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Vicky Pittman, PA-C
By Vicky Pittman, PA-C on August 07, 2023

Let’s Get (Sports) Physical

It’s August, which means sports physical season is upon us. Organized sports are an important way for children 6 and older to meet the recommended 60 minutes of physical activity per day. However, it’s important for clinicians to use the sports or pre-participation physical examination (PPE) to identify who can safely participate in these activities and who needs further evaluation before they are cleared to participate.  

For those of us seeing our clinic schedules fill up with PPE patients, here are some things to remember. 


Goals of the Pre-Participation Evaluation

The primary goals of the pre-participation evaluation are to:

  1. Identify potentially life-threatening medical conditions in young athletes. These are rare but serious, and almost all are cardiovascular. Luckily the American Heart Association (AHA) has published 14 recommended elements for the cardiac screening of adolescent athletes, which are a part of the standard PPE form that was created by the American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine.

    But, a recent pediatrics study found that only a minority of states (13) include all 14 AHA elements. Review the PPE form used by your state and consider including all 14 elements when taking your patient’s history. The PPE also helps to identify conditions that could be complicated by exercise (e.g., asthma) and high-risk conditions where sports participation could be dangerous (e.g., single kidney, testicle, eye).

  2. Provide access to a medical provider, primary care physican/preventative care, and a referral to cardiology or other specialists for further medical care if necessary. 

The 14-Element Screening for PPEs

Here are the 14 elements to evaluate when taking your patient’s history:

American Heart Association’s 14-Element Screening for PPEs

Personal medical history*:

1. Exertional chest pain/discomfort
2. Exertional syncope or near-syncope
3. Excessive exertional and unexplained fatigue or fatigue associated with exercise
4. Prior recognition of a heart murmur
5. Elevated systemic blood pressure
6. Prior restriction from participation from sports
7. Prior testing for the heart ordered by a physician

Family medical history*:

8. Premature death (sudden and unexpected) before the age of 50 due to heart disease, in one or more relatives
9. Disability from heart disease in a close relative < 50 yo
10. Specific knowledge of certain cardiac conditions in family members 
  • Hypertrophic or dilated cardiomyopathy, long-QT syndrome or other ion channelopathies, Marfan syndrome, or clinically significant arrhythmias

Physical exam:

11. Heart murmur 
  • Examine patient while both supine and standing, or with Valsalva, specifically to identify murmurs of dynamic L ventricular outflow tract obstruction
12. Femoral pulses to exclude aortic stenosis
13. Physical signs of Marfan syndrome
14. Brachial artery blood pressure
  • While sitting & preferably taken in both arms

* Parental verification is recommended for middle & high school athletes


The American Academy of Pediatrics provides downloadable forms that can be used during a preparticipation physical exam, which include a more comprehensive patient History Form and a Physical Exam Form. (Note:  the AAP requests that if any forms will be integrated into an EHR, to please contact permissions@aap.org.)


What to Do Next

What do we do if there are worrisome responses to the history or abnormal physical exam findings? 

  • A positive answer to a history question does NOT automatically preclude the athlete from participation.
  • Any affirmative answer warrants deeper questioning and further evaluation as needed.
  • A positive response to a cardiovascular question generates a referral to cardiology (typically for an ECG and echo).  
    • Consider holding the patient from activities until cleared by a specialist (case-by-case basis).
  • The AHA does not currently recommend routine use of 12-lead ECG for screening

Pre-participation physicals play a vital role in safeguarding the health and well-being of our school-aged athletes. These assessments can not only identify pre-existing conditions which could be exacerbated by physical activity, but can also offer valuable insight into injury prevention and athlete well-being. Regular sports physicals can promote a culture of proactive healthcare, helping to instill in these student-athletes the importance of understanding their bodies and their health. As providers, we strive to keep our patients healthy and active, and we hope to foster in them a lifetime of active, healthy living.

For more on sports physical exam needs and what to consider when taking your patient’s health history, listen to Sports Physicals: You Shall Not Pass on this month’s Urgent Care RAP podcast. We’d love to hear your thoughts! Leave us a comment (UC RAP > August 2023 > Chapter 10 > Discussion) and join us in discussing this important topic. Happy start to the professional and school sports seasons!

*1. https://www.aap.org/en/patient-care/preparticipation-physical-evaluation/

*2. https://pubmed.ncbi.nlm.nih.gov/36519230/

Published by Vicky Pittman, PA-C August 7, 2023
Vicky Pittman, PA-C