What is required for a sports physical examination?

What is Needed for a Sports Physical?

A sports physical requires a comprehensive 14-element cardiovascular screening that includes a detailed personal and family history plus a focused physical examination with blood pressure measurement, cardiac auscultation in multiple positions, assessment for Marfan syndrome stigmata, and femoral pulse evaluation. 1

Core Personal History Elements

The American Heart Association mandates specific cardiovascular screening questions that must be asked 2:

• Exertional chest symptoms: Ask about chest pain, discomfort, tightness, or pressure specifically related to physical activity 1
• Syncope or near-syncope: Inquire about any unexplained fainting or near-fainting episodes, particularly during or after exercise 1
• Exercise intolerance: Evaluate for excessive and unexplained dyspnea, fatigue, or palpitations during exercise that seem disproportionate to the activity level 1
• Prior cardiac findings: Determine if there has been previous recognition of a heart murmur or elevated blood pressure 1
• Previous restrictions: Ask if the athlete has ever been restricted from sports participation or had cardiac testing ordered by a physician 1

Parents must complete the history form for high school and middle school athletes to ensure accuracy, as young athletes may lack the medical knowledge or compliance to provide reliable information 2.

Family History Requirements

The family history component is critical for identifying inherited cardiac conditions 1:

• Premature cardiac death: Ask about sudden and unexpected death before age 50 attributable to heart disease in any relatives 1
• Early cardiac disability: Inquire about disability from heart disease in close relatives under age 50 1
• Specific genetic conditions: Screen for family history of hypertrophic or dilated cardiomyopathy, long-QT syndrome, other ion channelopathies, Marfan syndrome, or clinically significant arrhythmias 1

Physical Examination Components

Cardiovascular Assessment

The physical examination must include specific cardiovascular elements 2:

• Blood pressure measurement: Measure brachial artery blood pressure in the sitting position, preferably in both arms 1
• Cardiac auscultation: Carefully auscultate for heart murmurs in BOTH supine/sitting AND standing positions to identify dynamic left ventricular outflow tract obstruction, which may only be audible with positional changes 1, 2
• Femoral pulses: Check femoral pulses to exclude aortic coarctation 1
• Marfan syndrome screening: Look for physical stigmata including tall stature, arm span exceeding height, pectus deformities, joint hypermobility, and lens dislocation 1

Musculoskeletal Examination

While cardiovascular screening receives the most attention, musculoskeletal problems are actually the leading cause of sports restriction (43.4% of disqualifications) and should not be overlooked 3. The musculoskeletal examination should assess joint stability, range of motion, and prior injuries 4.

Who Should Perform the Examination

The examination should be performed only by physicians or healthcare workers with requisite training, medical skills, and background to reliably recognize or raise reasonable suspicion of heart disease 2. While licensed physicians are preferable, nurse practitioners or physician assistants formally trained in physical examination techniques may perform these evaluations 2. The American Heart Association specifically warns against the practice in 18 states that allow chiropractors or naturopathic clinicians to perform these examinations, as they lack formal professional training for this activity 2.

Timing and Frequency

• Initial screening: A comprehensive evaluation should be mandatory before initial engagement in organized competitive sports 2
• High school athletes: Repeat comprehensive screening every 2 years 2
• College athletes: Complete history and physical examination on matriculation, then interim history with blood pressure measurement in each of the subsequent 3 years 2

Role of Additional Testing

ECG and Echocardiography

Routine ECG and echocardiography are NOT recommended for universal screening in the United States 2. The American Heart Association concluded that widespread noninvasive testing would result in false-positive results well in excess of true-positives, creating unnecessary anxiety and potential for unjustified exclusion from competition 2. However, these tests remain optional and may be considered in individual cases or local screening programs 2.

Additional testing should be pursued when the history or physical examination reveals abnormalities 1. The presence of concerning symptoms (syncope, chest pain with exertion) or family history of sudden cardiac death should trigger more comprehensive evaluation 1.

Special Considerations for Older Athletes

For competitive athletes aged 35-40 years or older, exercise stress testing may be useful in men ≥40 years (women ≥55 years) who have 2 or more coronary risk factors (other than age and gender), or possibly a single markedly abnormal risk factor 2. These athletes should also be cautioned about the significance of prodromal cardiac symptoms like exertional chest pain 2.

Common Pitfalls to Avoid

• Inadequate auscultation: Failing to perform cardiac auscultation in both supine and standing positions can miss dynamic outflow tract obstruction characteristic of hypertrophic cardiomyopathy 1
• Relying solely on physical examination: The standard history and physical examination lack the power to reliably identify certain potentially lethal cardiovascular abnormalities, as many conditions (like hypertrophic cardiomyopathy) often have no audible murmur at rest 1, 2
• Incomplete family history: Not obtaining adequate family history, particularly regarding premature cardiac death or inherited cardiac conditions, represents a critical missed opportunity 1
• Poor examination environment: Examinations should be conducted in a physical environment conducive to optimal cardiac auscultation 2

Laboratory and Urine Testing

U.S. medical and athletic organizations discourage routine screening blood and urine testing in asymptomatic athletes 4. These tests should only be performed when clinically indicated based on history or physical examination findings.