Preparticipation Orthopedic Screening Evaluation

[Thematic Issue]
Garrick, James G. MD
From the Department of Pediatrics, University of California-San
Francisco, San Francisco, CA.
Accepted March 2004.
Reprints: Dr. James G. Garrick, Center for Sports Medicine, 900 Hyde,
San Francisco (e-mail: JGGarrick@mac.com).

Abstract
Objective: To review evidence-based support for the preparticipation
orthopedic evaluation.
Data Sources/Methods: Articles were reviewed that dealt with the
sensitivity, specificity, and predictive value of the components of the
standardized preparticipation orthopedic evaluation. In addition,
studies describing musculoskeletal conditions/findings predictive of
future injuries were sought through a PubMed search.
Results: The sensitivity of the evaluation questionnaire appears to be
adequate, exceeding 90% in some studies. There is little or no
published information documenting that the physical examination (1)
approaches the questionnaire in either sensitivity or specificity or (2)
identifies elements of value based on their association with future
injuries or reinjuries. There are no readily discernible elements even in
an expanded examination that are documented as being predictive of
future problems.
Conclusions: The current questionnaire and examination appear to
fulfill adequately both legal and institutional requirements.
Practitioners should be aware of the absence of data linking virtually
any of the findings on the examination to either an increase or a
decrease in the likelihood of future injuries. There is no evidence that
increasing the scope of the examination would enhance its predictive
value.

The original preseason orthopedic screening examination, described in

1977, 1 had 5 major purposes: (1) it would fulfill the institution's legal
and insurance requirements, (2) it would assure the coaches that team
members would start the season with some common level of health
and fitness, (3) it would provide the medical team with the opportunity
to discover treatable conditions that might interfere with or be
worsened by athletic participation, (4) it might aid in
predicting/preventing future injuries, and (5) it would be appropriate
for all sports. It represented a pragmatic approach to a vexing
problem.
The various components of the examination were based on our
observations of athletes who had been injured and were not yet (in our
opinion) ready to return to full participation. We also based the
examination on the type and frequency of injuries we encountered in
various sports. We had not tested any of the hypotheses embedded in
the examination.
Now, over a quarter of a century later, the goals remain the same,
some of the hypotheses have been testedand largely found wanting,
and the issue of injury prevention continues to be elusive.

MUSCULOSKELETAL HISTORY
The original history questionnaire and the more recent history form
found in the joint publication Preparticipation Physical Evaluation 2
were attempts to provide an expedient, generic, historical screening
tool for participants in all sports. However, both the type and the
consequence of injuries varies greatly among sports. For example, the
lack of 10 degrees of elbow extension is devastating for a gymnast but
of little consequence for the football player. Yet to attempt to create
sports-specific history forms for every activity would not be practical.
Interpretation of information reported on the currently used history
form requires little or no knowledge of the individual sports activities;
thus, a wide variety of medical professionals can adequately execute
the evaluation.
As they are currently employed, the history and the examination
function independently. If an appreciable problem surfaces on the
history, the athlete is singled out for a directed examination. Likewise,
if a significant abnormality is found on the physical examination, a
similar directed evaluationand perhaps a more directed historyis
sought. The screening examination is not driven by information
gleaned from the history. To integrate the history and the examination

would require a substantially higher level of knowledge and skill on the

part of the examiner, making the task impractical, especially at the
high school and youth sports levels.
In general, a positive response from the history, regardless of how
comprehensive the form is, will in itself neither preclude nor delay
approval for participation. This decision rests with the findings from a
directed examination.
However, none would argue that the history portion of the evaluation,
even though far from perfect, is the most valuable tool for
documenting previous injuries and musculoskeletal problems. Indeed,
virtually every investigator has found that the preparticipation history
is much more likely to unearth previous injuries than the actual
physical examination. One of the more comprehensive studies of
efficacy of the evaluation places the sensitivity of the history at 91.6%
far above the 50.8% sensitivity for the screening examination in the
same study. 3 In general, investigators have found that the sensitivity
of the questionnaire is in excess of 50%. 4,5

MUSCULOSKELETAL EXAMINATION
Like the original history form, the screening examination was based on
observations of injured athletes at varying stages of their recovery and
rehabilitation. For example, it had been our observation that returning
an athlete to sport participation in the face of visible quadriceps
atrophy usually resulted in his/her return to the training roomnot
necessarily because he was reinjured but rather because he wasn't
ready to play.
This and virtually all of the recommendations arising from the
examination were based on the hoary axiom that treatment and
rehabilitation were not complete until strength and range of motion
had been returned to normal. The implication of this was that those
not completing treatment were more likely to be reinjured. There was
no evidence-based medicine in 1977, and even if there had been,
there was little or no scientific documentation that failure to adhere to
the strength/motion adage would result in new or worsened injuries.
Thus, in reality, the examination sought to identify those who were
ready to play rather than those who might be more likely to be
injured.
Even today, there is virtually no documentation of the premise that
any level of loss of motion or strength is predictive of an increased

likelihood of subsequent injury. PubMed searches of the terms

weakness or strength against the commonly injured anatomic regions
(for example, knee, ankle, thigh, and shoulder) revealed but a single
citation that suggested weakness as a predictor of future injuryin
this case, adductor weakness in ice hockey players. 6 The search failed
to reveal any other investigation that identified a specific abnormality
of strength or motion that was associated with an increased injury
rate.* There were, however, many articles describing the weakness
accompanying various injuries.
There are indeed tests for specific injuries that are both sensitive and
specific. In their meta-analysis of tests commonly used in an
orthopedic examination of the knee, Malanga et al 7 pointed out that,
for example, the Lachman and pivot shift tests often reached
sensitivities exceeding 90%. Aside from the fact that the performance
of these tests requires an experienced examiner, the predictive value
of a positive test remains elusive.
The 14-point examination presented in the Preparticipation Physical
Evaluation 2 appears to have withstood the test of time (Fig. 1). Three
major studies 3,8,9 examining the efficacy of the original screen may
have played some role in the addition of the hyperextension step to
the lumbar spine examination and the internal rotation step in the
shoulder examination. Based on their comparison of the screen with a
comprehensive orthopedic examination, Gomez et al 3 also suggest
adding a test for supraspinatus strength and a dynamic strength test
(balancing on 1 foot) in the ankle sequence.

FIGURE 1. General
m

Ideally, a screening examination would be high in sensitivity, leaving

specificity to the directed examination. Unfortunately, the studies
described revealed overall sensitivities rarely approaching 50%.
Specificity of some of the steps was generally high, but false-positives
were not uncommon, highest among the shoulder steps, and exceeded
true-positives in the ankle screen. More worrisome was the high
frequency of false-negatives, most common in the ankle screen. 3
Usefulness of the examination has been based on 2 criteria: (1) the
capacity of the screen being able to identify abnormalities picked up on
a more comprehensive orthopedic examination, 3 and (2) the
identification of conditions predictive of an increased likelihood of
subsequent injuries. 8
The identification of abnormalities picked up on a comprehensive
orthopedic examination but missed by the screen represents a failure
of the screen only if those conditions are associated with an enhanced
likelihood of future injury. Unfortunately, even a measurable finding
such as residual laxity of the lateral ligaments of the ankle following a
sprain is neither a compelling predictor of future sprains nor a reason
to with hold clearance.
The value of a comprehensive orthopedic examination rests primarily
with determining the significance of a subsequent injuryfor example,
are the ankle (or knee) ligaments now more lax than they were prior
to the new injury? However, such documentation is neither the
purpose nor the purview of the screening examination. Were we to
require such documentation, the size of the examiner pool would be
decreased appreciably because of the skills required to perform the
examination.
What, then, of predicting future injuries based on the results of the
screening examination? In their study of 712 intercollegiate athletes,
Meeuwisse and Fowler 9 came to the following conclusion: New
injuries were found to have no relation to previous injury, flexibility,
range of motion, strength or other factors identifiable on preseason
musculoskeletal examination. Smith and Laskowski 8 noted that the
absence of concrete recommendations concerning the findings from a
preparticipation screening examination are attributable to (1) the lack
of consensus regarding the threshold for abnormality, (2) the
unavailability of data indicating the predictive value of specific physical

abnormalities for injury, and (3) the lack definitive proof that
corrective interventions alter outcome. We have been unable to find
any evidence contrary to the above statements.
There does appear to be abundant evidence that many anatomic
regions, once injured, have an increased likelihood of future injury.
These regions include the knee, ankle, and shoulder. Unfortunately, the
actual reason for the propensity to future injuries has escaped
detection. Precluding athletic participation based simply on the
presence of a previous injury, even though the athlete may be more
likely to sustain a future similar injury, is not a realistic approach.
Performing a musculoskeletal examination is a chilling experience for
the nonorthopedist with little sports medicine experiencethe very
individual for whom the screening examination was designed. From the
standpoint of musculoskeletal familiarity, the examination must play to
the least common denominator. An examination that is based on visual
observations relieves the examiner of the necessity of acquiring new
skills required to perform the tests so common in orthopedic
examinations. Indeed, the currently used and approved examination is
essentially a test of symmetry. 2 The examiner need not know how big
a quadriceps muscle should be but rather whether it is similar to the
contralateral side. Likewise, one need not know the normal range of
motion of the shoulder but rather only that both sides are equal.

CONCLUSIONS
The Preparticipation Physical Evaluation has served as the approved
evaluation since 1992. Revised in 1997, it has remained unchanged
since that time. Although investigators have questioned both its utility
and accuracy, no one has offered an alternative appropriate for those
who will actually be performing the examination. Absent
documentation of conditions truly predictive of future injuries, the
creation of a better evaluation is unlikely.

REFERENCES
1. Garrick JG, Requa RK. Injuries in high school sports. Pediatrics.
1978;61:465469. Bibliographic Links Library Holdings [Context Link]
2. American Academy of Family Physicians, American Academy of Pediatrics,
American Medical Society for Sports Medicine, American Orthopaedic Society
for Sports Medicine, American Osteopathic Academy of Sports Medicine.

Preparticipation Physical Evaluation. 2nd ed. Minneapolis: The Physician and

Sportsmedicine; 1997. [Context Link]
3. Gomez JE, Landry GL, Bernhardt DT. Critical evaluation of the 2-minute
orthopedic screening examination. Sports Med. 1993;147:11091113.
[Context Link]

4. Goldberg B, Saraniti A, Witman P, et al. Preparticipation sports assessment

an objective evaluation. Pediatrics. 1980;66:736745. Bibliographic Links
Library Holdings [Context Link]

5. Risser W, Hoffman HM, Bellah GG Jr. Frequency of preparticipation sports

examinations in secondary school athletes: are the university inter-scholastic
league guidelines appropriate?Tex Med. 1985;81:3539. [Context Link]
6. Tyler TF, Nicholas SJ, Campbell RJ, et al. The effectiveness of a pre-season
exercise program to prevent adductor muscle strains in professional ice
hockey players. Am J Sports Med. 2002;30:680683. Bibliographic Links
Library Holdings [Context Link]

7. Malanga GA, Andrus S, Nadler S, et al. Physical examination of the knee: a

review of the original test description and scientific validity of common
orthopedic tests. Arch Phys Med Rehabil. 2003;84:592603. Bibliographic
Links Library Holdings [Context Link]

8. Smith J, Laskowski E. The preparticipation physical examination: Mayo

Clinic experience with 2,739 examinations. Mayo Clin Proc. 1998;73:419
429. Bibliographic Links Library Holdings [Context Link]
9. Meeuwisse WH, Fowler PJ. Frequency and predictability of sports injuries in
intercollegiate athletes. Can J Sport Sci. 1988;13:3542. Bibliographic Links
Library Holdings [Context Link]

*The PubMed search was focused on citations with the key words in
either the title or abstract. The key word strings were, weakness AND
knee injuries (n = 6), weakness AND ankle injuries (n = 3),
weakness AND ankle sprains (n = 11), weakness AND shoulder
injuries (n = 76), weakness AND injury prevention (n = 26), and
injury prevention AND range of motion. Date ranges were from 1966
to February 2004. [Context Link]
Keywords: preparticipation orthopedic screening evaluation; evidence
based; orthopedic screening evaluation

Accession Number: 00042752-200405000-00003

Copyright (c) 2000-2006 Ovid Technologies, Inc.