Letters to the Editor

The Preparticipation Sports Evaluation: Losing the Forest for the Trees?


Am Fam Physician. 2016 Sep 15;94(6):411-414.

Original Article: The Preparticipation Sports Evaluation

Issue Date: September 1, 2015

See additional reader comments at: https://www.aafp.org/afp/2015/0901/p371.html

to the editor: Ensuring that adolescents are physically well and knowledgeable about self-care prior to athletic participation is important. Similarly, assessment for stress, risk behaviors, and vaccinations is paramount to adolescent wellness. Are these initiatives mutually exclusive?

Approximately 40% of adolescents receive the recommended yearly comprehensive preventive visits; in these encounters, 60% of patients do not have time alone with their clinician.1 Because 30 million student-athletes in the United States play organized sports and many require clearance, the preparticipation evaluation (PPE) may be an adolescent's only exposure to the medical system.13

The PPE was not designed to replace health maintenance. However, it provides an excellent opportunity to address issues commonly overlooked in this vulnerable patient population. At least 25% of PPEs occur outside of the adolescent's medical home, and the extent to which adolescents are offered essential care (e.g., confidential psychosocial screening, vaccinations) in PPEs is unknown.3 Because 70% of deaths among 10- to 24-year-olds in the United States involve unintentional injuries, suicide, and homicide, compared with 5% from heart disease and congenital malformations, we wonder if clinicians miss the opportunity to incorporate psychosocial risk assessment in the PPE.2,4

Through this lens, we read this article with great interest. Written in accordance with national recommendations, Mirabelli and colleagues emphasize screening for physical pathology with relatively brief attention paid to psychosocial risk. As the highly technical and important debate over appropriate cardiovascular risk assessment in the PPE ensues, physicians may find themselves entrenched in the search for rare physical diseases. Unfortunately, the PPE is not particularly effective in preventing mortality associated with these diseases.2

Most morbidity in adolescents results from risk-taking behaviors and psychosocial stressors. In a survey of behaviors from the previous month, 40% of adolescent drivers reported texting while driving and 24% reported using marijuana; during the previous year, 15% reported being electronically bullied and 8% attempted suicide.5 Issues related to sexuality, social media, eating, and other stressors are rampant.5

As a result, we endorse the provision of preventive care, including confidential psychosocial history-taking and vaccination, in all visits, including the PPE. An essential step is to build this conceptual framework into family physicians' approach to the PPE. Useful resources for psychosocial history-taking are available at http://www.modernmedicine.com/tag/heeadsss-30-and-sshadess. Expanded efforts in sports clearance will identify significant risk to be addressed, and it will often have nothing to do with sports.

Author disclosure: No relevant financial affiliations.

The opinions and assertions contained herein are the personal views of the authors and are not to be construed as official or as reflecting the views of the U.S. Armed Services or any of their medical departments.


show all references

1. Irwin CE Jr, Adams SH, Park MJ, Newacheck PW. Preventive care for adolescents: few get visits and fewer get services. Pediatrics. 2009;123(4):e565–e572....

2. Bernhardt DT, Roberts WO; American Academy of Pediatrics. PPE: Preparticipation Physical Evaluation. 4th ed. Elk Grove Village, Ill.: American Academy of Pediatrics; 2010.

3. C.S. Mott Children's Hospital National Poll on Children's Health. Sports physicals: convenient versus comprehensive? http://mottnpch.org/reports-surveys/sports-physicals-convenient-versus-comprehensive. Accessed September 12, 2015.

4. Heron M. Deaths: leading causes for 2010. Natl Vital Stat Rep. 2013;62(6):1–96.

5. Kann L, Kinchen S, Shanklin SL, et al.; Centers for Disease Control and Prevention (CDC). Youth risk behavior surveillance—United States, 2013 [published correction appears in MMWR Morb Wkly Rep. 2014;63(26):576]. MMWR Surveill Summ. 2014;63(suppl 4):1–168.

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This series is coordinated by Kenny Lin, MD, MPH, Associate Deputy Editor for AFP Online.



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