I sat in the pediatrics section meeting at a local community hospital when they asked for volunteers for preparticipation sports physical examinations. As a pediatric cardiologist, I figured I might offer valuable help. When I arrived at the enormous gymnasium of the local community college, there was no electrocardiogram machine and I learned that I was going to examine cheerleaders from the ages of six to 16 years. So, with a chaperone present I examined and cleared about 100 middle-class “cheerleaders” for an activity that has never been associated with a case of sudden cardiac death. Somewhat amused, I watched other physicians clear boys for sports such as golf, swimming and tennis. I was only surprised that no one from the debate team was present.
Kurowski and Chandran address the steps of the preparticipation physical in their article in this issue1 of American Family Physician; however, I have reservations about clearing children who should be seeing their primary care physicians anyway, especially children who are participating in sports that the American Heart Association allows children with a single ventricle to do without restrictions. The other physicians, mostly family physicians, felt that they were providing good primary care. They diagnosed diseases such as warts and hernias. I told them that while good primary care is important, I wasn't sure that this was the reason I gave up an evening to volunteer. Most of these children had primary care physicians. I wasn't looking for warts; I was trying to keep children from dying.
There is something unsettling about volunteering your time to examine patients who can afford to receive primary care. While my colleagues may have provided a valuable service, I am not sure I see a justification for providing primary care under the guise of “sports physicals.” While there is a scientific foundation and a medical need for primary care, it is questionable whether the scientific basis for the preparticipation sports physical examination has been demonstrated. The preparticipation sports physical didn't evolve from a public health need. It didn't arise out of a lack of primary care. It evolved because of media attention on athletes who had an adverse event while competing. The preparticipation sports physical is a medical event that is not inspired by medical need. If there is no scientific way of preventing athletes from getting injured or dying, I contend that an athlete can never be “cleared” to compete.
If we focus on sudden cardiac death during exercise, certainly the most catastrophic impetus for sports physicals, we do not find an epidemiologic justification for performing physicals to prevent sudden cardiac death. First, the fundamental basis of screening is to identify the specific purpose of screening. In the case of the preparticipation sports physical, the intention is not evident. There are no standardized forms, the forms that exist are inadequate, and many states have no forms. Some states do not require a medical license to perform the examination.2 Studies frequently cite the history as being the most important part of the examination, yet there is no standardized history and athletes report that the history-taking is poor.3
Even if you standardized the history and physical examination so that you are trying to detect athletes who are at risk of sudden cardiac death, the incidence of sudden cardiac death is so low it could never be made a public health priority worthy of the effort. The effort is beyond trying to find a needle in a haystack. It is like trying to find a needle in Kansas. From 1985 to 1995, 158 cases of sudden deaths during competitive exercise have been documented in the United States.4
Depending on how you define the denominator, the incidence of sudden cardiac death in athletes is somewhere around one in 150,000 participants to one in several million participants.5 Only four sports (football, basketball, track and soccer) have been associated with more than five sudden deaths,4 yet more athletes and younger children are being included in screening. This makes the examination more inclusive, thereby making the effort less effective.
What can the preparticipation sports physical examination detect? The Mayo Clinic reported that significant cardiac abnormalities were found in 0.39 percent of 2,739 athletes who were screened.6 If we assume that the Mayo clinic screening procedure is reproducible nationwide, a major leap of faith considering the state of preparticipation sports physicals nationwide, then we are accepting that one in 500 children will be disqualified from competing in order to find an illness with an incidence of one in 100,000. In other words, we will be disqualifying thousands of children who will never have a problem.
Even if we accept that we could find an anomaly in one of 500 children, we have no way of knowing that these children will have a problem. It is possible the athlete who will experience sudden cardiac death will have slipped through the screening process. The one study that I am aware of to prospectively identify athletes at risk of sudden death was done at the University of Maryland in 1987 and was completely unsuccessful.7
The most common cause of sudden cardiac death is hypertrophic cardiomyopathy, which may have no physical examination findings and may even be associated with a normal electrocardiogram (that is, if an electrocardiographic study is performed).5,8 Yet, compared with the other common causes of sudden cardiac death (e.g., anomalies of the coronary arteries, arrhythmogenic right ventricular dysplasia, long QT syndrome), it is easy to diagnose.5,9 The first two entities invariably have no physical findings and a normal electrocardiogram, while long QT syndrome cannot be diagnosed without an electrocardiographic study.8
Yes, some hint of possible problems may be revealed by the history for some patients, but preparticipation sports physicals are usually done without the parents present. Since when do we rely on the history of adolescents who are trying to get clearance to pursue their dreams?
Of course, the point has never actually been to prevent injuries or death. If it were, the examination would have been standardized and upgraded to include electrocardiographic studies many years ago. It would appear that the preparticipation sports physical was designed to reassure parents and school administrators or to “trick” children into getting primary care. Yes, clearing athletes to compete is extremely important; however, the system currently in use is inefficient and cannot “clear” an athlete. The preparticipation sports physical is in fact detrimental because it provides a sense of assurance when there is no evidence that a disease process was prevented or even properly screened.
I know very little about orthopedic surgery. Yet, I have reviewed the literature on orthopedic preparticipation sports physicals and found it is not much different than the literature on sudden cardiac death. While there are criteria for disqualifying athletes, and a small percentage of athletes fail the criteria and are thus disqualified,10 I can find no evidence that these athletes are the ones who would be injured or that anyone can predict or prevent injuries. In addition, the orthopedic examination in preparticipation sports physicals fails the basic premise of screening tests—that abnormalities need to be detected.
If you're not convinced that we should question the usefulness of the preparticipation sports physical, ask yourself the following questions: Why are we doing thorough examinations on children who are already getting primary care? Why are we assessing children for sudden cardiac death who are going to engage in activities that have no risk of sudden cardiac death, such as cheerleading? Why do we assess children who are at minimal risk of any injury, such as those who play golf? What is the likelihood that a non-cardiologist can detect arrhythmogenic right ventricular dysplasia on the basis of an adolescent's history and a five-minute physical examination? Is it possible for a preparticipation sports physical, done by a nonorthopedic surgeon nonetheless, to establish the risk of a football player tearing his anterior cruciate ligament? The reason that your answers are most likely “no,”“I don't know,” or “dismal,” is that the terms “risk,” “prevalence,” “indication” and “likelihood” only have meaning in the context of science, and this effort is not being done for a scientific reason, nor is it being done scientifically.
A medical screening procedure can be effective and efficient only on an individual basis with the proper equipment. It cannot be done in a warehouse. First, only athletes who are truly at risk for sudden cardiac death need to be screened for sudden cardiac death. This would restrict the examination to football, basketball, track, soccer and perhaps ice hockey players. All other athletes could get a statement from their primary care physician that they are in good health, not that they are “cleared.” This would make the preparticipation sports physical redundant. If athletes don't have primary care, then this enormous effort should be transformed into an effort to provide more primary care. Second, we refer at-risk athletes who have a reason to be cleared; for example, we should refer athletes with complaints of syncope to their family physician. The cardiologists will have at their disposal the means necessary to properly assess and perhaps even “clear” the patient from a cardiovascular standpoint. Yes, someone will have to pay for it, but that's the trade-off for responsibility. Other medical subspecialists can make their own screening process using the medical literature to try to make the process scientific and thus productive.
Meanwhile, I propose that until someone demonstrates that it is prospectively possible to prevent sudden cardiac death, we put more effort into treating sudden cardiac death. Currently, the improvements in defibrillator technology are spurring on an effort to put defibrillators in gymnasiums and airplanes. For that matter, we certainly can have defibrillators in place not only at competitive sporting events but conceivably at little league baseball games. I propose that competitive sporting events be staffed by someone who is trained in advanced cardiac life support. A defibrillator and someone who knows how to use it should be present at every competitive sporting event.
If the parents don't want to pay for screening, or if the insurance companies or the schools demand it, they can stick with the gymnasium routine. But, it won't be me they'll be seeing.