Childhood athletic participation has dramaticallyincreased over the past twenty years. Children arebeing introduced to organised sports at increasinglyimmature stages of physical development. It is notuncommon to find five-year-{)ld 'athletes' participatingin dance classes, soccer camps, or martial arts. Pre-participation examination often represents the initialmedical contact, and frequently the only medicalcontact a child will have prior to engaging inpotentially injurious activities.

Despite general agreement over the necessity ofthe pre-participation evaluation, no widely recog-nised standard examination currently exists. Theadministrator of a pre-participation evaluation mustassess the overall health of the child as well as anyconditions which might limit participation orpredispose the child athlete to injury.

Under ideal circumstances, the examination isperformed by the athlete's primary care physician.A longstanding medical relationship promotescontinuity of care and facilitates the safe discussionof important psychosocial issues. In otherinstances, mass screenings of athletic teams may beperformed in an efficient and satisfactory fashionthrough the coordinated efforts of a team of healthcare professionals.2

A thorough medical history is obtained whichincludes past hospitalisations, surgery, medication,allergies, tetanus status, family history, menstrualhistory, and a review of systems. The physicalexamination should include assessment of height,weight, vision, cardiovascular vital signs, and levelof physical maturity. Additionally, evaluation of theskin, chest, lymphatics, abdomen, genitalia, andmusculo-skeletal systems must be performed. Thephysical examination may be specifically focused onproblem areas identified by the medical history.

Evaluation of the musculo-skeletal systemincludes structural integrity and alignment as wellas any pre-existing neuro-muscular deficits.Thorough examination of a specific portion of themusculo-skeletal system may be performed shouldan area of concern be identified in the history andgeneral physical examination. Furthermore, sports-

sp~cific mus.culo-sk~l~tal testing may identifychildren at risk for lllJUry depending upon therequirements of the activity and the physiologicalcondition of the athlete. Measurement of fitness,strength, and flexibility may reveal specificmuscular imbalances or weaknesses. With suchknowledge, therapeutic rehabilitative programmesmay be instituted prior to the onset of athletic

participation.Sports-specific performance testing reveals an

athlete's physical strengths and weaknesses. Whentesting has been completed the physician maymodify the athlete's training programme throughexercise prescription. In addition to optimisingathletic performance, the data obtained duringtesting may help to prevent injuries. Although thelevel of athletic fitness has not yet been proven todecrease the incidence of sports injuries, thepresence of specific deficiencies or imbalances inthe musculo-skeletal system would seem likely topredispose an individual to injury. The sports-specific testing of fitness includes measurements ofbody composition, flexibility, strength, endurance,power, speed, agility, balance, and dynamic balance.The performance profile not only helps a child toachieve their athletic potential, but also provides abaseline against which the success of exerciseprescription and recovery from injury can bemeasured.

Information obtained from the medical history,physical examination and any associated sports-specific performance testing allows a personalisedathletic profile to be created for the participant. Bypairing the profile with the recommendation forparticipation in competitive sports as published bythe American Academy of Pediatrics, a decisionregarding clearance for a given sport can berendered.! The decision for clearance is dividedinto three categories: unrestricted clearance,cleared after notification of either the coach, trainer,or team physician, or clearance deferred untilfurther evaluation by medical specialist.

When properly performed, the pre-participationexamination effectively identifies pre-morbid risk

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Sports Medicine in Childhood and Adolescence

General appearanceexamination

factors for the paediatric and adolescent athlete.Medical and social interventions prior to athleticparticipation may diminish these risks and preventcatastrophic cardiovascular or neurologic events. Ayearly evaluation of the growing child isrecommended to screen for new health problems,to monitor established conditions and to assess anathlete's preparedness for any given sportingactivity.

Instructions

The athlete stands straight with arms to the sideand feet together. General appearance, includingthe acromioclavicular, sternoclavicular knee andankle joints, should be symmetrical (7.1, 7.2).

7.1 7.2

7.1, 7.2 General appearance. Instructions.

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ere-ParticiPation Sports Examination: Musculo-Skeletal System

7.4

7.3, 7.4 General appearance. Abnormality.

7.5AbnormalityAsymmetry of the examination including chronicswelling or deformity often results from trauma.Chronic dislocation of the sternoclavicular jointtypically presents with anterior prominence of theclavicle (7.3, 7.4).

Marked femoral internal torsion and compen-satory external tibial torsion result in patello-femoral malalignment commonly associated withanterior knee pain and patellar instability (7.5).

7.5 General appearance. Abnormality.

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1~§pqrtsMedicine in Childhood and Adolescence

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Instructions

The athlete touches chin to chest (flexion), looks upward (extension), touches ear to shoulder Oateralbending) and looks over each shoulder Oateral rotation). The motion should be symmetrical and pain free(7.6-7.9).

7.6 7.7

7.8 7.9

7.6-7.9 Cervical spine examination. Instructions.

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Pre-Participation Sports Examination: Musculo-Skeletal System

AbnormalityPainful or asymmetrical cervical motion oftenresults from traumatic or congenital disorders ofthe cervical spine. Chronic rotary subluxation ofCI-C2 presents as a fixed deformity and a loss ofmotion (7.10,7.11).

7.11

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Sports fyJedicine in Childhood and AdolescenceCc.

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7.12

7.12 Neck and shoulderexamination. Instructions.

7.13

7.13 Neck and shoulderexamination. Abnormality.

Neck and shoulderexamination

Instructions

Shrug shoulders upward against examinerresistance (7.12).

AbnormalityAsymmetry of appearance, motion or strength mayindicate cervical or shoulder problems.Asymmetrical shoulder motion is noted in anathlete with a nerve palsy sustained during a skiingaccident (7.13).

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7.16

7.16 Shoulder examination. Abnormal ity.7.14, 7.15 Shoulder examination. Instructions.

Instructions AbnormalityPain, muscle atrophy, or asymmetrical motion mayreflect shoulder instability, impingement or nerveinjury. Specific testing of the shoulder will revealanterior glenohumeral instability as in this athletewith recurrent anterior shoulder dislocations

(7.16).

Raise arms outward from sides until parallel to thefloor. Then flex elbows with hands pointedupwards. The deltoid appearance and strengthshould be symmetrical. The range of motion of theshoulder should be pain-free and symmetrical(7.14, 7.15).

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Sports Medicine in Childhood and Adolescence

7.17

7.17 Elbowexamination.Instructions.

7.18

7.18 Elbowexamination.Abnormality.

Instructions

Stand and raise arms out from sides until parallel tothe ground. Palms face upward. Alternate elbowflexion and extension. The motion should besymmetrical and pain-free (7.17).

AbnormalityDeformity, loss of motion and pain are findingsoften associated with trauma as seen in this childwith a history of a supracondylar fracture of thehumerus (7.18).

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Pre-ParticiPation Sports EXamination: Musculo-Skeletal System

Instructions

Hold elbows to sides and flex foreanns until parallel to the floor. Rotate palms upward and downward in an

alternating fashion. The motion should be symmetrical and pain-free (7.19, 7.20).

7.20

7.19, 7.20 Elbow, forearm and wrist examination. Instructions.

Abnormality 7.21

Deformity, loss of motion or pain often accompan-ies traumatic conditions such as that manifested bya child with a history of an elbow fracture (7.21).

7.21 Elbow, forearm and wrist examination. Abnormality.

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\Sporls Medicine in Childhood and Adolescence

Instructions

Clench the fingers into a fist and then spread the fingers wide apart (7.22, 7.23).

7.22

7.22, 7.23 Hand examination. Instructions. 724

AbnormalityDeformity, loss of finger motion or weakness arecommon post-traumatic findings. Chronic oedemaand loss of motion affects this finger subsequent toa proximal interphalangeal joint dislocation (7.24).

7.24 Hand examination. Abnormality.

InstructionsThe athlete stands straight with back to theexaminer and raises arms forward until parallel tothe ground. The palms are placed together and theathlete flexes forward to touch their toes. This isrepeated with the examiner viewing the athletefrom the side. Motion should be pain-free andsymmetrical (7.25-7.28).

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!,~&.~ Pre-ParticiPation Sports Examination: Musculo-Skeletal System

7.25 7.26

7.27 7.28

7.25-7.28 SpinalInstructions.

examination

AbnormalityPathologic findings include shoulder asymmetry,scapular prominence, pelvic obliquity, cutaneousmanifestations of underlying spinal dysraphism andscoliotic and kyphotic deformity. Examples ofidiopathic thoracic scoliosis and Scheuermann'skyphosis are presented (7.29, 7.30).

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Spotts Medicine in Childhood and Adolescence

7.29 7.30

7.29,7.30 Spinal examination. Abnormality.

Lower extremityexamination

7.31

Instructions

The athlete squats down on heels, walks four stepsin squat position, and then rises to a standingposition. This complex activity demonstratessymmetrical lower extremity joint motion andstrength. The gait should be pain-free and haveequal heel-to-buttock distance. The child shouldhave no difficulty in rising to a standing position(7.31).

AbnormalityHip, knee and ankle problems result in weakness,joint instability or loss of joint motion whichpreclude a symmetrical duck walk (note heel-to-buttock difference). Specific testing of the affectedregion will identify the deficiency. Examples of theLachman and anterior drawer tests which assesscompetence of the anterior cruciate ligament arepresented (7.32-7.34).

7.31 Lower extremity examination.Instructions.

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~~i~tj,!

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Pre-Participation Sports Examination:

7.33

7.34

7.32-7.34 Lower extremityexamination. Abnormality.

Instructions

The athlete stands straight and then alternatelystands on toes and stands on heels. Motion shouldbe pain-free and symmetrical (7.35-7.37).

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sports Medicine in Childhood and Adolescence

7.35 7.36 7.37

7.387.35-7.37 Leg and ankle examination. Instructions.

AbnormalityPathologic findings of the leg examination includemuscle atrophy, asymmetry of motion and chronicswelling as seen in this athlete with chronic achillestendinitis (7.38).

References1. American Academy of Pediatrics Committee on

Sports Medicine (1988) Recommendations forparticipation in competitive sports. Pediatrics 81:737.

2. Micheli, L.j. and Yost. J.G. (1984) Preparticipationevaluation and first aid for sports. In: Micheli, L.j.(Ed.) Pediatric and Adolescent Sports Medicine. pp.30-48. little, Brown, Boston.

7.38 Leg and ankle examination. Abnormality.

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