1. The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore Hospital

2. The Preparticipation Physical Goal – To prepare for future preparticipation sports physicals

3. The Preparticipation Physical Objectives – Understand the controversies of performing preparticipation physicals – Review the common causes of Sudden Cardiac Death – Learn what elements of the history or physical exam are most important – Review the quick one minute orthopedic exam

4. Goal of Preparticipation Exam Maintain the health and safety of athletes and promote safe participation Not meant to exclude, but rather include safely

5. Purpose – Detect conditions that may be life threatening or disabling---HCM, AS, ARVD – Detect conditions that may predispose to injury--- chronic injury, laxity, subluxation, – Address legal or insurance requirements

6. Secondary objectives Provide primary care????? Determine general health Assess fitness level Counsel on health-related issues

7. What are the CONS?? Time consuming Costly: J Sch Health 1985 Sep;55(7):270-3 – Study of 763 students; 2.1% needed further eval, only 2 disqualified; costs $4500 per child 1 in 300,000 athletes/year have SCD Remember: they are screening examinations-most athletes that eventually die while on the field had one

8. Italian Study N Engl J Med 1998 Aug 6;339(6):364-9 Prospective study of >30,000 Italians 20 yr 269 deaths < 35yo; 49 in athletes-22% arrhythmogenic right ventricle dysplasia, 18% CAD, 12% anomalous coronary artery, 2% HCM – Non Athletes-7% HCM – HCM detected in 22 athletes-prevented participation  None Died

9. Evidence Base Review Clinical Journal of Sports Medicine; May 2004 – 639 papers about preparticipation screening and sudden cardiac death – 25 original research-all type II population based clinical studies, rest are type III case based opinion studies/position papers – 5 studies assessed effectiveness of PPE No randomized control trials exist

10. Screening Tests ECG AHA does not recommend ECG Italy requires ECG, Echo, Stress Tests Human physiologic cardiac adaptation vs pathologic changes-Athletic Heart Vs HCM Italian ECG study vs Echo: 51% sens, 61% specificity, PPV 7% HS Athletes: Sens 65%, Spec 97.4%; ECG picked up 23/33 problems; 2.6% further tested

11. Sudden Death Very Rare: 1 per 300,000-500,00 HS athletes/yr 1983-1993: Non Traumatic sports related death 126 high school; 34 college. 100 of these are cardiac in origin Male 5x > Female Congenital Cardiac Anomalies which lead to sudden and fatal arrhythmia

13. Hypertrophic Cardiomyopathy Most common cause of sudden cardiac death in young athletes in USA Mutations in cardiac sarcomere 21% of eventual deaths have prior symptoms: exert CP, Dyspnea, Light headed, Syncope Italy: 2% of sudden death: stringent screening

14. Hypertrophic Cardiomyopathy Asymmetric LV hypertrophy Dehydration/decreased preload cause increase outflow obstruction- presyncopal sx. Large muscle mass doesn’t get enough blood->ischemia- >arrhythmia

15. Hypertrophic Cardiomyopathy Harsh, systolic ejection murmur. Decreases with squatting (increased VR and preload); increases when standing up (decrease VR and preload) Diagnosis confirmed by ECHO Idiopathic LVH (10% of deaths):concentric

16. Congenital Coronary Anomaly 18-20% of sudden cardiac death Origin from right sinus 31% have previous sx Stress echo or Cardiac Cath

17. Marfan’s syndrome Autosomal Dominant, connective tissue dis. 1:5000; Defect in gene for fibrillin protein Complicated Diagnosis: Cardiac, Optho, Muskuloskeletal, Skin Involvement. Genetic Testing Echo: dilated aortic root or MVP w/MR Contact/Strenuous Sports Contraindicated

18. Other Causes of Sudden Death Myocarditis-Absolute Contraindication to physical activity. Viral; >50% coxsachie B – Need 6 months post illness before exertion Wolff Parkinson White-contraindication until ablated Long QT syndrome-risk of Torsades de Pointe; familial or from meds

19. ARVD Arthymogenic Right Ventricular Dysplasia Autosomal dominant with variable penetrance Replacement of cardiac cells with fat or fibrosis predominately in Right Ventricle Sudden arrhythmia and death MRI can be useful; Treatment is AICD

21. History Most important aspect of PPE to is screen for cardiac symptoms, asthma, review family hx. Board of Education form doesn’t list all important symptoms Family History of sudden death <50 yo in 1 st degree relative: HCM, Long QT, Congenital coronary anomaly, Arrhythmia

22. Cardiac Screening Questions: Dizzy or Syncope during/after exercise Chest Pain during/after exercise Tired more quickly than others Racing of heart or skipped beats High Blood Pressure/High Cholesterol Heart Murmur

23. Cardiac Screening Questions Family member died before age 50 Recent Mononucleosis/Myocarditis Has a physician ever limited your participation in sports Any relatives with cardiomyopathy, Marfan’s syndrome, heart arrhythmia

24. RED FLAG SYMPTOMS: Wheezing with exertion: EIB (85% of asthmatics have EIB) History of Concussion: MTBI causes neuropsychiatric symtoms-headaches, fatigue, memory loss

25. History Menstrual History: Primary amenorrhea, or secondary (>3 months): Female Triad Meds: Albuterol, Theophylline, TCA, Pseudophedrine, stimulants Anabolic Steroid Usage: 9% HS, 3% JHS

26. Hypertension Age Appropriate values most important Mild to Moderate HTN, no evidence of End-organ damage OK to compete; evidence of End organ damage NOT allowed until treated Severe HTN NOT allowed until treated

27. Hypertensive Values Pediatrics 99:637-678 AgeMildModerateSevereVery Severe 13-15135-39 85-89 140-149 90-94 150-159 95-99 >160 >100 16-18140-149 90-95 150-159 95-99 160-169 100-109 >170 >110

28. Orthopedic Issues Previous sports injuries: attention to ankles, knees, shoulders Ankle sprain need full rehabilitation to regain proprioception Shoulder dislocation may need surgical repair to decrease another incident; rehab for Rotator Cuff Symptoms Knee instability: r/o ACL, Meniscus tear

29. Physical Findings Gen: – Obesity, Phenotypic Variation (Marfan's) Skin: – Impetigo, Molluscum, Herpes, Scabies Visual Acuity > 20/40

30. Physical Findings Pulmonary: – Wheezing Abdomen: – Organomegaly GU: – Testicle Exam, teach STE – Single Testicle: Needs Protection

31. Cardiac Findings Palpate PMI; S 3, S 4, midsystolic click Ausculate with pt supine; again standing or Valsalva: – HCM: Murmur incr. with decreased end diastolic volume: when squatting - >standing; release of Valsalva – AS: Increases with squatting, decreases with Valsalva Femoral Pulses

32. One Minute Orthopedic Exam Screen for normal range of motion and strength

33. Orthopedic Issues Neck: – Previous C-Spine Injury – Stingers: OK as long as symptoms resolve Back: – Kyphosis, Scoliosis – Range of motion: pain with extension occurs with stress fractures, spondylolithesis

34. Orthopedic Issues Shoulder: – ROM, Instability, RTC strength Knee: – Lachmans, Valgus/Varus Stress, Q angle Ankle: – Anterior drawer test