Reviewing Value, Timing of the Preparticipation Physical Evaluation

The Preparticipation Physical Evaluation (PPE) or “sports physical” has become an established part of participation in high school sports. The purpose and process of administering the PPE has evolved over time.

The goals of the PPE are multi-faceted. It should be used to determine the individual’s general physical and psychological health. The PPE should also be performed to evaluate for life-threatening or disabling conditions. Another thing that the PPE should do is evaluate for conditions that may predispose the individual to injury or illness. Providing the individual who is performing the PPE an opportunity to discuss health and lifestyle issues with the person who is having the PPE performed on them is another benefit of the PPE. Finally, this exam will serve as an entry point into the health care system for adolescents without a health care home or medical home.

The PPE is the product of six national medical societies and is endorsed by the NFHS among others. The process for the medical history and evaluation is outlined in a monograph published by the American Academy of Pediatrics.

In the past, many schools scheduled mass physicals in the spring or fall to get as many of their student-athletes as possible a physical in one day. There has been a concerted effort to move away from mass physicals in the schools and to the medical home/ primary care provider’s office. Approximately 5-10 percent of adolescents have chronic conditions requiring ongoing treatment, and 50 percent have less-severe medical problems that still require some type of medical attention or follow up. All medical problems have the potential to affect sports participation. Therefore, determining eligibility is more effective if it is integrated into routine health care.

In the medical home, there is a greater opportunity to engage adolescents regarding their physical health, mental health, as well as addressing lifestyle and risk-taking behaviors. Up to 70 percent of adolescents desire more information from their personal physician who is more knowledgeable of their patient’s medical history. Most adolescents are not comfortable discussing sensitive subjects in a station-based exam setting, in a gym or locker room with a health-care provider who they have previously never met or had any interaction. The familiarity and trust that is fostered in the medical home is likely to create more productive discussions around sensitive subjects, including mental health, sexuality, birth control, sexually transmitted infections, gender identity, unsafe nutrition. Also, the use of vaping, alcohol, tobacco, recreational drugs, supplements and performance-enhancing substances may be discussed.

When considering under-served students, sports and the PPE offer an opportunity to establish a medical home to address their higher needs for both physical and mental health concerns, as well as risk-taking behaviors. While school-based pre-participation physicals are appealing for their convenience, most athletes have access to reasonably priced physicals through their primary care office and insurance or Medicaid coverage.

It is the opinion of the authors of the 5th edition of the PPE, that it is “inappropriate” to perform the PPE in a gym/locker-room setting, urgent care, retail-based center, fundraiser, or be used to increase market share. The PPE in the setting of the medical home is considered best practice.

The authors of the PPE further offer, “Performing a PPE outside of the medical home is ineffective, of little value, and presents a barrier to both health care supervision and participation in sports and activities.”

There is no universal evidence for or consensus regarding the best timing for the PPE. Ideally it is performed well in advance of the pre-season allowing time for any required diagnostic work-up, treatment or rehab of any condition identified. Six weeks has been suggested as the ideal interval as 3-14 percent of students require additional evaluation.

There is no universally accepted frequency for the PPE and this is evident across the nation as there is not one universally accepted requirement as the frequency varies from state to state. There is also no data for the authors to recommend an ideal interval. While most state associations require them yearly, others require them being done at intervals ranging from every 18 months to once at high school entry (with annual “statement of health”).

The authors of the PPE suggest the evaluation be performed:

• In the medical home

• Annually screen for updates regarding “head, heart, heat, mental health, and musculoskeletal injuries” (meaning concussions, cardiac issues, heat illness, etc. screening)

Every two to three years to allow for more comprehensive screening to include such conditions as depression and obesity:

• Recognizing the evolving development throughout childhood and adolescence

The PPE remains an important component toward minimizing risk of participating in high school sports. Putting it back into the medical home optimizes its effectiveness, safety and completeness.