Take a neurologic history
The neurologic system is highly susceptible to injury during sports activity. Identifying a history of concussion, nerve injury, or neurologic deficit is important both to prevent future injury and to avoid worsening of a current disability.
Always ask about transient neuropraxia, also known as a “stinger” or “burner”—a traction or compression injury to the nerves of the brachial plexus or cervical nerve roots that is sustained by 50% to 65% of college football players.11 The injury causes numbness, weakness, or both, in an upper extremity. Although symptoms are commonly transient, the injury may be severe enough to cause more prolonged symptoms; about 5% to 10% of the time, symptoms related to transient neuropraxia persist for hours to weeks.11
A history of numbness or weakness that occurs simultaneously in more than 1 extremity is suggestive of underlying cervical cord neuropraxia.12 Patients with such symptoms require further evaluation for the presence of spinal stenosis, cervical ligamentous injury, and spinal cord injury before being cleared to participate in sports.
Concussion is a common neurologic insult among competitive athletes (See “Update on concussion: Here’s what the experts have to say”), accounting for anywhere from 6.5% to 18.5% of injuries in collegiate contact sports.1,13 Identifying students who have had head injuries and are therefore at increased risk for future concussion is a key function of the PPE.13,14
An individual who suffers even a mild head injury prior to full resolution of an initial concussion is at risk for second impact syndrome—a devastating brain injury that causes a loss of autoregulation of cerebral blood flow, leading to rapid swelling, herniation, and death. Thus, any athlete with a recent history of concussion requires further evaluation—and disqualification from play until symptoms fully resolve. In fact, anyone with a history of concussion—recent or not—may need neuropsychologic testing to assess baseline level of cognitive function. Thorough documentation is critical in such cases. In the event of a repeat concussion, having this information may assist with treatment and return-to-play decisions.
Review other significant findings noted on the history form. Follow up, as needed, with questions about any missing or dysfunctional organ or bodily system (The ACSM Web site includes a supplemental history form for athletes with special needs to document additional details, if necessary).
In some cases, protective equipment may be sufficient (a student with defective vision in 1 eye can wear protective eyewear to prevent injury to the other eye, for instance). In other cases, a conversation with the patient and his or her family regarding the risk of serious injury may be in order. Parents of a child with only 1 kidney, for example, should be advised that contact sports pose a small, but real risk of damage to that kidney, potentially resulting in the need for dialysis.
Take the opportunity to discuss body image, mental health
For many adolescents—up to 50%, by some counts15—the PPE is their only interaction with a clinician. Thus, it provides a good opportunity for you to talk to young athletes about such sensitive topics as high-risk behaviors, mental health issues, body image, and personal safety. To help ensure that students feel free to talk openly, the new PPE forms have removed key questions about high-risk behaviors from the patient history (which requires a parent’s signature). Instead, a series of questions is listed under the heading “physician reminders” at the top of the form for the physical exam,3 which is typically conducted in a private setting.
Overweight? Underweight? Height and weight, a standard part of the physical along with blood pressure and pulse rate, may clue you in to the existence of an eating disorder. Calculate body mass index (BMI), looking for students who are underweight (BMI <19 kg/m2) or overweight (BMI >25 kg/m2). Overweight athletes are at increased risk for heat illness and may need a preseason conditioning program.16 Underweight athletes—particularly young women—may be at additional risk.
Female athlete triad. When examining young women, be alert to signs and symptoms of the female athlete triad, a syndrome of disordered eating, amenorrhea, and osteopenia or osteoporosis. This related spectrum of medical problems can pose a significant health risk, as it involves a cycle of low energy intake that “turns off” the reproductive cycle and creates a hypoestrogenic state. The lack of estrogen has a devastating effect on bone mineral resorption and can lead to osteopenia.17 While the prevalence of the female athlete triad is low in the general population, 1 study noted that nearly 6% of young female athletes met the criteria for 2 of the 3 components of the triad, and as many as 20% had at least 1.18