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The Preparticipation Sports Evaluation

2011; American Academy of Pediatrics; Volume: 32; Issue: 5 Linguagem: Inglês

10.1542/pir.32.5.e53

1529-7233

Andrew R. Peterson, David T. Bernhardt,

Injury Epidemiology and Prevention

After completing this article, readers should be able to: Sports participation among people of all ages has increased steadily over the past 4 decades. This trend generally has been considered to be a positive development, with conventional wisdom asserting that sports participation teaches leadership and cooperative skills that have a lifelong impact. In addition, as the obesity pandemic worsens, organized sports participation and unstructured play or physical exercise can be a source of needed physical activity for children and adolescents. The pediatrician often is asked to evaluate a child's or adolescent's suitability for sports participation. The purpose of this evaluation has remained constant since it was first described in 1978. (1)(2) The goals are to fulfill the institution's legal and liability requirements, provide some assurance to coaches that athletes will start the season at an acceptable level of health and fitness, provide an opportunity to discover treatable conditions, and aid in predicting and preventing future injuries. The evaluation should be practical and applicable to all sports. The specific objectives of the evaluation can vary, depending on viewpoint, which can create a situation in which parents, athletes, clinicians, and sponsoring institutions or organizations have discordant expectations. Parents may want to ensure the health and safety of their child. Clinicians may seek to provide preventive care and anticipatory guidance. Institutions and organizations may want to limit or transfer their liability for injuries or illnesses caused or worsened by sports participation. Finally, the athletes may just want to have their paperwork signed so they can go play with their friends. The clinician should coordinate and address the goals of parents, athletes, and organizations while promoting safe participation in physical activity.The utility of the sports preparticipation evaluation (PPE) has been questioned in recent years. Very few athletes are disqualified from sports on the basis of findings from the PPE. In the largest evaluation of the PPE, only 1.9% of 2,729 high school athletes were disqualified from sports participation and only 11.9% required any type of follow-up evaluation. (3) A recent systematic review of the literature identified 310 studies of the PPE and concluded that the evaluation likely does little to prevent morbidity and mortality in screened athletes and is ineffective for identifying athletes at risk for sudden cardiac death or orthopedic injuries and at detecting exercise-induced bronchospasm (EIB). (4) However, use of the PPE is endorsed by the American Academy of Pediatrics, American Academy of Family Physicians, and American College of Sports Medicine because it allows for establishment of a medical home, updating of immunizations, identification and management of chronic health conditions, and provision of anticipatory guidance related to sports and other lifestyle risk factors.The PPE is required before practice and play by most sporting organizations. The requirement is typically in place to shield the organization from liability and to ensure that the athlete can participate safely in sports. The evaluation is required by law in many states and some countries. Nearly all high-school and middle-school athletes are required to obtain signed documentation of a completed examination every 1 to 2 academic years. Athletes engaged in club- or federation-level sports are also often required to have documentation of an evaluation, but this practice varies regionally and by sport. Rarely, sports competitions not affiliated with institutions or federations (eg, open races or tournaments) require documentation of the athlete's suitability for competition. Generally, open or free play (such as on an open playground) does not require such documentation. However, the 2010 PPE Monograph emphasizes that clinicians should perform a PPE-type evaluation on all patients when promoting physical activity. (5) Most institutions and organizations that require an evaluation strictly prevent participation until proper documentation has been obtained. This practice seems to be due to a sense that protection from liability is not present until there is “proof” that the athlete is safe to participate. (6)(7) Although this concept has not been legally tested, a 1990 New York State Appellate Court decision (Murphy v. Blum) suggests that the issue of transfer of liability depends on the specifics of the relationship between the organization and the physician as well as between the physician and the athlete. (8)The athlete should be encouraged to schedule the PPE well in advance of the season, ideally at least 6 weeks before the start of practice. This timing allows sufficient time for full evaluation of issues that may arise during the initial visit. It also allows implementation of injury prevention programs or rehabilitation of injuries before the start of the season. The clinician should not be pressured into premature clearance of an athlete before appropriate evaluation is completed.The PPE can be completed in any of several formats, each of which has advantages and shortcomings. The most common and ideal format is the office-based PPE in which an athlete visits his or her primary care clinician in the office. The advantages of this strategy include improved continuity of care, access to medical records, time for anticipatory guidance, and ease of arranging follow-up diagnostic tests and treatment. The primary disadvantages are the time burden and cost of an office visit in addition to the possible limited availability of appointments before the start of sports seasons.To alleviate the time and cost burden of the PPE, the other strategy commonly employed is the station-based PPE. With this approach, the athlete cycles through a series of stations at which a single aspect of the evaluation is performed. Separate stations may address vital signs, visual acuity screening, medical history and physical examination, orthopedic history and physical examination, updating immunizations, and finally meeting with a clinician to review all of the accumulated data and make a decision regarding clearance. This approach is very efficient, can be inexpensive, and allows specialty care at each of the stations, limiting the need for a specialist. Entire teams or schools can be evaluated in a single session, reducing the administrative burden of scheduling each athlete privately.However, there are significant disadvantages to the station-based approach. Continuity of care is severely limited, including access to previous medical records. Coordination of care may be difficult for issues requiring follow-up. There is less privacy and time for anticipatory guidance, and the athlete may be less likely to discuss sensitive issues. Finally, athletes who previously have been disqualified from sports participation may attempt to take advantage of unfamiliar clinicians and use the station-based format as a second chance to get cleared.The history portion of the PPE is similar to the history in a typical health supervision visit for a child or adolescent of the same age. Although several efficient screening tools that have been designed specifically for the PPE are endorsed by multiple professional societies, they should not replace more extensive history collection when it is warranted. The history form from the 2010 PPE Monograph is shown in Figure 1.It is important to explore the past medical, surgical, family, social, and developmental histories, much as it would be done for a nonsports-related evaluation. It is also important to interview a parent or guardian, if available, because athlete and parent histories are often inconsistent. (9)(10)Some aspects of the history require additional attention. Although the following list is not comprehensive, it represents some of the most common challenges to the clinician during the PPE.The component of the PPE that receives the most attention from parents, coaches, administrators, the medical literature, and the popular press is the cardiovascular evaluation. Although a comprehensive discussion of the controversy surrounding preparticipation cardiovascular screening is beyond the scope of this article, Pediatrics in Review has published a summary of the topic, (11)(12) and clear guidelines from the American Heart Association (AHA) discuss the controversy surrounding the evaluation and the role of preparticipation electrocardiography and echocardiography. (13) The AHA-recommended components of the preparticipation cardiovascular evaluation are listed in the Table.Several red flags that may appear in the past medical and family history should prompt further investigation. Known congenital heart disease, cardiac channelopathies (such as long QT or Brugada syndrome), any history of myocarditis, and coronary anomalies such as those caused by Kawasaki disease should be evaluated by a cardiologist before sports participation. A personal history of syncope, near-syncope, chest pain, palpitations, or excessive shortness of breath or fatigue with exertion should prompt a more thorough evaluation, either by the primary clinician or a cardiologist. Postexertional syncope is a common occurrence that is frequently elicited in the PPE history. This benign condition should be differentiated from exercise-associated collapse, which occurs during exertion and is an ominous sign of hemodynamically significant cardiovascular disease or ventricular tachyarrhythmias. All patients who experience syncope should undergo electrocardiography, with further testing on a case-by-case basis.A family history of early sudden cardiac death, Marfan syndrome, cardiomyopathy, and arrhythmias (especially long QT syndrome) should prompt further cardiovascular evaluation. Particular attention should be paid to any family history of unexplained or poorly characterized deaths, such as from drowning, unexplained motor vehicle crashes, or seizures. These events may represent unrecognized sudden cardiac death.The musculoskeletal history is a remarkably sensitive method for identifying abnormalities and injuries. Gomez and associates (14) found the sensitivity of a basic musculoskeletal history to be 92%, which compares favorably with the estimated 75% sensitivity of a general medical history. Inquiring about current injuries and a history of injuries requiring evaluation, casting, bracing, surgery, or missed practice or play captures nearly all musculoskeletal abnormalities that require evaluation or treatment before sports participation. A sports medicine specialist may ask about specific orthopedic injuries that are unique or common to the athlete's sport, but this inquiry generally is not necessary for a primary care screening evaluation. A review of the athlete's list of current and past medications may provide clues to chronic or recurring medical conditions that may affect sports participation. In addition, the athlete's institution or governing sports federation may ban some medications and substances. A comprehensive review of banned substances is beyond the scope of this article. In general, the athlete is responsible for knowing what medications may be banned in his or her sport. The clinician may assist athletes by directing them to their governing body's website and banned substance list. Physicians who frequently care for college-, national-, and international-level athletes should be aware of the substances that are banned by the National Collegiate Athletic Association (15) and the World Anti-Doping Agency. (16) Comprehensive lists of banned substances can be found at: http://www.ncaa.org/wps/wcm/connect/public/ncaa/student-athlete+experience/ncaa+banned+drugs+list and http://www.wada-ama.org/en/World-Anti-Doping-Program/.Some medications can be taken if the athlete has a therapeutic use exemption (TUE) on file. In some cases, special testing may need to be obtained to meet the requirements of the TUE. TUEs should be filed well before the start of the season to avoid the possibility of miscommunication or a gap in treatment of chronic medical conditions. Often, a permitted medication can be substituted for a banned substance.Use of alcohol, tobacco, and other recreational drugs is common among teenagers, including athletes. It is useful to discuss these substances when discussing medications, vitamins, and supplements that the athlete may be taking.Athletes in certain sports are at additional risk for dermatologic conditions associated with their environment or contact with other athletes. Open wounds should be cleaned and covered for practice and play to reduce the risk of blood-borne pathogen transmission. Methicillin-resistant Staphylococcus aureus infections have received considerable attention because they can result in necrotizing fasciitis, sepsis, and even amputation. Skin infections such as impetigo, molluscum contagiosum, tinea, and herpes simplex infection are common in sports that involve close skin-to-skin contact, such as wrestling and rugby. Each of these conditions requires treatment to minimize the risk of transmission. Many sport federations have specific regulations for how skin infections should be treated and how long athletes should be asymptomatic or under treatment before returning to practice and competition. Some athletes and teams use prophylactic doses of antiviral medications, such as acyclovir, for prevention of herpes outbreaks during the season. This practice has not been systematically evaluated but anecdotally does seem effective for decreasing herpes gladiatorum transmission among wrestlers.Athletes who practice and compete in the sun should use a sun block lotion to minimize their risk of sun damage and skin cancer. Controversy surrounds the appropriate sun protection factor for outdoor athletes. In general, any over-the-counter sun block applied liberally and frequently provides sufficient protection. Athletes who have already had significant sun exposure require a careful examination of the sun-exposed skin to monitor for skin cancer and precancerous lesions.Although sports-related concussions are most common in contact and collision sports, all athletes should be asked about a personal history of concussion or other head injury. Often, directed questions about head injuries are required to elicit a history of concussion because many athletes do not consider an injury in which there was no loss of consciousness to be a concussion. Specifically, the clinician should ask about any type of head injury, feeling “dazed” or “foggy,” memory loss, headaches following a hit to the head, difficulty playing or practicing following a hit to the head, and any type of injury that resulted in a loss of consciousness. The clinician should be attuned to the fact that the presenting signs and symptoms of concussion can be subtle. If the athlete does provide a history of concussion, more detailed questioning is required to determine the presence or absence of frequent concussions, prolonged postconcussion symptoms, and concussions that occurred with seemingly trivial trauma. Athletes who have had rare, mild concussions that resolved spontaneously do not need additional evaluation. For athletes who have had frequent concussions, are more easily concussed, or have had prolonged postconcussive symptoms, careful discussion with the athlete and family is necessary to understand the risks of repeated concussions. A symptomatic athlete should never be allowed to return to play, and a graduated, stepwise approach should be used for returning to physical activity. (17)Obtaining baseline computer-based neurocognitive testing (NCT) before the start of the season is controversial. Although clinical assessment should be the mainstay of concussion evaluation, NCT increases the sensitivity for detecting residual concussion symptoms. (18) Specifically, if baseline NCT is available when a concussed athlete clinically appears ready to return to play, repeat NCT can provide an objective measurement of his or her recovery. However, NCT has poor specificity for concussion, and the utility of postinjury NCT in an athlete who does not have a baseline study is controversial.“Stingers,” also called “burners,” are injuries to the brachial plexus caused either by direct trauma or a traction injury. Symptoms are typically brief. Athletes who have had stingers with persistent symptoms of arm pain, paresthesia, or weakness may have more significant injuries to the brachial plexus or cervical nerve root injury. No athlete should be permitted to return to practice or play who has persistent symptoms.Cervical cord neurapraxia, also called transient quadriplegia, is a frightening condition characterized by temporary loss of motor control, with or without loss of sensation or paresthesia, caused by transient compression of the cervical spinal cord due to forced hyperextension, hyperflexion, or axial loading. The condition is more common in athletes who have cervical spinal stenosis. (19) Episodes are transient and typically last less than 15 minutes. It is very rare for symptoms to last longer than 48 hours. There is no increased risk of permanent spinal cord injury following a single episode, (19)(20) but athletes who have multiple episodes or persistent symptoms require additional evaluation. Those who are found to have instability, fractures, or degenerative changes in the cervical spine should not be allowed to return to contact or collision sports. Although athletes who have cervical spinal stenosis are at increased risk of cervical cord neurapraxia, it is unknown if they are at increased risk for permanent spinal cord injury. Whether athletes who have spinal stenosis should be allowed to play contact sports is controversial and should be evaluated on a case-by-case basis by a qualified physician.Heat illness kills more than 1,000 people in the United States every year. (21) Athletes who have had a history of heat illness are at risk for future heat illness, including heat stroke. Once identified, the athlete can take measures to assure proper hydration and acclimatization to minimize their risk. In addition, stimulants and antihistamines increase the risk of heat illness and should be avoided, if possible, during training and competition in warmer weather. Athletes who require corrective lenses for sports participation may need to work with an optometrist or ophthalmologist to ensure that they have appropriate lenses for sport. Some sports, such as wrestling, boxing, and rugby, do not allow eyewear, so athletes in need of corrective lenses must use contact lenses. Athletes whose best-corrected vision is worse than 20/40 in one eye (also referred to as “functionally one-eyed”) must wear American Society for Testing and Materials-approved protective eyewear. (22) Athletes who practice and compete in the sun or on the snow should wear ultraviolet-blocking eyewear to prevent acute photoretinitis and possibly decrease the chance of developing cataracts. In addition, any baseline ocular abnormality or normal variant should be documented. Being aware of baseline anisocoria or abnormally shaped pupils can help to prevent an unnecessary evaluation if the athlete presents later with a head or eye injury.Athletes who have baseline lung disease may require additional evaluation or a change in their treatment regimen before the season. Athletes who have known EIB should have an active prescription for a bronchodilator such as albuterol. Such athletes may benefit from having multiple inhalers to keep in multiple settings, such as at home, at school, and with their coach or athletic trainer. In general, athletes who have isolated EIB do not benefit from inhaled corticosteroids. However, there is significant overlap between asthma and EIB. In general, if an athlete has symptoms in other settings and the EIB is poorly controlled with bronchodilator monotherapy, adding a controller medication, such as an inhaled corticosteroid, may be beneficial. (23) Some athletes compete in sports or under federation rules that require them to obtain a TUE before using bronchodilators. As mentioned, it is important to obtain appropriate pulmonary function tests and to complete the TUE paperwork well in advance of the season.Vocal cord dysfunction (VCD) is another common respiratory complaint among athletes. Triggers or associated risk factors for VCD include allergic rhinitis, gastroesophageal reflux disease, anxiety, and poorly controlled asthma. The diagnosis can be made with a history of isolated inspiratory stridor (typically worse in competition situations) or with laryngoscopy. Most athletes can control their symptoms with special breathing techniques that require intensive teaching and are best taught by speech therapists or other professionals who are familiar with VCD. Like other chronic medical conditions, gaining control of VCD symptoms before the start of the sports season is important for increasing the likelihood of success.A history of other chronic pulmonary diseases, such as cystic fibrosis or chronic lung disease due to bronchopulmonary dysplasia, should not automatically disqualify a child or adolescent from sports participation. Careful partnership and close follow-up with a pulmonologist or other clinician who is familiar with the specific disorder is essential. It may be reasonable to dissuade children and adolescents who have severe lung disease from participating in sports that impose a high cardiovascular demand and steer them toward sports in which they are more likely to find success.Although gastrointestinal complaints are common among children and adolescents, very few require disqualification or modified sports participation. Diarrhea may put the athlete at increased risk of dehydration, but dehydration usually can be prevented with increased fluid intake. Gastroesophageal reflux disease can worsen with increased physical activity but usually can be controlled with diet modification. Gastric acid-suppressing medications (histamine-2 receptor blockers and proton pump inhibitors) may be necessary in some patients. Because inflammatory bowel disease can cause a profound anemia that can make physical activity more difficult and impair performance, close follow-up with a gastroenterologist to help ensure good control of symptoms is essential. Mononucleosis and mononucleosis-like infection caused by viral infections (typically Ebstein-Barr virus, but occasionally cytomegalovirus) can cause splenomegaly and put the athlete at increased risk for splenic rupture. Any athlete who has mononucleosis should be disqualified from practice and competition in any sport in which there is a risk of abdominal trauma. Most athletes are safe to return to sport by 3 to 4 weeks after the start of symptoms. (24) Blood-borne pathogens, including human immunodeficiency virus and infectious hepatitis, should not prompt disqualification from sports. (25) The athlete may participate in any sport that his or her health allows. Universal precautions should be used for all athletes, and skin lesions should always be covered properly, regardless of any known or suspected infectious disease.Few components of the genitourinary history should disqualify an athlete or require modified participation. Athletes who have a solitary or horseshoe kidney require individual assessment for contact and collision sports. (26) Protective equipment may be necessary to protect the remaining kidney, and the risks of injury should be weighed carefully against the benefits of contact or collision sport participation. Inguinal hernias may worsen with increased physical exertion, especially in sports such as weightlifting that impose a high static demand (increased muscle tension with relatively no change in muscle length or joint mobility). Females who experience amenorrhea or oligomenorrhea should be assessed for eating disorders and impaired bone health. Female adolescents who exercise intensively or play sports (especially those sports that emphasize leanness) are at risk for developing the “female athlete triad” of disordered eating, amenorrhea, and osteoporosis that is associated with significant health problems later in life. Eating disorders are common among athletes in weight-restricted and esthetic sports. Many athletes do not meet diagnostic criteria for anorexia nervosa or bulimia nervosa but clearly have disordered eating patterns. They can be diagnosed as having eating disorder not otherwise specified, which has been included in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders. (27) Screening for disordered eating should be performed as part of every PPE. Several validated screening instruments are available, but the most commonly used is the 26-item Eating Attitudes Test. (28) Screening tools for disordered eating generally assess the patient's body image and screen for abnormal eating behaviors, such as irrational avoidance of certain foods, ritualistic approaches to meals (eg, very slow eating, cutting food into very small pieces, extraordinary calorie counting), vomiting, or engaging in excessive exercise after meals. Disordered eating is one of the three elements of the female athlete triad, along with amenorrhea and decreased bone mineral density. The presence of any one of these conditions should prompt the clinician to evaluate for the other two. The female athlete triad puts the athlete at risk for stress fractures. Although not an absolute contraindication to sports participation, complications of an eating disorder (including electrolyte abnormalities and cardiac rhythm disturbances) need to be monitored. A multidisciplinary team, including physicians, dietitians, and mental health professionals, is essential for the necessary care of an athlete who has an eating disorder.Depression and anxiety are common mental health problems that can appear in athletes. Unless severe, these conditions should not disqualify the athlete from sports participation. Mental health professionals may help the athlete to cope better with his or her psychological symptoms. Often, athletes can be persuaded to use mental health services by discussing the possible performance improvements that might come from controlling their depression or anxiety.The prevalence of attention-deficit/hyperactivity disorder (ADHD) among athletes is similar to the prevalence among other children and adolescents of the same age. Stimulant medications are a common treatment but may require a TUE or documentation of ADHD testing before the start of the sports season.The PPE provides an opportunity to review the immunization history and provide catch-up immunizations. Although missing immunizations should not be criteria for sports disqualification, athletes and clinicians should be aware that some immunizations are required by schools and colleges for enrollment. In addition, athletes who are competing internationally may need documentation of specific immunizations to gain entry into certain countries. The PPE physical examination varies little from the standard health supervision evaluation, although a few components require additional attention in the athlete. The vital signs of an athlete may be different from what a clinician is used to seeing in nonathletes. A child or adolescent who has a high degree of cardiovascular fitness may have bradycardia and a wide pulse pressure. Respiratory rate may be lower than expected when resting but may be elevated for several hours after exercise. Body mass index may be an inaccurate method of screening for overweight and obesity in some athletes who are very muscular. The blood pressure should be normal. Elevated blood pressure in children and adolescents, regardless of sports participation, requires evaluation and treatment. For idiopathic or “essential” hypertension, one of the first-line treatments is exercise. Athletes who have mild-to-moderate hypertension (>95th percentile for age, sex, and height) require evaluation but should be encouraged, rather than prohibited, from participating in sports. Athletes who have severe hypertension (characterized as >5 mm Hg over the 99th percentile for age, sex, and height) should be disqualified from sports characterized by a high static demand and avoid heavy weight training and powerlifting. (29)(30) Corrected visual acuity should be better than 20/40 in both eyes. If not, protective lenses are required for contact sports participation. (22) Auricular cartilage damage should prompt the clinician to remind the athlete to use ear protection for sports such as wrestling and rugby. Nasal septum damage should prompt referral to an otolaryngologist. Dental carries may indicate overuse of sports drinks or eating disorders such as bulimia. The AHA-recommended elements of the cardiovascular evaluation are listed in the Table. In general, any cardiac abnormality that is not clearly benign should be fully evaluated before sports participation. A pediatric cardiologist who is familiar with the demands of sport participation should perform the follow-up evaluation. It is best to avoid ordering echocardiography and other advanced cardiac testing from facilities that are unfamiliar with congenital heart disease and sport participation in children. The female genitourinary examination is not a standard part of the PPE. However, any concerns raised by findings on the patient's history should be evaluated appropriately. Males should have two descended testicles. Any male who has an undescended or absent testicle should be evaluated by a urologist. Athletes who have only one functional testicle may participate in all sports but should be encouraged to use a protective cup to decrease the risk of injury in contact or collision sports. The PPE allows the clinician an opportunity to discuss testicular self-examination with the older adolescent. Males who have a history of groin pain should be evaluated for an inguinal hernia with a digital examination of the inguinal ring. Asymptomatic athletes do not need to be screened for hernias. (5) Any infectious skin condition should be treated before the athlete's return to sport. Any skin lesions that are suspicious for malignancy should be removed and evaluated by a pathologist. Any history of neurologic injury, including concussions and stingers, should prompt a detailed neurologic evaluation. The assessment should include cognitive function, cranial nerves, sensation, strength, tone, reflexes, and cerebellar function. Any abnormality should be evaluated thoroughly before sports participation. Clinicians often feel compelled to perform a detailed musculoskeletal examination on athletes who present for a PPE. However, as discussed, the physical examination adds little diagnostic value to the orthopedic history. (14) A cursory evaluation of strength and range of motion is sufficient for athletes who have no musculoskeletal complaints. Focused, detailed examinations of specific joints can be reserved for evaluating previous injuries or current complaints. No screening laboratory or imaging tests are required as part of a routine PPE. Significant controversy surrounds the use of screening echocardiography and electrocardiography to detect occult congenital heart disease. (13) In addition, the utility of testing for hemoglobinopathies, anemia, bleeding disorders, infectious diseases, cardiovascular risk factors (such as hypercholesterolemia), and other chronic diseases that may affect athletic performance or general health is unclear. Fewer than 2% of PPEs result in disqualification of the athlete from sport. However, many medical conditions require adaptation or close monitoring for complications related to sports participation. In addition, sporting activities are heterogeneous in their physical and cardiovascular demands as well as in their level of contact. Certain medical conditions may be incompatible with particular static or dynamic (changes in muscle length or joint mobility with relatively small change in muscle tension) demands or with the risks associated with contact or collision sports. A comprehensive review of the medical conditions affecting sports participation is beyond the scope of this article, but several conditions that frequently come to clinical attention during the PPE are discussed. This list is far from exhaustive, and the reader who is interested in learning more about the specific demands of sports participation and how many common and uncommon medical conditions affect sports participation should see the American Academy of Pediatrics Council on Sports Medicine and Fitness's report on “Medical Conditions Affecting Sports Participation.” (26) The child or adolescent who has a well-controlled seizure disorder should not be disqualified from sports participation. (26) In these athletes, the risk of having a seizure during practice or competition is very low, partially due to their already low seizure frequency but also due to the antiepileptic effects of exercise. It is sometimes surprising to officials and policy makers that athletes who have known seizure histories can be allowed to participate in contact and collision sports and in sports where they would seem to be at increased risk of injury should they have a seizure. The clinician may need to advocate for the athlete in such situations. A useful point of reference is the individual state's legal seizure-free interval before individuals who have epilepsy are allowed to return to driving. In most states, it is 3 to 6 months. Children and adolescents who have poorly controlled epilepsy also benefit from physical exercise, but more care must be taken to ensure the safety of these athletes and those around them. An individual assessment should be made to determine the athlete's suitability for contact and collision sports. The following sports should be avoided: Down syndrome, also known as trisomy 21, is a genetic syndrome involving multiple congenital anomalies. Children born with Down syndrome often require interdisciplinary care to maximize their health outcomes and quality of life, regardless of sports participation. Of note, instability of the cervical spine (primarily atlantoaxial instability, but also occipitoatlantal instability) has been reported in up to 30% of patients who have Down syndrome. (31) The Special Olympics® organization requires radiographic evaluation of the cervical spine before sports participation. It is common for patients who have had normal cervical spine radiographs to acquire cervical instability. For this reason, patients who have Down syndrome should be prohibited from participating in collision sports regardless of the radiographic appearance of their spines. However, no other limitations need be imposed for patients who have normal cervical spine radiographs. Patients who have radiographic evidence of cervical instability but no neurologic signs or symptoms should be disqualified from “neck-stressing” sports. Special Olympics considers diving, gymnastics, butterfly stroke, high jumping, soccer, and pentathlon to be “neck-stressing.” Athletes who have Down syndrome and cervical instability may use a cervical collar, but this practice does not change their sport restriction. Down syndrome is associated with other abnormalities that may influence sports participation, such as cardiac abnormalities (septum defects in particular), cataracts, diabetes, thyroid disease, hip and patellar instability, and foot abnormalities. Each of these conditions, if present, requires evaluation before sports participation. However, no other special precautions need to be taken for these children.Athletes who have a fever should be prohibited from practice and competition. (26) Fever puts the athlete at risk for acute heat illness (due to increased heat storage), reduced maximal exercise capacity, and hypotension (due to decreased peripheral vascular tone and possibly dehydration). Athletes who have type 1 diabetes mellitus (DM1) are permitted to participate in any sport without restriction. (26) However, DM1 monitoring and treatment often becomes more complex with the varying demands of organized sports. Careful evaluation and monitoring of blood glucose, diet, insulin types and doses, and hydration status are essential. Blood glucose should be checked more frequently than usual. At a minimum, athletes who have DM1 should measure their blood glucose every 30 minutes during continuous exercise, 15 minutes after completion of exercise, and at bedtime. For optimum control and performance, many athletes who have DM1 find that they need to measure their blood glucose and modulate their insulin and carbohydrate intake frequently. Insulin pumps and rapid-acting insulins have allowed athletes to fine-tune their glycemic control much more effectively than in the past. It is not uncommon for athletes who have DM1 to develop complex treatment plans involving both pump and injectable insulin therapy. Disabled athletes may face special challenges, but the clinician should encourage exercise and sports participation for the same reasons they are encouraged in able-bodied athletes. (5) Good communication among athletes, coaches, parents, and clinicians is essential for ensuring safe and successful sports participation. The supplemental history form from the 2010 PPE monograph (Fig. 2) can help to facilitate this communication.Although most complaints and abnormalities identified during the PPE are not absolute contraindications to sports participation, several conditions should prompt disqualification from sport. Most of these are cardiovascular conditions and have been outlined in the 36th Bethesda Conference guidelines: (32) Although the guidelines from the 36th Bethesda conference only comment on disqualification for these specific conditions, any cardiovascular disease should be thoroughly evaluated and treated by a pediatric cardiologist to ensure the athlete's safe participation in sports. In addition to cardiac abnormalities, any condition that cannot be well controlled and puts the athlete at risk of significant injury or death or endangers the health of teammates or competitors requires further evaluation or disqualification from sport. For example, a musculoskeletal injury that impairs the athlete's ability to protect him- or herself during practice and competition should prompt disqualification until the athlete is safely able to return to play. For a discussion of the evaluation and management of specific sports-related injuries, please see the recent Pediatrics in Review article, “Managing Sports Injuries in the Pediatric Office.” (33)In performing the PPE, the clinician's first responsibility is to ensure the health and safety of the patient. However, the physical and psychological benefits of exercise and sport participation should weigh heavily on decisions to disqualify an athlete from sport.