Sports physical (pediatrics): Clinical sciences

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. 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. 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.