Sports Physicals & PPE

The Preparticipation
Physical Exam
Jennifer A. Southard, MD, MSc
Saint Alphonsus Medical Group
Family Medicine and Sports Medicine
NP Idaho Fall Conference
August 24, 2013
Discuss purpose and timing of PPEs
Give Overview of PPE
Review 3 key areas: CV, Ortho, Neuro
Identify conditions which warrant further
investigation prior to allowing participation
Discuss populations of athletes with special
Discuss clearing athletes for participation
Purposes of the PPE
Objectives of the PPE
Primary Objectives
1. Screen for conditions that may be life-threatening or
2. Screen for conditions that may predispose to injury or
Secondary Objectives
1. Determine general health
2. Serve as an entry point to the healthcare system for
3. Provide opportunity to initiate discussion on healthrelated topics
What the PPE is NOT:
PPEs should NOT replace routine health care
or comprehensive physicals
– The PPE is a screening tool to determine fitness for
athletic participation
– The PPE often takes place in a format which does
not allow adequate time for anticipatory guidance
– The PPE often takes place in a format which does
not provide adequate privacy to discuss
confidential issues
Frequency and Timing of the PPE
Ideally do PPEs 4-6 weeks before athlete’s
season to allow for eval/treatment of problems
NFHS: PPE necessary - but leaves to states to
mandate & standardize
NCAA recommends & most institutions require
annual exams
Youth / club sports - no formal requirements
Effectiveness of PPE
Unknown as to:
Effectiveness of PPE as a screening
– Lack of efficacy data for PPE
– Little effect on morbidity & mortality
Ability of PPE to affect outcomes
Detect risk for catastrophic events
Is the PPE a good screening tool?
Significant burden of disease in population
Preclinical stage is detectable and prevalent
Early detection improves outcome (mortality)
with acceptable morbidity
Screening tests are acceptable to population,
inexpensive, and relatively accurate
Effective treatment available for detected
Approaches to the PPE
Historically: the HHH exam
– Hi, how are ya?
– Heart
– Hernia
Approaches to the PPE
Office Based: maximizes privacy, allows single
examiner to complete entire exam, but inefficient for
large groups of people. Recommended method
Locker-Room Approach: allows for one examiner to
complete each part of the PPE but is also inefficient
for large groups and does not allow for privacy
Station-Based: requires multiple examiners, each
doing a different part of the exam. Improves
efficiency and privacy
The History and Physical
PPE: The History
History forms are very helpful
– athletes and parents should jointly complete a history form
prior to the PPE
– Review form: 75% of issues detected through Hx alone
Web based history forms may be more convenient for
the athletes (ePPE)
Preparticipation form recommended by the AAFP,
AAP, AMSSM, and AOSSM is available in the
Preparticipation Physical Evaluation, 4th ed. 2010.
The Cardiovascular History
Screening for conditions that predispose to Sudden
Cardiac Death
Most common cause of SCD in US athletes <30 is
AHA Guidelines
Circulation, 2007
Personal History
– Exertional chest
– Syncope/nearsyncope
– Excessive fatigue
– Prior murmur
– Elevated BP
Family history of:
– Premature CV
– CV disease <50yo
– Specific conditions
(ie Marfans, Long
QT, HCM, etc)
Maron BJ et al. Circulation 2007;115:1643-1655
AHA Guidelines
A positive finding on >=1 element on
history is sufficient to warrant further
CV investigation
Might include ECG, ECHO, Stress test
or referral to cardiology
The Neurologic History
At each PPE, athletes should be asked about
previous neurologic problems:
Prior concussions
Previous neck injuries
Previous history of stingers/burners
Seizure history
Current neurologic symptoms (numbness,
tingling, weakness, etc.)
– Current learning/emotional problems
Neurologic History
Consider baseline neurocognitive
studies in athletes who have a
history of:
– Multiple concussions
– School performance problems
– ImPACT testing available to all Boise
Public HS students, free, or $15 via
The Musculoskeletal History
Complete history of musculoskeletal injuries
is important
– Operations
– Time lost from play
– Prior rehab
Ongoing musculoskeletal complaints
– Require a more complete history
– Deserve detailed evaluation
Screening for the Female Athlete Triad
All female athletes should be screened for the
Female Athlete Triad
Provider Knowledge
 240 health care professionals (physicians, medical
students, physical therapists, athletic trainers and
coaches) were surveyed to determine their
knowledge and comfort in treating the condition
 Results
– 48% of physicians, 43% of therapists, 38% of
trainers, 32% of medical students and 8% of
coaches could identify all 3 components
– Only 9% of physicians felt comfortable treating
the disorder
Troy K, Hoch A, Stavrakos, J. Awareness and comfort in treating the
female athlete triad: are we failing our athletes? Wisconsin Medical
Journal. 2006;105(7): 21-24.
Female Athlete Triad History
• Not a new entity – various
components have been noted for
• Defined in 1992 by American College
of Sports Medicine
• ACSM developed a Position
Statement in 1997
• revised statement in 2007
1997 ACSM Position Statement
• Syndrome that can
develop in
physically active
girls and women
with three
• Disordered eating
• Amenorrhea
• Osteoporosis
Otis CL, Drinkwater B, Johnson M, et al. American College of Sports
Medicine Position Stand: The female athlete triad. Med Sci Sports
Exerc 1997; 29(5): i-ix.
The Female Athlete Triad Today
• 2007 ACSM Definition (Renamed
• Disordered Eating
• Menstrual Dysfunction
• Low Bone Mineral Density (BMD)
• Greater emphasis on the full spectrum
of behaviors and conditions within a
given disorder.
• The original version focused more on
the extreme end point of each disorder.
Beals, K & Meyer, N. Female athlete triad update. Clin Sports
Med, 2007;26:69-89.
Who is at Risk?
• “Potentially all physically active girls and women
could be at risk for developing 1 or more
components of the Triad”
• Sports that emphasize low body weight
• Subjective scoring of performance (figure
• Endurance sports (distance running)
• Body contour-revealing clothing (track,
cheerleading, volleyball)
• Weight categories (wrestling, horse racing)
• Emphasis on prepubertal body habitus
• Male athletes are also at risk for disordered eating
and anorexia nervosa
• Disordered Eating: 8% - 62% depending on
population studied.
• More prevalent in sports that emphasize lean
physique BUT seen in all sports
• Athletes 2.6x more likely than non-athletes to
manifest DE Sx
• Burckes-Miller et al: Study 695 NCAA Div I
• 3% met criteria for anorexia nervosa
• 21% bulemia
Burckes-Miller ME, Black DR. Male and female college athletes: prevalence of
anorexia nervosa and bulimia nervosa. Athl Train J Natl Athl Train Assoc. 1988;23:
• Menstrual Dysfunction: 6% - 79%
depending on definitions used in study
• Prevalence of secondary amenorrhea in
adult female collegiate athletes reported
at 14-66% compared to 2-5% of the
general population
• Low Bone Mineral Density: 22% - 50%
(mainly osteopenia)
Nattiv A, Agostini R, Drinkwater B, Yeager KK. The female athlete triad. The interrelatedness of disordered eating, amenorrhea, and osteoporosis. Clin Sports Med 1994; 13:
Prevalence of the Triad
 Only 3 studies have examined all 3
disorders using direct measures of BMD in
female athletes (DEXA)
 The prevalence of all three components
simultaneously: 0.4% - 2.2%.
 Although prevalence small, presence of
any of the three should warrant further
provider investigation
Beals, K & Meyer, N. Female athlete triad update. Clin Sports
Med, 2007;26:69-89.
 In the 1970’s low body weight or low
body fat was thought to be the
primary cause of amenorrhea
 Exercise-stress hypothesis
 Deficit in energy availability
Hypothalamic Dysfunction
 Disruption of
hypothalamic-pituitaryovarian axis
– Decrease in pulsatile
GnRH disrupts pituitary
secretion of LH and FSH
– Disruption of LH and FSH
pulsatility shuts down
stimulation to the ovary,
ceasing production of
What causes hypothalamic
 Deficit in
Energy Availability
 Dietary energy intake minus exercise
energy expenditure OR
 The amount of dietary energy remaining
after exercise training to support
physiological processes
Loucks A & Nattiv A. The female athlete triad. Lancet 2005;
Disordered Eating
 Includes a wide spectrum of unhealthy
eating behaviors
– Skipping meals or limiting calorie intake
– Restricting certain foods such as those
high in fat or protein
– Binge eating or purging
– Diet pills, laxatives, diuretics
– Anorexia nervosa
– Bulimia nervosa
Disordered Eating
 May be intentional
or unintentional
– Lose a few
pounds before
an event
– “Inadvertently
failing to balance
with adequate
energy intake”
2007 ACSM Definition:
Menstrual Dysfunction
 Includes the full spectrum of menstrual
 Luteal suppression
 Anovulation
 Oligomenorrhea
 Amenorrhea
 Primary – redefined by American Society of
Reproductive Medicine as absence of menstruation by
15 years of age in girls with secondary sex
 Secondary – absence of 3 consecutive cycles
Beals, K & Meyer, N. Female athlete triad update. Clin Sports
Med, 2007;26:69-89.
Menstrual Dysfunction
 Prevalence studies
 Wide range (2-35%) of prevalence estimates
can be explained by methodologic differences
among studies
 differences in athletic populations studied
 failure to control for OCP use
 assessment and definition of menstrual
 Despite differences, menstrual dysfunction is
more prevalent in sports that emphasize
 Menstrual dysfunction is NOT a normal part of
Beals, K & Meyer, N. Female athlete triad update. Clin
Sports Med, 2007;26:69-89.
2007 ACSM Definition:
Low Bone Mineral Density
 Emphasis has been placed on the full
spectrum of bone health.
 Low bone mass
 Stress fractures
 Osteoporosis
 Bone strength is characterized by bone
mineral content and density as well as
quality of bone
 Bone quality refers to the process of bone
Beals, K & Meyer, N. Female athlete triad update. Clin
Sports Med, 2007;26:69-89.
Bone Health
 Estrogen suppresses osteoclast activity
 Female athletes have higher BMD than nonathletic
counterparts UNLESS they have menstrual
 Bone density declines in proportion to the number of
menstrual cycles missed
 Myburgh and colleagues showed a direct correlation
between time spent amenorrheic and number of
stress fractures
 Low bone mineral density may be irreversible
resulting in a lifetime lower bone density
 Multiple studies show irreplaceable bone loss after 3
years amenorrhea
 Risk of stress fractures is two-four fold higher in
athletes with menstrual disturbances compared to
those without
Bone Health
 Females gain more than
50% of skeletal mass
during adolescence and
reach peak bone mass
between 18 and 25
years of age
 Young women menstrual
dysfunction during these
years are at risk for
losing 2% of bone mass
annually instead of
gaining 2-4%
Bone Density
 Consider DEXA for
the following:
 Amenorrheic >
one year
 BMI < 19
 Documented
history of stress
Lo B, Hebert C, McClean A. The female athlete triad, no
pain, no gain? Clinical Pediatrics 2003; 42(7) 573-580.
How Should Athletes be evaluated
for the Triad?
Evaluation Options
 History Questionnaire (easy and
 All
 Blood Tests (measure ovarian steroid
 High Risk
 Dual Energy X-ray Absorptiometry
 High Risk
 Female Athlete Triad Coalition
Screening Questionnaire (ACSM and
– 12 Questions
– Sensitivity 91.5%
– Specificity 74.2%
– False Positive 25.8 %
– False negative 38.5%
Black DR, et al. Physiologic Screening Test for Eating Disorders/Disordered Eating Among
Female Collegiate Athletes. Journal of Athletic Training. 2003:38; 4; 286-297.
IHSAA PPE Questions (3/12 similar
 When was your first menstrual
 When was your last menstrual
 What was the longest time between
periods last year?
9 questions not on IHASS PPE
 Do you worry that you have lost
control over how much you eat?
 Do you make yourself vomit, use
diuretics or laxatives after you eat?
 Do you currently or have you ever
suffered from an eating disorder?
 Do you ever eat in secret?
 Have you ever had a stress fracture?
9 questions not on IHASS PPE
 Are you unhappy with your weight?
 Are you trying to gain or lose
 Has anyone recommended you
change your weight or eating habits?
 Do you limit or carefully control what
you eat?
Laboratory Evaluation
 CBC, CMP, ESR, Ferritin, VitB12, Folate, UA
 EKG and/or echocardiogram if abnormal cardiac
 Pregnancy test for amennorhea
 LH, FSH to rule out premature ovarian failure
 Prolactin to rule out pituitary tumor
 Consider imaging
 If hirsutism, free testosterone, DHEA-S, 17hydroxy-progesterone to screen for adrenal or
ovarian tumors
 Progesterone Challenge
 Medroxyprogesterone 5-10 mg for 5-10 days
Lo B, Hebert C, McClean A. The female athlete triad, no pain, no gain?
Clinical Pediatrics 2003; 42(7) 573-580.
Treatment Goal
 Restore reproductive and metabolic
hormones by increasing energy availability
 Increase energy intake
 Reduce energy expenditure
 Weight gain of 1-2 kilograms (or 23%) or 10% decrease in exercise load
in either duration or intensity is often
sufficient to reverse reproductive
Loucks A & Nattiv A. The female athlete triad. Lancet 2005; 366:549-550
Treatment Options
 Educate
 Correct energy deficit
– Increase calories by 10% per week until
target is reached.
– Decrease activity levels to assist in
correcting energy deficit.
– Limit weight gain to 1-2 pounds per
Treatment Options
 Add Calcium and Vit D supplement
 Treatment for osteoporosis with
bisphosphonates and calcitonin has
not been tested in younger patients,
nor patients with female athletic
Hormone Therapy
 No published longitudinal studies available on
long term benefits of HRT to slow or reverse
loss of BMD
– Longest studies currently available 60
– Several good studies show irreplaceable
bone loss occurs after three years of
 Minimal 4-11% BMD increases have been
noted in women with hypothalamic
amenorrhea on oral contraceptives
– increases in BMD of 6-17% have been seen
with spontaneous reversal of amenorrhea
– Increases slow to 3% following year and
plateau at BMD well below normal for age
Goodman, L & Warren, M. The female athlete and menstrual function.
Adolescent and Pediatric Gynecology. 2005;17(5): 466-470.
Hormone Replacement
 Retrospective study of amenorrheic runners
compared HRT with placebo over 24-30 months
 Combined estrogen and progesterone
 Pt’s on HRT showed 3.7% increase in BMD
 Pt’s in control showed decrease of 2.4% BMD
 In women who have not responded to nonpharmacological treatment, initiate therapy
with low-dose oral contraceptive to raise
estrogen concentrations and prevent further
bone loss
 Progesterone should be included in any tx
regimen to prevent endometrial hyperplasia
Cumming DC. Exercise-associated amenorrhea, low bone density, and estrogen replacement
therapy. Arch Intern Med 1996; 156: 2193-5.
Treatment of Eating Disorder
 Depending on severity SSRI may be
 Avoid bupropion because risk of sz
 TCAs and MAOIs cold be toxic in
underweight pts
 Consider Cognitive Behavioral
 Consider psychiatric evaluation
Treatment of Eating Disorder
– Recovery rates vary between 23% and
50%, and relapses range from 4% to
– Even for those who recover, one study
indicated that recovery took between
four and nearly seven years.
– Depending on the duration of the study,
anorexic patients have reported death
rates ranging from 4% to 25%.
 Educational programs targeting coaches,
athletes, parents, athletic trainers, school
– Currently there is a lack of such
 Nutrition education
– Emphasis should be placed on concept
of food as energy for training and
recovery rather than on body weight
 NCAA Handbook: “Managing the Female Athlete
 Academy for Eating Disorders:
 International Olympic Committee Position Stand on
the Female Athlete Triad:
 Female Athlete Triad Coalition:
 National Osteoporosis Foundation:
 National Eating Disorders Association:
Other Important Historical Issues
Respiratory- h/o asthma or allergic problems
Infectious- h/o HBV, HCV, HIV, EBV
Derm- Herpes gladiatorum, current rashes
Hematologic- Sickle Cell, bleeding disorders
Endo- diabetes
Other- prior heat-related illness, sickle trait
The Physical
Each PPE should include vitals, examination
of HEENT, CV, RESP, ABD, GU (males only),
MSK, DERM, and NEURO systems
Forms, such as the one published in the
Preparticipation Physical Evaluation, 4th ed. , 2010,
may be helpful.
The Physical
General: Attention for excessive height, Marfanoid
Vitals: especially important to check BP. Also Ht,
Wt, BMI.
Pediatric age and height percentile BP graphs
HEENT: Visual acuity, pupils, conjunctivae, lenses,
ear exam, oropharyngeal exam
If unable to correct to better than or equal to 20/40 in each
eye, need further evaluation and eye protection
RESP: resp effort, wheezes, crackles, etc.
ABD: masses, splenomegaly
The Physical
CV: Auscultation, Femoral/Radial pulses, BP,
provocative maneuvers for HCM
– Systolic Murmur that increases in
volume/intensity with Valsalva or with going from
supine  seated
– Murmur of HCM will diminish with squatting or
other maneuvers to increase venous return to the
Hypertrophic Cardiomyopathy
Further Eval.: CV Findings
Findings requiring further evaluation:
Systolic Murmur that is 3/6 or greater
ANY diastolic murmur
ANY murmur which increases in intensity with Valsalva
Any FH of SCD or predisposing condition (Long QT,
Marfans, AVRD, HCM) or worrisome personal hx
The Hypertrophic Cardiomyopathy Murmur:
– Cres-Decres systolic murmur heard best at LLSB
– Increases with maneuvers to decrease venous return (eg
Valsalva, lying to standing)
– Decreases with maneuvers to increase VR (ie squatting)
The Physical
GU (males only): hernia, mass, undescended
testicle. Instruction on TSE
Derm: Rashes, lesions
Neurologic: strength testing incorporated into
MSK exam; more extensive evaluation
required for pts with neurologic complaints
Extremity: arachnodactyly
The Physical
The Musculoskeletal Exam:
– Asymptomatic pts: General Screening Exam only
– Pts with specific complaints: Gen. Screening Exam
PLUS a joint specific exam
– Sport Specific Exam: consider doing a more
complete joint exam for commonly injured joints
(Shoulders in swimmers and throwers, Knees in
athletes who do cutting maneuvers, etc.)
Beyond the Physical
Are more tests necessary?
“A thing is worth precisely what it can do
for you not what you choose to pay for it”
JOHN RUSKIN (1819-1900)
Beyond the Physical: Screening Labs?
Screening labs are NOT recommended at routine PPE’s
Some sport governing bodies require lab tests for
performance enhancing substances
NCAA requires sickle trait screening
Captive adolescents: should we screen for STIs?
– Recent paper in J Adol Health found the following:
Males 2.8% + for chlamydia, 0.7% + for gonorrhea
Females 6.5% + for chlamydia, 2.0% + for gonorrhea
93.1% of all positives reported NO SYMPTOMS.
Nsuami M et al. J Adolesc Health, 2003, p336-339.
Beyond the Physical:
Screening CV Studies?
The Italians:
– Since 1982 Italy has screened ALL athletes with
PPE, EKG, as well as Stress tests and ECHO’s for
Elite/Olympic athletes
– 2.5% of all athletes screened were disqualified,
51% due to CV probs.
Beyond the Physical:
Screening CV Studies?
Baseline rate of SCD prior to
initiation of screening protocol was
After initiation of screening, rate of
SCD fell to 0.4/100000 (89%
Sounds really compelling for routine
use of ECGs, right?
Corrado D et al. JAMA 2006;296(13):1593-1601.
But Italy is not the USA…
Risk of SCD Now Equivalent in
Italy and US
2001-2006 Risk of SCD in US is
In Italy, the EXCESS risk from SCD
(3.6/100000) was related to ARVD
By doing EKG/ECHO, the risk to
Italian athletes is reduced to a
comparable risk that exists in the US
Maron BJ et al. Circulation,
Beyond the Physical:
Screening CV Studies?
Lausanne Recommendations of the
European Society of Cardiology,
– Similar screening questions to AHA
– Similar physical screening exam to AHA
– Adds 12-lead ECG after onset of puberty
for all athletes
Endorsed by IOC
Beyond the Physical:
Screening CV Studies?
AHA recommends against cardiovascular
screening of asymptomatic athletes with ECG or
Not practical for mass, universal screening
– Size of athlete cohort (huge)
– Prevalence of disease (low)
– Limited resources ($$, personnel)
– Absence of physician workforce to interpret
– Potential to create anxiety with False positive
results (morbidity)
Beyond the Physical:
Screening CV Studies?
Feinstein et al. in 1993 did 1570 ECHOs on
asymptomatic athletes, found no conditions
which would preclude competition, at a cost
of $500/test
Epstein and Maron estimated in 1986 that
ECHO alone would prevent 1 death per
200,000 athletes, at a total cost of
$100,000,000 per life saved
Beyond the Physical:
Screening Neurologic Studies?
Currently, the NHL, NFL, many colleges, and
increasing numbers of high schools require
screening neuropsychological testing for
athletes involved in contact/collision sports
Preseason neuropsych testing allows each
individual to provide his/her own control for
comparison should a head injury occur during
the season
ImPACT testing for BPS athletes
Further Eval: Prior Head Trauma
Prior concussion is an independent risk factor
increasing risk for subsequent concussion
Recurrent concussion increases risk for learning,
emotional, and cognitive problems
In pts with h/o concussion, consider baseline
neuropsychological evaluation
Consider neuropsych eval in kids with school
performance problems (baseline study)
Further Eval: MSK Injuries
Findings of new/recent injuries on PPE
deserve appropriate evaluation and treatment
Findings of inadequately rehabilitated injuries
on exam should be followed up for several
– Risk of re-injury or injury to others
– Risk of long term complications (arthritis, etc)
Athletes with Special Considerations
Special Populations of Athletes
Athletes with Down’s Syndrome
Paralympics / Handicapped Athletes
Athletes with one-organ or functionally oneorganed
Athletes s/p transplant
Athletes with specific medical problems:
bleeding disorders, infectious diseases, etc.
Athlete’s with Trisomy 21
Cardiovascular Abnormalities
– 50% of children with Down Syndrome have congenital
heart disease
– Occurs in 15% of kids with T-21
– Should be screened annually
Atlantoaxial Instability
– Should be screened for with flex/ext C-spine films at age 3
– Required for participation in Special Olympics or contact
The Functionally
One-Organed Athlete
Concern is for damage to the “good” organ:
– Ophtho: athletes with one eye or whose best corrected
vision is worse than 20/40
Recommend appropriate protective equipment
– Renal: athlete’s s/p nephrectomy
Recommend appropriate protective equipment
– GU: male’s s/p orchiectomy
Recommend appropriate protective equipment
Bottom Line- we are ALL one-organed athletes
competing w/ 1 brain, liver, pancreas, etc.
We’ve Got Clearance, Clarence
Clearing Athletes for Participation
3.1% to 13.9% of athletes are initially not cleared
pending further evaluation.
Ultimately, 0.3% to 1.3% are denied clearance
Options for Clearance:
– Cleared without restriction
– Cleared, pending evaluation or treatment of a specific
– Disqualified
Letter of clearance/DQ should be reviewed with
athlete, athlete should sign release of information
form, form should be passed on to coach/trainer
Conditions Which May Require
Final Thoughts
The PPE is an important skill for all providers
to be comfortable with
The PPE does not replace routine health care
maintenance visits
CV, neurologic, and orthopedic abnormalities
may require further evaluation prior to
Vast majority of athletes screened will be
permitted to participate without restriction
Selected References
Kurowski K and S Chandran. The preparticipation athletic
evaluation. American Family Physician,May 2000. p2683-98
Lyznicki JM et al. Cardiovascular screening of student
athletes. American Family Physician,Aug 2000. p765-84
Preparticipation Physical Evaluation, 4th ed., 2010
Madden CC and M Putukian. The Preparticipation Physical
Evaluation, Team Physician’s Handbook, 3rd ed., 2002,
Barrett JR et al. The Preparticipation Physical Evaluation,
Care of The Young Athlete, 2000. pp. 43-56.
Nsuami M et al. Screening for sexually transmitted diseases
during preparticipation sports examination of high school
adolescents. Journal of Adol Health May 2003, pp 336-339.
Selected References
Maron BJ et al. Cardiovascular Preparticipation Screening of
Competitive Athletes. Circulation, Aug 1996, pp850-856.
Fuller CM. Cost effectiveness analysis of screening of high
school athletes for risk of sudden cardiac death. Medicine
and Science in Sports and Exercise, 2000, pp887-890.
Corrado D et al. Screening for hypertrophic cardiomyopathy
in young athletes. NEJM 6 Aug 1998, pp364-369.
Pelliccia A and BJ Maron. Preparticipation cardiovascular
evaluation of the competitive athlete: perspectives from the
30 year Italian experience. Am J of Card. 15 April 95,
Selected References
Maron BJ et al. Sudden Deaths in Young Competitive Athletes,
Circulation, 2009:119:1085-1092
Corrado D et al. Trends in Sudden Cardiovascular Death in Young
Competitive Athletes After Implementation of a Preparticipation
Screening Program. JAMA 2006;296(13):1593-1601.
Maron BJ et al. Recommendations and considerations related to
preparticipation screening for cardiovascular abnormalities in
competitive athletes, 2007 Update. Circulation 2007;115:16431655
Bille K et al. Sudden cardiac death in athletes: the Lausanne
recommendations. European Journal of Cardiovascular prevention
and rehabilitation. 2006;13:859-875
Contact Info: [email protected]
SAMG Emerald: 367-4170
6533 Emerald St., Boise, ID

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