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Updated monograph offers new guidance on preparticipation physical evaluation :

May 15, 2019

A high school soccer player and a skateboarding middle schooler are athletes, and both should receive a sports physical from their pediatrician in the medical home.

The new Preparticipation Physical Evaluation (PPE)5th Edition has expanded in scope to include kids in activities outside of organized sports. It also urges middle-school through college-age athletes to have their sports physical during the well-child exam to ensure that they receive comprehensive care within the medical home.

Many children participate in physically demanding activities like snowboarding, skiing, jogging, climbing and hiking. Other youths are not physically active at all. By providing the PPE in the medical home, physicians can serve youths who are active outside of organized sports and counsel inactive children about the benefits of physical fitness, said co-editors David T. Bernhardt, M.D., FAAP, and William O. Roberts, M.D., M.S., FACSM, FAAFP.

“If they’re not participating, maybe they ought to be,” Dr. Roberts said. “Everything we do should be promoting physical activity as a health intervention and prevention strategy to bring down the cost of health care and to reduce the problems that occur with inactivity.”

Six organizations contributed to the PPE’s development: the AAP, American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine and American Osteopathic Academy of Sports Medicine. The National Athletic Trainer’s Association and National Federation of State High School Associations endorsed the resources.

The 240-page monograph offers recommendations on PPE timing, setting, structure, medical history and clearance. Also included are forms for history (in English and Spanish), physical examination, athletes with disabilities and medical eligibility (see resources).

Improving care for all children

Many athletes skip their routine health supervision visits because they assume that a sports exam is all they need, Dr. Roberts said.

But athletes who receive only a sports physical at a retail-based clinic or school screening miss out as their comprehensive health history is not readily available. If problems are found, they are not added to the electronic health record. Patients are referred back to their primary care physician for follow-up or pay extra fees if referred out of network. The athlete also may miss important anticipatory guidance and immunizations.

When all children receive routine screening, parents can avoid a last-minute scramble before students begin school sports. Most organizations send forms home for athletes before the season begins. Pediatricians can ask parents to complete the history form before the visit to allow more time for discussion during the examination. Patients and families should be encouraged to answer the questions honestly and thoroughly, especially the family history and heart-related questions, Dr. Bernhardt said.

“Sudden cardiac deaths are rare in athletes, but they shock communities and are in the backs of parents’ and pediatricians’ minds,” he said. “Most athletes are cleared without restriction. Ultimately, the majority of those referred with red flag conditions are still cleared, but it may be important to get the cardiologist’s opinion.”

If they did not have the exam during their routine health supervision visit, athletes should have a PPE at least six to eight weeks before the sports season begins to address any potential problems.

Other highlights of the 5th Edition include:

  • Mental health, an underrecognized problem for athletes.
  • New guidance on the care of transgender athletes. The history form has been updated with separate entries for athletes to state their sex at birth and to declare gender. Eligibility for high school transgender athletes is set by the state high school associations.
  • The female athlete triad of energy availability, menstrual health and bone mineral density. Male athletes also can experience a form of the energy deficit in common with the female athlete triad, Dr. Roberts said.
  • New musculoskeletal tests for risk of patellofemoral and anterior cruciate ligament injuries.
  • The importance of exercise for children with special needs.

“Children with special needs deserve the opportunity to compete and participate in sports just like any other child,” Dr. Bernhardt said. Pediatricians can use the monograph to find the right fit for the individual, access history and physical forms for children with cognitive or physical special needs, and find forms for Special Olympics athletes.

Measuring effectiveness, gathering data

Although the PPE has been used for over 50 years, it lacks data on effectiveness and was not developed as an evidence-based process.

Pediatricians can help incur more data by using the code for sport physical in addition to the routine health supervision visit code (if appropriate). The International Classification of Diseases, Tenth Revision, Clinical Modification code Z02.5 will document the encounter for a sport participation examination.

If all providers use the primary or secondary code when the PPE is performed alone or as part of a health supervision visit, the electronic medical record can become a powerful tool, according to Dr. Bernhardt.

“We are in the business of promoting physical activity for all children and adolescents,” Dr. Roberts said. “For every kid that walks in the door for a physical, we need to incorporate the preparticipation evaluation to make sure it’s safe for them to participate in those activities.”


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