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The importance of sports health check-ups
(by C. Goggin, J. Galcera, F. Galvan, M. Castillo Martinez, E Pechenkin,)
How many coaches and instructors reading this are aware of the health status of the athletes they are training? How many are training athletes who should not be involved in certain sports at all on medical grounds? How many coaches realise that they have a legal obligation to have key medical data on their athletes from a Duty of Care perspective?

Over the last couple of years and last few weeks in particular, the country’s media has given significant coverage to the sudden death of a small number of young athletes. On one hand this has made people think a little bit more about their own health or that of their children, but it has to be said that it has also caused unnecessary fear among parents that their children might drop dead suddenly. One of the main medical conditions that has attracted such attention is called hypertrophic cardiomyopathy (HCM). We would have to examine 200,000 children and adolescents to find 1,000 that might be described as “at risk” and then only one of those would actually die. That is to say 0.0005% of those examined. Having said that, it is thought that 1 in 500 people might have the condition.
The purpose of the sports health check-up is three-fold. Primarily it is to try and identify underlying medical conditions that may limit sports participation or place the athlete at increased risk. For example, the condition exercise-induced bronchospasm (EIB) is undiagnosed in up to 20% of athletes and can have catastrophic consequences. It is present in 40% of athletes with hay fever.
Secondly, the check-up tries to identify physical deficiencies that may increase the risk of injury for the athlete. For example, an incompletely rehabilitated ankle sprain or instability of the knee or shoulder. When such is identified a suitable rehabilitation programme should be given to the athlete.
Finally, it provides an opportunity for health promotion, giving the chance to discuss health related issues with the athlete. It also allows for interaction between adolescents and a health care professional and, as over 50% of adolescents never come into contact with the health care system during their development, this can be a significant aspect of the check-up. Given the chance, many teenagers will voice concerns or worries that they may have about their health. Something they might find very difficult with a parent.
The sports health check-up has two distinct parts. First is the personal and family health history, and second is the examination itself. The importance of the health history cannot be underestimated. If questions are answered honestly on the health questionnaire, it is capable of revealing up to 75% of conditions that may affect the athlete’s sports participation. It is actually more sensitive in many ways than the examination itself in this regard. The family history is extremely important in evaluating the risk of serious heart conditions such as HCM, Marfan’s syndrome (a connective tissue disorder that can affect the heart and lungs as well as other structures and organs), and Long QT syndrome (a disorder of the heart’s electrical system). However, more than 60% of teenage athletes do not complete the health questionnaire honestly. It light of this it is extremely important to stress to athletes that the overriding purpose of the sports health check-up is to protect them from possible future harm. It is essentially, for their own safety and protection.
The health history focuses primarily, though not exclusively, on the cardiovascular, musculoskeletal, and the neurologic systems. Key questions that should be asked are about:-
details of fainting during or after exercise
history chest pain during exercise
details of excessive tiredness
history of heart murmurs
history of high blood pressure
family history of sudden cardiac death
history of rheumatic fever
history of recent infections
wheezing or difficulty in breathing during or after exercise
coughing during or after exercise
history of concussion or head injury
history of numbness or pins & needles
recurrent headaches
previous sprains, fractures or dislocations
history of heat illness *
[Some sports organisations in Ireland are bringing their athletes to training camps or competitions overseas. However, travelling to warmer climates can pose serious threats to athletes who are unaccustomed to competing in hot conditions. The two leading causes of non-traumatic and non-heart-related deaths in sport are exertional hyperthermia and exertional rhabdomyolysis. When body temperature goes above 40OC it becomes life-threatening. At 41OC brain death begins, and at 45OC death is almost certain. Rhabdomyolysis is the breakdown of skeletal muscle that can lead to acute kidney failure and death].
With respect to the physical exam, the focus is on, but is not restricted to, the same three systems as in the health history. With some sports it is also important to monitor an athlete’s weight-to-height ratio as within weight classification sports, some athletes may use unsafe methods of weight control such as the use of diuretics to lose weight or steroids to increase weight. Such monitoring may also alert the examiner to eating disorders among athletes and consequently appropriate professional referral may be made if such conditions are thought to be present.

Key aspects of the cardiovascular exam should include blood pressure, peripheral pulse palpation (check), and auscultation of the heart (listening with a stethoscope). If the history or the physical exam raises concern to the examiner then the next stage in the evaluation is referral for a chest x-ray and electrocardiogram (ECG), but other tests might include stress testing and echocardiography. Nonetheless, an ECG is recommended in the following situations:-
the athlete is over 40 years of age
history of heart disease, previous arrhythmia (irregular heartbeat), or fainting
family history of sudden cardiac death or cardiac abnormalities
the athlete has diabetes

From a muscle and bone point of view, the concentration is on looking at the range of motion and symmetric strength of the major joints. In juvenile athletes the exam tries to identify bone related disorders, some of which are largely self-rectifying but others may require surgery or at the very least a consultation with an orthopaedic surgeon. These conditions mostly affect the spine, shoulder, elbow, hip, knee, ankle and toes. They include scoliosis, kyphosis, lordosis, Panner’s disease, bursitis, avulsion fractures, osteitis pubis, hernia, Perthes’ disease, slipped capital femoral epiphysis, stress fractures, Sinding-Larsen Johansson syndrome, Osgood-Schlatter’s disease, Pellegrini-Stieda’s disease, Sever’s disease, and Freiberg’s disease. It is extremely important that a juvenile athlete who has groin pain is medically assessed each time due to the number of possible causes of such pain. It should NEVER be assumed that groin pain in children and adolescents is simply a “groin strain”.

The neurologic exam should look at reflexes, pupil response and symmetry*, and with respect to contact sports, head injury baseline data is absolutely essential.
[* Some people have unequal pupils (anisocoria – shown right) and in most cases it is perfectly harmless. However, this must be documented for athletes in contact sports during a sports health check-up because unequal pupils as a result of a head injury is potentially an extremely serious sign, possibly requiring brain surgery within one hour].
Other aspects of the exam include an abdominal exam to rule out an enlarged liver or spleen. These conditions often accompany glandular fever, a common condition among adolescents and college students, (it is also known as the ‘kissing disease’ after all!). A check of visual acuity is also important, most especially for martial arts and boxing athletes. For example, an athlete with less that 20/60 vision in either eye would be prohibited from participation in many martial arts.
Genital exams are not routinely carried out on female athletes unless their health histories would indicate a value in doing so. Male genital exams are typically undertaken to rule out (1) undescended testes, (2) growths on the testes, and (3) hydroceles/spermatoceles (collections of fluid). All three require medical attention. It is also a valuable opportunity of teaching adolescents about the value of testicular self-examination.
Take a look at the list of medical conditions below where it is indicated whether it is safe or not to participate in sport at a given time or at all. You will notice immediately the number of times when an athlete would need a medical consultation before they can participate safely.
Bleeding disorders Needs medical evaluation before participation
Inflammation of the heart May NOT participate
High blood pressure Needs medical evaluation before participation
Congenital heart disease Needs medical evaluation before participation
Irregular heart rhythm Needs medical evaluation before participation
Heart murmur Needs medical evaluation before participation
Diabetes May participate
Diarrhoea May NOT participate
Eating disorders Needs medical evaluation before participation
Eye injury Needs medical evaluation before participation
(a repaired detached retina would prevent participation)
Epilepsy May NOT participate in contact martial arts unless cleared
to do so by a neurologist specialising in epilepsy.
Fever May NOT participate
History of heat illness Needs medical evaluation before participation
Hepatitis May participate
HIV May participate
Hydrocele/spermatocle Needs medical treatment before participation
Adsence of a kidney Needs medical evaluation before participation
Enlarged liver Needs medical evaluation before participation
Malignant growths Needs medical evaluation before participation
Neurologic disorders Needs medical evaluation before participation
Obesity Needs medical evaluation before participation
Organ transplant recipient Needs medical evaluation before participation
Absence of one ovary May participate
Respiratory conditions Needs medical evaluation before participation
Sickle cell disease Needs medical evaluation before participation
Sickle cell trait May participate
Skin disorders Needs medical evaluation before participation
Ligament sprains Needs a rehabilitation programme before participation
Enlarged spleen Needs medical evaluation before participation
Absence of one testicle Needs medical advice before participation
How are sports health check-ups arranged? Generally, the check-ups can be undertaken at a club’s premises is a suitable room is available. Suitable means not freezing cold, it should be well lit, very clean, and there should be access to running water nearby, though not coming through the roof as we experienced recently! Club coaches are given copies of the Health History Form for each athlete to complete and an appointment sheet where the coach should allocate a time for each athlete to attend. Generally it takes 15 minutes for the check-up to be completed but it is important that the health history is completed in advance of the check-up and brought along to it. The working day for Sports Medicine Ireland personnel is from 9.00am to 9.00pm, so we can examine an average of 50 athletes in a day. The cost of the sports health check-ups undertaken by Sports Medicine Ireland for 2007 is €20.00 per athlete. Your family GP can also undertake these examinations but the cost is likely to be higher. Please feel free to ask us for a copy of the medical form that should be completed for athletes if you are attending your GP for the examination. Sports health check-ups (just like pre-employment medicals) cannot be charged against medical cards according to the latest information from the Department of Social Welfare.
Sports Medicine Ireland is already heavily booked up for undertaking these sports health check-ups. If you are interested in these check-ups for your athletes, please contact us promptly. Further details are available by e-mail at medicals@sportsmedicineireland.org
The above article supplied by: corkcourse@sportsmedicineireland.org