Anticipatory Guidance

Preparticipation Examinations of Athletes


  • 14 million adolescents participate in organized sports yearly.
  • The preparticipation examination (PPE) is the most common reason for a healthy adolescent to visit their pediatrician. 
  • Should be done 4-6 weeks before the start of the sports season.
  • Sports are graded by contact level, for example:
    • High-contact/Collision: basketball, boxing, diving, field hockey, football, soccer, wrestling.
    • Moderate, Limited Contact: baseball, bicycling, cheerleading, gymnastics, skating, skiing, volleyball.
    • Low-Noncontact: badminton, crew, golf, running, swimming, tennis, track.

Objectives of the Exam:

  • Identify medical and musculoskeletal conditions that could make sports participation unsafe.
  • Screen for underlying illnesses through medical and family history, ROS, and PE.
  • Recognize pre-existing injury patterns from previous sports seasons and devise ways to prevent recurrences

Medical History

  • Refer to cardiologist prior to particpation for:
    • Feeling of faintness, weakness, or syncope during exercise.
    • Cardiac deaths comprise the majority of sports related fatalities in the US.
    • Asthma, hypoglycemia, and seizures can cause similar symptoms
  • ​Wheezing during sports:
    • ​Use of prophylactic Beta-agonist prior to participation recommended for those with exercise-induced bronchospasm
      • Easy to check PF in office- a decrease of 10-15% from baseline is suggestive of EIB.
      • ​ Incidence of exercise-induced bronchospasm (EIB) seen in 10-35% of all athletes
  •  Concussion:
    • Recent recommendations are asking for pre-participation psychologic testing to have a baseline in case there is a later concussion.  This may help dictate when an athlete may retun to participation.
  • Recent Mononucleosis:
    • Mono-induced splenomegaly can predispose to splenic rupture
    • Mono within 1 month of high- and moderate-contact sports is at risk because spleen size peaks within 3-4 weeks of onset of systemic signs of illnesd
  • Unilateral Organ:
    • Single kidney is a contraindication for high-contact sports per AAP
    • Single testicle requires mandatory protective cup.
  • Current medications:
    • Document drug use.
    • Albuterol, methylxanthines, macrolides, pseudoephedrine, illicit drugs have been linked to arrhythmias.
  • Menstrual History:
    • Screen for amenorrhea- primary or secondary.
    • Look for female athlete triad:   anorexia, amenorrhea, osteoporosis.
  • Seizure disorder:
    • Not direct contraindication if seizures are well controlled.
    • History of seizure within past 6 months should raise concern, especially for water sports.
  • Past history of injury:
    • Devise rehab protocols to prevent injuries such as chronic ankle sprains.
  • Ergogenic Aids:
    • No testing policy- 9% reported use in high school athletes.
    • Ask, "Have you ever taken a substance to enhance your athletic performance?"

The AAP's table on Medical Conditions that my rule out sport participation - Click here

Family History

Family history is more sensitive than than the physical examination in identifying conditions that may affedt participation.

Positive family history of:

  1. Cardiac-related death in a first-degree relative younger than 50 y/o.  Be suspicious of congenital heart disease, arrhythmia, prolonged QT syndrome, hypertrophic cardiomyopathy, and Marfan syndrome in first-degree relative.
  2. Family history of chronic disease—asthma, diabetes, epilepsy, bleeding disorders.

Physical Exam

1. Vital signs, height, weight, BP, HR, RR.
2. Visual- excessive thinness or obesity.
3. Skin- impetigo, molluscum, herpes, especially relevant to wrestling.
4. HEENT: visual acuity (must be 20/40 for clearance), pupils, dentition.
5. Cardiac:  History, ROS, VS, auscultation.

  • Unfortunately, majority of patients who suffer cardiac death are previously asymptomatic.
  • More than 50% of cardiac-related deaths are due to hypertrophic caridiomyopathy, which is autosomal dominant.
  • History of cardiac symptoms with exertion should be referred to cardiologist.

6. Pulmonary: Screen for asthma and EIB.
7. Abdominal:  Organomegaly and presence of unilateral organ.
8. GU: Hernia, testicular protection. 

  • Sexual maturity ratings should be used; the lower the rating, the higher risk of suffering a physeal fracture.

Musculoskeletal Exam


  • Previous cervical spine injuries should prompt one to obtain screening C-spine XRAYS
  • Cervical stenosis- need MRI
  •  Rule out kyphosis and scoliosis
  • Suspect spondylolysis and spondylolithesis with pain upon extension
  • Suspicion for neoplasm with unexpected back pain
  • On exam, pain with flexion-?discogenic pain; extension? posterior element overuse, such as spondylolysis; rotational ? paraspinous muscle pain.
  • Check reflexes.


  • Common for overuse syndromes (rotator cuff), esp. in overhead sports.
  • Preseason conditioning programs are helpful.


  • Focus on history of knee pain.
  • Screen both knees for ligamentous stability.
  • ACL injury 3-4:1 in female: male.
  • Persistent knee pain with flexion and swelling, consider 40view knee series to rule-out osteochondritis dessicans of the femoral condyle.


  • Most commonly affected joint.
  • Related to repetitive sprain and subsequent instability.
  • Preventive strengthening programs should be encouraged.

Conditioning Programs:

  • Weight training and aerobic conditioning.
  • Weight training should focus on high repetition and low resistance.
  • Because of the potential risk of apophyseal avulsion fracture, preadolescents should never undertake power lifting.  Strength training is safe.


1. Metzl, Jordan MD.  Preparticipation Examination of the Adolescent Athlete: Part I. Pediatrics in Review.  June 2001.  Vol 22 No.6 pp 199-204.
2. Metzl, Jordan MD.  Preparticipation Examination of the Adolescent Athlete: Part II. Pediatrics in Review.  July 2001.  Vol 22 No.7 pp 227-239..
3. Strength Training by Children and Adolescents American Academy of Pediatrics June 2001
4. Medical Conditions Affecting Sports Participation. American Academy of Pediatrics May 2001  
5. Kurowski K, Chandran S. The Prepparticipation Athletic Evaluation. American Family POhysician.  May 2000