudden, early cardiac deathFamily member with sudden, early cardiac death
Positive responses to any necessitate referral toPositive responses to any necessitate referral to
cardiologist for further evaluationcardiologist for further evaluation
23. Pulmonary ExaminationPulmonary Examination
Done in quiet area to maximize validityDone in quiet area to maximize validity
Auscultation of breath sounds in all lung lobes –Auscultation of breath sounds in all lung lobes –
look for symmetrical movement of diaphragmlook for symmetrical movement of diaphragm
Questions asked regardingQuestions asked regarding
Excessive coughing during/after activityExcessive coughing during/after activity
History of asthma, bronchitis, allergiesHistory of asthma, bronchitis, allergies
SOB, unusual breath sounds during/after activitySOB, unusual breath sounds during/after activity
History of collapsed lung (pneumothorax)History of collapsed lung (pneumothorax)
24. Musculoskeletal ExaminationMusculoskeletal Examination
Basic exam consists of observation forBasic exam consists of observation for
symmetry, ROM, strength tests for majorsymmetry, ROM, strength tests for major
muscles and specific tests for previously injuredmuscles and specific tests for previously injured
areasareas
Questions asked regardingQuestions asked regarding
Focus on history of injury, time frame, evaluation,Focus on history of injury, time frame, evaluation,
treatment and rehabilitationtreatment and rehabilitation
Use of protective devicesUse of protective devices
25.
26. Neurologic ExaminationNeurologic Examination
Evaluation consists of cranial nerve testsEvaluation consists of cranial nerve tests
including pupil function, sensory/motor tests ofincluding pupil function, sensory/motor tests of
UE/LE, deep tendon reflexesUE/LE, deep tendon reflexes
Questions asked regardingQuestions asked regarding
History of head injuriesHistory of head injuries
Any previous loss of consciousnessAny previous loss of consciousness
Numbness/tingling, loss of motor function in bodyNumbness/tingling, loss of motor function in body
History of seizures, burners/stingersHistory of seizures, burners/stingers
27. Eye ExaminationEye Examination
Visual acuity assessed via Snellen chart, bothVisual acuity assessed via Snellen chart, both
monocularly and binocularly (use corrective lenses)monocularly and binocularly (use corrective lenses)
Emmetropia (20/20 vision)Emmetropia (20/20 vision)
Myopia (nearsightedness)Myopia (nearsightedness)
Hypermetropia (farsightedness)Hypermetropia (farsightedness)
Questions asked regardingQuestions asked regarding
Use of corrective lenses/typeUse of corrective lenses/type
Blurring or double visionBlurring or double vision
Color blindness, peripheral vision lossColor blindness, peripheral vision loss
History of eye trauma, retinal detachmentHistory of eye trauma, retinal detachment
28. Dental ExaminationDental Examination
Typically done by dentist – not meant toTypically done by dentist – not meant to
perform preventative care but to establishperform preventative care but to establish
pre-existing conditions for liability reasonspre-existing conditions for liability reasons
in case of dental injuryin case of dental injury
Allows opportunity for dental molds to beAllows opportunity for dental molds to be
made for crafting of custom mouthguardmade for crafting of custom mouthguard
29. Gastrointestinal ExaminationGastrointestinal Examination
Evaluation of digestive system, eating habits andEvaluation of digestive system, eating habits and
nutritionnutrition
Concerns for athletes where image is important to activityConcerns for athletes where image is important to activity
Evaluation done supine with palpation for masses orEvaluation done supine with palpation for masses or
organomegalyorganomegaly
Questions regardingQuestions regarding
History of heartburn, indigestion, diarrhea or constipationHistory of heartburn, indigestion, diarrhea or constipation
Prior history of organ injury (spleen, liver, kidney)Prior history of organ injury (spleen, liver, kidney)
30. Genitourinary ExaminationGenitourinary Examination
For males, questions asked regardingFor males, questions asked regarding
Hernias, testicular torsion, absent or undescended testicleHernias, testicular torsion, absent or undescended testicle
For females, questions asked regardingFor females, questions asked regarding
Menstrual cycle, pregnancyMenstrual cycle, pregnancy
General questions asked regardingGeneral questions asked regarding
History of bladder/urinary tract infections, STDsHistory of bladder/urinary tract infections, STDs
Absence of one kidneyAbsence of one kidney
Can include urinalysis to look for proteins, blood, sugarCan include urinalysis to look for proteins, blood, sugar
and hemoglobin in urineand hemoglobin in urine
31. Dermatologic ExaminationDermatologic Examination
Skin evaluated for rashes, lesions, infectionsSkin evaluated for rashes, lesions, infections
that can be contagious to othersthat can be contagious to others
Herpes, fungal infections (tinea), impetigo, STDs,Herpes, fungal infections (tinea), impetigo, STDs,
acne/treatmentacne/treatment
Also look at existing blemishes (warts, moles,Also look at existing blemishes (warts, moles,
etc.)etc.)
Change in appearance (size, color, border, etc.) inChange in appearance (size, color, border, etc.) in
recent pastrecent past
32. Examination for Heat DisordersExamination for Heat Disorders
Especially important for activities taking placeEspecially important for activities taking place
under conditions of high temperature, highunder conditions of high temperature, high
humidity or a combination of the twohumidity or a combination of the two
Questions asked regardingQuestions asked regarding
History of heat illness (cramping, syncope,History of heat illness (cramping, syncope,
exhaustion, stroke)exhaustion, stroke)
Current meds (diuretics, antihistamines)Current meds (diuretics, antihistamines)
Use of caffeinated/alcoholic beveragesUse of caffeinated/alcoholic beverages
Nutritional and hydration habitsNutritional and hydration habits
33. Laboratory TestsLaboratory Tests
Not typical associated with PPE – usuallyNot typical associated with PPE – usually
due to cost of testing proceduresdue to cost of testing procedures
Often used when/if red flags appearOften used when/if red flags appear
during PPEduring PPE
UrinalysisUrinalysis
Blood workBlood work
ECGECG
34. Clearance for ParticipationClearance for Participation
Conditions to be met to allow clearance by MEConditions to be met to allow clearance by ME
at end of PPEat end of PPE
Will condition increase risk of injury to individual orWill condition increase risk of injury to individual or
others?others?
Can participation be allowed if meds, rehab orCan participation be allowed if meds, rehab or
protective bracing/padding is used? If so, can limitedprotective bracing/padding is used? If so, can limited
participation be allowed in interim?participation be allowed in interim?
If clearance is denied for particular activity, can otherIf clearance is denied for particular activity, can other
safe activities be identified and clearance be grantedsafe activities be identified and clearance be granted
for them?for them?
35. Clearance for ParticipationClearance for Participation
Individuals have right to participate in anyIndividuals have right to participate in any
activity regardless of pre-existing medicalactivity regardless of pre-existing medical
condition/scondition/s
PhysicianPhysician’’s cannot exclude individual froms cannot exclude individual from
participation – can only recommend againstparticipation – can only recommend against
participationparticipation
36. Conditions that ContraindicateConditions that Contraindicate
Sports ParticipationSports Participation
Active myocarditis or pericarditisActive myocarditis or pericarditis
Hypertrophic cardiomyopathyHypertrophic cardiomyopathy
Severe hypertension untilSevere hypertension until
Poorly controlled convulsive disorderPoorly controlled convulsive disorder
no archery, riflery, swimming, weight lifting or powerno archery, riflery, swimming, weight lifting or power
lifting, strength training or sports involving heights)lifting, strength training or sports involving heights)
Recurrent episodes of burning upper-extremityRecurrent episodes of burning upper-extremity
pain or weakness, or episodes of transientpain or weakness, or episodes of transient
quadriplegia until stability of cervical spine canquadriplegia until stability of cervical spine can
be assured (no contact or collision sports)be assured (no contact or collision sports)
37. Conditions that ContraindicateConditions that Contraindicate
Sports ParticipationSports Participation
Sickle cell disease (no high-exertion,Sickle cell disease (no high-exertion,
contact or collision sports)contact or collision sports)
Eating disorder where athlete is notEating disorder where athlete is not
compliant with therapy and follow-up, orcompliant with therapy and follow-up, or
where there is evidence of diminishedwhere there is evidence of diminished
performance or potential injury because ofperformance or potential injury because of
eating disordereating disorder
Acute enlargement of spleen or liverAcute enlargement of spleen or liver