What medical evaluations and tests are required for a sports physical, particularly for patients with pre-existing medical conditions such as asthma (chronic obstructive pulmonary disease) or diabetes (diabetes mellitus)?

What to Check for a Sports Physical

A sports physical should include a focused cardiovascular and musculoskeletal history and examination, with additional testing reserved for high-risk individuals based on age, pre-existing conditions, and planned exercise intensity. 1

Core Components for All Athletes

Medical History (Highest Yield Component)

The medical history is the most important aspect of the sports physical and identifies the majority of disqualifying conditions 2, 3. Essential elements include:

• Family history of premature sudden death (age <50), heart disease, hypertrophic cardiomyopathy, or other inherited cardiac conditions 1, 4
• Personal cardiac symptoms: exertional chest pain, unexplained syncope or near-syncope, excessive dyspnea, palpitations, or dizziness with exercise 1, 4, 2
• History of heart murmur, hypertension, or known cardiac disease including valvular disease, congenital heart disease, or arrhythmias 1
• Pulmonary conditions: asthma or chronic obstructive pulmonary disease, particularly noting exercise-induced symptoms 1, 5
• Diabetes mellitus: type, duration, control, and history of hypoglycemia or ketoacidosis 1
• Musculoskeletal history: previous injuries, joint instability, arthritis, or mobility limitations 1, 3
• Medication use: particularly nonsteroidal anti-inflammatory drugs, stimulants, anabolic steroids, insulin, or sulfonylureas 1
• Prior exercise habits and any symptoms during physical activity 1

Physical Examination

Cardiovascular assessment (critical for sudden death prevention):

• Blood pressure measurement in both arms 1
• Cardiac auscultation in both supine/sitting AND standing positions to detect dynamic murmurs 4
• Bilateral femoral pulse assessment (absent or diminished pulses suggest coarctation) 4
• Evaluation for Marfan syndrome stigmata: arm span-to-height ratio, pectus deformity, joint hypermobility, lens dislocation 4

Musculoskeletal examination (second highest yield):

• Spine evaluation for scoliosis or other deformities 1, 3
• Joint range of motion, stability, and strength testing 1, 3
• Assessment of previous injury sites 3
• Functional movement screening 3

Other essential elements:

• Visual acuity testing 2
• Body mass index calculation 1, 2
• Respiratory examination for wheezes or adventitious sounds 1

Risk-Stratified Additional Testing

Young Athletes (<35 years, no known disease)

No routine ECG or stress testing is recommended if history and physical examination are normal 4. However, refer for cardiology evaluation with ECG and echocardiography if:

• Abnormal cardiac findings on examination (murmur that changes with position, absent femoral pulses) 4
• Positive family history of sudden death or inherited cardiac disease 4
• Concerning symptoms (exertional syncope, chest pain) 4

Older Athletes or Those with Risk Factors

Men ≥45 years or women ≥55 years planning vigorous exercise should undergo:

• Medical evaluation including history, physical examination, and risk factor profile 1
• Electrocardiographic stress test is recommended if they have diabetes mellitus OR ≥2 cardiovascular risk factors 1

Athletes with Pre-existing Conditions

Diabetes mellitus: A graded exercise test is recommended if the athlete meets ANY of these criteria 1:

• Age ≥35 years
• Type 2 diabetes duration ≥10 years
• Type 1 diabetes duration ≥15 years
• Any additional coronary artery disease risk factor present
• Microvascular disease (retinopathy, nephropathy including microalbuminuria)
• Peripheral vascular disease
• Autonomic neuropathy

Additional diabetes-specific testing 1:

• Fasting glucose and hemoglobin A1c
• Lipid profile
• Urinary protein by dipstick
• Retinal examination to stratify exercise restrictions based on retinopathy severity
• Assessment for peripheral neuropathy

Asthma/COPD:

• Baseline spirometry if not recently performed 1
• Assessment of exercise-induced symptoms and current control 1
• Evaluation of medication regimen and proper inhaler technique 5

Hypertension (if present): 1

• Lipid profile (total cholesterol, HDL, triglycerides)
• Fasting glucose and electrolytes
• Hemoglobin
• Urinary protein by dipstick
• 12-lead ECG (recommended but not mandated)
• Echocardiogram if stage 2 hypertension (systolic ≥160 or diastolic ≥100 mmHg) to distinguish physiological from pathological left ventricular hypertrophy

Common Pitfalls to Avoid

• Do not skip the history: 58% of disqualifications are based on history alone, making it more valuable than the physical examination 2
• Do not perform routine ECG screening in low-risk young athletes: This is not recommended and can lead to false positives 4
• Do not clear athletes with concerning symptoms without further workup: Exertional syncope, chest pain, or unexplained dyspnea require cardiology evaluation before clearance 1, 4
• Do not overlook diabetes duration: Even well-controlled diabetes requires stress testing if duration thresholds are met 1
• Do not restrict athletes with active proliferative diabetic retinopathy from all exercise: They should avoid anaerobic exercise and activities involving straining, jarring, or Valsalva maneuvers, but can participate in other activities 1
• Asymptomatic status does not guarantee safety: Athletes must be educated to report new symptoms immediately and return for reevaluation 4