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

Related editorial: Clinical Considerations in Caring for Transgender Athletes

Patient information: A handout on sports safety is available at https://familydoctor.org/prevention-and-wellness/exercise-and-fitness/sports-safety.

This clinical content conforms to AAFP criteria for CME.

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

RecommendationSponsoring organization
Do not order annual electrocardiography or any other cardiac screening for asymptomatic, low-risk patients.American Academy of Family Physicians and American College of Physicians

The intent of the PPE is to promote the health and safety of young athletes participating in training and competition and to identify those who may need additional evaluation before participation or, rarely, exclusion from sports. The American Academy of Pediatrics has published the fifth edition of the most comprehensive, up-to-date guideline on the PPE, referred to as PPE5.4 It contains consensus recommendations from representatives of multiple stakeholder medical societies, including the American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine.4 In addition to information about physical examinations, the PPE5 contains new recommendations regarding mental health in athletes. It also addresses the specific needs of certain groups, including athletes experiencing relative energy deficiency, transgender athletes, and athletes with disabilities.4

Controversies and Concerns

A long-standing debate has surrounded the use of the PPE. This is primarily because there is limited evidence to support its effectiveness for detecting conditions that predispose athletes to injury or illness.5,6

Another concern is that requiring a PPE may be a barrier to sports participation, especially in socioeconomically or medically disadvantaged communities in which PPEs may not be readily available.4 Even for individuals with medical insurance, PPEs may be an out-of-pocket expense (Z02.5 is the current International Classification of Diseases [ICD] code for a sports-related PPE7). Billing for the PPE as though it is a routine health maintenance visit may allow for coverage; however, doing so may preclude additional covered preventive visits for the patient during the calendar year. It may also be difficult to incorporate a PPE into a routine wellness visit because of time limitations, lack of a standardized approach, and gaps in physician knowledge related to appropriate questions and recommended examinations.8

Despite these ongoing debates, PPEs are widely performed. The Special Olympics requires a PPE for all athletes before participation.4 PPEs are recommended by the National Federation of State High School Associations and the National Collegiate Athletic Association.9,10 Most state high school athletic associations require an annual PPE for participation in school-based athletics11; however, the PPE5 recommends a full evaluation every two to three years with annual updates only as needed to address potential areas of concern.4 Clinicians should be aware of their own state's recommendations regarding the required frequency of PPEs.4

General Goals and Recommendations

The general goals of a PPE are determining the general physical and psychological health of the athlete; 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.4

The PPE5 and the American Academy of Family Physicians recommend that the PPE take place in the athlete's primary care medical home, during an office visit and not in a group setting.4,12 Despite the insurance coverage limitations noted previously, the PPE may be an athlete's only contact with a physician in any given year, allowing an opportunity for the physician to incorporate routine preventive health care into the visit when possible.5,13

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