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Sports participation in children and adolescents: The preparticipation physical evaluation

Sports participation in children and adolescents: The preparticipation physical evaluation
Literature review current through: Sep 2023.
This topic last updated: Apr 13, 2023.

INTRODUCTION — In the Unites States, approximately 50 to 60 percent of children and adolescents participate in organized sports [1,2]. The standard of care is that these athletes have a preparticipation physical evaluation (PPE) before the season begins [3].

The PPE in children and adolescents is reviewed here. Broader guidelines for preventive care in adolescents are presented separately. (See "Guidelines for adolescent preventive services".)

Additional aspects of sports participation in children and adolescents are presented separately:

Benefits of physical activity and strength training (see "Physical activity and strength training in children and adolescents: An overview")

Sports-related concussion (see "Sideline evaluation of concussion" and "Concussion in children and adolescents: Clinical manifestations and diagnosis" and "Concussion in children and adolescents: Management")

Sports-related neck injuries (see "Evaluation of the child or adolescent athlete with neck pain or injury" and "Overview of musculoskeletal neck injuries in the child or adolescent athlete" and "Field care and evaluation of the child or adolescent athlete with acute neck injury" and "Overview of cervical spinal cord and cervical peripheral nerve injuries in the child or adolescent athlete")

Sports participation in children with heart disease (see "Physical activity and exercise in patients with congenital heart disease")

Risk of sudden death in athletes (see "Screening to prevent sudden cardiac death in competitive athletes" and "Athletes: Overview of sudden cardiac death risk and sport participation" and "Sudden cardiac arrest (SCA) and sudden cardiac death (SCD) in children")

Exercise-related amenorrhea (see "Functional hypothalamic amenorrhea: Pathophysiology and clinical manifestations")

BACKGROUND

Consensus guidelines — The approach to performing the preparticipation physical evaluation (PPE) described in the following sections is generally consistent with the 2019 guidelines of the American Academy of Family Physicians, American Academy of Pediatrics (AAP), American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy for Sports Medicine [3] as well as the recommendations of the American Heart Association and European Society of Cardiology [4].

Goals of the preparticipation physical evaluation — The goals of the PPE are to [3-5]:

Maximize safe participation by children and adolescents

Identify medical problems with risks of life-threatening complications during participation (eg, hypertrophic cardiomyopathy)

Identify conditions that require a treatment plan before or during participation (eg, hypertension)

Identify and rehabilitate old musculoskeletal injuries

Identify and treat conditions that interfere with performance (eg, exercise-induced bronchospasm)

Remove unnecessary restrictions on participation

The PPE is not intended to serve as the comprehensive adolescent health maintenance visit. Conversely, the comprehensive health maintenance visit should not substitute for the PPE unless it includes the necessary components of the sports history and physical examination. (See "Guidelines for adolescent preventive services".)

However, the PPE may serve a as an entry point into the health care system for adolescents without a medical home. In such cases, it is an opportunity to address the youth's health more broadly. The AAP guidelines encourage providers to include questions on topics such as drug use, sexual activity, violence, and mental health since these issues pose more serious threats to the health of teens than do injuries incurred during sports participation [3]. Whether it is feasible and/or appropriate to explore some of these areas depends, in part, on the setting. (See 'Setting' below.)

Avoid unnecessary restriction — One goal of the PPE is to remove unnecessary restriction on sports participation or exercise. Inappropriate restrictions can prevent children from establishing healthy lifestyle habits at a young age. (See "Physical activity and strength training in children and adolescents: An overview", section on 'Benefits of regular physical activity'.)

Examples of unnecessary restrictions include:

Children and adolescents with suspected heart disease may be restricted from sports participation pending further evaluation. However, restrictions are often not given an endpoint, which unnecessarily prolongs the child's exclusion from sports and exercise. Most children with chronic cardiovascular conditions can participate in sports at some level after an appropriate evaluation has been performed and proper preventative measures have been instituted, if warranted. (See 'Cardiovascular conditions' below.)

Another example is inappropriately restricting children with obesity from sports participation until they lose weight because of concern regarding risk for heat injury. Obesity is a risk factor for heat injury, and acclimatization is indicated in preparation for summer practices; however, exercise is an important component of obesity management, and restricting exercise in children with obesity is counterproductive. (See 'Obesity' below and "Prevention and management of childhood obesity in the primary care setting".)

Osgood-Schlatter disease is another common condition for which inappropriate limitations are often imposed. Avoidance of sports activity is neither necessary nor recommended in Osgood-Schlatter disease since inactivity can lead to deconditioning, which increases the risk of recurrence or other injury after returning to sports participation. (See 'Osgood-Schlatter disease' below and "Osgood-Schlatter disease (tibial tuberosity avulsion)", section on 'Activity continuation'.)

PRACTICAL CONSIDERATIONS

Timing — Ideally, the preparticipation physical evaluation (PPE) should take place four to six weeks before the season starts, permitting time to evaluate and treat medical problems and/or rehabilitate musculoskeletal injuries before sports participation.

Frequency — Most sports medicine clinicians recommend performing a complete PPE before each new level of participation (eg, middle school, junior high, high school, and college), with yearly updates of the history and targeted physical examinations [3,6]. Requirements for the frequency of PPE vary by state, but most state high school athletic associations require annual evaluations [3].

Setting — The PPE may be performed in the office setting or through a station approach. Both methods are acceptable and each has advantages and disadvantages [3]:

Office setting – Examination in the office setting by the athlete's primary care provider has the advantages of privacy, continuity of care, and the provider's knowledge of past medical and family history. However, the complete examination is time consuming and may have insufficient focus on the important sports-related components of the PPE.

Station approach – In the station approach, the athlete is examined by multiple examiners through a series of stations specific to individual components of the evaluation. The station approach is time efficient, sports oriented, and inexpensive, and has a high yield for identifying abnormalities; however, it generally does not afford confidentiality and may not provide for continuity of care. If the station approach is used, the providers should have access to the athletes comprehensive medical and injury history [3].

Examiner — The PPE should be performed by an examiner with appropriate training and experience in evaluating the musculoskeletal system in children. Pediatric providers routinely conduct PPEs, yet many lack specific training in sports medicine or the performance of these examinations [7]. The clinician performing the PPE should have a low threshold for referring athletes to a sports medicine specialist if pain or other limitations are noted in the screening musculoskeletal portion of the PPE. Similarly, the threshold for referral to a pediatric cardiologist should be low when concerns are noted in the cardiovascular assessment. (See 'Musculoskeletal examination' below and 'Cardiovascular examination' below.)

COMPONENTS OF THE EVALUATION — The preparticipation physical evaluation (PPE) includes a targeted medical and family history and a targeted physical examination, with emphasis on the musculoskeletal and cardiovascular systems.

Evaluation forms — The American Academy of Family Physicians, American Academy of Pediatrics (AAP), American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine have endorsed a standardized preparticipation athletic evaluation form that addresses important aspects of the history and examination [3]. It is available through the AAP website.

Medical history — The medical history is the most sensitive and specific component of the PPE for detecting conditions that preclude participation in sports [3]. Personal and family history and review of systems detect approximately 75 percent of conditions that restrict participation or require further evaluation [8]. Parent/caregivers should review the family history with the athlete if they will not be present for the examination.

The history should include a general medical history, injury history, and a cardiovascular history, including pertinent family history. Particular attention should be paid to:

Past medical history, including conditions currently being treated

Prior surgery and sequelae

Loss of function in one of any paired organs (eg, eye, testis, kidney)

History of heat-related illness

Current medications, supplements, or herbal therapy

Immunization history

Recent illness history, including coronavirus disease 2019 (COVID-19)

Menstrual history in female athletes

A history of rapid increase or decrease in body weight and the athlete's perception of his or her current body weight

Injury history — Injuries are common in sports participation and if not adequately rehabilitated, can predispose the athlete to further injury. Simple screening questions are generally more sensitive than the musculoskeletal examination for detecting injuries and other orthopedic problems [9].

The examiner should inquire about:

Past injuries, including musculoskeletal injuries, concussions, and spine injuries

Loss of time from participation and current sequelae of prior injuries (eg, paresthesias from spinal injury)

Previous exclusion from sports for any reason

Cardiovascular history — The cardiovascular history is aimed at identifying conditions that predispose athletes to sudden death. These conditions are rare and often difficult to detect.

Questions of importance in the cardiovascular history include [3] (see "Screening to prevent sudden cardiac death in competitive athletes", section on 'History and physical examination'):

History of hypertension, cardiac murmur, high cholesterol, Kawasaki disease, or myocarditis.

History of syncope, near syncope, dizziness, angina, or palpitations during exercise – The athlete should be asked if they have ever passed out; nearly passed out; felt lightheaded; or had chest pain, an irregular heartbeat, or excessive, unexpected, or exceptional unexplained shortness of breath or fatigue during or after exercise [3,10,11]. The presence of any of the above symptoms that cannot be explained (eg, by vasovagal presyncope) requires exclusion from participation in competitive sports pending cardiac evaluation, and the patient should also be counseled to avoid strenuous exercise until that evaluation is complete. (See 'Noninvasive cardiovascular testing' below.)

History of chest pain – Chest pain is a common complaint in children and adolescents and is usually due to benign causes. Findings that suggest a more serious etiology (table 1) and that require further evaluation include (see "Causes of nontraumatic chest pain in children and adolescents"):

Chest pain in association with fever.

Pain that interrupts sleep.

True anginal pain (ie, characterized by substernal, deep, pressure-like pain that radiates to the arm or jaw, is associated with dyspnea, and causes the athlete to stop activity).

Pain associated with palpitations and/or syncope during exercise.

Abnormal findings on physical examination

In addition, if the athlete has recent onset of chest pain (within 48 hours of performing the PPE), evaluation for the etiology may be appropriate, as discussed separately. (See "Nontraumatic chest pain in children and adolescents: Approach and initial management", section on 'Evaluation'.)

History of unexplained seizure.

History of abnormal cardiac testing (eg, electrocardiogram, echocardiogram).

Feeling tired or short of breath more quickly than peers during exercise that is not due to poor conditioning or exercise-induced bronchospasm.

Family history of death or disability from heart problems, or unexpected or unexplained sudden death before age 50 years (including drowning, unexplained car accident, or sudden infant death syndrome).

Family history of heritable cardiomyopathy or arrythmia syndrome (eg, hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia) [10,11].

Family history of a heart problem, pacemaker, or implanted defibrillator.

Family history of unexplained fainting, unexplained seizures, or near drowning.

Review of symptoms — The review of symptoms is an important component of the PPE and can identify issues that may warrant further evaluation.

Musculoskeletal symptoms – The examiner should ask about musculoskeletal symptoms, including back pain, neck pain, or other joint pain or stiffness (knee, shoulder, ankle).

Cardiovascular symptoms – Concerning cardiovascular symptoms include syncope, near syncope, dizziness, chest pain, dyspnea, and/or palpitations during exercise, as discussed above. (See 'Cardiovascular history' above.)

Concussion-like symptoms – Because concussion-like symptoms are frequently reported even among children and adolescents without prior head injury [12], a baseline assessment of symptoms (eg, Sport Concussion Assessment Tool [SCAT-3]) may be warranted as part of the PPE for athletes participating in contact sports. This can reduce over-diagnosis of postconcussion syndrome in youth who may have baseline symptoms such as fatigue, sleep difficulties, poor concentration, and headache. In a cross-sectional sample of high school students without a history of concussion, 19 percent of boys and 28 percent of girls reported having a symptom constellation consistent with postconcussion syndrome [12]. (See "Postconcussion syndrome" and "Concussion in children and adolescents: Clinical manifestations and diagnosis", section on 'Preparticipation assessment'.)

Respiratory symptoms – Asthma and exercise-induced bronchospasm occur frequently in athletes; however, exercise-induced bronchospasm may be unrecognized in the young athlete [13,14]. It is important to ask about asthma symptoms, particularly symptoms that occur with exercise. Spirometry may be warranted based on the reported symptoms; however, postexercise spirometry as a routine in the PPE is not recommended.

Musculoskeletal examination — All athletes should undergo a screening musculoskeletal examination during the PPE. If there is a history of injury or abnormalities reported on the screening questionnaire, the joint or region in question should be examined in detail. In addition, we suggest complete examination of high-risk areas (ie, shoulder, knee, and ankle); however, there is no evidence that this increases the sensitivity of the evaluation or predicts future injuries [9].

The screening musculoskeletal examination includes the following components:

General inspection – The examination requires the athlete to wear clothing that permits inspection of the shoulders and extremities. The screening orthopedic examination begins with inspection of the adolescent standing with arms at the sides, facing the examiner. The observer is looking for asymmetry. Specifically:

A tilt of the head to one side can indicate a primary cervical spine injury, primary or secondary trapezius strain, or other cervical muscle spasm. Ask the athlete if any maneuver hurts or, if the parent/caregiver or coach is in the room, ask them if this is a change in the athlete's posture. If pain occurs with movement or restriction of movement, the athlete is not permitted to participate in contact sports until further evaluation. Participation in noncontact sports is appropriate if participation does not exacerbate pain. (See "Approach to neck stiffness in children".)

Prominence of one acromioclavicular joint may indicate a previous acromioclavicular joint sprain (shoulder separation). The athlete can participate in all sports if no tenderness to palpation at the joint is present and if the range of motion and strength of the shoulder are normal. The joint should be padded during participation so that the force, such as in direct contact of the shoulder with another athlete, can be distributed anterior and posterior to the acromioclavicular joint.

Asymmetric shoulder heights may indicate trapezius strain or spasm secondary to neck or shoulder injury, paraspinous strain, primary spine injury causing secondary paraspinous muscle spasm, limb length discrepancy, or scoliosis. The athlete is not permitted to participate in contact sports until the etiology is established and appropriate treatment, if necessary, is completed.

Asymmetric iliac crest heights indicate scoliosis, leg length discrepancy, asymmetric pelvic rotation, or lumbar paraspinous muscle spasm.

Atrophy of the vastus medialis obliquus, demonstrated by asking the athlete to contract their quadriceps muscles putting the knee in full extension, is characteristic of any leg injury that leads the athlete to avoid normal use.

A prominent, tender tibial tuberosity indicates Osgood-Schlatter disease. (See "Osgood-Schlatter disease (tibial tuberosity avulsion)".)

Swelling of any extremity may be secondary to trauma or other inflammatory processes, and the etiology should be established before the athlete is cleared.

Long limbs relative to the trunk, arachnodactyly, and pectus deformity of the chest may be present in Marfan syndrome.

Neck – The neck examination is especially important in players with a previous history of neck injury, limited neck motion, or brachial plexopathy (stinging or burning in any dermatome of the brachial plexus distribution, referred to as "stingers" or "burners"). Ask the athlete to look at the floor (cervical flexion), the ceiling (cervical extension), over left and right shoulders (left and right rotation), and put the right ear on the right shoulder and the left ear on the left shoulder (right and left lateral flexion). Any athlete with limitation of range of motion, weakness, or pain with neck examination is excluded from contact sports until further evaluation. (See "Overview of cervical spinal cord and cervical peripheral nerve injuries in the child or adolescent athlete" and "Overview of musculoskeletal neck injuries in the child or adolescent athlete".)

Shoulder – Ask the athlete to raise the arms from the side and touch hands above the head, keeping elbows extended (full abduction). Asymmetric elevation of the shoulder before 90 degrees of abduction or inability to fully abduct the arms to 180 degrees could be caused by shoulder weakness or instability.

Ask the athlete to hold the arms in front of the body while the examiner presses down on the hands (resisted forward flexion) and then repeat this procedure at 90 degrees of abduction. Weakness, atrophy, or fasciculations of anterior and middle deltoid muscles and pain or weakness with these maneuvers may indicate neurologic, skeletal, or muscular injury.

Ask the athlete to put the hands behind the neck and bring the elbows back as far as possible (abduction and external rotation of the shoulder). Inability to perform this maneuver fully or apprehension about performing it, coupled with a history of the shoulder "slipping out" or "going dead," suggests previous shoulder subluxation or dislocation that has not been adequately rehabilitated or may need surgical correction.

Athletes with limitation of motion in any of the above maneuvers should be further evaluated before they are cleared for participation.

Elbow – Ask the athlete to extend and flex the elbows with arms to the side (90 degrees abduction). Then, with the elbows flexed at 90 degrees and the hands pointing forward, ask the athlete to pronate and supinate. Asymmetry or loss of motion in any of these maneuvers suggests previous injury. Further evaluation is necessary before the athlete can be cleared for participation, especially in throwing sports.

Hands – Ask the athlete to spread the fingers and then to make a fist. Look for decreased finger flexion, swollen joints, or finger deformities as residuals of previous injuries. The need for further evaluation of hand injuries and recommendations for sports participation are based upon the severity of the injury and the sport the athlete wishes to play.

Back – Inspect the back from behind and in front of the athlete, looking for manifestations of scoliosis. Idiopathic scoliosis rarely is a contraindication for sports participation unless the angle of curvature is severe (eg, >40 degrees). If the spine is painful by history or tender to palpation, the diagnosis of idiopathic scoliosis should be reconsidered; the definitive diagnosis should be established before clearance for sports participation is provided. If the athlete reports lumbar pain and there is pain in the midline in the lumbar region with lumbar extension, lumbar spondylolysis should be considered. (See "Back pain in children and adolescents: Causes", section on 'Spondylolysis and spondylolisthesis'.)

Knee and hip – Ask the athlete to squat by placing the buttocks on the heels and then, remaining in this position, to take four steps forward ("duck walk"), turn around, and take four steps back to the starting position.

Prominent, tender tibial tuberosities, diagnostic of Osgood-Schlatter disease and common in young adolescents, may cause pain when the athlete tries to squat in full knee flexion. Athletes with Osgood-Schlatter should not be disqualified from play but should participate in a rehabilitative program that includes stretching of the quadriceps and hamstring muscles, strengthening of the quadriceps muscles, and wearing a protective pad over the tibial tuberosity. The athlete should miss little if any sports participation with this treatment. (See "Osgood-Schlatter disease (tibial tuberosity avulsion)".)

The inability to do the "duck walk" maneuver should prompt a more thorough knee and hip examination and exclusion from painful activities until a definitive diagnosis and rehabilitation plan are established. Most diagnoses of knee problems can be made on the basis of history and physical examination. Consultation with a sports medicine specialist may be necessary to determine the need for additional studies, such as radiographs and/or magnetic resonance imaging, especially if the knee and hip condition does not improve with rehabilitation.

Ankle – Ask the athlete to hop as high as they can five times on each foot. The inability to hop five times on an ankle without pain or instability indicates an undiagnosed or unrehabilitated ankle or foot injury. The injury should be evaluated and fully rehabilitated before full participation is allowed.

Cardiovascular examination — The cardiovascular physical examination should include, at a minimum, the following components [3,4,15]:

Measurement of blood pressure and resting heart rate – Blood pressure should be measured in the right arm with the athlete sitting and with the proper size cuff. Normative values for blood pressure and heart rate are provided in the tables (table 2 and table 3 and table 4). (See "Definition and diagnosis of hypertension in children and adolescents", section on 'Measurement of blood pressure'.)

Most well-trained endurance athletes have resting sinus bradycardia; elite athletes may have a resting heart rate <40 beats per minute. Sinus bradycardia generally does not require any additional evaluation if the patient is asymptomatic and otherwise healthy. (See "Bradycardia in children", section on 'Athletes'.)

The exception is the adolescent female aerobic athlete who present with weight loss and bradycardia beyond what would be expected from training alone (ie, heart rate <40 beats per minute), which suggests inadequate caloric intake. This can occur with or without disordered eating and may be associated with other findings such as menstrual dysfunction and low bone density (the so-called the "female athlete triad") [16,17]. Eating disorders and the female athlete triad are discussed in greater detail below and in a separate topic review. (See 'Specific conditions' below and "Eating disorders: Overview of epidemiology, clinical features, and diagnosis".)

Auscultation – The PPE examiner should listen for murmurs and other abnormal heart sounds (eg, gallop, clicks). The approach to cardiac auscultation, assessment of murmurs and other abnormal heart sounds, and criteria for referral (table 5) are discussed in detail separately. (See "Approach to the infant or child with a cardiac murmur".)

Assessment of femoral pulses to exclude coarctation of the aorta. (See "Clinical manifestations and diagnosis of coarctation of the aorta".)

Recognition of the physical stigmata of syndromes associated with potentially serious cardiovascular complications (eg, Marfan syndrome). (See "Genetics, clinical features, and diagnosis of Marfan syndrome and related disorders".)

Targeted physical examination — The remainder of the physical examination aids in the detection of other medical conditions that may restrict, affect, or worsen with participation:

Anthropometry – Height and weight should be assessed in all children. In addition, estimating body composition may be appropriate in certain circumstances.

Body mass index (BMI) – BMI is calculated based on the height and weight (calculator 1 and calculator 2). BMI is the preferred measure of adiposity. (See "Measurement of body composition in children", section on 'Body mass index' and "Clinical evaluation of the child or adolescent with obesity".)

In evaluating patients with weight loss, BMI should be assessed in the context of the patient's prior growth charts. For example, a patient with a BMI measurement at the 25th percentile for age and sex who has prior measurements consistently tracking at the 75th percentile may be malnourished despite having a BMI within the normal range.

Ideal body weight (IBW) – The percent IBW is another method to assess proportionality and nutritional status and is particularly useful in assessing undernourishment. (See "Normal growth patterns in infants and prepubertal children", section on 'Ideal body weight'.)

Low percent IBW, especially in wrestlers and female athletes with menstrual or eating disorders, should be noted. Further evaluation and restriction from full participation may be warranted, depending upon the degree of malnutrition. (See 'Specific conditions' below and "Eating disorders: Overview of epidemiology, clinical features, and diagnosis".)

Body composition – Estimating body composition using anthropometric (eg, skinfold) measurements is indicated in wrestling because prediction equations for minimum wrestling weight have been established [18,19]. The American College of Sports Medicine recommends that wrestlers with low body fat (defined as <7 percent for boys <16 years old, <5 percent for boys >16 years, and <12 percent for girls) have medical clearance before participation [19,20]. (See "Measurement of body composition in children", section on 'Anthropometrics'.)

In most other circumstances, we typically monitor percent IBW along with heart rate, blood pressure, and body temperature to assess for evidence of a hypometabolic state as may be seen in patients with restricting eating disorders. (See "Eating disorders: Overview of epidemiology, clinical features, and diagnosis" and 'Specific conditions' below.)

Eyes – Athletes with best corrected visual acuity less than 20/40 in one or both eyes should be referred for further evaluation but are not excluded from participation. They should wear protective eyewear during sports participation since injury to the better eye could leave them with significant disability. Among 148 eye injuries reported in the 1995-1997 National Athletic Trainers' Association High School Injury Surveillance Study, 28 percent occurred while playing basketball, 20 percent during wrestling, 15 percent in baseball/softball, 15 percent in football, and 14 percent in soccer [21]. (See "Vision screening and assessment in infants and children", section on 'Referral indications'.)

Skin – Athletes who have skin infections that are contagious (eg, varicella, impetigo, tinea corporis, scabies, molluscum contagiosum, and herpes simplex virus) require disqualification from sports that involve close physical contact or shared equipment such as gymnastics mats. Participation can resume when the athlete's lesions can be adequately covered or when they are no longer infectious. The Centers for Disease Control and Prevention provide guidance about preventing methicillin-resistant Staphylococcus aureus infections in athletic facilities.

Lymphadenopathy – Lymphadenopathy alone is not a criterion for disqualification from sports but should prompt further evaluation because it may be the manifestation of an infectious or malignant process that might preclude sports participation. (See "Cervical lymphadenitis in children: Diagnostic approach and initial management" and "Peripheral lymphadenopathy in children: Evaluation and diagnostic approach", section on 'Initial evaluation'.)

Respiratory system – Wheezing that is noted on auscultation of the lungs, especially after exercise, in an otherwise asymptomatic athlete is suggestive of asthma or exercise-induced bronchoconstriction. The athlete also may have a history of exercise-related cough or chest tightness. (See "Exercise-induced bronchoconstriction".)

Production of chest pain by applying pressure over the sternum while the athlete is in the supine position is characteristic of costochondritis, a common condition in adolescents that need not exclude them from participation but should be distinguished from cardiovascular causes of chest pain. (See "Nontraumatic chest pain in children and adolescents: Approach and initial management".)

Abdomen – Organomegaly is a disqualifying condition for contact sports (table 6) [22].

Genitourinary – Boys with a single testicle (eg, undescended testicle, orchiectomy) can participate in contact sports if they wear a protective cup. In a study from the National Athletic Trainers' Association High School Injury Surveillance registry, which included data on nearly 3 million male athlete exposures (one athlete participating in one game or practice), there were only 17 testicular injuries over the two-year study period [21]. Of these, 12 occurred while playing football, 3 soccer, and 1 wrestling. Further urologic evaluation is indicated to determine the etiology and management of the undescended testis. (See "Undescended testes (cryptorchidism) in children: Clinical features and evaluation", section on 'Diagnostic approach'.)

Sports participation in children with a single kidney is discussed below. (See 'Other conditions' below.)

Maturation – Assessing biologic maturity (eg, based on Tanner stage or assessment of the athlete's percent attainment of predicted adult stature) can be useful in helping athletes to choose a sport in which they are likely to succeed. Athletes whose small size or maturational immaturity put them at a disadvantage in sports where size and strength are critical to performance can be encouraged to participate in other sports until their maturation ensues. Grouping adolescents based on similar biologic maturity has been done in soccer leagues in the United Kingdom and may reduce mismatches in size and strength compared with groupings based on chronologic age alone [23]. This holds potential advantages for both the early-maturing and late-maturing athletes.

LABORATORY TESTING — Routine laboratory testing is not recommended as part of the preparticipation physical evaluation (PPE) in the absence of symptoms [3]. State regulations that require blood and urine testing as part of the PPE are antiquated. Most of the positive screening tests are false positives because the conditions being tested for have a low prevalence in the young, athletic population.

Measurement of hemoglobin is not recommended for athletes who receive regular health maintenance care and have no symptoms of anemia. Some experts advocate screening for iron deficiency in menstruating female athletes for iron deficiency, especially if they run long-distance events. Screening for iron deficiency is also appropriate if there is evidence of malnutrition. Screening for sickle cell trait is discussed separately. (See "Iron requirements and iron deficiency in adolescents", section on 'Whom to screen' and "Sickle cell trait", section on 'Adolescents and adults'.)

STRENGTH EVALUATION — Isokinetic or isotonic equipment to assess for muscle weakness, especially quadriceps and hamstring weakness or asymmetry, is used in some settings. For most athletes, we suggest using the history and physical examination to screen for residua of previous injuries that would prevent sports participation rather than performing a formal strength evaluation. However, this testing may be reasonable if the equipment is available to the athletes at no extra cost and if it is used to evaluate the recovery of athletes with previous injuries.

The utility of screening all athletes with strength-testing equipment compared with the history and physical examination has not been established. Athletes with previous injuries and with identified asymmetry in strength and flexibility on specific directed testing of the lower extremities may have an increased risk of injury to either extremity during the season [24]. However, the etiology of that increased risk, in terms of physiologic factors, has not been established [9]. The rate of injury can be reduced with rehabilitation of previous deficits.

NONINVASIVE CARDIOVASCULAR TESTING — Noninvasive cardiovascular testing of athletes before participation is controversial [25-32]. Screening electrocardiograms (ECGs), echocardiograms, or graded exercise testing are not routinely necessary in the context of the preparticipation physical evaluation (PPE) unless there is a clinical concern for cardiovascular disease. This is consistent with the recommendations of the American Heart Association and the American College of Cardiology [4,15]. Screening to prevent sudden cardiac death in athletes is discussed in greater detail separately. (See "Screening to prevent sudden cardiac death in competitive athletes" and "Sudden cardiac arrest (SCA) and sudden cardiac death (SCD) in children", section on 'Primary prevention of SCD'.)

If cardiovascular abnormalities are identified or suspected on the basis of the history and physical examination, the athlete should undergo further evaluation, which may include ECG, event capture monitor, echocardiogram, and/or a maximum stress test [15,31]. Referral to a pediatric cardiologist is generally warranted to help guide the diagnostic evaluation, and athletes should be excluded from participation in competitive sports pending the cardiac evaluation. (See "Suspected heart disease in infants and children: Criteria for referral".)

Eligibility for sports participation in athletes with confirmed cardiovascular abnormalities should be determined in concordance with the guidelines of American Heart Association and the American College of Cardiology [33]. These recommendations are reviewed in detail separately. (See "Physical activity and exercise in patients with congenital heart disease" and "Athletes: Overview of sudden cardiac death risk and sport participation" and "Athletes with arrhythmias: Treatment and returning to athletic participation".)

SPORTS PARTICIPATION

Overview — After the preparticipation physical evaluation (PPE) is performed, the athlete should be given full clearance for participation, clearance to participate with limitations, or exclusion from participation pending further evaluation. Most children and adolescents with chronic medical conditions can participate in a sport at some level after appropriate evaluation and/or treatment [22]. The clinician's recommendation to play after diagnosis of a medical or musculoskeletal problem should be made in the context of the age and maturity of the patient, the severity of the injury, the sport activity, the importance of the upcoming event to the athlete (eg, a state championship game versus a preseason scrimmage), and the sequelae if the athlete is injured further. The health of the athlete is the overriding priority.

Sports can be classified according to the static and dynamic cardiovascular load (figure 1) or by the level of contact with other athletes (table 6). These classifications help the clinician in advising athletes regarding appropriate sports in which to participate.

Restrictions to participation — Sports participation recommendations for specific medical conditions are available through the American Academy of Pediatrics (AAP) website [22]. Some conditions restrict participation in contact sports or may have qualified restrictions [4,22]. For many conditions, the decision is made on a case-by-case basis as there are not sufficient data to determine the risk of injury for every condition.

Restrictions and limitations to participation should be discussed in detail with the athlete, the athlete's parents/caregivers, and the coach to minimize the likelihood of misinterpretation. The risks of continued participation must be discussed in the context of the medical problem and the athlete's chosen sport. The plan for further evaluation and treatment also should be discussed [3].

Specific conditions — Sports participation considerations in selected medical and musculoskeletal conditions are discussed here. Recommendations for other specific conditions are available through the AAP website [22].

Infectious illnesses

Febrile illness — Children and adolescents with fever should be restricted from participation because fever may accompany myocarditis or other infections that can make exercise dangerous. In addition, fever increases the risk of heat illness [22]. (See "Heat stroke in children" and "Heat illness (other than heat stroke) in children".)

COVID-19 — The AAP has issued guidance on returning to sports and physical activity after COVID-19 in pediatric patients [34]. Key points are summarized here. Additional details are provided separately. (See "COVID-19: Return to sport or strenuous activity following infection".)

As part of the PPE, clinicians should inquire about any known history of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and vaccination/booster status (the AAP's PPE history and physical examination forms have been revised to include this information).

The AAP encourages COVID-19 vaccination, as discussed separately. (See "COVID-19: Vaccines".)

Routine testing for COVID-19 before participating in sports is not necessary unless the athlete is symptomatic or has been exposed to someone with SARS-CoV-2.

Any child or youth with SARS-CoV-2 infection, regardless of symptoms, should initially isolate at home, as recommended by the Centers for Disease Control and Prevention. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Isolation at home'.)

Patients with more than mild symptoms should be cleared by their clinician before gradually returning to exercise and sports.

Patients with severe COVID-19-related illness (ie, multisystem inflammatory syndrome [MIS-C] or severe acute COVID-19 requiring intensive care) and those who have evidence of cardiac impairment should be restricted from exercise for three to six months and then cleared to return to sports by a cardiologist. (See "COVID-19: Multisystem inflammatory syndrome in children (MIS-C) management and outcome", section on 'Follow-up'.)

Children and youth with a history of SARS-CoV-2 infection who have already advanced back to physical activity/sports on their own and do not have any abnormal signs/symptoms do not require further evaluation.

For children and youth who are returning to play after recovering from COVID-19, the return-to-play protocol should be tailored to the individual. For athletes who had more than mild COVID-19 symptoms, return to play should be graduated over several days or longer [34]. Patients, parents/caregivers, and coaches should be educated to monitor for concerning symptoms (eg, chest pain, shortness of breath, new-onset palpitations, syncope) when returning to exercise. If these symptoms occur, the athlete should immediately stop exercising and should see his or her pediatrician.

COVID-19 in children is reviewed in greater detail separately. (See "COVID-19: Clinical manifestations and diagnosis in children" and "COVID-19: Management in children".)

Cardiovascular conditions — Life-threatening cardiovascular diseases in young athletes are rare, and the PPE has poor sensitivity for detecting most of these conditions. When cardiovascular disease is diagnosed or suspected, restrictions or limitations on sports participation and exercise may be warranted because of the potential risk of sudden cardiac death. (See "Athletes: Overview of sudden cardiac death risk and sport participation".)

Hypertension — Recommendations on the level of sports participation are typically made based on the degree of blood pressure elevation. Hypertension may be associated with an increased risk for sudden death and complex ventricular arrhythmias. However, hypertension has not been implicated as cause of sudden cardiac death in young, competitive athletes. Professional society guidelines recommend that athletes with uncontrolled stage 2 hypertension (table 2 and table 3 and table 7) or end-organ sequelae (eg, left ventricular hypertrophy) be excluded from sports participation and highly static activities (figure 1) until hypertension is better controlled [35]. These recommendations are based largely on expert opinion. In addition, the treating clinician and the athlete should be aware that the use of diuretics and beta blockers has been prohibited by some athletic governing bodies; the treatment plan may need to be modified to permit participation. Information regarding banned substances can be obtained through the  and National Collegiate Athletic Association (United States) websites. The athlete should be counseled to avoid medications and supplements that may contribute to elevated blood pressure (eg, exogenous androgens, growth hormone, supplements that contain ephedrine or other stimulants). Sports participation in children with hypertension is discussed in greater detail separately. (See "Nonemergent treatment of hypertension in children and adolescents", section on 'Sports participation' and "Hypertension in athletes".)

Asymptomatic bradycardia — Most well-trained endurance athletes have resting sinus bradycardia; elite athletes may have a resting heart rate <40 beats per minute. Adolescent athletes with asymptomatic bradycardia in this range can participate without further evaluation unless there is a suspicion of an eating disorder or inadequate caloric intake. (See 'Cardiovascular examination' above and "Bradycardia in children", section on 'Athletes'.)

Other cardiovascular conditions — Sports participation recommendations for specific cardiovascular diseases that may be associated with increased risk of sudden cardiac death are discussed in greater detail separately:

Congenital heart disease (see "Physical activity and exercise in patients with congenital heart disease", section on 'Patients who wish to engage in competitive sports')

Coronary artery abnormalities due to Kawasaki disease (see "Cardiovascular sequelae of Kawasaki disease: Management and prognosis", section on 'Participation in competitive sports')

Hypertrophic cardiomyopathy (see "Hypertrophic cardiomyopathy: Management of ventricular arrhythmias and sudden cardiac death risk")

Commotio cordis (see "Commotio cordis", section on 'Return to athletics')

Myocarditis (see "Treatment and prognosis of myocarditis in children", section on 'Activity')

Marfan syndrome (see "Management of Marfan syndrome and related disorders", section on 'Restriction of strenuous activity')

Mitral valve prolapse (see "Mitral valve prolapse: Overview of complications and their management" and "Chronic primary mitral regurgitation: General management", section on 'Exercise')

Arrhythmogenic right ventricular cardiomyopathy (see "Arrhythmogenic right ventricular cardiomyopathy: Treatment and prognosis", section on 'Activity restriction')

Inherited arrhythmia syndromes (eg, congenital long QT syndrome, Brugada syndrome) (see "Athletes: Overview of sudden cardiac death risk and sport participation", section on 'Inherited arrhythmia syndromes')

Prior injuries

Musculoskeletal injuries — Musculoskeletal injuries are common among athletes, and identifying and fully rehabilitating old injuries is vital to prevent reinjury and optimize subsequent athletic performance [36,37]. Previous musculoskeletal injuries can have residua, such as decreased flexibility and strength related to inadequate rehabilitation, the demands of the sport, or both [24]. Players with injuries to an extremity are more likely to injure that extremity during the season than an extremity that has not been injured [38,39]. Proper rehabilitation can lead to lower injury rates.

Consultation with a sports medicine specialist may be warranted to establish a definitive diagnosis and to determine the need for radiologic imaging. In addition, the sports medicine specialist assists in managing rehabilitation of sports-related injuries and determining the plan for returning to play.

An accurate diagnosis must be established before a recommendation to participate is made. The diagnosis of a "sprained knee" or shoulder "bursitis," for example, is not adequate. If the PPE alone is insufficient to establish a definitive diagnosis, the athlete can return for further evaluation but should not be cleared to participate until the diagnosis is made.

Once a diagnosis is made, a plan is made for rehabilitating strength, endurance, proprioception, and flexibility. In addition, the clinician should provide the athlete with a plan for returning to play. The athlete is at risk of reinjury and delayed recovery if they return to competition too soon. Training errors, such as too-rapid increases in pace, distance, repetitions, or weight/resistance, are the most common factor in overuse injuries.

Prior concussion — The plan for return to play after a concussion should be individualized, gradual, and progressive. Recommendations for return to sports participation following a concussion are discussed in detail separately. (See "Concussion in children and adolescents: Management", section on 'Return to play (RTP)' and "Concussion in children and adolescents: Management", section on 'Retirement from contact sports'.)

Neck injuries — The plan for return to play in children with neck injury or neck pain should be individualized. The safety of the athlete is the most important consideration, and the decision-making process should involve consultation with members of the specialty teams participating in the athlete's care (eg, neurosurgery, orthopedics, sports medicine, physical therapy). Recommendations for return to sports participation in children with neck injuries are discussed in detail separately. (See "Evaluation of the child or adolescent athlete with neck pain or injury", section on 'Return to play'.)

Osgood-Schlatter disease — Osgood-Schlatter disease is an overuse injury caused by repetitive strain and chronic traction and resultant irritation of the secondary ossification center of the tibial tubercle. It occurs among young athletes in sports that involve running, cutting, and jumping and those who have recently undergone a rapid growth spurt. Therapy consists of conservative measures (a protective pad around the tibial tuberosity, analgesic medications) and physical therapy. Continued sports participation is encouraged in most children with Osgood-Schlatter disease, provided that the pain can be tolerated. This is one of the few pediatric conditions where it is acceptable to exercise with pain. (See "Osgood-Schlatter disease (tibial tuberosity avulsion)".)

Asthma and exercise-induced bronchoconstriction (EIB) — EIB occurs in athletes at a prevalence similar to that of the general population (9 to 15 percent), yet it may be unrecognized in the young athlete [13,14]. Pulmonary disease accounts for 2 percent of sudden death in sports [40]. EIB can be treated with pre-exercise medication in most patients and is not a reason to avoid exercise. (See "Exercise-induced bronchoconstriction".)

Eating disorders and the female athlete triad — Athletes in the lean sports (ie, dance, cheer, gymnastics, and distance running) tend to be at higher risk of developing chronic energy deficit, which can have considerable consequences. In female athletes, the combination of low caloric intake with or without disordered eating, menstrual dysfunction, and low bone density is called the "female athlete triad" [16,17]. (See "Functional hypothalamic amenorrhea: Pathophysiology and clinical manifestations" and "Eating disorders: Overview of epidemiology, clinical features, and diagnosis".)

Persistent exercise in the malnourished amenorrheic female athlete can cause short- and long-term consequences. Recommendations for exercise restriction made as part of the PPE are aimed at restoring the positive energy balance by reducing energy expenditure and increasing energy intake. In doing so, hypothalamic-pituitary-ovarian function can be restored and bone health enhanced.

For female athletes who have been losing weight and have developed amenorrhea or oligomenorrhea related to the weight loss, we typically advise, after an appropriate medical evaluation, reducing training by 25 percent and increasing daily energy intake by 200 to 600 calories. Follow-up should occur in one to two weeks, and, if weight gain has been achieved, then the exercise restriction can be reduced accompanied by an equivalent increase in calorie intake so that weight gain continues. If a trend continues over several visits, the clinician can reduce the frequency of follow-up visits appropriately. This is best accomplished with the consultation of a sports dietitian.

Other aspects of the management of exercise-associated amenorrhea and eating disorders in adolescence are discussed separately. (See "Eating disorders: Overview of prevention and treatment" and "Functional hypothalamic amenorrhea: Pathophysiology and clinical manifestations".)

Obesity — Obesity alone is not a reason for exclusion from sports. Obese children should receive counseling regarding the risk of heat illness (as well as other obesity-related risks) and the benefits of weight loss. If the athlete would like to lose weight, the clinician can develop a plan with the child and parents/caregivers that includes a gradually staggered exercise program as tolerated. The plan should emphasize healthy lifestyle habits, including proper nutrition and adequate sleep. However, some athletes (eg, football lineman) may not be interested in losing weight since obesity is advantageous to their sport or position and may be encouraged by coaches. (See "Prevention and management of childhood obesity in the primary care setting".)

Diabetes mellitus — Regular exercise is likely to be beneficial in most children and adolescents with type 1 or type 2 diabetes mellitus (DM). Children with type 1 DM may require modifications in the pre-exercise insulin dose and additional glucose monitoring. This is discussed separately. (See "Management of exercise for children and adolescents with type 1 diabetes mellitus".)

Other conditions — Recommendations for other specific conditions are available through the AAP website [22].

Idiopathic scoliosis – Adolescent idiopathic scoliosis that causes no functional limitations is not a reason for limitation from sports. (See "Adolescent idiopathic scoliosis: Clinical features, evaluation, and diagnosis".)

Medical risk factors for heat illness – Athletes at risk of heat illness (table 8) should follow guidelines for appropriate clothing, fluid intake, heat acclimatization, adjustment of activity level for heat and humidity levels, and timing of practices. (See "Heat stroke in children" and "Heat illness (other than heat stroke) in children".)

Sickle cell trait – Athletes with sickle cell trait are at increased risk for sudden death during strenuous physical activity compared with the general population. Anticipatory interventions to prevent dehydration and hyperthermia during intensive exercise or physical training should be enforced (as is the case for all athletes), particularly at the onset of conditioning training. Exercise and sickle cell trait is discussed in further detail separately. (See "Sickle cell trait", section on 'Intensive exercise/physical training'.)

Solitary kidney – Having a single kidney has historically been considered a disqualifying condition for contact sports. However, based on the available data, it is reasonable to allow individuals with a single kidney to participate in contact sports after discussion of the potential risks. The child's nephrologist should ideally be involved in decision-making. (See "Overview of congenital anomalies of the kidney and urinary tract (CAKUT)", section on 'Follow-up care'.)

The risk of kidney injury in children and adolescents participating in sports is very low [21,41,42]. In a study from the National Athletic Trainers' Association High School Injury Surveillance registry, which included data on nearly 75,000 individual high school athlete-seasons, there were only 18 kidney injuries over the two-year study period [21]. Of these, 12 occurred while playing football, 3 soccer, 2 basketball, and 1 baseball. None of the injuries required surgery. Similarly, data from trauma registries suggest that only a small minority of traumatic kidney injuries are sports-related [41,42]. In a registry study of 813 children and adolescents with traumatic kidney injury, 10 percent (n = 85) were sports-related and an additional 11 percent (n = 92) were sustained from bicycle injuries. Of the sports-related kidney injuries, 12 percent (n = 10) were severe (grade IV or V) and 5 percent (n = 4) required nephrectomy. None of the patients who required nephrectomy sustained their injuries from contact sports (two cases were from sledding, one from skiing, and one from roller blading).

Legal issues — Athletes have had legal recourse to seek the right to participate in a sport against medical advice [43]. However, the courts have upheld clinicians' decisions to exclude athletes based upon recommendations in published expert guidelines (Knapp versus Northwestern, 1996) [43]. In these circumstances, the clinician should document in the medical record the recommendation to avoid participation and that this recommendation was discussed with the athlete and the athlete's parents/caregivers. Some clinicians suggest requesting that the parents/caregivers and athlete sign a document describing these discussions [3,43].

SUMMARY AND RECOMMENDATIONS

Goals – The goals of the preparticipation physical evaluation (PPE) are to (see 'Goals of the preparticipation physical evaluation' above):

Maximize safe participation by children and adolescents

Identify medical problems with risks of life-threatening complications during participation (eg, hypertrophic cardiomyopathy)

Identify conditions that require a treatment plan before or during participation (eg, hypertension)

Identify and rehabilitate old musculoskeletal injuries

Identify and treat conditions that interfere with performance (eg, exercise-induced bronchospasm)

Remove unnecessary restrictions on participation

Timing – The PPE ideally should take place four to six weeks before the season starts and before each new level of participation (eg, middle school, junior high, high school, and college), with yearly updates of the history and targeted physical examinations. The PPE should be performed by an examiner with appropriate training and experience in evaluating the musculoskeletal system in children. (See 'Practical considerations' above.)

Components of the PPE – The PPE includes a targeted medical and family history and a targeted physical examination, with particular emphasis on the musculoskeletal and cardiovascular systems. Important aspects of the injury history include past injuries, loss of time from participation and current sequelae of those injuries, and previous exclusion from sports for any reason. The review of symptoms assesses for musculoskeletal (eg, back pain, neck pain, or other joint pain or stiffness), cardiovascular (eg, syncope, near syncope, dizziness, chest pain, dyspnea, and/or palpitations during exercise), neurologic (eg, concussion-like symptoms), and respiratory complaints. (See 'Components of the evaluation' above.)

Musculoskeletal examination – All athletes should undergo a screening musculoskeletal examination during the PPE. If there is a history of injury or abnormalities reported on screening questionnaire, the joint or region in question should be examined in detail. (See 'Musculoskeletal examination' above.)

Cardiovascular examination – The cardiovascular physical examination should include, but not be limited to, measurement of blood pressure and resting heart rate, precordial auscultation in the supine and standing positions, simultaneous assessment of the radial and femoral pulses, and recognition of the physical stigmata of conditions such as Marfan syndrome that are associated with cardiovascular complications. (See 'Cardiovascular examination' above.)

No role for routine laboratory or cardiac tests – Routine laboratory or cardiac tests (eg, electrocardiogram) are not necessary as part of the PPE unless specific clinical concerns arise from the history and/or examination. (See 'Laboratory testing' above and 'Noninvasive cardiovascular testing' above and "Screening to prevent sudden cardiac death in competitive athletes".)

Sports participation – After the PPE is performed, the athlete should be given full clearance for participation, clearance to participate with limitations, or exclusion from participation pending further evaluation. Most children and adolescents with chronic medical conditions can participate in a sport at some level after appropriate evaluation and/or treatment. Sports participation recommendations for specific medical conditions are available through the American Academy of Pediatrics (AAP) website. (See 'Sports participation' above.)

  1. Youth sports facts; Sports participation rates. Available at: https://www.aspenprojectplay.org/youth-sports/facts/participation-rates (Accessed on April 11, 2023).
  2. Black LI, Terlizzi EP, Vahratian A. Organized Sports Participation Among Children Aged 6-17 Years: United States, 2020. NCHS Data Brief 2022; :1.
  3. American Academy of Pediatrics, American Academy of Family Physicians, Am College of Sports Med. Preparticipation Physical Evaluation, 5th Ed, American Academy of Pediatrics, Elk Grove Village, IL 2019.
  4. Maron BJ, Levine BD, Washington RL, et al. Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 2: Preparticipation Screening for Cardiovascular Disease in Competitive Athletes: A Scientific Statement From the American Heart Association and American College of Cardiology. Circulation 2015; 132:e267.
  5. Roberts WO, Löllgen H, Matheson GO, et al. Advancing the preparticipation physical evaluation (PPE): an ACSM and FIMS joint consensus statement. Curr Sports Med Rep 2014; 13:395.
  6. Roberts WO, Löllgen H, Matheson GO, et al. Advancing the preparticipation physical evaluation: an ACSM and FIMS joint consensus statement. Clin J Sport Med 2014; 24:442.
  7. Demorest RA, Bernhardt DT, Best TM, Landry GL. Pediatric residency education: is sports medicine getting its fair share? Pediatrics 2005; 115:28.
  8. Carek PJ, Mainous AG 3rd. A thorough yet efficient exam identifies most problems in school athletes. J Fam Pract 2003; 52:127.
  9. Garrick JG. Preparticipation orthopedic screening evaluation. Clin J Sport Med 2004; 14:123.
  10. Maron BJ, Thompson PD, Puffer JC, et al. Cardiovascular preparticipation screening of competitive athletes. A statement for health professionals from the Sudden Death Committee (clinical cardiology) and Congenital Cardiac Defects Committee (cardiovascular disease in the young), American Heart Association. Circulation 1996; 94:850.
  11. Maron BJ, Thompson PD, Ackerman MJ, et al. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation. Circulation 2007; 115:1643.
  12. Iverson GL, Silverberg ND, Mannix R, et al. Factors Associated With Concussion-like Symptom Reporting in High School Athletes. JAMA Pediatr 2015; 169:1132.
  13. Rupp NT, Guill MF, Brudno DS. Unrecognized exercise-induced bronchospasm in adolescent athletes. Am J Dis Child 1992; 146:941.
  14. Hallstrand TS, Curtis JR, Koepsell TD, et al. Effectiveness of screening examinations to detect unrecognized exercise-induced bronchoconstriction. J Pediatr 2002; 141:343.
  15. Maron BJ, Friedman RA, Kligfield P, et al. Assessment of the 12-lead ECG as a screening test for detection of cardiovascular disease in healthy general populations of young people (12-25 Years of Age): a scientific statement from the American Heart Association and the American College of Cardiology. Circulation 2014; 130:1303.
  16. De Souza MJ, Nattiv A, Joy E, et al. 2014 Female Athlete Triad Coalition consensus statement on treatment and return to play of the female athlete triad: 1st International Conference held in San Francisco, CA, May 2012, and 2nd International Conference held in Indianapolis, IN, May 2013. Clin J Sport Med 2014; 24:96.
  17. Hergenroeder AC, De Souza MJ, Anding RH. The Female Athlete Triad: Energy Deficiency, Physiologic Consequences, and Treatment. Adolesc Med State Art Rev 2015; 26:116.
  18. Oppliger RA, Harms RD, Herrmann DE, et al. The Wisconsin wrestling minimum weight project: a model for weight control among high school wrestlers. Med Sci Sports Exerc 1995; 27:1220.
  19. Oppliger RA, Case HS, Horswill CA, et al. American College of Sports Medicine position stand. Weight loss in wrestlers. Med Sci Sports Exerc 1996; 28:ix.
  20. Thorland WG, Tipton CM, Lohman TG, et al. Midwest wrestling study: prediction of minimal weight for high school wrestlers. Med Sci Sports Exerc 1991; 23:1102.
  21. Grinsell MM, Butz K, Gurka MJ, et al. Sport-related kidney injury among high school athletes. Pediatrics 2012; 130:e40.
  22. Rice SG, American Academy of Pediatrics Council on Sports Medicine and Fitness. Medical conditions affecting sports participation. Pediatrics 2008; 121:841.
  23. Rogol AD, Cumming SP, Malina RM. Biobanding: A New Paradigm for Youth Sports and Training. Pediatrics 2018; 142.
  24. Knapik JJ, Bauman CL, Jones BH, et al. Preseason strength and flexibility imbalances associated with athletic injuries in female collegiate athletes. Am J Sports Med 1991; 19:76.
  25. Chaitman BR. An electrocardiogram should not be included in routine preparticipation screening of young athletes. Circulation 2007; 116:2610.
  26. Myerburg RJ, Vetter VL. Electrocardiograms should be included in preparticipation screening of athletes. Circulation 2007; 116:2616.
  27. Corrado D, Thiene G. Protagonist: routine screening of all athletes prior to participation in competitive sports should be mandatory to prevent sudden cardiac death. Heart Rhythm 2007; 4:520.
  28. Viskin S. Antagonist: routine screening of all athletes prior to participation in competitive sports should be mandatory to prevent sudden cardiac death. Heart Rhythm 2007; 4:525.
  29. Sharma S, Estes NA 3rd, Vetter VL, Corrado D. Clinical decisions. Cardiac screening before participation in sports. N Engl J Med 2013; 369:2049.
  30. Maron BJ, Winkel BG, Tfelt-Hansen J. Perspectives on cardiovascular screening. JAMA 2015; 313:31.
  31. Niebauer J, Corrado D, Pelliccia A. Cardiovascular screening for young athletes. JAMA 2015; 313:1674.
  32. Harmon KG, Drezner JA. Cardiovascular screening for young athletes. JAMA 2015; 313:1673.
  33. Maron BJ, Zipes DP, Kovacs RJ, American Heart Association Electrocardiography and Arrhythmias Committee of Council on Clinical Cardiology, Council on Cardiovascular Disease in Young, Council on Cardiovascular and Stroke Nursing, Council on Functional Genomics and Translational Biology, and American College of Cardiology. Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Preamble, Principles, and General Considerations: A Scientific Statement From the American Heart Association and American College of Cardiology. Circulation 2015; 132:e256.
  34. American Academy of Pediatrics, COVID-19 Interim Guidance: Return to Sports and Physical Activity, available at: https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid-19-interim-guidance-return-to-sports/ (Accessed on October 07, 2022).
  35. Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics 2017; 140.
  36. Centers for Disease Control and Prevention (CDC). Sports-related injuries among high school athletes--United States, 2005-06 school year. MMWR Morb Mortal Wkly Rep 2006; 55:1037.
  37. Brooks MA, Schiff MA, Rivara FP. Identifying previous sports injury among high school athletes. Clin Pediatr (Phila) 2009; 48:548.
  38. Jones BH, Cowan DN, Tomlinson JP, et al. Epidemiology of injuries associated with physical training among young men in the army. Med Sci Sports Exerc 1993; 25:197.
  39. Schmidt-Olsen S, Jørgensen U, Kaalund S, Sørensen J. Injuries among young soccer players. Am J Sports Med 1991; 19:273.
  40. Maron BJ, Doerer JJ, Haas TS, et al. Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980-2006. Circulation 2009; 119:1085.
  41. Johnson B, Christensen C, Dirusso S, et al. A need for reevaluation of sports participation recommendations for children with a solitary kidney. J Urol 2005; 174:686.
  42. Grinsell MM, Showalter S, Gordon KA, Norwood VF. Single kidney and sports participation: perception versus reality. Pediatrics 2006; 118:1019.
  43. Mitten MJ, Zipes DP, Maron BJ, et al. Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 15: Legal Aspects of Medical Eligibility and Disqualification Recommendations: A Scientific Statement From the American Heart Association and American College of Cardiology. Circulation 2015; 132:e346.
Topic 6472 Version 51.0

References

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