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To Compete or not to Compete: The Athletic Physical
Abstract & Commentary
By John Shufeldt, MD, JD, MBA, FACEP, Chief Executive Officer, NextCare, Inc.; Attending Physician/Vice Chair, Department of Emergency Medicine, St. Joseph's Hospital and Medical Center, Mesa, AZ, is Editor for Urgent Care Alert.
Dr. Shufeldt reports no financial relationship to this field of study.
Synopsis: Thousands of young athletes receive sports physicals every year. This article discusses what findings should cause concern.
Source: Giese EA, et al. The athletic participation evaluation: Cardiovascular assessment. Am Fam Physician. 2007;75:1008-1014.
Cardiovascular abnormalities that cause or contribute to a traumatic sudden death during athletic events are believed to occur in 1 out of every 200,000 young athletes.1 Often time, these cardiac abnormalities are found only upon autopsy. These finding include hypertrophic cardiomyopathy, congenital coronary anomalies, repolarization abnormalities, myocarditis, and Marfan syndrome. Since these abnormalities are difficult to detect, physicians should use standardized history and physical exam forms. When practicable, the athlete's parents should also be questioned about family history of sudden death.
The four components of the preparticipation cardiovascular exam are blood pressure measurement, palpation of femoral and radial pulse, dynamic cardiac auscultation, and evaluation for Marfan syndrome (eg, slit lamp exam, and echo to assess the aortic root). A normal radial pulse should have a smooth, rapid upstroke, a smooth summit and a gradual downstroke. Radial and femoral pulses should be palpated simultaneously to screen for coarctation of the aorta. If the femoral pulse is delayed, further evaluation is needed to rule out coarctation.
The cardiac assessment should be performed in a quiet setting and should include inspection, palpation, and auscultation. Precordial palpation is used to detect thrills or abnormal apical impulse locations. Physicians should auscultate for a split S2. The widening of the S2 during inspiration is normal and a reassuring sign. A fixed S2 during inspiration or narrowing S2 can be a sign of atrial septal defect, severe aortic stenosis, hypertrophic cardiomyopathy or left bundle branch block. Blood pressure elevation above the 95th percentile should be rechecked after the patient sits quietly for a period of time. If it is still elevated, a recheck should be performed in one to two weeks and then a prompt referral if the BP remains elevated.
There are a number of specific signs and symptoms which should raise the red flag. These include exercise related syncope or presyncope, palpations (a gradual onset and relief signifies sinus tachycardia, a rapid onset or abatement can signify ventricular tachycardia). Dyspnea on exertion may simply be a sign of poor conditioning; however, it may also be a sign of pulmonary hypertension, anemia, or exercise induced reactive airway disease. A family history of sudden cardiac death particularly at a young age (less than 50 years old) may signify a congenital abnormality.
Liability exists for providers who stray outside the recommended guidelines when they allow an athlete to engage in sporting events despite history or physical exam findings which may indicate pathology.
Urgent care providers are often called upon to perform sports physicals. It is imperative that we do not allow ourselves to be lulled into complacency while performing these exams. This article is gives a great overview of what to look for and what tests and exam criteria you should use to discover the high risk conditions.
The challenge is that finding a life threatening condition during one of these physicals is like finding the proverbial needle in a high stack. However, if one is overlooked, the liability and more importantly, the risk to the patient is very significant.