Importance of Pre-Participation Physical Exam (PPPE)

By Terry Zeigler, EdD, ATC 

This is the time of year when hundreds of young athletes are lining up for pre-participation physical exams (PPPE). Pre-participation physical exams are required for athletes to participate in middle school and high school sports and summer camps.

With the increased media attention on including electrocardiograms as part of PPPEs for the purpose of detecting hypertrophic cardiomyopathy, the leading cause of sudden death in young athletes,pre-participation physical exams are receiving more consideration (Maron, B., 2010). Specifically, sports medicine personnel are reviewing the quality and what is required in these exams to ensure that they are sufficient to identify young athletes who may be at risk for further injury or possible sudden death.

What is the purpose of a PPPE?

The purpose of the PPPE is to identify athletes that may be at risk for further injury or illness and to refer these athletes for additional medical evaluation prior to allowing them to participate. The specific purposes include the following:

• To identify athletes at risk of sudden death
• To identify medical conditions that may require further evaluation and treatment before participation
• To identify orthopedic conditions that may require further evaluation and treatment, including physical therapy, before participation
• To identify at-risk adolescents and young adults who are at risk for substance abuse, STDs, pregnancy, violence, depression, and so on
• To satisfy legal requirements of athletic governing boards

Identification of athletes who may be at risk for sudden death is currently a hot topic in the world of sports medicine. Recent studies have indicated that the addition of an electrocardiogram would identify athletes with hypertrophic cardiomyopathy and that this test should be a requirement of the PPPE.

pre participation physical exam
Pre-Participation Physical Exam

Although this would be a beneficial tool, there is controversy over whether this test should be included. Some of the reasons against including an ECG as part of a PPPE include the cost and the logistics of running ECGs on the thousands of youngsters who participate in sports.

The PPPE is also an opportunity to identify athletes who have a history of concussion and who may still be experiencing post-concussion symptoms.

Identifying these athletes and referring them for further medical treatment is one way to reduce the incidence of second impact syndrome, another cause of sudden death in young athletes.

Depending on the type of medical testing available during the PPPEs, athletes with medical conditions may also be identified so that they can be referred for further treatment. Common medical conditions that may be identified during a PPPE include anemia, amenorrhea, eating disorders, asthma, and hypertension.

Identification of recent orthopedic injuries or of musculoskeletal injuries that have not healed is another reason for the PPPE. Athletes who have sustained knee, ankle, or shoulder injuries can be identified during the PPPE. The athlete can be screened for joint range of motion, strength deficits, and joint instability. If any deficits are present, the athlete can either be referred to a local physical therapist or to a certified athletic trainer for specific rehabilitation protocols so that the athlete can reduce the risk of further injury to the area.

Adolescents with at-risk behaviors may also be identified during the PPPE. This is an opportunity for the athlete to speak candidly with a physician providing a window of opportunity for the athlete to seek help if he/she chooses. Even during a PPPE, the medical personnel have a duty to maintain confidentiality between themselves and their patients. This can provide a safe place for an athlete to discuss concerns that they may have with their own health.

Last, the PPPE is a legal document that protects the schools, school districts, and camps from potential lawsuits. The purpose of the PPPE is to ensure that the athlete is healthy enough to participate safely in sports.

However, this does bring a concern to the current PPPE practice of mass physical screenings with little physician interaction. Are these mass screenings comprehensive enough to identify athletes who may be at risk for further injury or possible sudden death?

What are the current types of pre-participation physical exams?

Currently, there are two common types of pre-participation physical exams available for school-aged athletes. They include a PPPE by the athlete’s personal physician and the mass screening station exam commonly held on location at the athlete’s school.

Both can be effective if they include a comprehensive medical history (most important component of PPPE), vital signs, vision test, general medical exam, orthopedic exam, lab testing (if available), and fitness testing.

The benefits of a PPPE by the athlete’s personal physician are that the physician knows the medical history of the athlete and that most can be covered by the family’s medical insurance. Any possible conditions that may be identified can be immediately followed-up on by the physician including additional lab tests.

The downside of requiring athletes to obtain their PPPE by their own physician is that getting the physicals completed is placed into the hands of the athlete’s parents who may or may not be responsible to get it completed in a timely manner.

In order to ensure compliance, programs started offering mass physical screenings on site at the school. In these exams, the medical staff is brought to the school using a “station-type” approach. Typically, a large space is needed (the gym) and stations are set up throughout the building.

The “station” exam begins with the athlete turning in their medical history and associated paperwork. They then proceed through a number of stations staffed by medical personnel concluding with a station staffed by a physician. The physician’s responsibility is to review all of the data collected during the physical exam and to make any recommendations for the athlete for further medical follow-up if needed. If the athlete’s physical exam does not bring up any red flags, the physician signs that the athlete is able to participate fully in sports.

The “station” exams tend to cost less than a regular physical exam because of the number of athletes sharing the cost. Physicians associated with schools may also donate all or a portion of the money collected from the mass screenings back into the school.

The benefit of the “station” exam is that a large number of athletes can be screened in a few hours. However, the downside is that a large number of athletes are screened in a very short time. This can bring into question the comprehensive nature and the quality of the exam.

Why is the medical history the most important component of the PPPE?

The medical history is the most important component of the PPPE because it can identify if the athlete may be at risk for a number of medical and/or orthopedic conditions that need follow-up. It is vitally important that the athlete take his/her time when completing the medical history and that he/she is honest about reporting signs or symptoms of problems.

The medical history is only as good as it is accurate. Athletes who may conceal important medical information may be passed during a PPPE but then may place themselves at serious risk for further injury or possible sudden death.

It is the medical history of the athlete that will identify the athlete for hypertrophic cardiomyopathy, second-impact syndrome, and other possibly life-threatening conditions. These conditions are not currently found through any physical tests that may be administered during the screening. They are only picked up by reviewing the medical history of the athlete.

Crucial cardiac history questions that may identify the athlete for life-threatening conditions in a medical history include the following:

• Does the athlete have a history of chest pain or discomfort?
• Does the athlete have a history of fainting?
• Does the athlete have a history of unexplained shortness of breath or fatigue with exercise?
• Does the athlete have a history of heart murmur or high blood pressure?
• Does the athlete have a family history of premature death (sudden or otherwise) or significant disability from cardiovascular disease in close relative(s) younger than 50 years of age?
• Does the athlete have a family member with hypertrophic cardiomyopathy, dilated cardiomyopathy, long QT syndrome, Marfan’s syndrome, or clinically relevant arrhythmia?

If an athlete answers yes to any of the above questions, a referral to a cardiologist may be necessary to run further diagnostic tests prior to the athlete being released to participate in sports.

The medical history should also include a section of questions related to history of concussion and concussion symptoms. With the recent attention on the effects of multiple concussions and permanent injury to the brain, there is a renewed interest in the proper diagnosis and management of concussion.

Questions on a medical history pertaining to concussion should include questions asking if the athlete has experienced any of the following symptoms associated with a head injury including:

• Loss of consciousness
• Dizziness
• Fogginess
• Nausea/Vomiting
• Confusion
• Inability to focus/concentrate
• Ringing in the ears

If the athlete has experienced or may have experienced a concussion, the athlete needs to be referred to a sports medicine professional or neurologist for further testing before being released to participate.

Most athletes undergoing PPPEs are released to full participation in sports. However, the value of the PPPE is to identify those athletes who may need further medical intervention to either prevent more serious injuries (as in musculoskeletal injuries) or prevent possible sudden death (athletes identified with hypertrophic cardiomyopathy, history of concussion).

The parent has the right to choose which type of PPPE is right for their child. If an athlete has a history of musculoskeletal injury or medical condition that may preclude the athlete from participating in sports and that may need medical follow-up, the parent can bypass the school’s exam and choose the route of a more thorough physical exam through the family’s personal physician.


Landry, G.L. & Bernhardt, D.T. (2003). Essentials of Primary Care Sports Medicine. Human Kinetics: Champaign, IL.

Maron, B. (March 2, 2010). National Electrocardiography Screening for Competitive Athletes: Feasibility in the United States? Annals of Internal Medicine, 152(5), 324-355.

Stein, J. (March 2, 2010). Tests could identify at-risk youth athletes. Los Angeles Times: Los Angeles, CA.

Wheeler, M., Heidenreich, P., Froelicher, V., Hlatky, M., & Ashley, E. (March 2,2010). Cost-Effectiveness of Preparticipation Screening for Prevention of Sudden Cardiac Death in Young Athletes. Annals of Internal Medicine, 152(5), 276-296.

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