Practice Guidelines

Preparticipation Physical Evaluation: AAFP and Others Update Recommendations


Am Fam Physician. 2020 Jun 1;101(11):692-694.

Author disclosure: No relevant financial affiliations.

Key Points for Practice

• The PPE should be performed as part of an athlete's routine preventive medical care with their primary physician.

• Comprehensive PPEs are recommended every two to three years with annual focused history updates in intervening years.

• Personal and family history should be reviewed for risk factors of sudden cardiac death.

• Musculoskeletal evaluation should be primarily focused on previous injuries and current symptoms.

• Screening for anxiety or depression symptoms should be included in PPEs.

From the AFP Editors

The American Academy of Family Physicians (AAFP), the American Academy of Pediatrics, the American College of Sports Medicine, the American Medical Society for Sports Medicine, the American Orthopedic Society for Sports Medicine, and the American Osteopathic Academy of Sports Medicine have published the 5th edition of the preparticipation physical evaluation (PPE) monograph. Revisions include new mental health and transgender sections and expansion of the female athlete chapter. Additions to existing chapters include evaluation timing and format, musculoskeletal screening for increased injury risk, more discussion of relative energy deficiency, and screening recommendations for athletes with disabilities.

Timing and Location for PPEs

Ideally, the PPE is incorporated into regular preventive health care visits with an athlete's primary physician to ensure comprehensive knowledge of the athlete's personal and family history. Group or station-based examinations and evaluation in urgent care or retail clinics are discouraged because of the loss of continuity and medical history. Goals of the PPE are characterization of athletes' physical and psychological health and evaluation for potentially life-threatening conditions or predisposition for injury or illness. The PPE is an opportunity to provide health and lifestyle counseling and connect young people with medical care. The PPE should be performed by clinicians prepared to address the full scope of issues potentially encountered. Evaluations should be conducted at least six weeks before the start of practices to allow follow-up for any identified concerns.

Although evidence supporting specific evaluation frequency is lacking, high school and younger athletes are recommended to receive a comprehensive PPE every two to three years with an annual focused history update in intervening years. For college athletes, a single comprehensive evaluation during the first year of school followed by annual history updates is recommended. Updated forms should be used to standardize examination content and facilitate further evaluation and refinement (Table 1). Clinicians are requested to consistently use the International Classification of Diseases (ICD)-10 code Z02.5 to facilitate research.

Evaluation for Sudden Cardiac Death Risk

A key PPE element is assessment of personal and family history to identify athletes at risk for sudden cardiac death. A focused cardiac examination should include auscultation for murmurs, palpation of femoral pulses, examination for stigmata of Marfan syndrome, and seated blood pressure. Screening all athletes with electrocardiography is not recommended, although it may be considered in higher-risk athletes, such as participants in men's collegiate basketball. If electrocardiography is used for screening, specific interpretation criteria are recommended for athletes.


Athletes with a history of concussion identified during PPE should not participate unless all symptoms have resolved. Athletes with multiple previous concussions should receive further evaluation before participation. Baseline testing

Sean Wise, MD, CAQSM, Officer In Charge, Sports Medicine Clinic/Associate Fellowship Director, Fort Belvoir Community Hospital, Fort Belvoir, Virginia

Jeffrey Leggit, MD, CAQSM, Associate Professor and Director of Healthcare Operations, Department of Family Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

Address correspondence to Jeffrey Leggit, MD, CAQSM, at Reprints are not available from the authors.

This series is coordinated by Sumi Sexton, MD, editor-in-chief.

A collection of Practice Guidelines published in AFP is available at



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