Athletes’ readiness to participate in activity is determined through a standardized pre-participation physical examination (PPE) screening process.
For nearly four decades a number of medical organizations have formalized the pre-participation physical examination (PPE).4, 5, 6 This PPE is meant to identify areas of concern in the health of the athlete which could contribute to impaired function during participation in athletics. This formalization creates a base framework for all health care providers to work from. No matter who is performing the PPE, they should all be held to the same standard outlined by the document. The PPE should be performed early enough before participation to ensure that any areas of concern can be addressed prior to beginning participation. Pre-participation physical exams should be conducted in accordance with local and state guidelines.
Does the organization require each athlete to complete a standardized PPE screening process and be cleared by a QMP before participation in athletic activity?
The following best-practice recommendations should be considered supplementary to any state/local regulations. The physical exam should be conducted and clearance granted before any athletic participation including strength and conditioning sessions, try-out sessions, practices, or games. If another health care provider (physician assistant or nurse practitioner) performs the physical exam, the provider should be held to the same standards and expectations of a physician. Ideally, the physical exam should be conducted 4 to 6 weeks prior to athletic participation to allow proper time for follow up of any findings that require additional evaluation. A organizational representative should keep a copy of each athlete's PPE on file.
- Organizational or governing body policy statement requiring each athlete complete a standardized PPE screening process.
- Organizational or governing body policy statement on which QMP is given authority to clear a student for athletic activity.
PPE screening instruments used by the organization with their medical community reference(s).
Does the organization require a comprehensive medical and family history survey be completed by the athlete and parents as part of the PPE screening process?
Key areas to be included or addressed in the PPE:
- Risk factors and symptoms of a cardiovascular disease (should be based on the current American Heart Association recommendations for pre-participation cardiovascular screening of competitive athletes).
- Detection of any underlining musculoskeletal condition that might predispose an athlete to injury with special focus given to any areas that have been injured or undergone surgery.
- History associated with heat acclimatization.
- History of concussion.
- Risk factors and symptoms of under-nutrition or obesity, and disordered eating.
- Collect information that will assist in determining the mental health status of the athlete.
The medical and family history form should be completed by the parents prior to the PPE screening process.
Screening instruments used to survey medical and family history during the PPE screening process.
Does the organization require a medical physical examination be completed on each athlete by a QMP as part of the PPE screening process?
It should be noted that while it is ultimately the decision of the physician conducting the exam to provide a pre-participation physical exam he/she deems appropriate for medical clearance for sports participation, there is good evidence that following key areas to be included: vital signs (e.g. height, weight, and blood pressure); visual acuity testing; cardiovascular, neurologic, and general medical (e.g. pulmonary, abdominal, skin, genitalia [for males]) examination; and musculoskeletal examination. Additional examination may be warranted when the patient has a history of illness or injury reported on the health history portion of the PPE. An organization can encourage inclusion of these key areas by utilizing a PPE form that includes them.
Screening instrument used to do a general physical examination by a QMP.
Such a plan may involve additional screening or referral to the appropriate provider. Of particular concern are referral for appropriate tests and screenings for athletes who have a history of anemia, diabetes mellitus type 1 or 2, sickle cell trait, cardiovascular conditions or exercise-induced bronchospasms; or are female and have abnormal menstrual cycles. For athletes with such issues whose condition is currently being managed by a specialist, sharing of the providers recommendations for the management of the condition during athletic participation should be obtained and the care plan implemented.
Medical or injury management plan completed by the QMP, athlete and parent or guardian for any condition discovered during the PPE screening process that requires activity limitations, modifications or further testing/evaluation.
Does the organization include questions to assess the mental health status of the athlete during the PPE screening process along with a plan for referral and follow-up where appropriate?
The PPE is a great screening instrument to identify athletes at risk for many conditions, including mental health issues particularly those common to young athletes in this stage of life. The health history questions that include mental health will help the organization develop educational programs for coaches, parents and athletes. This information will help identify those at risk and establish action plans for at risk athletes with potential if left untreated could be catastrophic.
Questions or instruments utilized for screening athletes for psychological concerns.
Organizational plan for referring an athlete to the appropriate mental health professional and the how the follow-up process is completed.
Educational materials provided to athletes and parents during the PPE screening process that promotes health and safety issues.
Does the organization require written authorization from parent or guardian before sharing his/her child’s protected health and medical information with designated individuals such as coaches or other designated medical professionals?
Before the information gathered in the pre-participation screening can be shared with coaches and school officials, the parent or athlete must sign a consent form allowing the information to be released. The ability to share key medical information identified in the pre-participation screening that might predispose an athlete to injury/illness is an important component in providing appropriate medical care and an important strategy in preventing further injury or a catastrophic event.
Parental consent form that gives permission for the organization to share an athlete’s protected health and medical information with designated individuals such as a coach or other medical professionals.
- The Inter-Association Task Force for Preventing Sudden Death in Secondary School Athletics Programs: Best-Practices Recommendations; Journal of Athletic Training 2013;48(4):546–553 https://www.nata.org/sites/default/files/preventing-sudden-death.pdf
- Advancing the Pre-participation Physical Evaluation: An ACSM and FIMS Joint Consensus Statement
- American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, American Academy of Pediatrics. PPE: Pre-participation Physical Evaluation. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2010. https://www.aap.org/en-us/about-the-aap/Councils/Council-on-Sports-Medicine-and-Fitness/Pages/Preparticipation-Physical-Evaluation.aspx
- BOC Guiding Principles for AT Policy and Procedures
- NATA Secondary School Value Model
- National Athletic Trainers' Association Position Statement: Preventing Sudden Death in Sports; Journal of Athletic Training 2012:47(1):96-118 http://natajournals.org/doi/pdf/10.4085/1062-6050-47.1.96
- National Athletic Trainers’ Association Position Statement: Pre-participation Physical Examinations and Disqualifying Conditions; Journal of Athletic Training 2014;49(1):102–120 https://www.ncaa.org/sites/default/files/NATA-Position-Statement-PPEs-and-Disqualifying-Conditions.pdf
- Pre-participation cardiovascular evaluation for athletic participants to prevent sudden death: Position paper from the EHRA and the EACPR, branches of the ESC. Endorsed by APHRS, HRS, and SOLAECE.
- Screening for Sudden Cardiac Death Before Participation in High School and Collegiate Sports: American College of Preventive Medicine Position Statement on Preventive Practice
- Wingfield K, Matheson GO, Meeuwisse WH. Pre-participation evaluation: an evidence-based review. Clin J Sport Med. 2004;14(3):109–122. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3924614/
Hill v. Slippery Rock University, 138 A.3d 673 (PA Super. Ct. 5/3/16), 332 Ed. Law Rep. 361
In September, 2011 Jack Hill, Jr. was participating in a late-night, high-intensity basketball practice for Division II Slippery Rock University when he complained of feeling ill, and collapsed to the floor, unresponsive. Hill went into respiratory and cardiac arrest and passed away. Hemoglobin electrophoresis disclosed Sickle Cell Trait (“SCT”). The lawsuit alleged the negligence of Slippery Rock University, Slippery Rock University Health Center, and the nurse for not testing or requiring testing for SCT in pre-participation physical examinations. Hill completed a pre-participation physical questionnaire, which asked if the student-athlete had Sickle Cell Anemia (“SCA”) or SCT. Hill answered that he had neither SCA nor SCT, because he was unaware that he had SCT.
Although Division I schools required testing for SCT, Division II schools did not until 2012, and Division III schools until 2013. Relying partly on the fact that the questionnaire asked about SCA or SCT, but did not test for the presence of either, the Superior Court of Pennsylvania stated, “the incomplete medical clearance may have led Mr. Hill to believe that he was physically fit for basketball.” Finally, the Court held the lawsuit could proceed, as the plaintiffs sufficiently alleged that the medical and physical evaluations increased Mr. Hill’s risk of harm.