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Sports Physicals: What You Need to Know
The sports physical should be more than just getting a form for a student signed.

By Deborah L. Squire, MD and Dennis Clements, MD, PhD, MPH

Every year more than seven million high school students participate in interscholastic athletics. Almost all of these athletes are required to undergo a physical evaluation prior to starting practice.

For the vast majority of students, these physicals serve as their only contact with the health care system, and should not be considered as an annual inconvenience.

The purpose of the sports physical is to:

Identify medical or musculoskeletal conditions that might make participation in a particular sport unsafe

Screen for any previously undetected health problem

Assure that any previous injuries have been adequately rehabilitated so that the athlete is not at risk for further injury

But these visits can also provide an opportunity to educate athletes and parents about injury prevention, conditioning, and training appropriate for level of physical maturity, as well as healthy nutritional approaches to sport participation.

Many youth are seen in mass screenings in high schools or sports medicine clinics; such physicals should not replace an annual evaluation by the student’s primary care provider.

However, at an annual evaluation a pediatrician can incorporate the essential elements of the pre-sports physical into a yearly checkup. With access to the medical record, including growth charts and previous blood pressures, chances of identifying medical problems are significantly increased.

In addition, referrals to specialists for additional evaluation are more easily coordinated by the primary care provider.

When to Go
Timing for the sports physical is very important. Ideally, the sports physical should be at least six to eight weeks prior to start of practice. Too often parents forget how quickly the year has gone, and end up scheduling a visit in urgent fashion -- “She needs this form filled out today because tryouts are tomorrow.”

This does not allow sufficient time for any further evaluation of a newly found medical condition or rehabilitation of an injury. Unfortunately, this may keep an athlete from trying out for a sport.

Medical History Is Key
Studies show that the vast majority of significant medical conditions identified at pre-participation evaluations are picked up through a detailed history.

Although many schools use limited, outdated sports physical forms, pediatricians have access through the American Academy of Pediatrics to a more complete, standardized form endorsed by the majority of sports medicine organizations in the US.

Parents and athletes should jointly complete the history portion of any sports form prior to arriving at the office to assure accurate responses. Family history is especially important.

Premature death or significant disability from cardiovascular disease in a close relative under 50 years of age or specific knowledge of close relatives with certain cardiovascular conditions such as hypertrophic cardiomyopathy, long QT syndrome, or Marfan’s syndrome, all require further evaluation and, in many cases, clearance by a cardiologist before participation in sports.

Dietary Concerns
A complete nutritional history, including use of supplements, is also important. The sports physical provides an early opportunity to identify athletes with disordered eating patterns, and those at risk for a true eating disorder.

This is where a growth chart covering several years is essential. In addition to dietary intake information (servings of dairy, fruits, vegetables, meat, soda), information should be obtained about the athlete’s highest and lowest weight over the past 12 months, as well as the athlete’s perceived ideal weight.

Your pediatrician should ask about use of any pathogenic weight control behaviors, such as self-induced vomiting, use of laxatives or diet pills, or excessive exercise. If an athlete is developing disordered eating patterns, careful follow-up and early intervention is critical in preventing a potential life-threatening condition.

Best Diet for Performance
Many athletes are interested in the best diet for athletic performance or to gain weight. For endurance athletes, like cross country runners or soccer players, it is important that at least 55 percent of their total calories come from carbohydrates like breads and pasta. This saturates their muscles with glycogen, the optimum energy source for working muscles.

Non-athletic adolescents age 15 to 18 need only 0.8 gram of protein per kilogram (2.2 pounds) of body weight each day. Some adolescent athletes who are training intensively and trying to put on muscle mass may need as much as 1.5 gm of protein per kilogram body weight per day.

For many American children, their standard diet already fulfills this need; rarely are expensive protein supplements needed -- or helpful. Vegetarian athletes need to pay special attention to both their protein and iron intake.

Proper Hydration
During the school year, most adolescents exist in a state of relative dehydration -- they just don’t drink enough throughout the day.

In addition to the recommended eight to 10 glasses of liquid as baseline, athletes with fluid losses in sweat may require as additional 1 to 3 liters of fluid per day. Attention to hydration is important both to maximize athletic performance as well as decrease susceptibility to heat illness.

Guidelines for fluid intake are:

Drink 16 ounces of water 30 to 60 minutes before activity
Drink 4 to 8 ounces water every 15 to 30 minutes during activity
Drink 16 ounces (1 pint) water for every pound of weight lost after activity
Signs and symptoms of heat illness should be reviewed. Any athlete exercising in the heat who experiences muscle cramps, dizziness, nausea, severe headache, or unusual muscle weakness should stop exercising, get in as cool a place as possible and start drinking cool water.

Many sports programs are now willing to reschedule or cancel practices when conditions of extreme heat and humidity occur.

Weight Loss Guidelines
Many athletes who want or need to lose weight (body fat) do not have the luxury of consultation with a dietitian.

These athletes can follow some basic guidelines:

Aerobic activity (walking, running, biking) can be increased by 30 minutes a day

Consume more fruits and vegetables

Water should be the primary fluid source; Drink less soda, juice, and sports drinks

Use reduced-fat or fat-free dairy

Limit use of butter, margarine, mayonnaise, and dressings. Mustard can be used on sandwiches and salsa on salads and baked potatoes

Portion sizes of meat can be decreased, and only served at one meal a day

Never try to lose more than two pounds per week

Weight Training
Weight training can play an important role in preventing athletic injuries as well as improving athletic performance. Weight training can serve to balance the strength in muscle groups around specific joints and reduce the risk of injury; consultation with an athletic trainer, physical therapist or sports medicine physician may help design such programs.

As the adolescent grows and develops, the design and goal of a weight training program changes.

For the pre-teen, a program using lighter weights with 12 to 15 repetitions per set and a maximum of two sets per exercise will improve muscle strength by causing more of the muscle fibers to respond to nerve stimulation; a significant increase in muscle bulk will not occur until after the athlete stops growing taller.

It is important that proper technique be used by the athletes, and that careful stretching is done before and after lifting to maintain or improve flexibility.

Off-Season Workouts
It is important for the one-season athlete to maintain fitness throughout the year by engaging in at least 30 minutes of moderately vigorous activity five days a week.

In anticipation of the start of the season, slowly advance training loads to reduce the risk of stress fractures. Workouts should be increased by no more than 10 percent per week.

This means that fall sport athletes need to begin their conditioning program early in the summer to be ready when school practices officially begin.

For Female Athletes
Finally, for the female athlete, attention should be paid to menstrual function.

An athlete who hasn’t begun menstruation by age 16 or misses more than three consecutive cycles after regular monthly cycles are established should be evaluated for nutritional adequacies as well as other hormonal abnormalities that can affect menstrual function. Missing repetitive periods is not normal for an athlete.

A history of stress fractures should prompt evaluation for the “female athlete triad”: eating disorder, menstrual abnormalities, and osteoporosis.

Deborah L. Squire, MD , is a physician in Duke’s Children’s Primary Care department. Dennis Clements, MD, PhD, MPH, is the chief medical officer of Duke Children's Hospital. For more information, visit www.dukehealth.org

The information presented on this site is intended solely as a general educational aid, and is neither medical nor healthcare advice for any individual problem, nor a substitute for medical or other professional advice and services from a qualified healthcare provider familiar with your unique circumstances. Always seek the advice of your physician or other qualified healthcare professional regarding any medical condition and before starting any new treatment.

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