Definition and Overview

Also known as pre-participation physical evaluation (PPE), pre-sports evaluation is conducted to assess the physical and mental health of athletes before they undergo training or join a sports competition. The main objective is to ensure that they are fit so they can at least minimize the risk of injuries and other potentially serious conditions. .

Since this is a medical exam, it is conducted by a physician, preferably a health care provider with an extensive background in sports medicine. Based on the results of the PPE, the physician will make some recommendations, which may include non-participation, complete participation, or limited participation. The physician may also suggest treating or managing the diagnosed illness or health condition before the athlete is allowed to participate in any type of sports.

PPE is a collaborative effort by several organizations including but not limited to the American Academy of Family Physicians, the American College of Sports Medicine, and the American Orthopedic Society for Sports Medicine. Many of the specific details that are involved in PPE including the objectives, benefits, and how to perform the clinical examinations are outlined in PPE Monograph, which was developed by these organizations.

PPE was first advised by former President Theodore Roosevelt in the early twentieth century after a number of student athletes suddenly died while playing football. One of the leading causes of the sudden death is cardiac arrest. For this reason, the American Heart Association (AHA) has also published some recommendations on this topic.

Who Should Undergo and Expected Results

PPE is recommended—and, in some states like California, required—to all participating athletes, particularly teens and students. The test was primarily designed to evaluate the risk of dying from sudden cardiac death (SCD).

According to Southwest Athletic Trainers’ Association (SWATA), more than 100 athletes died due to sports-related conditions between 2008 and 2009. The number dropped to 40 in 2011. Their numbers also revealed that teens between the ages of 15 and 17 are more likely to be treated in an emergency room for sports-related injuries.

Another possible cause of death that PPE aims to avoid is second impact syndrome, which is characterized by an injury to the brain triggered by the premature sports engagement of a player after suffering from a primary injury.

There are many advantages for carrying out PPE and these include:

  1. Physicians are able to identify undiagnosed conditions that may affect the performance and overall lifestyle of athletes. For instance, patients may be diagnosed with elevated cholesterol or hypertension, which can increase their risk of heart disease. Doctors may also be able to spot other common causes of cardiac arrest (myocardial infarction) like stenosis (narrowing of the cardiac arteries) or cardiomyopathy (the abnormal changes in the heart muscles like rigidity or thickening).

  2. Physicians can make a more accurate and reliable recommendation to the athlete, keeping in mind his overall health and safety. It should be stressed that disqualification is not the deliberate goal of PPE, although an athlete may be disqualified based on the results of the PPE. Doctors can also provide clearance for returning players.

  3. Sports-related death can be significantly reduced

  4. PPE helps promote athletics especially among the teens. Athletics remains one of the best forms of exercises. Also, according to Stanford University, teen athletes perform better in school and are less likely to drop out.

How Does the Procedure Work?

PPE is often carried out at least six weeks before the start of the practice or training. This is necessary to give athletes, who may have an increased risk of injury or condition, to manage their health by following the protocol created by their respective physicians.

Several pieces of information are obtained and examined during PPE. These include:

  • History of allergies, drug abuse or medical condition
  • Current health condition
  • Intake of prescriptions and supplements
  • History of sports-related injuries such as concussions
  • Performance among players with only one surviving organ (e.g., kidney)
  • Visual acuity
  • Physical profile such as height, weight, and body mass index (BMI), which is one of the indications of obesity
  • Blood pressure
  • Examination of the vital organs such as the brain, lungs, liver, and abdomen
  • Orthopedic or musculoskeletal exam

The initial information may be provided by the athlete and/or the parent in the PPE medical history form where the person ticks the corresponding box—whether yes or no—based on the questions. For a more comprehensive PPE, equipment such as electrocardiography, treadmill for stress tests, and imaging scanners like MRI or CT are used. The athlete also goes through blood, stress, and eye tests, among others.

Possible Risks and Complications

In spite of the many benefits of PPE, there are also limitations. One, there’s no standard screening guideline. This simply means that the rules on how to perform it can greatly vary among schools, health care facilities, and state. If an athlete therefore is found to be unfit to compete in one state, there’s a chance he will be allowed if he is evaluated in another state due to lack of screening standardization.

Moreover, in some cases, non-health care professionals may be permitted to conduct PPE. It’s also probable that the doctor who carries out the evaluation doesn’t have an extensive knowledge on PPE and sports medicine.


  • Ball JW, Dains JE, Flynn JA, Solomon BS, Stewart RW. Sports participation evaluation. In: Ball JW, Dains JE, Flynn JA, Solomon BS, Stewart RW. Seidel's Guide to Physical Examination. 8th ed. Philadelphia, PA: Elsevier Mosby; 2015:chap 23.
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