Guidance Updated for Sports Physicals

Troy Brown, RN

May 23, 2019

Updated guidance for the sports physical examination includes expanded sections on female athletes and athletes with disabilities and a new section on transgender athletes. The recommendations also include information on legal and ethical issues regarding these exams.

The publication, "Preparticipation Physical Evaluation (PPE) Monograph, 5th Edition," was jointly produced by the American Academy of Pediatrics (AAP), the American Academy of Family Physicians, the American College of Sports Medicine, the American Medical Society for Sports Medicine, the American Osteopathic Academy of Sports Medicine, and the American Orthopaedic Society for Sports Medicine.

The National Federation of State High School Associations and the National Athletic Trainers' Association also endorse the recommendations.

PPEs are used to determine eligibility to participate in sports and sport camps for youth from middle school through college. How often PPEs should be performed varies by state, but they are typically required every 1 to 3 years. Other requirements may also differ. They can be determined by various athletic organizations, high school state athletic/activity associations, or state law.

"The sports physical can alert us to any red flags if a family is predisposed to a condition or illness," William O. Roberts, MD, FACSM, FAAFP, coeditor of the publication, said in an American Academy of Pediatrics news release. "For instance, if a parent or sibling has a history of heart disease or if the child has had prior concussions, the primary care physician would want to know that for future monitoring."

Medical Home Best Setting for PPEs

"Whenever possible, the sports physical should be performed in the primary care physician's office, the same place where the child receives immunizations and other healthcare," David T. Bernhardt, MD, FAAP, coeditor of the edition, said in the news release. "These are the doctors who know [the athlete] best, so we can start conversations about health, diet, and physical activity."

Roberts told Medscape Medical News an emphasis on the medical home is one of the biggest changes to the recommendations.

When it is not possible to conduct the PPE in the medical home, the athlete should undergo the PPE at least 6 weeks prior to the first preseason practice to provide time to evaluate the athlete and treat any medical problems identified during the visit.

An MD, DO, nurse practitioner, or physician assistant clinically trained in evaluating and assessing athletes' medical ability should conduct the PPE examination. Legal requirements vary by state.

The authors say athletes or their families should complete a medical history form prior to the examination. Medical history forms in English and Spanish, a physical evaluation form, a medical eligibility form, and forms related to athletes with disabilities are available on the AAP website.

Other changes to the recommendations are the addition of a chapter on transgender issues, as well as expanded chapters on athletes with disabilities and female athletes, Roberts said. The evaluation form includes a question on sexual identity at birth and identifying gender.

The clinician should review the medical history with the athlete and their guardian privately and then again privately with the athlete to give the athlete an opportunity to discuss confidential information. The authors discourage conducting PPEs in locker-rooms or gymnasiums because of a lack of confidential space.

"When station-based group examinations are used, follow-up becomes a critical component of the PPE process. A careful and deliberate process for follow-up visits and referrals is essential for group model PPEs not done one-on-one in the health care home," the authors write.

Group examinations may be preferred in college settings that have formal medical teams and when complete access to the athlete's medical history is available.

Liability and Ethical Issues Can Arise

The authors note that legal and ethical issues can arise, particularly if a physician decides that it is not safe for an athlete to play a sport.

"When an athlete is medically ineligible to participate in a sport or all sports, the questions of who needs to know of the restriction and how this should be communicated frequently arise," they write.

Coaches and school administrators can be told that the student isn't eligible to participate without violating the Health Insurance Portability and Accountability Act or other privacy laws. Further explanation may require a signed medical release.

Regarding medical liability, the authors emphasize that "medical eligibility recommendations should be individualized after appropriate studies and consultant opinions are obtained."

Roberts told Medscape Medical News, "Medical liability extends to what you're doing in your office, and as long as you're practicing good medicine, you're not going to get in any trouble with this. I don't think it changes your liability beyond what you normally do in your office."

He added that medical liability does not extend to athletes "who tear their ACLs [anterior cruciate ligaments] during play or get concussions. In some ways, that's part of the risk of sports."

"We Want Every Child to Get Exercise"

Roberts said he views the PPE as a collaborative effort between him and the athlete. He said one of his objectives when he examines athletes is to make the athletic experience a positive one for the athlete. He also uses routine healthcare visits to encourage his patients to participate in sports and "develop a lifelong habit of physical activity."

Bernhardt agrees: "Every patient coming into your clinic should be considered an athlete, as we are in the business of promoting wellness and physical activity. We want every child to get exercise, whether that's on the playground, on a bike, a hike, or skateboard," he said in the news release.

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