General Principles and Preparticipation Evaluation
Purpose and limits
The preparticipation physical evaluation (PPE) is a screening encounter: it aims to detect conditions that raise the risk of injury or sudden death, meet administrative and legal requirements, and establish a baseline for future care. It is not a substitute for routine health maintenance, and its positive predictive value is low. Describe it as a screen that triggers further evaluation, not a diagnostic test.
The history matters most
Most lethal conditions are found by history rather than examination. Ask about exertional chest pain or pressure, syncope or near-syncope, unexplained dyspnea or fatigue, prior murmur, elevated blood pressure, and previous restrictions. Family history should cover sudden cardiac death before age 50, cardiomyopathy, Marfan syndrome, long QT syndrome, and other inherited arrhythmias. Examination emphasizes cardiac auscultation supine and standing, femoral pulses, Marfan stigmata, brachial blood pressure, vision, and a directed musculoskeletal screen.
Traps
Questions often give a reassuring finding to tempt you. A normal resting ECG does not exclude hypertrophic cardiomyopathy. A murmur that grows louder with Valsalva and softer with squatting suggests HCM, whereas a benign flow murmur softens on standing. Exertional syncope is never benign until proven otherwise. Universal ECG screening remains contested, with European guidance more supportive than US guidance. Know the clearance categories: cleared, cleared with restrictions, deferred pending evaluation, and not cleared.
Rule of thumb
Any athlete with exertional syncope, exertional chest pain, or a family history of sudden death before age 50 is withheld from competition until cardiology evaluation is complete.
Worked example: a 16-year-old collapses at the finish of an 800 m race and recovers within seconds. That is exertional syncope until disproven; restriction and urgent cardiology referral are correct, not reassurance because the examination is normal.