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Pre-Participation Physical Evaluations (PPEs): A Primer for Parents

Important injury prevention tool but not foolproof

A consensus of experts has emerged that a thorough pre-participation exam or evaluation (PPE) is the primary means of identifying athletes at risk of sports injury and initiating preventative measures (1).  

The main objective of the PPE is to not just to detect life-threatening conditions such as congenital heart defects, or disabling medical conditions, such as a history of concussions (3), but to screen athletes for medical or musculoskelatal conditions that may predispose them to injury or illness and effect sports participation, such as asthma or the female athlete triad.

Parents need to understand, however, that the ability of PPEs to detect the kind of cardiac abnormalities that can predispose athletes to sudden cardiac death is limited. In fact, the American Heart Association admits that screening by history-taking and physical examination alone (without non-invasive testing) is insufficient to guarantee detection of many critical cardiovascular abnormalities in large populations of young athletes.

No National Standard

There a number of problems with PPEs, however, primarily because national standards do not exist, and the PPE is often incompletely and inconsistently performed (1).
  • A 2014 study (4) found that only 11% of athletes receive a PPE consistent with the national form;
  • Some states have no standardized questionnaires for the history and physical examination components of a PPE, and 1 state (Rhode Island) did not require any exam; the screening forms of another 12 states contained four or fewer of the AHA cardiac screening questions;
  • In 1999, only 17.2% of the PPE forms in one high school study asked questions about exercise-related cardiac symptoms, a previous diagnosis of a heart murmur or high blood pressure, and about family history of heart attack before age 50 or sudden cardiac death (three main components of the cardiac history portion of the PPE recommended by the AHA);
  • Less than one high school in five in uses the most up to date form containing all the elements developed and recommended by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine and the American Osteopathic Academy of Sports Medicine (the "five-society monograph")(1); and
  • The person allowed to perform a PPE also varies from state to state: 21 states allow a PPE to be conducted by a nurse or physician's assistant; and 11 states allow chiropractors to perform a PPE.
  • A PPE is often not a requirement for those participating in club-based or youth sports.

My advice is to make sure that whoever performs your child's PPE asks the right questions even if they aren't required.

Goals and Objectives

A PPE has the following goals and objectives:

  • Meet legal [every state requires a PPE before participation in interscholastic sports], insurance or club mandates.
  • Maintain and promote health and safety of athlete in training and competition by:Identifying conditions that may limit participation or predispose an athlete to injury, disability, or (in rare cases) death
  • Evaluating overall fitness (the examiner may recommend a conditioning/strengthening program);
  • Treating current injuries, and preventing future injuries (such as overuse injuries)
  • Help athletes to participate safely, not to disqualify them from competition. Studies show that only 0.3 to 1.3% of athletes are denied clearance as a result of a PPE.
  • Educate athlete on variety of health topics (time constraints often limit the opportunity for education)
  • Give athlete chance to discuss health goals as they relate to their own athletic performance