Some special concerns of the physical examination are as follows:8
Most viral infections are worsened by physical activity. They may adversely affect performance in the following situations:
- Pharyngeal inflammation may decrease upper airway capacity.
- Inner ear infections may affect balance and equilibrium.
- Viral disease can occasionally lead to myocarditis.
- Infectious mononucleosis may result in splenomegaly, predisposing the spleen to blunt trauma.
- Herpetic skin lesions can be transmitted between players.
II. Hematological Disorders
These disorders are not screened for in all individuals, however in those complaining of fatigue be careful:
a) Test for suspected anemia or abnormalities of the RBC. b) A sickle cell crisis can be precipitated by dehydration, lactic acidosis, or hypoxia. c) Remember the false physiologic anemia associated with increased volume expansion.
Up to 17 percent of youngsters have exercise induced bronchospasm. Dry, cold weather and prolonged intense activity worse the condition.
Children with a unilateral kidney are predisposed to serious renal problems with dehydration.
V. Cardiovascular Disease and Hypertension
Key cardiovascular concerns on the physical exam include:
a. heart rate over 120 bpm or any inappropriate tachycardia;
c. midsystolyic clicks;
d. murmurs that are Grade 3 or 4.
Most innocent murmurs should diminish with Valsalva's maneuver. The murmur associated with hypertrophic cardiomyopathy increases usually with sitting and standing, and also with exercise.
e. resting BPs:
- over 130/80 with ages 6-11;
- over 140/90 with ages 12 and older; f. discrepancy between femoral and brachial pulse (coarctation of the aorta.
Conditions that have cardiovascular risk potential and should be looked for on history and physical include:
i) hypertrophic cardiomyopathy (HC);
ii) mitral valve prolapse syndrome;
iii) marfan's syndrome;
iv) congenital heart disease.
Some forms of congenital heart disease are contraindications for sports participation including some conduction deficits. If there is an obvious immediate family history of cardiovascular disease it might be prudent to test the child for cholesterol/HDL. Most children with high blood pressure are "hyperadrenergic" and in fact benefit from exercise. Still it would be best to avoid purely anaerobic activities such as weightlifting. Also strong isometric exercise should be avoided.
Physical and mental activities seem to be deterrents to seizure activity. Many school systems make little distinction between epileptic and non-epileptic children in their athletic programs.
Concerns here are overfatigue, skipped meals, excessive alcohol intake, and "street drugs." Hyperventilation with activity is not a concern, but voluntary or forced hyperventilation may precipitate petit mal spells.
Epilepsy is not a contraindication to sports participation although caution should be used with climbing, horseback riding, diving, and swimming in general. Buddy participation is recommended. With gymnastics the biggest concern is a fall due to a seizure.
Regularly exercising diabetics are better controlled than sedentary diabetics. Special concerns though are:
a. One may anticipate a reduction in insulin requirements.
b. Food may be necessary before, during, and after exercise to avoid hypoglycemia.
c. Exercise should be avoided before bedtime to avoid hypoglycemia during sleep.
d. Changes in insulin and diet need to be established by trial and error realizing that a reduction is often necessary on days of strenuous exercise.
e. Active children are better controlled with two doses of insulin a day (before breakfast and dinner).
f. There is an increase release of insulin from the injection site which can be decreased by the above twice a day, meal- related dosage, or injection in the abdomen instead of the arms or legs.
g. Availability of a portable snack is necessary.
h. In long duration diabetes with severe microangiopathic complications exercise should be limited because:
- decreased splanchnic blood flow during strenuous exercise may lead to renal cortical ischemia;
- the exercised induced increase in BP may stress the vasculature in the eye leading to hemorrhage
- increased transglomerular passage of albumin (exercise induced) may lead to nephropathy.
i. Children must be taught to give prompt attentions to abrasions, and lacerations, and burning or freezing of the feet. They should trim their toenails properly and not wear tight shoes or socks.
j. Dehydration can complicate diabetes.
VIII. Chronic Fatigue
Fatigue is common with illness, lack of sleep, and poor diet. Chronic fatigue, lasting weeks or longer, should be investigated. Some of the possibilities include:
f. ergolytic drugs
g. endocrine dysfunction
h. respiratory and cardiovascular dysfunction
IX. Other Concerns
a. Unequal or unreactive pupils should be documented prior to sports participation as a comparison when head trauma is nvolved
b. Look for necrotic or perforated nasal septum which would indicate drug abuse.
Strength Training There is a large debate regarding the appropriateness of prepubescent participation in strength training programs. These concerns center around the tendency towards strains, tendinitis, epiphysitis, avulsions, fractures, and vertebral injuries. Most of these injuries are avoidable with proper training, supervision, and progression. It has been demonstrated that prepubescent children do increase muscle strength with training. The American Academy of Pediatrics, the National Strength and Conditioning Association, and the American Orthopedic Society of Sports Medicine have made the following recommendations:9
- A mandatory preparticipation exam.
- Emotional maturity to accept coaching and instruction.
- Adequate supervision by coaches knowledgeable in the area of children's weight training.
- Strength training should be a part of a more comprehensive program.
- Training should be preceded by a warm-up and followed by a cool-down.
- Should emphasize full range of motion concentric contractions.
- Competition is prohibited.
- No maximum lift should ever be attempted.
The prescribed program is two to three workouts per week for 20-30 minute periods. No resistance should be applied until proper form is demonstrated. Six to 15 repetitions and one to three sets per exercise are done. Weight is increased in one to three pound increments after the child is able to do 15 reps with good form.
- Smith NJ. Children and parents: Growth development, and sports. In: Straus RH, ed. Sports Medicine, Philadelphia, PA, WB Saunders. 1984:207-217.
- Thornburg HD, Clark DC. Middle school/junior high school research needs questionnaire. National Middle School Association Symposium, 1980.
- Goldberg B. Pediatric sports medicine. In: Scott WN, Nisomon B, Nicholas J, eds. Principles of Sports Medicine. Baltimore, MD: Williams & Wilkins, 1984: 403-426.
- Bar-Or O. Pediatric Sports Medicine for the Practitioner. New York, NY Springer-Verlag, 1983.
- Pappas Am, Cummings NM. Sports injuries in the skeletally immature. In: Pappas AM, ed. Upper Extremity Injuries in the Athlete. New York, NY, Churchill Livingstone, 1995: 117.
- Paletta GA Jr., Andrish JT. Injuries about the hip and pelvis in the young athlete. Clin Sports Med. 1995: 14:591.
- Risser WL, Hoffman HM, Bellah G. Frequency of preparticipation sports examinations in secondary school athletes. Are the university interscholastic legal guidelines appropriate? Tex Med 1985: 81:35-39.
- Small E, Bar-Or O. The young athlete with chronic disease. Clin Sports Med. 1995: 14: 709.
- Duda M. Prepubescent strength training gains support. Physician Sportsmed. 1986: 14:157-161.
Thomas Souza, DC, DACBSP
5980 Indian Ave.
San Jose, CA 95123