PREPARTICIPATION PHYSICAL EVALUATION Flashcards Preview

ORTHO > PREPARTICIPATION PHYSICAL EVALUATION > Flashcards

Flashcards in PREPARTICIPATION PHYSICAL EVALUATION Deck (56)
Loading flashcards...
1
Q

What is the PPE (preparticipation physical evaluation)

A

sports physical…

  • this is an important first step in assisting athletes in maintaining health and ensuring safe participation in training & competition
  • wide variation in recommendations / requirements of what makes up a PPE
2
Q

most PPE recommendations carry a level____ supported data recommendations

A

level C

3
Q

STATE DIFFERENCES: MONTANA VS TEXAS

A

o Montana = annual exam completed after May 1st for next year - can be performed by any licensed medical professional

o Texas = need 2 forms (medical HX & PE). Medical hx completed yearly, but PE performed every other year unless yes to any hx questions that warrant PE

4
Q

OBJECTIVES OF PPE

  • primary (essential) vs secondary (ideal)
A

o Primary or Essential
⦁ This is the only medical contact for 30-88% of these adolescents (not getting other contact with any other medical professional that year other than for PPE)
⦁ To detect conditions that may limit participation
⦁ To detect conditions that may predispose patient to injury
⦁ Meet legal & insurance requirements

o Secondary or Ideal Objectives
⦁ Assessing general health & identifying health risk behaviors (ie: CV health, mental health
⦁ Assess physical maturity
⦁ Determine fitness & performance level

5
Q

TIMING & FREQUENCY OF PPE

A
  • Should be performed at least 6 weeks before starting sports season to allow adequate time to address any issues
  • Montana regulations = must be done annually for high school athletes
  • Need a comprehensive baseline PPE before initiating a sports season
  • Subsequent annual PPEs may be limited to recent injuries that may have occurred (focus on that), but also includes a review of Cardiopulmonary system
6
Q

PPE should be formed at least _________ before starting sports season to allow adequate time to address any issues

A

6 weeks

7
Q

Need a comprehensive ____________ before initiating a sports season

A

baseline PPE

8
Q
  • Subsequent annual PPEs may be limited to recent injuries that may have occurred (focus on that), but also includes a review of ____________ system
A

Cardiopulmonary

9
Q

PPE FORMAT

OFFICE-BASED VS GROUP SCREENING

A

o OFFICE BASED
⦁ Advantages = physician-patient familiarity, privacy, and continuity of care
⦁ Disadvantages = cost, limited appointment time, and lack of communication back to the school’s athletic staff

o GROUP SCREENING
⦁ Advantages = specialized personnel, time, and cost-efficiency
⦁ Disadvantages = rushed, lack of privacy, and potential for poor follow-up of identified problems
⦁ Mayo Clinic study of PPE - found that station type formats (group screening) = effective and safe

10
Q

advantages & disadvantages to an office-based PPE

A

⦁ Advantages = physician-patient familiarity, privacy, and continuity of care

⦁ Disadvantages = cost, limited appointment time, and lack of communication back to the school’s athletic staff

11
Q

advantages & disadvantages to a group screening PPE

A

⦁ Advantages = specialized personnel, time, and cost-efficiency

⦁ Disadvantages = rushed, lack of privacy, and potential for poor follow-up of identified problems

⦁ Mayo Clinic study of PPE - found that station type formats (group screening) = effective and safe

12
Q

cornerstone of PPE

A

history

may identify 75% of problems affecting athletes

13
Q

key history questions of PPE = focus on

A

CARDIOVASCULAR QUESTIONS

14
Q

Cardiovascular Questions of PPE

A

⦁ Identifies hypertrophic cardiomyopathy - leading cause of sudden cardiac death in athletes
⦁ Marfans (leads to aortic rupture)
⦁ Premature atherosclerosis

15
Q

EKG DEBATE IN PPEs

A

not currently used on all athletes; consensus = not cost effective or time-effective. Don’t have resources for pediatric cardiologists to read all of these EKGs, so general consensus = not needed

16
Q

MOST COMMON CARDIOVASCULAR CAUSE OF SUDDEN DEATH

A

HYPERTROPHIC CARDIOMYOPATHY

17
Q

CARDIOVASCULAR CAUSES OF SUDDEN DEATH

A
⦁	Hypertrophic cardiomyopathy = MC***
⦁	Anomalies of the coronary arteries
⦁	Atherosclerotic Heart Disease
⦁	Marfan's Syndrome ( --> aortic rupture)
⦁	Aortic Stenosis
⦁	Mitral Valve Prolapse
18
Q

what is hypertrophic cardiomyopathy

A
  • Primarily a disease of the myocardium with hypertrophy without any obvious cause
  • FREQUENTLY ASYMPTOMATIC until sudden cardiac death
  • May be identified by ECG or PE
19
Q

danger of hypertrophic cardiomyopathy is that it is frequently

A

ASYMPTOMATIC until sudden cardiac death

Hypertrophic cardiomyopathy may be identified via:

  • EKG
  • PE
20
Q

specific CV questions from PPE

A

⦁ Have you ever passed out during exercise?
⦁ Have you ever been dizzy or lightheaded during or after exercise?
⦁ Chest Pain during or after exercise?
⦁ Have you ever passed out during or after exercise?
⦁ Have you ever noticed a racing heart or skipped beats?
⦁ Have you ever been told you have a heart murmur or heart condition?

IF YES TO ANY OF THESE QUESTIONS —> FULL CV WORK-UP

21
Q

PPE PHYSICAL EXAM

A
  • Should be comprehensive, however, focused on any pertinent findings from HX
  • Should not be in such an environment that specific findings of concern cannot be adequately addressed at the time
22
Q

BP values during PE

if pt is < 10 =

if pt > 10 =

A

pt < 10 = > 125/75

pt > 10 = > 135/85

23
Q

Palpation of UE & LE pulses

⦁ brachial - femoral delay may mean

A

coarctation of the aorta

24
Q

MURMURS DURING PPE EXAM

A
  • Heart auscultation in 2 positions, and with provocative maneuvers - may help detect murmurs
    ⦁ Valsalva, Position change
  • Location of Murmur
  • Precordial Palpation (increased)
  • PMI displaced laterally
25
Q

the only level A recommendation with PPE

A

MSK EXAM

26
Q

MSK EXAM

A
  • This is the ONLY LEVEL A RECOMMENDATION
  • Orthopedic Screening 9: The MSK hx screening & exam can be combined for asymptomatic athletes with no previous injuries
  • If athlete has had a previous injury or has signs of an injury = the relevant elements of a site specific exam should be performed
27
Q

It is important to identify musculotendinous bone or joint problems that may limit athletic participation or predispose to injury

such as:

A

⦁ shoulder instability
⦁ ACL deficiency
⦁ un-rehabbed ankle instability*** - predisposed to future injuries

  • Any positive responses in history = requires a thorough evaluation
  • Screening for flexibility
  • Screening for general neurologic exam & Scoliosis
28
Q

in a mayo study, 1/2 of all disqualifications from further participation were related to ________

A

MSK ISSUES

29
Q

major concern if found in PPE MSK exam

A
  • unrehabbed ankle instability = predisposed to future injuries
30
Q

routine screening tests needed for PPE?

A
  • The use of routine screening tests is not recommended and remains unproven

⦁ CBC, UA, CMP, Sickle cell trait

⦁ Electrocardiogram / Echocardiogram; Current recommendation = good screening tool, but not practical / cost effective

⦁ Radiographs / MRIs = not unless indicated by focused MSK exam

31
Q

perform 90 second MSK exam

A

⦁ Neck ROM
⦁ Shoulder passive / active ROM
⦁ Supine - examine Hip / knee
⦁ Ankle instability / examination

32
Q

CLEARANCE FOR PARTICIPATION

A
  • Providers must be familiar with the demands of specific sports
  • Consider these questions
    ⦁ Will the problem increase the athlete’s risk of morbidity / mortality?

⦁ Will other participants be at risk of morbidity?

⦁ Will further evaluation, treatment or rehab allow full participation?

⦁ Could the athlete be allowed limited participation?

33
Q

SPECIFIC MEDICAL CONDITIONS THAT REQUIRE FURTHER EVAL

A

o Heart Murmurs
⦁ any new undiagnosed heart murmur
⦁ need documentation & clearance for any previously identified heart murmur

o Family Hx of Wolff-Parkinson-White (extra electrical pathway in heart - delta wave)

o Arrhythmias

o Strong concern for Marfan Syndrome (phenotype characteristics)

o HIV
⦁ cleared, but health care personnel must use universal caution

o Absence of Kidney
⦁ cleared, but with counseling & protection for contact (have to be on supplements)

o Mono
⦁ NOT cleared for contact with any concern for splenic enlargement / active disease
⦁ 84% are normal at 1 month

o Sickle Cell Trait
⦁ Unlikely that the patient has an increased risk of sudden death or other medical problems, with the exception of at extreme conditions of heat / humidity / elevation

34
Q

OTHER CONCERNS

  • mental health
  • supplements / medications
A

o Mental Health
⦁ should we be including more questions?
⦁ what is the referral process?
⦁ what about clearance of athletes who are positive for mental health concerns?

o Supplements / Medications
⦁ unique opportunity to counsel patients on supplements
⦁ counsel on energy drinks / performance enhancers

35
Q

FEMALE ATHLETE TRIAD (3)

A

1) Eating disorder (anorexia nervosa or bulimia)
2) Amenorrhea
3) Osteopenia / Osteoporosis (lack of estrogen leads to lack of bone development)

36
Q

SIGNS / SYMPTOMS OF FEMALE ATHLETE TRIAD

A

SIGNS / SYMPTOMS

  • Thin appearance
  • Highly concerned with food / body
  • Decreased performance
  • Stress fractures

Mental Health Counseling / Treatment

37
Q

OSGOOD SCHLATTER’S DISEASE

A
  • Osteochondritis of the patellar tendon at the tibial tuberosity from OVERUSE (repetitive stress) or small avulsions due to quadriceps contraction

MC cause of chronic knee pain in young, active adolescents

  • occurs in immature athletes
  • more common in males (10-15) with “growth spurts” - the bone grows faster than soft tissue, so quadriceps contraction is transmitted through the patellar tendon to the tuberosity
38
Q

MC CAUSE OF CHRONIC KNEE PAIN IN YOUNG, ACTIVE ADOLESCENTS

A

OSGOOD SCHLATTER DISEASE

39
Q

clinical manifestations of Osgood-Schlatter disease

A
  • activity-related knee pain / swelling - usually asymptomatic at rest
  • painful lump below the knee - tenderness to the anterior tibial tubercle

can be unilateral or bilateral

40
Q

treatment for Osgood-schlatters

A

usually resolves with time

  • RICE
  • NSAIDS
  • Quadriceps stretching
  • surgery only in refractory cases (but only done after growth plate has closed)
41
Q

__________ is less common that Osgood-schlatters

A

Sever’s disease

42
Q

SEVER’S DISEASE

A

Calcaneal apophysitis

  • less common than Osgood Schlatters
  • Involves the Achilles & Calcaneal growth plate - have pain at back of heel where achilles tendon attaches to calcaneous
  • bone grows faster than muscles / tendons / ligaments, so when the muscles and tendons can’t grow fast enough, they get stretched
  • if child is active / athlete = extra strain on already overstretched tendons. This leads to swelling and pain at the point where the tendons attach to the growing part of her heel.
43
Q

signs / symptoms of sever’s disease

A
  • pain / swelling / redness in one or both heels
  • Tenderness and tightness in the back of the heel that feels worse when the area is squeezed
  • Heel pain that gets worse after running or jumping, and feels better after rest
44
Q

other risk factors for sever’s disease

A

overweight / obese

pronation

45
Q

TREATMENT FOR SEVER’S DISEASE

A

RICE, heel lift, corrective orthotics, stretching

46
Q

CASE #1

20y/o - 1 year hx of locking knee with certain activities. Hx of locking with lifting activities (usually squatting). Has to manually unlock the knee. Started 1 year ago at end of football. Occurs occasionally, and does well when knee is not locked. No swelling, no giving out

A
  • need to ask previous hx or surgeries (had a meniscus repair a year ago)
  • PE = do McMurray’s test (good test for meniscus). Do full motion tests with knee
  • want to palpate joint lines (has lateral joint line pain, no medial joint line pain), no patellar pain; no crepitation, no catching/locking on McMurray’s test…

LIKELY HAS LATERAL MENISCUS TEAR
- needs an MRI

47
Q

which meniscal tear is more common

A

medial

medial meniscal tear is 3x more common than lateral

depends on where the joint line pain is

48
Q

MENISCAL TEARS

A
  • degenerative
  • medial more common - due to bony attachments
  • *Locking
  • popping
  • “giving way”
  • effusion after activities
  • joint line tenderness (medial or lateral)

***McMURRAY’S SIGN (pop or click when tibia is externally and internally rotated

Apley’s Compression Test = patient lies prone with leg flexed at knee (lower leg is pointing up) - compress down on foot while holding down distal thigh, and rotate leg externally (valgus - tests medial meniscus) or internally (varus - tests lateral meniscus)

TREATMENT

  • NSAIDS
  • partial weight bearing until orthopedic f/u
  • arthroscopy (surgical procedure to examine the joint and treat damage if needed)
49
Q

test for knee meniscus tear

A

mcmurray’s test - patient lies supine with knee flexed
external rotation of lower leg - knee goes inward, foot goes outward (valgus) -tests medial meniscus

internal rotation of lower leg - knee goes outward, foot goes inward (varus) - tests lateral meniscus

will have clicking / catching / popping

Apley’s compression test - patient lies prone with knee flexed. compress on foot that is up in the air and hold distal posterior thigh down, then rotate

  • external rotation of tibia tests medial meniscus
  • internal rotation of tibia tests lateral meniscus
50
Q

McMurray’s test

A

for meniscus tears

  • valgus for medial meniscus
  • varus for latera l meniscus
51
Q

shoulder subluxation

A

partial dislocation of the shoulder

52
Q

Labral tear (labrum = lines the glenoid cavity for the humeral head to properly fit into the glenoid socket) test

A

O’briens test

53
Q

what test can be done for shoulder instability (dislocation or subluxation)

A

apprehension test - patient supine and by compression on shoulder joint, can bring arm back farther than when patient was standing and tried to bring arm bent at 90 degrees backwards

54
Q

BONY BANKART LESION

A

when some of the glenoid bone is broken off with the anterior labrum tear - so have shoulder instability or dislocation as well as tear as well as broken off glenoid bone

55
Q

ACL INJURIES

A
  • MC knee ligament injury
  • many are associated with meniscal tears

S/S

  • Pop
  • swelling - hemarthrosis
  • knee buckling
  • inability to bear weight

more common in women

Most sensitive test = Lachman’s test

Treatment = therapy vs surgical - depends on activity level of the patient
- can aspirate knee for blood first if needed

56
Q

CAR ACCIDENT - KNEE HIT THE DASHBOARD

A

PCL TEAR