Sports Physical for a 16-Year-Old
A 16-year-old athlete requires a comprehensive cardiovascular-focused preparticipation evaluation using the 14-element American Heart Association screening protocol, including detailed personal and family cardiac history, targeted physical examination with blood pressure measurement and cardiac auscultation in multiple positions, and musculoskeletal assessment—with routine ECG or echocardiography NOT recommended for universal screening. 1, 2
Cardiovascular Screening: The Primary Focus
The cardiovascular evaluation is paramount because sudden cardiac death, though rare (approximately 1:200,000 per year in high school athletes), represents the most catastrophic outcome of sports participation. 1
Personal History (7 Critical Elements)
You must specifically ask about:
- Exertional chest pain, discomfort, tightness, or pressure during physical activity 2
- Unexplained syncope or near-syncope episodes, particularly during or immediately after exercise 2
- Excessive dyspnea, fatigue, or palpitations disproportionate to the level of exertion 2
- Prior recognition of a heart murmur by any healthcare provider 2
- History of elevated blood pressure at any previous evaluation 2
- Prior restriction from sports participation for any cardiac reason 2
- Previous cardiac testing ordered by a physician (ECG, echocardiogram, stress test) 2
Family History (Critical for Inherited Conditions)
Inquire specifically about:
- Premature sudden death (unexpected, before age 50) in any family member, particularly if attributed to heart disease 2
- Disability from heart disease in close relatives under age 50 2
- Specific inherited conditions: hypertrophic cardiomyopathy, dilated cardiomyopathy, long-QT syndrome, other ion channelopathies, Marfan syndrome, or clinically significant arrhythmias 2
Parental verification of the medical history is mandatory for high school athletes, as adolescents may not accurately report or understand family cardiac history. 1
Physical Examination Components
Cardiovascular Examination
- Cardiac auscultation in BOTH supine/sitting AND standing positions to identify dynamic left ventricular outflow tract obstruction characteristic of hypertrophic cardiomyopathy 2
- Brachial artery blood pressure measurement in sitting position, preferably in both arms 2
- Femoral pulse palpation to exclude aortic coarctation 2
- Assessment for Marfan syndrome stigmata: arm span-to-height ratio, pectus deformity, arachnodactyly, joint hypermobility 2
Critical pitfall: Hypertrophic cardiomyopathy, the leading cause of sudden cardiac death in young athletes, often has NO audible murmur at rest—making the history and standing auscultation essential. 2
Musculoskeletal Examination
The musculoskeletal examination has the highest yield for identifying conditions requiring restriction or referral. 3 Focus on:
- Joint stability and range of motion, particularly knees, ankles, and shoulders
- Spine alignment and flexibility
- Previous injury sites for adequate healing and rehabilitation
- Muscle strength symmetry between limbs 3
Approximately 1% of athletes are restricted for orthopedic problems, and 5% require additional orthopedic evaluation. 3
Additional Screening
- Vision screening (visual acuity problems are among the most common reasons for denying clearance) 4
- Mental health screening for depression, anxiety, and attention-deficit/hyperactivity disorder 5
- Assessment for relative energy deficiency in sport (RED-S) syndrome, particularly in female athletes or those in weight-sensitive sports 5
Timing and Frequency
Comprehensive screening evaluations should be performed every 2 years for high school athletes. 1 In intervening years, an interim history focusing on new symptoms, injuries, or family cardiac events is appropriate. 1
ECG and Echocardiography: When to Order
Routine ECG or echocardiography is NOT recommended for universal screening due to high false-positive rates, limited resources, cost-inefficiency, and potential for unnecessary anxiety and exclusion from sports. 1
Indications for Additional Testing
Order ECG or echocardiography when:
- Abnormal cardiovascular history (syncope, exertional chest pain, palpitations) 2
- Concerning family history of sudden cardiac death or inherited cardiac conditions 2
- Abnormal physical examination findings (pathologic murmur, absent femoral pulses, Marfan features) 2
If ECG is performed: In adolescents under 16 years, T-wave inversion in anterior leads (V1-V3) may represent a normal "juvenile ECG pattern" and should not prompt further evaluation in the absence of symptoms or family history. 2
Setting and Examiner Qualifications
The evaluation should be performed in a physician's office by a qualified healthcare provider, not in mass screening settings, to allow for adequate privacy, proper auscultation environment, and individualized assessment. 1, 5
Significant concern exists about 18 states that allow chiropractors or naturopathic clinicians to perform preparticipation examinations—these practitioners lack adequate training for cardiovascular screening. 1
Common Pitfalls to Avoid
- Failing to auscultate in standing position, missing dynamic outflow obstruction 2
- Inadequate family history, particularly not asking specifically about sudden death before age 50 2
- Relying solely on physical examination, which has limited sensitivity for detecting conditions like hypertrophic cardiomyopathy 2
- Not obtaining parental verification of the medical history in adolescents 1
- Performing examinations in noisy environments that preclude adequate cardiac auscultation 1
Clearance Decisions
Most athletes (>98%) receive full clearance for sports participation. 3 The most common reasons for restriction are:
- Musculoskeletal conditions (1% restricted, 5% requiring additional evaluation) 3
- Hypertension 4
- Visual acuity problems 4
When cardiovascular abnormalities are identified, refer to sport-specific eligibility guidelines based on the severity of the condition and the classification of the sport (static vs. dynamic intensity). 1