Summer comes to an end and fall sports start up.  High school sports are a big part of many teenagers’ life and the Pre-Participation Physical Examination (PPPE) is a necessary step to help ensure that youth athletes are healthy and can participate in their respective sport.  The topic of this blog covers the first part of our discussion on the PPPE.  As always, enjoy, subscribe to our YouTube channel, and share.  This is important information for parents and their athletes, alike.

So, let’s start from the top…

Approximately 30 million athletes younger than 18 years undergo a Pre-Participation Physical Examination (PPE) to participate in high school sports every year. The sports physical  is required by all 50 states and the District of Columbia.  In 2019, the American Academy of Pediatrics (AAP), with representatives from other medical organizations, published the 5th version of the sports physical. According to the AAP, “the general goals of the PPE are determining general physical and psychological health; evaluating for life-threatening or disabling conditions, including risk of sudden cardiac arrest and other conditions that may predispose the athlete to illness or injury.”

A PPPE is a necessary component to help identify health issues

Each state has a high school sports association and these associations have their own sports physical guidelines and forms. You can find the National Federation of State High School Associations list of state associations here. A 2022 paper looking at state sports physical guidelines stated, “All states evaluated, except Vermont, required a physical examination before participation in high school athletics. An annual physical examination was required by 68% (n = 35), whereas the remaining states varied in requirement every 2–3 years or the requirement determined by each school.” Completion of the PPE is usually required prior to the first practice.

For example, you can find the Maryland Public Schools Athletic Association health and safety page here. Their sports physical form was updated in May 2024. 

The sports physical has two parts: a HISTORY form, which the parent and athlete complete and PHYSICAL EXAMINATION form, which the doctor completes. 

The AAP PPE has easy to understand headings for each set of questions on the history: Heart Health, Bone and Joint, General Medical (which includes concussions). For heart health, we recommend reviewing these short videos which discuss syncope (passing out), heart palpitations, chest pain, and shortness of breath. In addition, we recommend reviewing this Sudden Cardiac Arrest Awareness Form (your state should have one). For concussions, we recommend reviewing the Texas Medical History Form as well as this Concussion Acknowledgement Form (your state should have one). For heat injury, please see Table 2 in this paper for questions related to exertional heat stroke.

Here is a very important comment from the AAP: “A parent or guardian should be involved in completion of the history form. A study of high school athletes undergoing PPEs found that only about 19% of students’ answers were in concordance with their parents’ responses.”

The AAP recommends that the sports physical “take place in the athlete’s primary care medical home, during an office visit and not in a group setting,” yet most sports physicals are performed in the group setting. 

The exam includes vital signs like height, weight, blood pressure, pulse as well as a basic vision test (Snellen chart). It also includes:

•         Checking for Marfan’s syndrome. See See #1, #2, #8, #9, #11.
•         Eyes, ears, nose, and throat 
•         Hearing 
•         Lymph nodes 
•         Listening to the heart and lungs (sitting, lying on back, standing to squat)
•         Feeling the abdomen
•         Checking the skin
•         Checking the neck, back, shoulders, elbows, wrists, hands, hips, knees, ankles, feet.

Identifying potentially deadly health conditions is of utmost importance.

What about other screening evaluations such as electrocardiograms (ECGs), echocardiograms, urinalysis (UA), blood work, and X-rays? For the most part, authorities have recommended against random screening with these tools as the research is at best equivocal as to the efficacy of these evaluations. The American Heart Association continues to recommend its 14-element cardiovascular history and physical examination as opposed to electrocardiogram screening. 

The 14-Element Cardiovascular Screening Checklist for Congenital and Genetic Heart Disease:

Personal history:

1. Chest pain/discomfort/tightness/pressure related to exertion
2. Unexplained syncope/near-syncope*
3. Excessive exertional and unexplained dyspnea/fatigue or palpitations, associated with exercise
4. Prior recognition of a heart murmur
5. Elevated systemic blood pressure
6. Prior restriction from participation in sports
7. Prior testing for the heart, ordered by a physician

Family history:

1. Premature death (sudden and unexpected, or otherwise) before age 50 attributable to heart disease in ≥1 relative
2. Disability from heart disease in close relative <50 y of age
3. Hypertrophic or dilated cardiomyopathy, long-QT syndrome, or other ion channelopathies, Marfan syndrome, or clinically significant arrhythmias; specific knowledge of certain cardiac conditions in family members

Physical examination:

1. Heart murmur**
2. Femoral pulses to exclude aortic coarctation
3. Physical stigmata of Marfan syndrome
4. Brachial artery blood pressure (sitting position)***

*Judged not to be of neurocardiogenic (vasovagal) origin; of particular concern when occurring during or after physical exertion.
**Refers to heart murmurs judged likely to be organic and unlikely to be innocent; auscultation should be performed with the patient in both the supine and standing positions (or with Valsalva maneuver), specifically to identify murmurs of dynamic left ventricular outflow tract obstruction.
***Preferably taken in both arms.

Part II of this blog series will cover some items and concerns that are not covered by the PPPE.  Although the PPPE is designed to help identify significant health issues, it does tend to lack adequate means to identify common musculoskeletal and genetic issues that can sideline many youth athletes.  These conditions can be easily identified and there tend to be ways to address these conditions to avoid potential significant injury.

Steven Horwitz, DC, CSCS, RKC, PCC
Two Time TSC Master’s Champion (2016)
1996 United States Olympic Team Medical Staff Chiropractor

Don’t Be a Meathead is protected by Copyright laws.  If you wish to post any content from www.dontbeameathead.com, you must obtain express (written…this can be email) permission before doing so. We love sharing important information to help people and we do appreciate your respect for our intellectual property.