EVIDENCE-BASED ANSWER
Though clinical preparticipation exams (PPE) are recommended by experts and required in most states, we found no medium- or better-quality evidence that demonstrates they reduce mortality or morbidity. PPEs detect only a very small percentage of cardiac abnormalities among athletes who subsequently die suddenly (strength of recommendation [SOR]: C, case series study). PPEs are also unable to accurately identify athletes with exercise-induced bronchospasm (SOR: C, small cross-sectional study) and are poorly predictive of which athletes are at increased risk of orthopedic injuries (SOR: C, cross-sectional study).
Evidence summary
A systematic review of the literature on PPE identified 310 studies of athletes age <36 years. The authors searched multiple electronic databases and reviewed the bibliographies of retrieved articles but did not perform hand searches of journals or contact authors directly. The review did not find any prospective cohort or randomized trials addressing the effectiveness of clinical PPE. The 5 studies that assessed the format of the PPE concluded that it is not adequately standardized, does not consistently address the American Heart Association (AHA) recommendations for cardiovascular screening and exam, and is administered by a variety of health care professionals, some without proper training.1
Sudden cardiac death is defined as a nontraumatic, nonviolent, unexpected event resulting from sudden cardiac arrest within 6 hours of a previously witnessed state of normal health.2 Such events occur in about 1 in 200,000 high school athletes per academic year (about 16 deaths in the US annually). Detection of cardiovascular abnormalities that may cause morbidity or mortality is difficult. A case series reviewed 158 sudden deaths that occurred in trained athletes in the US from 1985 to 1995. The athletes were identified from news accounts, the National Center for Catastrophic Sports Injury Registry, and informal communications and reports. The authors interviewed families, witnesses, and coaches, and they analyzed postmortem information. Of the 115 athletes who had a standard preparticipation medical evaluation, only 4 (3%) were suspected of having cardiovascular disease. The cardiovascular abnormality responsible for sudden death was prospectively identified in only 1 athlete.3
PPE does not accurately identify student athletes with exercise-induced bronchospasm (EIB). Of the studies on EIB, the best was a prospective cross-sectional study of 352 adolescents from 3 suburban Washington state schools. The students completed a 14-item EIB questionnaire, had a physical exam, and underwent a 7-minute exercise challenge spirometry. Complete data were available for 256 of the students. EIB was diagnosed by spirometry in 9.4% of the athletes. No student had EIB detected solely by physical exam. Using a cutoff of 2 positive questions, the questionnaire had a sensitivity of 71% and a specificity of 47%, with a negative and positive predictive value of 6% and 12%, respectively. This study concluded that EIB occurs frequently in adolescent athletes, but screening by physical exam and medical history does not accurately detect it.4
PPEs are not able to predict which student athletes will experience an orthopedic injury, and no controlled studies have been done to determine whether PPE prevents or reduces the severity of orthopedic injuries. A study surveyed 1204 student athletes (aged 13–20 years) from Richmond County, Georgia, who had a standardized PPE before participating in sports. The questionnaire was administered via mail or telephone and inquired about injuries sustained after the PPE. The response rate to the survey was 56%. The study found that a history of knee or ankle injury and abnormal findings on exam in male athletes slightly increased the likelihood of repeated injury of the same joint. However, the sensitivities of history or physical exam for ankle or knee injuries were all <25%.5