Pediatric Primary Care Case Studies, 1st Ed.

Chapter 10. The Teen Needing a Sports Physical

Catherine G. Blosser

The preparticipation sports examination (PPE) is often the only health examination for the majority of youth and adolescents in any given year. One percent to 8% of teens undergoing a PPE will have findings that require further evaluation or referral prior to authorizing sports participation; fewer than 1% will need to be excluded from sports because of a significant finding (Landry & Logan, 2007). The PPE should be performed according to customary and standard practices; all history and physical findings need to be documented, including any perceived risk factors and advice about potential dangers of participation that have been discussed with the youth and his or her family. (A signed consent is warranted in such a case.) Ideally, the PPE is performed by the primary care provider. Massive sports examination screenings (i.e., examination stations) are offered in many communities to allay costs and time for both the youth and parent. However, there is a loss of continuity from the history to the examination and then to follow-up, a lack of privacy and patient–provider familiarity, and little time for health promotion discussions when this process is used.

Educational Objectives

1.  Identify the two parts of the PPE.

2.  Apply customary and standard practices for performing a PPE, including a thorough assessment of health status, fitness level, maturity level, and detection of injuries and illnesses that might limit participation and/or lead to morbidity or mortality.

3.  Discuss the advantages to using a PPE form.

4.  Discuss necessary documentation components of the cardiovascular examination.

5.  Discuss lifestyle risk factors and ways to promote healthy choices.

6.  Discuss risk factors specific to females athletes.

7.  Recommend ways to improve athletic performance.

8.  Discuss the pros and cons of mass screenings designed with stations for conducting the PPE that are standard within some school districts.

9.  Identify opportunities within your practice community for establishing stronger ties with coaches and trainers.

  Case Presentation and Discussion

Nikola Avery is a 16-year-old Caucasian female who is planning to try out for the crosscountry running team at her high school. She comes today with her 20-year-old sister, who is in the waiting room because their parents both work. Nikola has just transferred into the school district from another state; she relates that this will be her second year of running competitively in high school.

You tell Nikola that before doing the physical examination, you want to review the history form she and her mother completed (it is cosigned). This form was sent out by the clinic to the family at the time the appointment was made.

Assessing Risk Factors for Sports Participation

The assessment of a young person for sports participation needs to include any history or physical findings that would alert the provider about the need for further inquiry or raise concerns regarding the activity appropriate for that particular person. A well-designed preparticipation physical examination form would serve this purpose and also allow for a time-efficient examination. A sample form is available in Figure 10-1.

What risk factors for sports participation come to your mind? image

Risk factors

Risk factors of note include:

•  Previous trauma, especially to the musculoskeletal or central nervous system

•  Cardiovascular disease (including congenital heart disease, carditis, dysrhythmia, mitral valve prolapse, hypertension above the 90th percentile, and exertional syncope)

•  Prior history of heat intolerance

•  Chronic medical conditions, including allergic reactions, respiratory problems, sickle cell disease, diabetes, human immunodeficiency virus (HIV), eating disorders, cerebral palsy, and hemophilia

•  Seizures

•  Infectious mononucleosis

•  Skin infections

•  Anatomic abnormalities, including missing paired organs, or Down or Marfan syndromes (or history of Marfan syndrome in family)

•  Obesity

•  In females, menstrual and eating habit irregularities

•  Family history of sudden death

Table 10-1 will help the provider determine whether sports participation should be allowed, whether further evaluation is needed before being allowed, or if the risk factor precludes participation. In some cases, an alternative sport can be proposed that reduces risk and allows participation for the individual.



Figure 10-1  Preparticipation physical examination form.

Table 10–1 Sports Participation Clearance Based on Medical Conditions




Advantages and Disadvantages of Sports Participation

The well-formulated PPE assesses both physical and psychosocial readiness factors. The sporting activity should lead to a reduction in stress rather than induce it. The individual’s personality, motivation, or other situational factors contribute to the level of stress experienced. Therefore, the provider should assess the individual’s level of awareness of the demands of the sport, the anticipated response to these demands (experiencing defeat), and consequences of participation within the context of the time commitment.

Positive aspects of any sport include an overall increase in fitness, gained social skills, increased self-esteem and confidence, increased coordination and physical skills, enjoyment, recreation, and a chance for increased family involvement. Negative factors can involve the stress of competition or meeting adult goals, potential injuries, and comparison of abilities to those of others.

The following items have been checked “yes” on the form that Nikola returned:

1. She had an injury since her last checkup.

2. She has been hospitalized overnight.

3. She has been told she had a heart murmur “as a child.”

4. She has had a head injury.

5. She wears soft contact lenses.

Under the explanation area on the form is written: “Motor vehicle accident 2 months ago; she spent night in hospital after hitting her head; had stress fracture left ankle 6 months ago–OK now.”

What other key questions do you need to ask Nikola? image

You ask Nikola more questions about the motor vehicle accident (MVA) and hospital stay. She reports going to the emergency room 2 months ago after a family motor vehicle accident because “I hit my head against the side of the door, even though I had my seat-belt on. I was pretty dizzy and threw up a couple of times.” She stayed in the hospital overnight and then saw a physician a couple of times after that.

Then you ask Nikola about some health-related and lifestyle issues. She replies that she runs every day for an hour (weekends maybe more) and works out at her local gym (to build muscle). She is happy with her current weight. She has always liked to run a lot, but didn’t get into track and field at school until the beginning of the last school year. She also likes to play tennis, swim, cycle, and downhill ski.

Health Care

Other than after the MVA, her last physical examination was about 2 years ago.


She has always had some occasional headaches (have not increased since the MVA); acetaminophen relieves the pain. She has no nausea, vomiting, or photophobia. She takes a store-brand multivitamin daily. “My Mom buys whatever is cheapest for the whole family.”

Past Medical History

She had asthma as a child, but has not used her inhaler “in years.”

Psychosocial History

She admits to using alcohol and marijuana “a few times, but only if my friends have it.” She denies using any steroids or sports-enhancing drugs. She has had sex “off and on” since she was 15 years old, using condoms “most of the time.” She was on birth control pills last year, but is not on any birth control method now. She has had only one partner and vice versa with no steady boyfriend at this time.

She gets mostly A’s in school and hopes to run throughout high school.

Review of Systems

image  Complaints: None; 0/10 pain scale.

image  Gynecological: Her menses are mostly regular, with a cycle of 30 days. “Sometimes I skip a month.” Menarche at age 12 years. She used to have more irregular, heavy periods until she was on birth control pills last year. Last menstural period was 3 weeks ago, normal flow and duration.

image  Head: Occasional headaches (1–2 per month), relieved with over-the-counter (OTC) medications.

image  Musculoskeletal: Occasional right knee swelling, relieved with cold packs and OTC pain medications.

image  Remainder of systems: No complaints; review of sudden death criteria negative. (See Table 10-1 under Do Not Clear for Participation.)

Family History

Her maternal grandmother has diabetes and high blood pressure; both paternal grandparents have high blood pressure. Her maternal grandfather died last year of a heart attack (age 58). “I think my Mom has high cholesterol—she is always on a diet.” Father has high blood pressure. A younger sister has asthma, for which she uses an inhaler. She thinks her 20-year-old sister is “OK.”


You ask Nikola about her nutritional habits:

image  Do you skip meals? “I don’t usually eat breakfast; I eat lunch at school.” Dinner is usually at home or “I grab a snack if there is a track meet.”

image  What do you eat during a typical day? Breakfast: glass of orange juice; lunch: salad and candy bar; dinner: hamburger and milkshake or salad if she eats out or meat/vegetable/potato at home; snacks: candy bar or power bar. Lots of water or sports drink if running.

image  Who prepares the meals at your house? “My Mom or Dad usually. We sometimes just go out for a hamburger or pizza on weekends.”

image  As a follow-up to the above question, you ask, “Do you ever cause yourself to throw up or do you take laxatives? “No, I’d never do that.” Have you lost weight over the last year or two? “Yes, about 5 pounds, after I broke up with my boyfriend and started running more to forget.”

Based on the information provided, what else do you need to consider? image

From the history and answers gleaned from Nikola up to this point, there are further questions you need answered before you could reasonably be expected to clear her for sports participation.

•  What was the nature and diagnosis of the head injury after the MVA? Did she exhibit any postconcussive syndrome symptoms? Would running place her at further risk of neurological trauma?

•  Does this young lady exhibit risks for the female athlete triad?

Previous Head Trauma

Postconcussive syndrome is a side effect of a minor head injury. The incidence is quite variable, depending upon the definition—29% to 90% (Legome, Alt, & Wu, 2006). Most literature defines this syndrome as comprising the continuation of at least three of the following signs: headache, dizziness, fatigue, irritability, impaired memory and concentration, insomnia, and sensitivity to noise and light. The definition of the syndrome is based upon the onset and duration of symptoms and varies across the literature. It can be defined as occurring within a week of the injury with a duration of a few weeks to 6 months (Legome et al.).

A repeat concussion is often progressively more serious, especially if it occurs before the neurological symptoms from the prior head injury have completely resolved (referred to as second-impact syndrome). The sequelae of the second impact—even as minor as a blow to the chest or back—can cause massive brain swelling and herniation; mortality can approach 50% (Cantu, 2003; Stevenson & Adelson, 2003).

Approximately 300,000 second impact or concussion injuries occur annually in the United States from sports or recreational-related activities (Brain Injury Association, 2004). A participant in an organized sport is six times more likely to suffer such trauma than someone performing a recreational sports activity (Browne & Lam, 2006).

Given that Nikola’s chosen sport is running, a noncontact sport, you can be reasonably assured that she is less likely to suffer another head injury as a consequence of participating in her organized sport. However, had she chosen a contact or collision sport (e.g., soccer) your advice might be different pending further information regarding the nature of her head injury and return-to-play guidelines. (See Table 10-3.)

You need to know the following to complete Nikola’s history regarding her head injury (send for her medical records from the hospital and physician who saw her afterwards):

•  Did she suffer from a Grade 1, 2, or 3 concussion? (The definition is based on a recognized set of criteria such as length of loss of consciousness, mental status [impaired orientation, memory, concentration, or delayed information or reaction time], and duration of mental changes.)

•  How long did she exhibit headaches or cranial nerve symptoms after the injury (dizziness, vertigo, nausea, tinnitus, blurry vision, hearing loss, diplopia, diminished sense of taste and smell, sensitivity to light and noise)?

•  Did she exhibit anxiety, irritability, depression, sleep disturbance, change in appetite, decreased libido, fatigue, or personality changes?

•  If she exhibited cognitive changes, for how long after her injury were they experienced?

Female Athlete Triad

Sudden death, one sports-related problem, is less likely to occur in females, but they are more at risk of other conditions. Their risks are altered due to environmental, anatomic, hormonal, biomechanical, and neuromuscular factors (Blosser, 2009). One such condition is referred to as the female athlete triad, which is composed of a progressive set of three interrelated conditions. Anorexia (or disordered eating), amenorrhea (including oligomenorrhea), and osteopenia/osteoporosis occur along a continuum rather than in unison. The existence of one of these symptoms, therefore, should serve as a red flag during the PPE. Females engaged in sports where leanness and/or endurance are particularly advantageous are more prone to this disorder (e.g., gymnasts, ballerinas, swimmers and divers, figure skaters, distance runners, and cross-country skiers) (American Academy of Pediatrics [AAP], 2002). Additionally, female runners, cheerleaders, and gymnasts (i.e., those in high impact sports) are at greater risk of suffering a stress fracture than males (Loud et al., 2005). Although the fracture can be an isolated event due to the nature of the exercise itself, footwear, or musculoskeletal factors, it can also be due to osteopenia, osteoporosis, menstrual dysfunction, poor nutrition, or an eating disorder. Common anatomical areas for stress fractures include the foot, tibia, fibula, femur, and pelvis.

The incidence of amenorrhea in athletes can be as high as 66%, depending on the sport. The amenorrhea may be primary (delayed menarche past 16 years), secondary (no menses for 3–6 months after regular menses has been established), or oligomenorrhea (cycle length greater than 35 days but less than 3 months). None of these is a normal response to exercise, and caloric intake will need to be increased and/or exercise will need to be decreased in order to return to a normal body fat-to-lean ratio (AAP, 2002; Griffin et al., 2003). Serum gonadotropin concentrations are reduced due to reduced hypothalamic pulsatile release of gonadotropin-releasing factor.

Nutritional deficits in an active female athlete can result in an imbalance when energy (caloric) expenditure exceeds energy (caloric) intake. Nutritional intake must meet both growth and activity needs. The adolescent is growing at a rate second only to that of infancy. Disordered eating, such as binging and purging, or the use of laxatives, diuretics, and diet pills for weight control can result in the same energy deficit. The normal hypothalamic-pituitary-ovarian axis necessary for normal menstruation is surmised to be compromised by the caloric input-output imbalance (Griffin et al., 2003).

Osteopenia (with resulting weakened bones) can be a result of the amenorrhea that is in turn due to inadequate body fat and the resultant hypoestrogenemic state. Inadequate bone formation results. Recovery from this state is slow, and whether it is entirely reversible is unclear. Early intervention is crucial because adult bone mineral density is largely determined by the status of bone mass during adolescence and young adulthood (Davidson, 2003; Griffin et al., 2003). Thus, failing to achieve adequate bone mass during this crucial time in life increases the risk of osteoporosis and fractures as an adult. Changes in weight, height, and body mass index (BMI) are good clues to changes in bone mineral density.

In lieu of an eating disorder, hypothalamic amenorrheic female athletes appear fit, their estimated ideal body weight is more than 85%, and their resting pulse is 40–60 beats/minute (Hergenroeder & Chorley, 2004). Early identification, such as that afforded by the PPE, is imperative so preventive interventions can be instituted. This will ensure that the female may be able to return to a high performance level and enjoy good health in the future.

Fractures or Other Musculoskeletal Disorders in the Female Athlete

As stated earlier, an array of factors can lead to stress fractures. When there is an imbalance between bone resorption and bone deposition, the bone may not be physiologically capable of holding up under repetitive loads. The PPE affords the opportunity to explore the underlying risk factors that contribute (or contributed) to the fracture, conduct a pertinent examination, and implement strategies to prevent recurrence.

The female is 2 to 10 times more likely to experience a noncontact sports anterior cruciate ligament injury than a male. These injuries commonly occur during deceleration, landing, or cutting activities (Griffin et al., 2003).

The anatomy and biomechanics of the patellofemoral joint also put the female athlete at greater risk of having a problem with this joint. Malalignment or an imbalance between muscles of the pelvis, hip, knee, ankle, and foot; articular cartilage lesions; instability; soft tissue factors; and psychosocial factors can contribute to pain and dysfunction of this joint. Additionally, improper training, overuse, or injury can contribute to the pathophysiology. Runners can be afflicted with a painful knee condition known as runner’s knee; it results from overuse and causes micro-trauma to the sleeve of the knee joint. Distinguishing factors include pain around the knee joint (rather than inside it) and initial minor discomfort that progresses to increased pain after running.

The Use of Medroxyprogesterone (Depo-Provera) by the Female Athlete

Since 2004, the Food and Drug Administration has required a “black box” warning about the use of medroxyprogesterone as a contraceptive for adolescents and young adults. Some studies had found that prolonged use resulted in loss of bone mineral density; the loss was duration dependent. Current prescribing recommendations, therefore, advise not using this method of contraception in this age group for longer than 2 years unless there is no other alternative (American Society of Health-System Pharmacists, 2008).

What parts of the physical examination do you want to emphasize? image

Physical Examination

The PPE should consist of two parts, the musculoskeletal and general physical examinations. The simple, standardized 90-second musculoskeletal screening (Figure 10-2) reliably detects 90% of significant injuries, and has a 51% sensitivity and 97% specificity (McCarthy, 2006). Limitations or dysfunction in alignment, flexibility, and proprioception will be detected. Table 10-2 shows the components of an appropriate general organ examination. You want to pay special attention to assessing Nikola’s mental status because of her prior head injury, her musculoskeletal examination because of her prior stress fracture history, and her growth parameters and pulse because of concerns regarding her nutrition and eating habits.

Nikola’s examination reveals the following:

image  Height: 67 inches (slightly under 90%)

image  Weight: 127 pounds (approximately 60%)

image  BMI: 20 (between 25% and 50%)

image  Blood pressure: 115/68, Pulse: 60

image  Snellen: 20/20 OD/OS/OU with glasses

image  Appearance: Alert, cooperative, good historian, good eye-to-eye contact, smiles frequently, slender

The examination is negative except for a Grade I/VI, short, musical, midsystolic murmur best heard at the apex without radiation, increased slightly when supine.

What diagnostic studies would you consider? image

The only routine diagnostic test for a PPE is a hemoglobin/hematocrit for females, unless there is a particular risk factor for the individual. Females are more at risk for iron deficiency anemia. Urine drug screening and human immunodeficiency virus (HIV) testing may be required by some organizations.





Figure 10-2  Illustration of the 90-second sports musculoskeletal examination.

From For the practitioner: Orthopaedic screening examination for participation in sports. © 1981 Ross Products Division, Abbott Laboratories. Text adapted from Garrich, J. G. (1977). Sports medicine. Pediatric Clinics of North America, 24, 737–747.

Table 10–2 Example of an Appropriate Preparticipation Physical Examination

Examination Feature



Height and weight

Establish baseline and monitor for eating disorders, steroid abuse.


Blood pressure

Assess in the context of participant’s age, height, and sex.


General appearance

Excessive height and excessive long-bone growth (arachnodactyly, arm span greater than height, pectus, excavatum) suggest Marfan syndrome.



Important to detect vision defects that leave one of the eyes with < 20/40 corrected vision. Lens subluxations, severe myopia, retinal detachments, and strabismus are associated with Marfan syndrome. Note any anisometropia for the record. Absence of one eye will limit some sport choices.



Palpate the point of maximal impulse for increased intensity and displacement, which suggest hypertrophy and failure, respectively. Note heart rate, rhythm. Check for murmurs. A murmur that worsens with standing or Valsalva suggests hypertrophic cardiomyopathy.


Perform auscultation with the patient supine and again with the patient standing or straining during Valsalva maneuver.


Check femoral against radial pulses; femoral pulse diminishment suggests aortic coarctation.



Observe for accessory muscle use or prolonged expiration and auscultate for wheezing. Exercise-induced asthma will not produce manifestations on a resting examination and requires exercise testing for diagnosis.



Assess for masses, tenderness, organomegaly (especially liver and spleen). In females, assess for any pain and/or enlargement over hypogastric area or pelvis that might suggest pregnancy or gynecologic problem; proceed with further work-up as indicated.



Hernias and varicoceles do not usually preclude sports participation. Check for single, undescended testicle, masses. Discuss testicular cancer and provide information about the self-testicular exam.



Use the 90-second musculoskeletal examination (see Figure 10-2). Consider supplemental shoulder, knee, and ankle examinations as indicated specific to the chosen sports injury-prone areas.



Evidence of Molluscum cotagiosum, herpes simplex, impetigo, tinea corporis, or scabies would temporarily prohibit participation in sports where direct skin-to-skin compositor contact occurs (e.g., wrestling, martial arts).



Gross motor assessment with attention to equality of strength, especially with a history of recurrent stingers or burners, head injury. Usually sufficiently grossly assessed during the 90-second musculoskeletal exam.


Source: From Kuravski, K., & Chandran, S. (2000). The preparticipation athletic evaluation. American Family Physician, 61, 2683–2690, 2696–2698.

Nikola’s hemoglobin is 12.6. Because this is a female runner with a history of stress fracture, weight loss, questionable adequate caloric intake, and transient oligomenorrhea, you are suspicious for early female athlete triad, but also want to rule out thyroid dysfunction. She has also been sexually active. You add the following tests:

•  TSH: 3.6 UIU/mL (normal: 0.7–6.4 UIU/mL)

•  T4: 1.20 ng/dL (normal: 0.8–2.7 ng/dL)

•  Nucleic acid amplification test (NAAT) urine screen: negative (NAATs have high sensitivity and specificity for chlamydia and gonorrhea with the exception of the PCR type NAAT, which does not detect gonorrhea as well as the other two (Cook, Hutchinson, Ostergaard, Braithwaite, & Ness, 2005).

Making the Diagnosis

What other diagnoses will you consider? image

Differential Diagnoses

The differential diagnoses are secondary to the underlying features of the female athlete triad and include anorexia (malnutrition), leukemia, thyroid disorder, depression and other psychological conditions, osteopenia, osteoporosis, menstrual dysfunction, inadequate sports footwear, anatomical (joint or muscle) factors, osteogenesis imperfecta, early onset juvenile idiopathic arthritis, and overuse. If the amenorrhea continues despite nutritional and weight correction, you would proceed to explore other diagnostic differentials for this condition covered in other references.

Nikola’s PPE is reassuringly normal, as far as any residual effects from her head injury. She is at risk of second-impact syndrome should she receive another head trauma. If this should happen, it is not likely it would be a result of her noncontact running sport, but could be a result of recreational activities. Before clearing her for sports you need to obtain the prior head injury treatment records, as previously stated. However, based on the criteria listed in Table 10-3, you surmise it will be doubtful that she would be limited in her ability to run.

Because she is female, she is not as likely to suffer from sudden death as are males, and her review of systems and cardiac examination were all normal. Your review of the criteria suggestive of potential sudden death was also negative. Her murmur is typical of that of an innocent murmur, and no further workup is required.

Aspects of Nikola’s examination prompt you to weigh heavily her need to ensure she is obtaining adequate nutritional calories to meet her energy and sex steroids needs, and thus avoid full-blown manifestations of the female athlete triad. Her headaches are controlled; no further workup is necessary unless they worsen or become more debilitating.

Table 10–3 Recommendations for Management of Concussiona in Sports



General Management Strategies

The prevention of injury is not necessarily the most important aspect of PPE management. There are a myriad of health-related topics that should be taken into consideration, as discussed earlier. The provider will need to perform an assessment regarding developmental readiness and the type of preseason conditioning needed. Table 10-4 lists training (conditioning) and other management strategies the provider can recommend.

Educating coaches, parents, and the individual about heat illness (hyperthermia) prevention is important, especially for those participating in high performance recreational activities. See Table 10-4.

Active teenagers need to exceed their baseline caloric needs by 1,500 to 3,000 calories, depending upon the sport. Children require an intake of 60 kcal/kg of ideal body weight per day to maintain normal growth. The daily caloric needs consist of:

•  Carbohydrates (CHO): 55% to 75%

•  Fats: 25% to 30%

•  Protein: 15% to 20%

Women need to ensure adequate iron and calcium intake and may need supplements to achieve adequate levels of both. Calcium intake should be 1,200–1,500 mg/day for all youth.

Different sports involve the use of different fuel sources. Short-term, high-intensity sports (e.g., high jumping, diving) use anaerobic fuel sources, such as carbohydrates. Long-term activities (e.g., running, cross-country skiing) involve aerobic fuel sources, such as carbohydrates (both an aerobic and anaerobic source), protein, and fats. The carbohydrates should come from fruits, vegetables, whole grains, and milk sugars rather than from processed sugar sources. Carbohydrate loading prior to an activity has not been studied in children nor has it proven to enhance performance (Blosser, 2009). However, for activities that last longer than one hour, performance has shown improvement with carbohydrate intake. Additionally, muscle glycogen resynthesis is improved with the intake of CHOs if taken 30 minutes and 2 hours after strenuous activity. Additional protein may be efficacious for intense endurance sports and strength training (1,500 to 3,000 kcal above the recommended daily allowance of 1 g/kg/day). It is important to counsel that eating additional protein should not replace necessary CHOs and fats; extra fat will be stored from excessive, unused protein.

Some athletes (notably wrestlers) may practice weight cycling (weight loss). This practice has not been shown to lead to long-term adverse effects or to affect height and weight; however, it can deplete electrolytes; affect glycogen stores, hormones, and nutrition status; impair mental and academic performance; reduce immunity; and cause pulmonary emboli and pancreatitis (Housh & Johns, 2001). The practice should be discouraged; it is a risk factor for longer term dysfunctional eating. Other rapid weight loss measures practiced by athletes may include removing fluids from the body via sauna or a sweat suit, laxatives, diuretics, diet pills, licit or illicit drugs, nicotine, prolonged fasting, overexercising, or vomiting (Blosser, 2009).

Table 10–4 Management Strategies for the PPE




Those who are using drugs to enhance their performance should receive as much information as possible about their side effects. Such information is beyond the scope of this case study, but is available from a plethora of references and community resources. A referral for alcohol and drug assessment and counseling is in order.

Management Considerations for the Female Athlete Triad

The PPE provides an opportunity for the provider to be vigilant for features of the triad in female athletes. The presence of an eating disorder, rapid and progressive weight loss, change in menses patterns with either irregularity or loss of periods, and repeated stress fractures should prompt a team approach for management. This team of specialists often includes a nutritionist, medical provider, and psychiatrist or psychologist. The parents, athletic trainer(s), and athlete are included as part of the team. Exercise may need to be limited until the negative energy balance and unhealthy weight are corrected. If the individual is frankly amenorrheic, gaining weight through reduced training (exercise decreased to 3 days/week only if less than 85% of the estimated ideal body weight; otherwise, no change is necessary) would be part of the management strategy (Landry, 2007). If the amenorrhea has been prolonged and increasing calories is problematic, estrogen/progesterone replacement should be considered (AAP, 2002; Landry, 2007).

The female athlete may neither recognize she has a problem nor be aware of the serious physical consequences. Your education should focus on the benefits of treating the disorder in order to enhance her athletic performance–increasing strength, endurance, and concentration.

How do you plan to manage this adolescent?image

Female Athlete Triad Issues

Nikola’s history and PPE have some elements that suggest early female athlete triad (stress fracture, poor nutrition, oligomenorrhea). Correction of any inadequate calorie consumption should resolve her issues completely. Therefore, you arrange for her to talk with a nutritionist (a sport nutritionist is preferable). If you had discerned a frank eating disorder, then you would also refer her to a specialist in this field in order to deal with the psychological aspects of this condition. You prescribe a calcium supplement of 1,200–1,500 mg/day and ensure that her multivitamin contains iron and vitamin D. You schedule a recheck examination for Nikola in 3 months to recheck her weight and menstruation status.

Second-Impact Syndrome Issues

You also address her risk for second-impact syndrome. Any potential contact/collision activities should involve her using a helmet (e.g., while cycling or for any aggressive downhill skiing). You get permission from her (and note it in her chart) to notify her parents about the dangers of a second head injury.

Family Planning and Lifestyle Issues

You provide her with a pamphlet on birth control options, emphasize the continued use of condoms, and encourage her to return for a prescribed method should she resume sexual activity. You also emphasize the benefits to her health, academics, and sport success of abstaining from drugs and alcohol. Additionally, you advise her to seek medical attention should she have worsening or persistent bone or joint pain during daily activities, because she would need to be evaluated for a stress fracture, runner’s knee, or other musculoskeletal disorder. Track and field sports activities have a small risk of eye trauma, but she needs to be wearing any specific recommended eyewear for her sport.

Preparticipation Permission

You give her a quantitative “yes” clearance for sports pending review of her medical records pertaining to the MVA. You receive these records a week later. They reveal that Nikola was given a diagnosis of Grade 1 concussion with some mental confusion to date, time, and event; she was watched overnight in the hospital as a precaution. She demonstrated limited recall about the event and had a mild headache a week later at the clinic; by the second recheck appoint (week 2 post-MVA), she was fully oriented, her headaches had resolved, and no further follow-up was advised. You note in her record receipt of these records, give her a diagnosis of “cleared for sports,” and mail off a copy of the sports examination form (the second side of the form in Figure 10-1) to Nikola.

What follow-up care do you want to plan for Nikola? image

Nikola needs to return for her weight check in 3 months. You place a note in the system you use in your clinic for important recall purposes.

Additionally, you call her parents and discuss second-impact syndrome with them and Nikola’s risk factors for another head injury. You note your call in her chart.

Key Points from the Case

1. The PPE is often the only health examination for the majority of youth and adolescents in any given year. There are two parts: the musculoskeletal and general physical examinations.

2. A standard PPE form should be used.

3. All history and physical findings need to be documented. Findings will help the provider determine whether sports participation should be allowed, whether further evaluation is needed before being allowed, or if risk factors preclude participation.

4. Psychological and physical well-being need to be assessed in order to ascertain the individual’s level of awareness of the demands of the sport, the anticipated response to these demands (experiencing defeat), and consequences of participation within the context of the time commitment.

5. Adequate nutritional intake is crucial for maintaining normal growth and meeting the added demands of the physical activity.

6. Postconcussive syndrome/second impact syndrome can be a side effect of a minor head injury; any history of a head injury needs to be fully explored before allowing participation in contact or collision sports.

7. The female athlete’s health risks are altered due to environmental, anatomic, hormonal, biomechanical, and neuromuscular factors.

8. The female athlete triad is comprised of a progressive set of three interrelated conditions that occur along a continuum rather than in unison: anorexia, amenorrhea, and osteopenia. The existence of one of these symptoms serves as a red flag during the PPE. Management involves a team approach.

9. Medroxyprogesterone (Depo-provera) has a “black box” warning as a contraceptive for adolescents and young adults because of a chance of prolonged bone mineral density loss; careful consideration is indicated before prescribing.

10. General counseling topics should also include preparatory training and warm-ups, heat illness prevention, eye protection, caloric needs, added minerals that may be necessary, drug and alcohol avoidance (including performance enhancing drugs), and risky behaviors.


American Academy of Pediatrics. (2002). Guidelines for pediatricians: Female athlete triad. Sportsshorts, 8. Retrieved April 13, 2009, from

American Society of Health-System Pharmacists. (2008). American Hospital Formulary Service (AHFS) Drug Information 2008. Bethesda, MD: American Society of Health-System Pharmacists.

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