Sports physical (pediatrics): Clinical sciences

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Introduction0:00–0:27

The goal of a pre-participation sports physical examination is to identify any underlying condition that may increase an athlete’s risk of injury, illness, or death.
The sports physical can often be performed during a well-child visit, which provides the opportunity to offer immunizations, preventative care, and anticipatory guidance.
When a pediatric patient presents for a sports physical, start with a comprehensive history and physical exam. First, review the medical history, and ask about any previous injuries or concussions.

Comprehensive H&P0:27–4:44

Then, screen for cardiovascular conditions by asking your patient if they had chest pain, syncope, difficulty breathing, or palpitations.
Additionally, find out if there is a family history of cardiomyopathy; arrhythmias; or early, sudden, or unexplained cardiac death.
If your patient has a chronic health condition, discuss their current management plan, and determine whether the condition is well-controlled.
Ask about symptoms that suggest an underlying mental health condition, such as anxiety, depression, or disordered eating.
Next, ask if they use any supplements or recreational substances such as tobacco, alcohol, drugs, or performance-enhancing substances, like anabolic steroids.
Finally, if your patient is biologically female, obtain a menstrual history, including their age of menarche, and their cycle duration and frequency.Next, measure your patient’s height, weight, and BMI; and take their blood pressure.
Additionally, perform vision and hearing screening, if possible.Then, perform a physical exam, starting with an assessment of your patient’s general appearance.
Be sure to look for phenotypic features suggesting Marfan syndrome, such as arachnodactyly, tall stature, or pectus excavatum, since patients with this condition are at risk of aortic dissection and sudden death.Also, perform a head-to-toe musculoskeletal exam to evaluate the range of motion, stability, and strength of each major joint and muscle group.
First, assess postural alignment and symmetry; as well as extension, forward flexion, rotation, and lateral bending of the neck.
Then, evaluate flexion and extension of the back, and palpate the full length of the spine. Next, examine the upper extremities by evaluating strength and range of motion in the shoulder, elbow, hands, and fingers.
Then, move on to the hips and lower extremities. Have your patient squat as low as they can and perform a “duck walk” by taking 4 steps forward.
The “duck walk” is used to evaluate hip, knee, and ankle range of motion, as well as lower extremity strength and balance.
Finally, have your patient balance on their tip toes and heels to evaluate calf strength and symmetry as well as their overall balance.Let’s move on to the cardiovascular exam.
Perform cardiac auscultation with your patient in both a supine and standing position and during a Valsalva maneuver. A murmur that increases in intensity during the Valsalva or after standing raises suspicion for hypertrophic cardiomyopathy with dynamic left ventricular outflow obstruction, which is the leading cause of sudden death in young athletes.
Also, palpate the brachial and femoral artery pulses, and compare their strength and timing. A strong brachial pulse in association with a delayed or comparatively weaker femoral pulse is called a brachial-femoral delay.
This finding is highly specific for aortic coarctation and requires further evaluation.Now, if your patient is biologically male, you may decide to perform a chaperoned genitourinary exam, to confirm the presence of bilaterally descended testicles.
Keep in mind that biologically female adolescents do not require a genitourinary exam during a sports preparticipation physical.Here’s a clinical pearl!
If your patient is missing one paired organ, such as a testicle, ovary, or eye; or if they have a solitary kidney; they may require additional evaluation and should use protective equipment once they are cleared to play sports.
Once you have completed the history and physical exam, review your findings to assess for musculoskeletal concerns. So, if you find a recent musculoskeletal injury; joint pain, effusion, or symptomatic instability; limited range of motion; or muscle weakness, your patient is unsafe for sports participation at this time and will require further evaluation.If you don’t identify any musculoskeletal concerns, continue with an assessment for neurological concerns.

MSK concerns4:44–5:11

Neurological concerns5:11–6:20

Ask your patient whether they have had a recent concussion, and if they have; ask about persistent symptoms, like headache, cognitive difficulty, dizziness, and sensitivity to light or noise.
Athletes with a recent concussion should abstain from sports until they have been asymptomatic for at least one week. Additionally, “burners” and “stingers” are common nerve injuries caused by traction or compression of the brachial plexus or cervical nerve roots, usually after trauma to the neck or shoulder.
This injury presents with a recurrent burning or electric shock-like sensation in one or both arms. Athletes with burners or stingers should be free of pain and demonstrate full strength and range of motion before participating in sports.
If you identify any neurologic concerns, your patient is unsafe for sports participation at this time and requires further evaluation.If you don’t identify any neurological concerns, your next step is to assess for cardiovascular concerns.

Cardiovascular concerns6:20–7:23

Some worrisome symptoms include chest pain, syncope, difficulty breathing, or palpitations that occur during rest or exertion.
Other possible concerns include a family history of sudden cardiac death in a relative under 50 years old, or any family history of cardiomyopathy or arrhythmias, which could indicate an inherited condition such as long QT syndrome.During the exam, look out for hypertension or a loud or harsh murmur.
Be especially alert for a murmur that intensifies during a Valsalva maneuver, which suggests hypertrophic cardiomyopathy; or brachial-femoral delay, which suggests aortic coarctation.
If you identify any of these concerns, the patient is unsafe for sports participation at this time and requires further evaluation.If you don’t identify any cardiovascular concerns, your next step is to assess for chronic health conditions.

Chronic health concerns7:23–8:56

If your patient has a condition such as asthma, a severe allergy, diabetes, sickle cell trait or disease, a physical or mental disability, or a seizure disorder; work with them and their caregiver to identify potential safety concerns, and create a safety plan.
Athletes should have immediate access to any rescue medications during all sport activities. For example, those with asthma should have an albuterol inhaler.
Those at risk of anaphylaxis should have an epinephrine injector; and those with diabetes require access to glucose and glucagon in the event of hypoglycemia.
Because individuals with sickle cell trait or disease are at risk of exertional rhabdomyolysis, they should take frequent rest and water breaks to avoid overexertion and dehydration.
Additionally, children with physical or mental disabilities are encouraged to play sports, with the use of appropriate accommodations and safety equipment.
Finally, individuals with a known seizure disorder may participate in most supervised sports as long as their seizures are well-controlled, but those with poorly controlled seizures should avoid contact and collision sports.
If you identify any of these concerns, your patient is conditionally safe for sports participation after the implementation of an individualized safety plan.On the other hand, if the patient has no chronic health conditions, your next step is to assess for psychosocial concerns, like mental illness, supplement or substance use, and disordered eating.

Psychosocial concerns8:56–11:05

If your patient reports symptoms suggesting a mental health condition such as anxiety or depression, initiate treatment as needed, and connect them to therapeutic resources.
Adolescents who use supplements or substances, such as alcohol, tobacco, recreational drugs, or performance-enhancing substances, should receive counseling and education about the risks of substance use.
Although mental health issues and substance use do not usually preclude sports participation; disordered eating and significant weight loss require close medical supervision.
You should suspect an eating disorder if your patient describes a disordered eating pattern, if they are losing weight, or if they have a low BMI.
Most athletes with disordered eating can be cleared for sports participation with close monitoring. Still, those with severely disordered eating or excessive weight loss should abstain from sports to focus on recovery.
Generally speaking, patients with psychosocial concerns are conditionally safe for sports participation, with therapeutic support.Here’s another clinical pearl!
The female athlete triad is a phenomenon characterized by insufficient caloric intake, with or without disordered eating; amenorrhea, and decreased bone mineral density.
Biologically female athletes who participate in sports that emphasize leanness, such as endurance running and gymnastics, are especially susceptible to the female athlete triad.
These athletes can usually be cleared for sports participation after a psychiatric and medical assessment. Finally, if you don’t identify any concerns after a thorough assessment, your patient is safe for full sports participation.Alright, as a quick recap… The goal of a sports physical is to identify safety concerns before athletic participation.

Safe for sports participation11:05–11:15

Review11:15–11:50

The presence of musculoskeletal; neurological; or cardiovascular concerns indicates that your patient is not safe for sports participation and requires further evaluation.
However, chronic health conditions and psychosocial concerns can be managed or accommodated to allow safe sports participation.
Finally, if you don’t identify any safety concerns, they are safe for full sports participation.