It’s currently pre-season in the UK for our Football Leagues, and many Football Club doctors like myself are being kept busy with new player signing medicals and pre-participation evaluations (PPE).
Despite the widespread use of pre-participation evaluation testing, there is still little consensus on the exact nature, composition, and effectiveness of the PPE as a screening procedure for the primary and secondary prevention of medical conditions, and as part of an overall injury prevention strategy. Similarly, there is much variation in the way that new player medicals are conducted, depending amongst other things on the Country, the Sport, and the availability of local resources.
During the PPEs in which I have been involved, in a number of different settings and in the context of a number of different sports and with a number of different teams, I have always wondered if I have been performing the most appropriate examinations and ordering the correct investigations at the right time to make a difference to the health of the sports participant.
Here are just three of many different points to ponder with regard to PPEs and player screening medicals :
1) Special tests in physical examination – which, when, who and why?
Many PPE and medical screening proformas include a battery of physical examination tests which must be completed and ticked off as either ‘normal’ or showing some abnormality which may or may not have particular relevance. One has to consider which tests are appropriate for different individuals in different sports, and the reliability and validity of these tests. It is easy to forget the difference in pre-test probabilities when comparing asymptomatic athletes with those with specific symptoms, and sometimes a puzzle to know what to do if some of the tests do turn out to be positive. Who conducts the examination obviously has an effect on reliability, validity and reproducibility. Importantly, we need to ask ourselves why we are doing the tests – is it to detect problems and potential issues, to document ‘baseline’ observations against future observations, or both?
2) Cost-effectiveness
There is a wide variation of resources available to different teams and individual athletes, and it is sometimes hard to know if a screening programme or new player medical is a cost-effective intervention. What’s even harder is to work out is which tests and investigations are the ones that are likely to give the most ‘bang for your buck.’ One example is the routine MRI scanning employed by some Football Clubs as a screening tool to detect joint problems. These are done at considerable cost, and may detect lesions whose natural history may be difficult to interpret when put into context of the whole clinical picture.
For those Clubs that are less well off, can the cost of video-analysis and functional movement testing be justified as cost-effective? What about ‘routine’ blood tests for haemoglobin and iron etc?
3) Risk-benefit ratio
Using the MRI screening issue as an example, if an asymptomatic lesion is discovered which may have a poorly understood natural course, in sharing that information with the individual how much physical and possibly psychological harm can be caused? Will scans lead to unnecessary and possibly harmful interventions? Will the results affect the player’s career in terms of ongoing transfers? Will player concern about lesions detected on scans lead to poor performance?
There are still perhaps many more questions to be answered in relation to PPE and new player medicals than we currently have the evidence-based answers for.
Check out this 2004 thematic issue of CJSM for a wider look at some of the issues involved in PPE. The other resource well worth a read is the 4th Edition of ‘Preparticipation Physical Evaluation’ published by the American Academy of Pediatrics and co-authored by the AAFP, AAP, ACSM, AMSSM, AOSSM and AOASM.
CJSM would like to know about your experience with PPEs and new player medicals – what dilemmas you have come across with these, and what goes on in your PPEs and new player medicals?
(photograph by Charlie Goldberg, UCSD School of Medicine)
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