Childhood athletic participation has dramatically increased over the past twenty years. Children are being introduced to organised sports at increasingly immature stages of physical development. It is not uncommon to find five-year-{)ld 'athletes' participating in dance classes, soccer camps, or martial arts. Preparticipation examination often represents the initial medical contact, and frequently the only medical contact a child will have prior to engaging in potentially injurious activities. Despite general agreement over the necessity of the pre-participation evaluation, no widely recognised standard examination currently exists. The administrator of a pre-participation evaluation must assess the overall health of the child as well as any conditions which might limit participation or predispose the child athlete to injury. Under ideal circumstances, the examination is performed by the athlete's primary care physician. A longstanding medical relationship promotes continuity of care and facilitates the safe discussion of important psychosocial issues. In other instances, mass screenings of athletic teams may be performed in an efficient and satisfactory fashion through the coordinated efforts of a team of health care professionals.2 A thorough medical history is obtained which includes past hospitalisations, surgery, medication, allergies, tetanus status, family history, menstrual history, and a review of systems. The physical examination should include assessment of height, weight, vision, cardiovascular vital signs, and level of physical maturity. Additionally, evaluation of the skin, chest, lymphatics, abdomen, genitalia, and musculo-skeletal systems must be performed. The physical examination may be specifically focused on problem areas identified by the medical history. Evaluation of the musculo-skeletal system includes structural integrity and alignment as well as any pre-existing neuro-muscular deficits. Thorough examination of a specific portion of the musculo-skeletal system may be performed should an area of concern be identified in the history and general physical examination. Furthermore, sportsspcific mus.culo-skltal testing may identify children at risk for llljury depending upon the requirements of the activity and the physiological condition of the athlete. Measurement of fitness, strength, and flexibility may reveal specific muscular imbalances or weaknesses. With such knowledge, therapeutic rehabilitative programmes may be instituted prior to the onset of athletic participation. Sports-specific performance testing reveals an athlete's physical strengths and weaknesses. When testing has been completed the physician may modify the athlete's training programme through exercise prescription. In addition to optimising athletic performance, the data obtained during testing may help to prevent injuries. Although the level of athletic fitness has not yet been proven to decrease the incidence of sports injuries, the presence of specific deficiencies or imbalances in the musculo-skeletal system would seem likely to predispose an individual to injury. The sportsspecific testing of fitness includes measurements of body composition, flexibility, strength, endurance, power, speed, agility, balance, and dynamic balance. The performance profile not only helps a child to achieve their athletic potential, but also provides a baseline against which the success of exercise prescription and recovery from injury can be measured. Information obtained from the medical history, physical examination and any associated sportsspecific performance testing allows a personalised athletic profile to be created for the participant. By pairing the profile with the recommendation for participation in competitive sports as published by the American Academy of Pediatrics, a decision regarding clearance for a given sport can be rendered.! The decision for clearance is divided into three categories: unrestricted clearance, cleared after notification of either the coach, trainer, or team physician, or clearance deferred until further evaluation by medical specialist. When properly performed, the pre-participation examination effectively identifies pre-morbid risk 73
Sports Medicine in Childhood and Adolescence factors for the paediatric and adolescent athlete. Medical and social interventions prior to athletic participation may diminish these risks and prevent catastrophic cardiovascular or neurologic events. A yearly evaluation of the growing child is recommended to screen for new health problems, to monitor established conditions and to assess an athlete's preparedness for any given sporting activity. General appearance examination The athlete stands straight with arms to the side and feet together. General appearance, including the acromioclavicular, sternoclavicular knee and ankle joints, should be symmetrical (7.1, 7.2). 7.1 7.2 7.1, 7.2 General appearance.. 74
ere-participation Sports Examination: Musculo-Skeletal System 7.4 7.3, 7.4 General appearance.. Asymmetry of the examination including chronic swelling or deformity often results from trauma. Chronic dislocation of the sternoclavicular joint typically presents with anterior prominence of the clavicle (7.3, 7.4). Marked femoral internal torsion and compensatory external tibial torsion result in patellofemoral malalignment commonly associated with anterior knee pain and patellar instability (7.5). 7.5 7.5 General appearance... 75 Co --
1 pqrtsmedicine in Childhood and Adolescence The athlete touches chin to chest (flexion), looks upward (extension), touches ear to shoulder Oateral bending) and looks over each shoulder Oateral rotation). The motion should be symmetrical and pain free (7.6-7.9). 7.6 7.7 7.8 7.9 7.6-7.9 Cervical spine examination.. 76
Painful or asymmetrical cervical motion often results from traumatic or congenital disorders of the cervical spine. Chronic rotary subluxation of CI-C2 presents as a fixed deformity and a loss of motion (7.10,7.11). Pre-Participation Sports Examination: Musculo-Skeletal System 7.11 77
Sports fyjedicine in Childhood and Adolescence Cc. 7.12 7.13 7.12 Neck and shoulder examination.. 7.13 Neck and shoulder examination.. Neck and shoulder examination Shrug shoulders upward against examiner resistance (7.12). Asymmetry of appearance, motion or strength may indicate cervical or shoulder problems. Asymmetrical shoulder motion is noted in an athlete with a nerve palsy sustained during a skiing accident (7.13). 78
7.16 7.14, 7.15 Shoulder examination.. 7.16 Shoulder examination. Abnormal ity. Raise arms outward from sides until parallel to the floor. Then flex elbows with hands pointed upwards. The deltoid appearance and strength should be symmetrical. The range of motion of the shoulder should be pain-free and symmetrical (7.14, 7.15). Pain, muscle atrophy, or asymmetrical motion may reflect shoulder instability, impingement or nerve injury. Specific testing of the shoulder will reveal anterior glenohumeral instability as in this athlete with recurrent anterior shoulder dislocations (7.16). 79 "."' CC"o.,.,.",-
Sports Medicine in Childhood and Adolescence 7.17 7.17 Elbow examination.. 7.18 7.18 Elbow examination.. Stand and raise arms out from sides until parallel to the ground. Palms face upward. Alternate elbow flexion and extension. The motion should be symmetrical and pain-free (7.17). Deformity, loss of motion and pain are findings often associated with trauma as seen in this child with a history of a supracondylar fracture of the humerus (7.18). 80
Pre-ParticiPation Sports EXamination: Musculo-Skeletal System Hold elbows to sides and flex foreanns until parallel to the floor. Rotate palms upward and downward in an alternating fashion. The motion should be symmetrical and pain-free (7.19, 7.20). 7.20 7.19, 7.20 Elbow, forearm and wrist examination.. 7.21 Deformity, loss of motion or pain often accompanies traumatic conditions such as that manifested by a child with a history of an elbow fracture (7.21). 7.21 Elbow, forearm and wrist examination.. 81
- \Sporls Medicine in Childhood and Adolescence Clench the fingers into a fist and then spread the fingers wide apart (7.22, 7.23). 7.22 7.22, 7.23 Hand examination.. 724 Deformity, loss of finger motion or weakness are common post-traumatic findings. Chronic oedema and loss of motion affects this finger subsequent to a proximal interphalangeal joint dislocation (7.24). 7.24 Hand examination.. The athlete stands straight with back to the examiner and raises arms forward until parallel to the ground. The palms are placed together and the athlete flexes forward to touch their toes. This is repeated with the examiner viewing the athlete from the side. Motion should be pain-free and symmetrical (7.25-7.28). 82
!, &. Pre-ParticiPation Sports Examination: Musculo-Skeletal System 7.25 7.26 7.27 7.28 7.25-7.28 Spinal. examination Pathologic findings include shoulder asymmetry, scapular prominence, pelvic obliquity, cutaneous manifestations of underlying spinal dysraphism and scoliotic and kyphotic deformity. Examples of idiopathic thoracic scoliosis and Scheuermann's kyphosis are presented (7.29, 7.30). 83
Spotts Medicine in Childhood and Adolescence 7.29 7.30 7.29,7.30 Spinal examination.. Lower extremity examination 7.31 The athlete squats down on heels, walks four steps in squat position, and then rises to a standing position. This complex activity demonstrates symmetrical lower extremity joint motion and strength. The gait should be pain-free and have equal heel-to-buttock distance. The child should have no difficulty in rising to a standing position (7.31). Hip, knee and ankle problems result in weakness, joint instability or loss of joint motion which preclude a symmetrical duck walk (note heel-tobuttock difference). Specific testing of the affected region will identify the deficiency. Examples of the Lachman and anterior drawer tests which assess competence of the anterior cruciate ligament are presented (7.32-7.34). 7.31 Lower extremity examination.. 84
itj,! Pre-Participation Sports Examination: 7.33 7.34 7.32-7.34 Lower extremity examination.. The athlete stands straight and then alternately stands on toes and stands on heels. Motion should be pain-free and symmetrical (7.35-7.37). 85
sports Medicine in Childhood and Adolescence 7.35 7.36 7.37 7.35-7.37 Leg and ankle examination.. 7.38 Pathologic findings of the leg examination include muscle atrophy, asymmetry of motion and chronic swelling as seen in this athlete with chronic achilles tendinitis (7.38). References 1. American Academy of Pediatrics Committee on Sports Medicine (1988) Recommendations for participation in competitive sports. Pediatrics 81: 737. 2. Micheli, L.j. and Yost. J.G. (1984) Preparticipation evaluation and first aid for sports. In: Micheli, L.j. (Ed.) Pediatric and Adolescent Sports Medicine. pp. 30-48. little, Brown, Boston. 7.38 Leg and ankle examination.. 86