The preparticipation physical examination: an update.

The evolution of the preparticipation physical examination (PPE) in the United States continues to advance. In May 2010, the fourth edition of the Preparticipation Physical Examination Evaluation (PPE-4) monograph was published. The monograph is a product reflecting the collaborative efforts of 6 author societies. This article provides a brief historical review of the PPE and then highlights the recent changes and updates contained in the PPE-4 monograph, including cardiovascular screening in athletes. New recommendations to include the PPE in all well-child care visits and the need to develop a nationwide standard for the PPE are discussed.

Pediatric running injuries.

As more children have become involved in athletic activities and running, there has been a significant increase in overuse injuries. The young athlete with open growth plates is vulnerable to unique overuse injuries involving the apophyses, articular cartilage, and growth plate. The physician caring for these young athletes needs to be aware of these conditions to diagnose and treat them appropriately. Physicians should also be aware of the risk of overtraining and overuse injury in athletes participating in year-round sports and competition. Current guidelines for overuse injury prevention in young athletes are primarily based on consensus and expert opinion. Further research is needed to provide evidence-based guidelines for overuse injury prevention in young athletes and runners.

Preparticipation cardiovascular screening in young athletes: current guidelines and dilemmas.

How to best screen athletes for conditions predisposing to sudden cardiac death is a topic of debate. The European Society of Cardiology and International Olympic Committee recently endorsed a standardized screening evaluation modeled after the successful Italian system, which utilizes a 12-lead electrocardiogram (ECG) along with a detailed history and physical exam. The ECG increases the power of the history and physical exam to detect underlying causes of sudden cardiac death. In 2007, the American Heart Association (AHA) panel recommended against implementation of such a system in the United States because of a lack of current infrastructure, providers, and expertise. The lack of standardization of the current cardiovascular screening system in the United States hinders its effectiveness and prevents systematic evaluation. The AHA strongly recommends establishing a national standard for cardiovascular screening as well as a certification process for non-physicians who perform screening exams. Well designed studies are needed in the U.S. to demonstrate the effectiveness of the ECG for identifying underlying cardiovascular abnormalities in young athletes.

Acute lumbar disk pain: navigating evaluation and treatment choices.

Acute lumbar disk herniations are the most common cause of sciatica. After excluding emergent causes, such as cauda equina syndrome, epidural abscess, fracture, or malignancy, a six-week trial of conservative management is indicated. Patients should be advised to stay active. If symptoms persist after six weeks, or if there is worsening neurologic function, imaging and invasive procedures may be considered. Most patients with lumbar disk herniations improve over six weeks. Because there is no difference in outcomes between surgical and conservative treatment after two years, patient preference and the severity of the disability from the pain should be considered when choosing treatment modalities. If a disk herniation is identified that correlates with physical findings, surgical diskectomy may improve symptoms more quickly than continued conservative management. Epidural steroid injections can also provide short-term relief.

Environmental illness in athletes.

This article examines environmental illness in athletes. Causes, symptoms, and treatment of heat-related illness, cold-related illness, and altitude-related illness are discussed.

Preparticipation cardiovascular screening.

Regular aerobic exercise provides many health benefits regardless of age, and should be promoted by health care providers to all patients. In older athletes, coronary artery disease is the most common cause of sudden death. There is widespread consensus, however, that the overall health benefits derived from exercise outweigh the risks of participation. Screening should focus on identifying signs and symptoms of underlying cardiovascular disease by obtaining a personal and family history and performing a focused physical examination according to the recommendations of the AHA. Exercise testing is recommended in males older than 40 and females older than 50, and individuals with cardiac risk factors. Cardiovascular PPE screening in young athletes remains a challenge, because potentially fatal abnormalities are uncommon and in some cases are undetectable without sophisticated testing. Most sudden cardiac deaths in athletes are caused by anomalies that are clinically silent, are rare, or are difficult to detect by history and physical examination. Many athletes may not experience symptoms consistent with heart disease or may not report family histories of sudden cardiac death. Important clues to a cardiac abnormality include history of syncope, chest pain, and family history of sudden death. Any underlying condition suspected on the basis of history or physical examination requires further diagnostic evaluation before the athlete can be cleared for activity. Currently there is considerable variability and inconsistency among state requirements for PPEs. A national adoption of a more uniform PPE screening process should be encouraged. The screening process should include the AHA's cardiovascular screening recommendations, as this would assist in closing the gap between screening practices recommended by sports medicine experts and the reality of current screening practices. Although the extent of screening continues to be debated, clinical guidelines for performing PPEs and determining clearance have been established. Without a uniform implementation of the current guidelines, it will not be possible to assess the value of the current cardiovascular screening recommendations in detecting and preventing cardiovascular death in young athletes. Physicians should be aware of the emerging role of genetic testing for cardiovascular diseases in athletes with a family history of heart disease or sudden death. Advances in the diagnosis and understanding of cardiovascular disease may provide better tools for preventing sudden death of young athletes in the future [11].