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The P.P.E.

J. Bryan Mann, MD, FAAP (316) 978-5735 Mann@chp.twsu.edu. Preparticipation Physical evaluation (PPE) Preparticipation Athletic Examination Sports physical. The P.P.E.

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The P.P.E.

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  1. J. Bryan Mann, MD, FAAP (316) 978-5735 Mann@chp.twsu.edu Preparticipation Physical evaluation (PPE) Preparticipation Athletic Examination Sports physical The P.P.E.

  2. Sports ParticipationAAP: Committee on Sports Medicine and Fitness and Committee on School Health. Organized Sports for Children and Preadolescents. Pediatrics. 2001. 107;6:1459-1462 There is no consensus as to the overall value of organized sports for preadolescents. The younger the participant, the greater the concern about safety and benefits. Basic motor skills do not develop sooner simply as a result of introducing them to children at an earlier age. The shift from child-oriented goals to adult-oriented goals can further negate positive aspects of organized sports.

  3. Intensive Training AAP: Committee on Sports Medicine and Fitness. Intensive Training and Sports Specialization in Young Athletes. Pediatrics. 2000. Volume 106: pp 154-157 • Research supports the recommendation that child athletes avoid early sports specialization. • Those who participate in a variety of sports and specialize only after reaching the age of puberty tend to be more consistent performers, have fewer injuries, and adhere to sports play longer than those who specialize early.

  4. Preparticipation Physical Evaluation (PPE) • Recommendations for PPE exist and are based on consensus of the literature (AAP, AAFP, AAOSSM) • Primary Goals of PPE: • Detect conditions that may cause injury • Detect conditions that may be life-threatening • Meet legal/insurance requirements

  5. PPE Goals • Identify conditions that may interfere with participation • Identify conditions that may be exacerbated by participation • Help select an appropriate sport or the child’s particular abilities and physical maturity

  6. PPE Goals • Poorly conditioned children • Children with muscle or joint weakness (usually related to recent injury) • Immature children (physically) • Previously unsuspected disease

  7. PPE 1% of children undergoing PPE’s have conditions that might limit sports participation and are generally discovered through the history.

  8. Sports - The Numbers • 30 million American children annually participate in sports (7 million adolescents) • Majority of sports examinations are ineffective in determining potential health problems • 80% of pediatric population will have no other health care during the year • Majority of adolescents and their parents regard the PPE as sufficient annual health examination.

  9. PPE - Utility • Value of PPE remains unproven • Screening of a healthy population is somewhat dubious • 35 of 7 million adolescents participants are at risk of sudden death • $4,537.00/athlete identified with any significant medical condition • Only “proven” utility is the recognition of “at risk” participants from poorly rehabilitated or recent orthopedic injuries • Ideally, incorporate health maintenance exam, anticipatory guidance, with the PPE

  10. Morbidity and Mortality • 6,000,000 cases of adolescent STD’s/year • 1,000,000 pregnancies/year to < 19 yrs • 500,000 live births • 15,000- 18,000 adolescent MVA deaths/year • 6,000 young adult homicides/year • 5,000 adolescent suicides/year

  11. Locker room method Station method Individual office-based method PPE

  12. PPE-History 1. Significant underlying health conditions Surgical Hospitalization Duration > one week 2. Sustained a significant injury 3. Use of medication(s) Ergogenic aids, substance abuse 4. Medical allergies/Anaphylaxis 5. Tetanus/Immunizations

  13. PPE-History 6.Cardiovascular disease? Syncope, dizziness, or chest pain with exercise Hear murmur or hypertension? Sudden cardiac death before age 35 yrs 7. Concussion? 8. Exercise tolerance 9. Corrective lenses/dental appliances 10. Missing a paired organ? 11. Menstrual history 12. Heat-related illness

  14. Taken from: Contemporary Pediatrics (2000)

  15. Px – What’s Important? • Musculoskeletal exam • 10% of males examined will have an orthopedic abnormality, usually minor • 92% will be detected by history alone • “Two minute” orthopedic examination

  16. PPE – Laboratory? • Generally thought to be unnecessary as screening tools • Hematocrit • UA • Body fat measurement • Aerobic capacity

  17. Physical Exam • Ht • Wt • BP • Visual acuity • CV exam • Palpation of the abdomen • GU exam (males) • Screening musculoskeletal exam

  18. Obesity • Obesity - excess of body fat relative to lean body mass • Third National Health and Nutrition Examination Survey (NTHANES III): • 33% of adult Americans are obese • 25% of children and adolescents are either “overweight” or “highly at risk”

  19. Obesity: > 95%tile BMI for age and sex “At risk” for obesity 85-95%tile or age and sex BMI tables are available from the CDC: http://www.cdc.gov/growthcharts/ Expert Committee on Obesity

  20. Expert Committee on Obesity - Recommendations • Weight maintenance (slowing of excessive weight gain) for: • Children 2-7 years with “at risk” BMI • BMI > 95% and no complications of obesity • > 7 yrs < 95% and no complications • Weight Loss: • > 2 yrs and BMI > 95% and complications of obesity • > 7 yrs with a BMI > 85% and a secondary health complication

  21. PPE - CV Exam • Evaluate peripheral pulses, murmurs, BP • BP > 135/85 (in adolescence) should prompt concern and repeat exams • 3/6 systolic and all diastolic murmurs should be referred • IHSS apical murmur that increases with Valsalva maneuver and intensifies with standing • Femoral pulses in coarctation • Marfan’s syndrome habitus

  22. “Youth who have severe hypertension need to be restricted from competitive sports and highly static (isometric) activities until their hypertension is under adequate control and they have no evidence of target organ damage.” HypertensionAAP: Athletic Participation by Children and Adolescents Who Have Systemic Hypertension. Pediatrics. 1997.99;4:637-638.

  23. Cardiomyopathy Hypertropic cardiomyopathy* Congenital heart disease Anomalous left or hypoplastic coronary artery Aortic rupture Cardiac Arryhthmias Prolonged QT syndrome* (Romano-Ward) WPW Sudden Death - Cardiac

  24. Tall and skinny Long, narrow face High arched palate Pectus deformity Long fingers and toes Hyperflexible Myopia/lentis ectopia Family hx of early, sudden death Marfan syndrome

  25. Hepatomegaly Splenomegaly IM return to play one month after onset of illness and no splenic enlargement Absence or atrophy of testicles Tanner staging Inguinal hernia Varicolcele Testicular mass Abdomen and Genitalia

  26. Taken from: Adelman and Joffe. Contempory Pediatics. 1999. Varicolcele

  27. Most common scrotal mass 15% of teenagers have a varicoceles Usually asymptomatic “Bag of worms” Controversy as to therapy Surgical repair: Large varicocele and testicle not growing normally Left testis 3 ml smaller than right - 2 SD for testicular size Bilateral or symptomatic varicoles Pain Varicocele

  28. “Preadolescents and adolescents should avoid competitive weight lifting, power lifting, body building, and maximal lifts until they reach physical and skeletal maturity.” - AAP:Strength Training by Children and Adolescents. Pediatrics. 2001.107;6:1470-1472 Caution with Tanner stage < 3 in collision sports. Sexual Maturity

  29. Skin • Active impetigo • Tinea corporis • Scabies • Molluscum contagiosum • Herpes simplex

  30. PPE - Musculoskeletal • Majority of all abnormalities identified • “two-minute” musculoskeletal examination • Garrick – 1977 • 14 screening positions • Specificity of 97.5%

  31. 1. Acromioclavicular joint/general habitus 2. Cervical spine motion 3. Trapezius strength 4. Deltoid strength 5. Shoulder motion 6. Elbow motion 7. Elbow and wrist motion 8. Hand/finger deformity 9. Symmetry/effusion 10/12. LE symmetry/strength 11. Lower back 12. Scoliosis 13. Knee effusion 14. Calf symmetry/strength Orthopedic Screening Exam (Garrick)

  32. Adolescent Scoliosis • Lateral curvature of the spine • Usually not painful • Most common spinal deformity in the 10-16 year • 30% will have a family history

  33. Knees fully extended Hands to side Bends forward to a horizontal position Document asymmetry with a scoliometer 7 degrees on scoliometer = 20 degrees on x-ray Scolisosis - Adam’s Forward Bend Test

  34. Immunizations Tetanus Varicella Hepatitis B Meningococcemia Behavioral/ Psychosocial screen Testicular/Breast self-exam Discussion of: Androgenic agents “Natural” agents DHEA Creatine Female athlete “triad” Adolescent PPE - Anticipatory Guidance

  35. Participation - Medical Conditions AAP: Committee on Sports Medicine and Fitness. Medical Conditions Affecting Sports Participation (RE0046). Pediatrics. 2001. 107:5:1205-1209. • Who should and should not participate in a particular sport? • What, if any, modifications are necessary? • Risk of injury related to any conditions present

  36. Participation - Medical Conditions AAP: Committee on Sports Medicine and Fitness. Medical Conditions Affecting Sports Participation (RE0046). Pediatrics.2001. 107:5:1205-1209. • Sports are categorized into three categories by degree of contact • Collision • Limited Contact • Noncontact • Assessment of various medical conditions: • Risk of injury • Risk of adversely affecting the medical condition

  37. Sports Classifi

  38. When an athlete's family disregards medical advice against participation, the physician should ask all parents or guardians to sign a written informed consent statement indicating that they have been advised of the potential dangers of participation and that they understand them. The physician should also document, with the child's signature, that the child athlete also understands the risks of participation.” - AAP: Committee on Sports Medicine and Fitness. Medical Conditions Affecting Sports Participation (RE0046). Pediatrics. 2001. 107:5:1205-1209.

  39. Adolescent Female - Sports • 1972 = 1:27 • 2000 = 1:3 • Injury rates are similar between male and female adolescents in the same sport except: • “Female Athlete Triad” • Stress fractures • ACL injuries

  40. Eating disorder or Disordered eating Less severe and more subtle than true eating disorders fasting vomiting food restriction diet pills/laxatives Amenorrhea Osteoporosis Risk factors: Highly structured life Social isolation Lack of support system Family hx of eating disorders Female Athlete Triad

  41. Amenorrhea - Definitions • Primary amenorrhea: • No menses by age 16 years • No menses 4.5 years after onset of breast development • Secondary amenorrhea: • Absence of at least 3-6 menstrual cycles in a female that has begun menstruation

  42. Female Athlete Triad AAP: Committee on Sports Medicine and Fitness. Medical Concerns in the Female Athlete. Pediatrics.2000. 106;3610-613 • 3-60% will have amenorrhea vs. 2-5% in adult women • Normal weight athletes usually don’t have menstrual problems • Disordered eating may occur in 15-65% of all female athletes • Disordered eating should be considered in adolescent amenorrhea

  43. Disordered Eating - Amenorrhea Decreased calories “Energy” drain Hypothalamic dysfunction Decreased estrogen production Amenorrhea Decreased BMD

  44. Female Athlete - Amenorrhea • Athletes with amenorrhea have lower bone mineral density (BMD) • Bone mass maybe unrecoverable after resumption of menses • Complete exam is necessary for any adolescent with primary or secondary amenorrhea

  45. Amenorrhea - Treatment • Decrease training • Attempt to increase weight/height to 10% • Calcium intake • Addressing any eating disorders • Premarin/OCT?

  46. 3.5X more common in female athletes (vs. male athletes) “Load” exceeds bodies attempts at skeletal repair More common in tibia, femur and pelvis Pain with activity initially, later pain at rest Risk factors: Smoker Asian Corticosteroids Female Athlete Amenorrhea Family history Stress Fractures

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