The Preparticipation Physical Evaluation


Am Fam Physician. 2021 May 1;103(9):539-546.

  Patient information: A handout on sports safety is available at

Related editorial: Clinical Considerations in Caring for Transgender Athletes

Author disclosure: No relevant financial affiliations.

The preparticipation physical evaluation (PPE) is a common reason for young athletes to see a primary care physician. An annual PPE is required by most state high school athletic associations for participation in school-based sports, although there is limited evidence to support its effectiveness for detecting conditions that predispose athletes to injury or illness. In 2019, the American Academy of Pediatrics, with representatives from the American Academy of Family Physicians and other organizations, published updated PPE recommendations (PPE5). According to the guideline, the general goals of the PPE are determining general physical and psychological health; evaluating for life-threatening or disabling conditions, including risk of sudden cardiac arrest and other conditions that may predispose the athlete to illness or injury; and serving as an entry point into the health care system for those without a medical home or primary care physician. The guideline recommends that the evaluation take place in the physician's office rather than in a group setting. The PPE should include a structured physical examination that focuses on the cardiovascular, musculoskeletal, and neurologic systems. Screening for depression, anxiety disorders, and attention-deficit/hyperactivity disorder is also recommended. Clinicians should recognize any findings suggestive of the relative energy deficiency in sport syndrome. Additional consideration is required to address the needs and concerns of transgender athletes and athletes with physical and intellectual disabilities. Finally, guidelines have been published regarding return to play for athletes who have had COVID-19.

Approximately 60 million children and adolescents, including 7.9 million high school students, participate in some form of sports in the United States.1,2 The preparticipation physical evaluation (PPE) has long been used to determine medical eligibility for youth sports in the United States, with the first PPE recommendations published in 1992 by a task force of five physician organizations.3

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Do not order annual electrocardiography or any other cardiac screening for asymptomatic, low-risk patients.

American Academy of Family

The Authors

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JAMES MACDONALD, MD, MPH, is director of research and a physician at Nationwide Children's Hospital, Columbus, Ohio. He is also a clinical associate professor in the Department of Pediatrics and Family Medicine at Ohio State University College of Medicine, Columbus....

MARIE SCHAEFER, MD, is associate director of the Sports Medicine Fellowship and a clinical assistant professor in the Department of Orthopaedics and the Department of Family Medicine at the Cleveland (Ohio) Clinic Lerner College of Medicine of Case Western Reserve University.

JUSTIN STUMPH, DO, is a resident in the Cleveland Clinic Family Medicine Residency Program.

Author disclosure: No relevant financial affiliations.

Address correspondence to James MacDonald, MD, MPH, Nationwide Children's Hospital, Division of Sports Medicine, 584 County Line Rd. West, Westerville, OH 43082 (email: Reprints are not available from the authors.


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