Is eye protection needed? Ear plugs?
Check vision in each eye, both with and without corrective lenses. A student whose corrected vision is 20/50 or worse in 1 eye qualifies as functionally one-eyed—and must wear full eye protection during athletic activities.19 Document pupil size for all patients to ensure that anisocoria is not confused with a neurological insult in the event of a sports injury.
Water sports? Examine the nares, inspecting the septum for signs of deviation or perforation. Th is portion of the exam, however, can be tailored to the type of sport in which the patient plans to participate. Students who expect to be on a swim team or participate in other water sports require an evaluation of the ears, including the tympanic membranes and external auditory canals. Swimming and humid environments are risk factors for otitis externa, and repeated cold water exposure is a risk for the development of external auditory exostoses.20,21 A swimmer with perforated tympanic membranes should be advised to wear ear plugs to protect the middle ear.
Is the patient a wrestler? Pay close attention to the ears of any student who plans to join a wrestling team, documenting the absence—or presence—of cauliflower ear. A notation about the presence of this ear-deforming condition in the medical record ensures that any new auricular hematoma can be evaluated and treated with knowledge of the prior injury.
Cardiac findings that warrant further work-up
Elevated blood pressure, the most common cardiovascular abnormality in people participating in competitive sports,22 is categorized in stages as defined by the Second Task Force on Blood Pressure Control in Children23 and the Joint National Commission VII for adults ages 18 and older.24 Children with significant hypertension (TABLE 2) and adults with stage I hypertension (140-159/90-99 mm Hg) may participate as long as there is no indication of end organ disease. A child with severe hypertension or an adult with stage II hypertension (>159/99 mm Hg), however, should not be cleared for participation until he or she has had further evaluation and treatment.22,25
Similarly, any patient with an elevated heart rate needs a medical work-up prior to participation to determine the underlying cause of tachycardia.22 This may be a sign of an underlying cardiac arrhythmia or another medical condition that must be treated prior to athletic competition.
Auscultate the heart to screen for underlying cardiac disease. Listen to all 4 standard regions, with the patient in both a supine and a standing position. If you detect a murmur, perform auscultation while the patient squats and while performing the Valsalva maneuver. The murmur of hypertrophic cardiomyopathy (HCM)—the key cause of sudden cardiac death—is systolic, increasing with standing and the Valsalva maneuver and decreasing with squatting and a supine position. Any murmur that is 3/6 or greater in sound or has characteristics of HCM needs further evaluation before the patient can be cleared for sports activities. (See “Hypertrophic cardiomyopathy: Ask athletes these 9 questions,” J Fam Pract. 2009;58:576-584).
Palpate the femoral pulses. Absence of, or decreased, femoral pulses compared with brachial pulses may suggest coarctation of the aorta.
TABLE 2
Hypertension in children: Is it significant or severe?24
| Age | Significant HTN (mm Hg) | Severe HTN (mm Hg) |
|---|---|---|
| 6-9 y Systolic Diastolic | 122-129 78-85 | >129 >85 |
| 10-12 y Systolic Diastolic | 126-133 82-89 | >133 >89 |
| 13-15 y Systolic Diastolic | 136-143 86-91 | >143 >91 |
| 16-18 y Systolic Diastolic | 142-149 92-97 | >149 >97 |
| HTN, hypertension. | ||
Check lungs, abdomen, and skin
Auscultate the lungs, which should be clear and absent of adventitious or diminished breath sounds. Any patient with abnormal breath sounds requires further evaluation and/or treatment before being cleared for sports participation.
Examine the abdomen to assess the presence of organomegaly. Enlargement of the liver and spleen may be a sign of an underlying disease process. Mononucleosis, which causes splenomegaly, is associated with a 0.1% to 0.2% rate of rupture that may be related to trauma or the Valsalva maneuver.26 Athletes with organomegaly should not be cleared for athletic activity without further evaluation.3
Perform a genitourinary examination on young men. Check for the presence of both testicles and palpate for masses and inguinal hernias. A patient with a solitary testicle will require protective gear during certain sporting events to prevent injury.27
Assess the condition of the skin. In this case, the activity the student plans to pursue will determine the extent of the examination. Skin condition is particularly important for wrestlers, as the close contact involved predisposes the athletes to infectious skin conditions. Molluscum contagiosum, tinea corporis, and herpes gladiatorum, in particular, should be treated before the student is cleared to participate in wrestling. Regardless of the sport involved, however, identify chronic skin problems and institute prophylaxis, as needed.