Sports Physicals

Updated: Apr 27, 2023
Author: Henry T Goitz, MD; Chief Editor: Craig C Young, MD 


Need and cost

The number of children, adolescents, and college students in the United States participating in organized sports has ranged between 30 and 45 million. This results in a substantial number of healthcare hours that are spent on performing preparticipation evaluations each year. Owing to the low yield of significant abnormalities in this relatively healthy population, the extent and cost-effectiveness of these evaluations have been challenged.[1]


The approach to preparticipation evaluations (PPE) is geared towards assessing general physical and psychological health, while also identifying conditions that could compromise an athlete's safety and well-being. In 2019, collaborative efforts from the American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), American College of Sports Medicine (ACSM), American Medical Society of Sports Medicine (AMSSM), American Orthopedic Society of Sports Medicine (AOSSM), and American Osteopathic Academy for Sports Medicine (AOASM) published updated recommendations (PPE 5th edition).[2]  Ideally, these evalutions would be performed at the primary care physician's office, owing to the familiarity with the athlete's past medical and family histories as well as a maintenance of continuity of care. 

Fifty states, together with the District of Columbia, require preparticipation examinations prior to competing at the high school level; in fact, some examinations are deemed legal requirements.[3]  Some practitioners approach sports physicals as thorough, periodic health evaluations, whereas others consider these evaluations to be risk-based screening examinations. Neither approach is perfect, and no universal standard exists for what constitutes an adequate or appropriate evaluation for this population.[4]

Main issues

The main athletic assessment issues can be classified into 3 categories: administrative, coaching/athletic, and medical.

Athletic directors are the ones who usually address the administrative issues, which are often based on institutional policy and on local, state, or national laws. These administrative issues involve liabilities, matters to do with insurers, and the rights of athletes to participate in competitive sports. The administrators rely on the physician to assess athletes for compliance with the relevant administrative codes.

The coaching/athletic issues involve both the coaches and athletes. The athletes want medical clearance so that they can safely compete and train. If they have a history of injuries or medical problems, the athletes desire information about how to treat or rehabilitate those conditions to improve their performance and safety. Coaches are interested in fielding a team of healthy athletes. When injuries or illness preclude their athletes from competing, coaches need to know the time period that is required for the injury or illness to heal so that they can make decisions about finding capable substitutes. Both athletes and coaches depend on the physician to help them in making these types of decisions.

Medical issues are handled by the physician, athletic medical staff, athlete, coaching staff, and administrators. The goal is to ensure, as completely and accurately as possible, that an athlete with a specific medical condition can compete safely. Achieving this goal is usually straightforward, but a particular situation can become complicated. Although a number of guidelines are available, many are difficult to interpret or implement. Furthermore, some conditions that affect an athlete's participation in sports do not have clear-cut guidelines. The physician's role is vital in these cases. He or she must not only determine the athlete's safety but also assist team coaches in making decisions about administrative and legal matters.

Goals and objectives

The goals of a preparticipation sports evaluation can be summarized as follows:

  • Promote the health, wellness, and safety of all athletes evaluated

  • Assess the athlete's present fitness level and overall health status

  • Detect conditions that increase the risk of life-threatening complications with participation

  • Evaluate any existing injuries of the athlete

  • Assess the size and developmental maturation of the athlete

  • Advise athletes in the safe and appropriate sport(s) in which to participate, concordant with their underlying health conditions

  • Detect congenital anomalies that increase the athlete's risk of injury

  • Detect poor preparticipation conditioning that may put the athlete at increased risk

  • Adequately screen for and evaluate potential mental health disorders


Timing, Frequency, and Types of Evaluations

Timing of the evaluation

The timing of an athletic preparticipation evaluation is dependent upon the season of the sport. Many evaluations are performed throughout an entire institution that has teams competing in many sports during various seasons. In this circumstance, one approach is to perform the evaluations before each major season. This method may be optimal for each sport in its season, but it also requires organization and frequent involvement by the medical team. Another option is to conduct all physical examinations for the institution at the same time each year. Although this approach is more convenient for the medical team, the evaluations may not be optimally timed for all sports.

The optimal timing for the preparticipation sports evaluation is approximately 6 weeks before the onset of the sports season because this period affords time for further evaluation of any problems that may be identified. If treatable problems are detected, some rehabilitation success can be achieved during those 6 weeks. Furthermore, unconditioned athletes may have an opportunity to improve their conditioning in this time frame and, thus, hopefully prevent additional injury.[5]

If the physical examination is performed less than 6 weeks before the start of a sports season, some athletes may not have time to recover from injury, to become conditioned, or to complete a specific evaluation that may necessitate medical clearance for play. As a result, athletes may miss part of the sports season. If the preparticipation evaluation is performed earlier, there is time for other conditions to develop, and the findings of the initial evaluation may no longer be up to date.

Frequency of evaluations

No requirements are established for the frequency of these physical evaluations. Approaches vary from annual, to season-specific, to single evaluations performed when an athlete enters a sports program.

High schools typically require annual evaluations before a student's participation. These are usually considered valid for the entire academic year and may diminish the number of evaluations needed by multisport athletes. 

Many higher-level institutions use thorough initial evaluations upon the student's admission to its athletic programs, with annual follow-up examinations that are focused on particular items together with a review of the athlete's medical history. Some of these follow-up examinations may address only the history if the individual is healthy. If abnormalities are suspected from the history screening, these problems should be evaluated thoroughly.

In a number of organized professional sports, preseason and postseason physical examinations are the standard.

Types of evaluations

Two main types of athletic preparticipation evaluations exist: one by the athlete's personal physician and the other by multiple providers in a multistation setting. Either evaluation is adequate if the proper assessment and documentation are complete.

An increased effort has been made to have these evaluations performed in the primary care physician's office.[2]  The private office examination is ideal from the standpoint of continuity of care, building rapport, and providing an improved opportunity for counseling. Furthermore, the athlete may feel at ease in the surroundings of a familiar physician. The main drawbacks to this approach include the increased cost and decreased efficiency with performing these evaluations in the office setting.

Another avenue used is the multistation evaluation, which involves multiple professionals and examination-based specialists. Whereas primary care sports physicians often perform the preparticipation examinations, in some situations, multidisciplinary evaluation is desired. For example, professional teams often use multistation, multidisciplinary evaluation to allow them to efficiently perform in-depth specialty evaluations, such as complete dental examination, echocardiography, functional movement evaluations, VO2max testing, and body composition.

This multistation approach requires a coordinated effort of many more personnel. These types of evaluations are often performed in gymnasiums, locker rooms, or auditoriums; thus, privacy for the patient is potentially compromised. Multistation evaluation is ideal for large volumes of athletes and provides immediate access to a specialist if abnormalities surface. To achieve patient cooperation, personnel such as coaches may assist in supervising athletes who are waiting to be examined. Trainers and therapists are often used to assess vital signs, evaluate visual acuity, and assess flexibility and joint range of motion. See Table 1 for common recommendations for a station-based setup.

Table 1. Recommendations for Station-Based Preparticipation Physical Evaluations (Open Table in a new window)



Sign in

Height and weight

Vital signs


Physical examination*

Medical history review, assessment, and clearance

Ancillary personnel (coach, nurse, community volunteer)

Ancillary personnel

Ancillary personnel

Ancillary personnel

Physician/ ATC

Physician/ ATC



Injury evaluation†


Body composition


Speed, agility, power endurance, balance




Athletic trainer, physical therapist

Athletic trainer, exercise physiologist, physical therapist

Athletic trainer, coach, exercise physiologist, physical therapist

Athletic trainer, coach, exercise physiologist

*The physical examination can be subdivided if more than one physician is present. Qualified medical personnel may perform the musculoskeletal examination under the direction of a physician.

†A station for the evaluation of musculoskeletal injury may be used to provide a more complete evaluation when a musculoskeletal injury is detected during the required musculoskeletal screening examination.

With the multistation approach, a lead physician should be designated. This physician reviews the results from all the stations and signs the needed forms to clear the athlete for play. The lead physician also checks to ensure that nothing is missed and supplies the appropriate personnel information about athletes who have abnormalities, including those who are still able to compete.



A thorough medical history is the most important part of the athletic preparticipation evaluation. When completed and thoroughly reviewed, it is the most sensitive and specific tool to detect if an athlete can safely compete in a given sport.[2]

Source of the history: In the case of a young athlete, a minor, it is "best practice" to review the history with both the athlete and a parent or guardian. 

In the case of minors, medical and surgical histories should be obtained with a parent or guardian present. If this is not possible, history forms should be filled out with their signature(s). Without the parent's or guardian's involvement, the athlete's history cannot always be considered reliable.

Many established tools are available to facilitate the collection of key medical information. Much research and thought has gone into the forms that are jointly recommended by the American Osteopathic Academy of Sports Medicine (AOASM), the American Academy of Family Physicians (AAFP), the American Medical Society for Sports Medicine (AMSSM), and the American Orthopaedic Society for Sports Medicine (AOSSM). These forms are easily accessible online. 

An athlete's medical history should include past medical, surgical, and cardiovascular history; concussion; musculoskeletal injuries; mental health; and general well-being. 

If any concerns arise while obtaining the history, strongly consider additional testing and/or referral to a specialist for appropriate diagnosis and management. 

Key issues that should be addressed in a sports history include the following:

  • Past medical history

    • History of anaphylactic reactions

      • This finding is especially important if an athlete has known anaphylaxis with environmental exposures that may be more sport specific. That is, the athlete may have higher exposure to insect bites or other environmental allergens if the sporting activity takes place in an outdoor setting, particularly at certain times of year. 

      • Exercise-induced anaphylaxis (EIA), albeit rare, is a potentially deadly condition that all healthcare providers must be aware of.

      • If an athlete has a positive history, he or she can be advised to always keep an anaphylaxis kit at hand.

      • Advance knowledge of an athlete's allergy can alert coaches, trainers, and team physicians to be prepared to treat this life-threatening condition. (See also the Medscape Reference article Anaphylaxis.) 

    • Asthma

      • Because asthma is often triggered by exercise or exertion, the severity of the previous episodes should be evaluated further. In addition, adequate instruction about treatment can help prevent dire consequences. (See also the Medscape Reference articles Exercise-Induced Asthma [in the Sports Medicine Section] and Asthma [in the Pulmonology section].)

    • Previous heat illness 

      • Individuals with a prior episode(s) of heat illness are at increased risk of recurrence.

      • This finding is especially important for certain sports or geographic locations where elevated temperatures and humidity increase the risk of participation for the athlete. (See also the Medscape Reference article Heatstroke.)  

    • Loss or dysfunction in one of a pair of organs

      • If the remaining organ of a pair is injured, entire function can be lost.

      • For the most part, this assessment applies to the eyes, kidneys, and testicles.

      • See Clearance for Sport section below.
    • Diabetes

      • Regular exercise and activity are important for those with diabetes.

      • Modifications in medications and pre-exercise insulin dose may be appropriate.

      • Additional glucose monitoring is necessary, especially with prolonged activity.

    • ​Infectious disease

      • ​History of COVID-19 (SARS-CoV-2 infection):  Our understanding of COVID-19 and its potential sequelae is still evolving. There is an increased risk of various conditions including, but not limited to, myocarditis, coagulopathy, pulmonary embolism, respiratory dysfunction, fatigue, and myalgias.[6]  It is important to understand and discuss the most current local guidelines regarding the removal from sport for exposure and/or confirmed positive testing, as well as a graduated return to play.[7]

      • History of human immunodeficiency virus (HIV) infection: Low risk for transmission in sport. Universal precautions are recomended for blood and bodily fluid.
    • Menstrual history

      • An abnormality in menstrual function can be a clue to significant underlying medical conditions, including pregnancy, osteoporosis, nutritional deficits, drug abuse, psychiatric conditions, and eating disorders. (See also the Medscape Reference article Female Athlete Triad.)

      • Note menarche (age of first period), regularity of cycles, and amenorrhea. 

    • Medications and supplements

      • Over-the-counter and prescription medications should be reviewed.

      • Some classes of medications may be better tolerated by certain athletes based on medical history and specific sport demands.

      • Some medications, even when prescribed correctly, may be banned or deemed performance-enhancing substances.

      • Knowledge of the local and national governing bodies of sport and their policy of banned substances is recomended.
      • Use of supplements and performance-enhancing substances should be reviewed and discussed. 

    • Vaccination record

      • Tetanus status: With any athletic endeavor, the risk of abrasion and laceration is increased. All athletes should be up to date regarding tetanus immunization.

  • Cardiovascular

    • Sudden cardiac death (SCD) is the leading cause of mortality in athletes during sport.[8]  This includes structural, electrical, and familial causes.

    • The American Heart Association (AHA) 14-component screening tool includes the following history questions:
      • Personal history
      •  Chest pain/discomfort/tightness/pressure related to exertion
      •  Unexplained syncope/near-syncope
      •  Excessive exertional and unexplained dyspnea/fatigue or palpitations, associated with exercise
      •  Prior recognition of a heart murmur
      •  Elevated systemic blood pressure
      •  Prior restriction from participation in sports
      •  Prior cardiac testing ordered by a physician
      • Family history
      •  Premature death (sudden and unexpected, or otherwise) before age 50 attributable to heart disease in ≥1 relative
      •  Disability from heart disease in close relative aged < 50 years
      •  Hypertrophic or dilated cardiomyopathy, long-QT syndrome or other ion channelopathies, Marfan syndrome, or clinically significant arrhythmias; specific knowledge of certain cardiac conditions in family members [9]
  • Sport related concussion (SRC) 

    • Personal concussion history should include the total number of concussions, date of each event, as well as the length of time to recover per event.

    • It is important to understand athletes may not recall all prior SRCs. With this in mind, ask about all prior head, neck, and facial injuries.

    • The goal of this screening is to recognize athletes who may be in a high-risk category and provide an opportunity for education, risk mitigation, and shared decision making as it relates to athletic engagement.[10]

    • Baseline testing: Although not required, it can be useful 

      • A preseason sideline assessment tool or computerized neuropsychiatric testing can be helpful should the athlete have a suspected SRC during the season. 

      • Review of concussion-like symptoms: Headache, dizziness, nausea, blurred vision, light and sound sensitivity, feeling "in a fog," difficulty concentrating or remembering.[10]

      • Prior knowledge of baseline concussion symptoms can be helpful in determing postconcussion syndrome
  • Past surgical history

    • Knowlege of prior surgery and dates can prompt more thorough questioning including the examination and functional assessment of the affected area. This will help to determine if the patient has fully recovered or if additional workup or rehabilitation is neccessary. 

  • Musculoskeletal injuries

    • Recent or recurrent fractures, dislocations, and other injuries: A history of these types of injuries may indicate a condition that requires further treatment or surgery. It may also indicate an abnormality in the athlete's playing mechanics, style, or equipment.

    • A benefit of completing the sports physical at least 6 weeks prior to the season is that it allows for additional rehabilitation or treatment as necessary.

    • If the provider does not feel comfortable assessing or discussing the treatment of a specific injury with ongoing symptoms, referral to a sports medicine physician is recommended.

  • Mental health

    • The development of validated assessment tools to improve early identification of mental health issues in athletes is optimal

    • There has been a call for improved mental health awareness and policy change.[8]  

    • Eating disorder/disordered eating: Annual screening is recommended.[11]  

    • Depression/suicide: Athletes have unique risk factors for depression.

    • Early recognition and appropriate management lead to improved performance and outcomes.

  • Use of contact lenses, dental appliances, and other devices: It is important to be aware of the athlete's use of any lenses or devices because they may become dislodged during competition. Some items should not be worn during competition. In addition, athletes may wear jewelry or have body piercings; these should be noted and assessed.

  • General wellness

    • Optimizing sleep, hydration, nutrition, and stress management to improve performance and overall health.

  • Current review of systems

    • Helpful for determining if additional focused examination and testing are warranted.


Physical Examination

The physical examination should be global and complete because any abnormality can affect an athlete's sports participation and, ultimately, his or her health. However, the examination is still somewhat focused on screening for major anomalies. The athletic preparticipation physical evaluation includes a medical and orthopedic examination. If the athlete's medical history reveals any concerns, those areas of concern should be examined thoroughly. 

A comprehensive general physical examination is beyond the scope of this article. However, the following is a list of areas that should receive specific attention in an athletic preparticipation evaluation.

  • Height and weight: These measures indicate growth and development and may reflect general fitness (eg, obesity) and pathology (eg, eating disorders). These measures are also valuable in evaluating an athlete's risks for competing at certain levels. Furthermore, some sports are classified according to the athlete's size or weight, and these measures may affect participation.

  • Blood pressure (BP): Although a BP measurement is rarely an indication for disqualification from sport, abnormalities are often first noted during the sports physical examination setting. Athletes with BP changes can be referred for follow-up care with their primary physician. Certain sports may cause significant BP elevations, and this may be a reason to limit an athlete's participation. The BP must be evaluated more than once, and normal BPs for the athlete's age must be considered. Normative values based on the 2017 American Academy of Pediatrics Guidelines are a systolic blood pressure (SBP) or diastolic blood pressure (DBP) less than the 90th percentile for age, sex, and height for children and less than 120/80 mm Hg for those aged 13 years and older.[12]

  • Visual acuity: Visual acuity does not need to be 20/20 for sports participation, but poor vision can affect the athlete's performance and increase the likelihood of injury. If the athlete's visual acuity is abnormal, interventions can be recommended before his or her participation in sports activities. Some recommendations advocate clearance without intervention for any person with visual acuity of 20/40 or better using both eyes.

  • Skin: Certain sports, such as wrestling, disqualify athletes who have infectious dermatoses, which include impetigo, herpes, and forms of tinea. Other conditions (eg, acne, scabies, nevi) can be detected, and the athlete should be counseled in such cases.

  • Eyes: Pupil reactivity and anisocoria should be noted. Knowledge of preexisting abnormalities can be useful information at a later time in case an athlete has a head injury.

  • Cardiovascular: Routine auscultation for murmurs or irregular rhythms is indicated. Examination should be obtained with the patient in at least two positions (usually sitting and supine), which increase the likelihood of detecting subtle abnormalities. A familiarity with the definitive findings of different valvular lesions is essential. 

    • The classic murmur of hypertrophic cardiomyopathy (HCM) is a systolic murmur along the left sternal border, which is accentuated by Valsalva maneuvers and standing; the murmur decreases with handgrip and squat maneuvers.

    • Auscultatory findings can reveal many murmurs, which are mostly benign systolic flow murmurs, but the examiner must have a trained ear to be able to determine the need for further evaluation.[13]

    • Femoral pulses to exclude aortic coarctation.
    • Stigmata of Marfan syndrome. [9]
  • Abdomen: The abdominal examination should be conducted to assess organomegaly, especially hepatomegaly and splenomegaly, because of the risk of rupture in contact sports.

  • Genitalia: The need for a genital examination is an area of controversy among sports medicine physicians. This examination can be used for Tanner staging in adolescents to classify athletes by maturity; thus, developmental delays can be detected. The genital examination can also be used to assess males for the presence of an undescended testicle or masses, and to evaluate for the presence of hernias. Some sports physicians omit the genital examination unless the history indicates a single testicle or inguinal or scrotal swelling; the medical history may be adequate for finding these problems. Furthermore, unless hernias are incarcerated, sports participation may not be prohibited.

  • Musculoskeletal: If the screening history is negative, this evaluation can be quickly completed by using an orthopedic screening as outlined below. 

    • Note the general body habitus.

    • When assessing joint range of motion (ROM), evaluate for symmetry. Asymmetry warrants a more detailed examination of the compromised body part, as does joint swelling.

    • Assess the cervical ROM.

    • Assess shoulder strength, particularly resisted abduction and external rotation at 0 degrees of shoulder abduction. Evaluate shoulder ROM.

    • Visually inspect the forearms and have the athlete supinate and pronate the forearms with the elbows flexed at 90°.

    • Evaluate the hands for rotational deformities by asking the athlete to open and close the hands and spread the fingers.

    • Have the athlete perform a duck walk to evaluate the function of the hips, knees, and ankles.

    • Assess the knee for swelling, ROM, and patellar tracking.

    • Perform a Lachman test for anterior cruciate ligament integrity.  

    • Ask the athlete to toe walk and heel walk.

    • Ask the athlete to touch his or her toes and assess for scoliosis.


Other Screening Evaluations

The role of other screening evaluations without cause, such as electrocardiograms (ECGs), echocardiograms, urinalysis (UA), blood work, and radiographs before sports participation has been questioned.

For the most part, authorities have recommended against random screening with these tools. Some of these tests are expensive, and some have been evaluated and deemed to have no significant advantage over a thorough medical history and physical evaluation. Also, false-positive findings can lead to unnecessary evaluation, investigation, and anxiety for the athlete.

Cardiac screening

  • Electrocardiography is also considered a screening tool for detecting anomalies that may place the athlete at risk for sudden cardiac death.
    • European Society of Cardiology (ESC) provided recommendations for ECG interpretation in athletes in 2010. Since then, standards and screening guidelines have continued to evolve but have also been a source of controversy and debate. 
    • The international consensus recommendations for ECG interpretation in athletes were last published in 2017 after an expert panel meeting in 2015. These updated criteria have improved the specificity of ECG screening without decreasing sensitivity. [8]
    • Studies comparing history screening and history plus ECG have failed to demonstrate a mortality benefit for universal screening. [14]
    • Williams et al performed a large prospective study comparing the AHA 14-point questionnaire to screening ECG, and they found ECG screening outperforms the AHA 14‐point questionnaire by all measures of statistical performance when interpreted by experienced clinicians. [9]
  • Echocardiography: 
    • A study of 964 athletes found abnormalities in 35% of the echocardiograms: 10% of the total deemed to require an echocardiogram. Ultimately, 0.6% of the athletes had conditions that required disqualifications from activity or further treatment or evaluations beyond echocardiography.
    • The echocardiograms revealed no additional abnormalities when added to the history, physical examination, and ECG findings. [15]  

Urinalysis (UA): The UA had long been a part of the sports physical evaluation, but this test eventually proved to yield several false-positive results.[16]

Blood screening: At one point, complete blood cell (CBC) counts were measured to evaluate for anemias, which are common among elite athletes; however, the findings as a screening tool are of questionable value.

Radiographs: Orthopedic evaluations may include radiography of the cervical spine, especially among football players. The purpose is to try to detect an athlete's risk for spinal cord injury. Studies show that this kind of screening may not be effective without a history of cervical related symptomatology. 

Most guidelines for athletic preparticipation evaluations do not include the above tests. Some institutions, particularly professional teams' predrafting of an athlete, may require such studies. However, these tests are generally not considered as good screening tools without associated symptoms. In short, they should not be performed in patients with an unremarkable medical history. However, when a risk is evident, a full workup should be performed. For example, some clinicians advocate radiography of the cervical spine in athletes with Down syndrome because these individuals have a higher incidence of congenital instability of the upper cervical spine.

(See also the Medscape Reference article Down Syndrome and the Medscape News articles Part I: Clinical Practice Guidelines With Down Syndrome From Birth to 12 Years and Part II: Clinical Practice Guidelines for Adolescents and Young Adults With Down Syndrome: 12-21 Years.)


Clearance for Sports Participation

An athlete should be medically cleared for sports participation only after the medical history and physical evaluation are deemed unremarkable. If the history or physical findings raise concerns, a negative complete workup can help in clearing the athlete for participation. Even then, however, the physician must realize that the athlete is only cleared for a specific sport. Sports with different levels of contact, static versus dynamic activity, have different criteria for participation clearance. A single athlete may qualify to participate in one sport but not in another. Similarly, clearance for participation in one sport may not apply to another sport or another level of the same sport.

To help clarify the risks of different sports, the American Academy of Pediatrics (AAP) developed two sports classifications based on the level of contact and the level of intensity, as determined by the dynamic and static demands of the sport. Neither classification is all-inclusive, but most of the common sports are included. These range from popular sports, such as football, baseball, hockey, soccer, and basketball, to less common sports, such as skiing, sailing, rodeo, and weight lifting. (Note: Although water sports have their own concerns, the AAP does not consider them a category of sports.)

Contact is divided into three categories: contact/collision, limited contact, and noncontact (see Table 3).

Intensity is divided into two categories: high to moderate intensity and low intensity. Sports with high to moderate intensity can be subdivided into those with high-dynamic and high-static demands, those with high-dynamic and low-static demands, and those with low-dynamic and high-static demands (see Table 4). Low-intensity sports have low-dynamic and low-static demands; these sports include bowling, cricket, curling, golf, and riflery.

Medical clearance for a sport is easily granted in most cases because the athletes' medical histories and physical findings are often unremarkable. However, when an abnormality is detected, the sport and the severity of the abnormality must be considered together in making a decision about an athlete's participation. The AAP addresses common conditions that arise in athletic preparticipation evaluations and discusses how they are related to clearance for different sports (see Table 5). The physician in charge makes one of the following four choices[17] :

  • Unrestricted participation for a particular sport: If an athlete is cleared to participate in a contact sport with high dynamic and static demands, the athlete could potentially qualify to participate in any sport. However, this is not always the case.

  • Clearance with notification of the coach, trainer, and team physician: This choice may be selected for athletes with conditions that allow their participation in a sport; however, these athletes may need special treatment on occasion. A good example is an athlete with mild to moderate, yet well-controlled, exercise-induced asthma. (See also the Medscape Reference article Exercise-Induced Asthma.)

  • Deferred clearance: This category can be used when suspicious symptoms or signs indicate further workup should be conducted in an athlete who may eventually be cleared.  A good example is an athlete with a newly discovered cardiac murmur that has suspicious characteristics or an individual with a recent concussion and postconcussion syndrome.

  • Disqualification: This category is used when a known condition prohibits an athlete's participation in the given sport. Generally, this decision is not reversible for that particular sport; however, the condition may not preclude the athlete's participation in a sport with a lower safety risk.

Sports are classified by contact level in the table below.[18]

Table 3. Classification of Sports by Contact level (Open Table in a new window)

Contact/Collision Sports

Limited-Contact Sports

Noncontact Sports




Field hockey

Football (flag or tackle)

Ice hockey


Martial arts



Ski jumping


Team handball

Water polo





Canoeing/kayaking (white water)


Field events (high jump, pole vault)

Floor hockey



Horseback riding


Skating (ice, inline, roller)

Skiing (cross-country, downhill, water)



Ultimate Frisbee






Canoeing/kayaking (flat water)




Field events (discus, javelin, shot put)



Power lifting

Race walking


Rope jumping



Scuba diving

Strength training


Table tennis



Weight lifting

*Participation not recommended by the AAP.[19]  

Table 4. Sports of High to Moderate Intensity [20] (Open Table in a new window)

Sports With High to Moderate Dynamic and Static Demands

Sports With High to Moderate Dynamic and Low Static Demands

Sports With Low Dynamic and High to Moderate Static Demands



Cross-country skiing (skating technique)


Downhill skiing



Ice hockey


Running (sprinting)

Speed skating


Water polo





Field hockey




Race walking





Table tennis




Auto racing


Equestrian activities

Field events (jumping)

Field events (throwing)


Karate or judo


Rock climbing



Ski jumping

Water skiing

Weight lifting

*Participation not recommended by the AAP.[19]  

Table 5. Medical Conditions and Sports Participation [21] (Open Table in a new window)




Atlantoaxial instability (instability of the joint between cervical vertebrae 1 and 2)*

The athlete needs evaluation to assess the risk of spinal cord injury during sports participation.

Qualified yes

Bleeding disorder*

The athlete needs an evaluation.

Qualified yes

Carditis (inflammation of the heart)

Carditis may result in sudden death with exertion.


Hypertension (high BP)

Those athletes with significant essential (unexplained) hypertension should avoid weight lifting and power lifting, body building, and strength training. Those with secondary hypertension (hypertension caused by a previously identified disease) or severe essential hypertension need evaluation.†

Qualified yes

Congenital heart disease (structural heart defects present at birth)

Those athletes with mild forms of congenital heart disease may participate fully. Those with moderate or severe forms and those who have undergone surgery need evaluation.‡

Qualified yes

Dysrhythmia (irregular heart rhythm)

The athlete needs evaluation because some types of cardiac dysrhythmia require therapy, make certain sports dangerous, or both.

Qualified yes

Heart murmur

If the murmur is innocent (ie, it does not indicate heart disease), full participation is permitted. Otherwise, the athlete needs an evaluation (see Congenital heart disease and Mitral valve prolapse, above).

Qualified yes

Structural/acquired heart disease Consultation with a cardiologist is recommended.  

Hypertrophic cardiomyopathy*

Coronary artery anomalies*

Arrhythmogenic right ventricular cardiomyopathy*

Acute rheumatic fever with carditis*

Ehlers-Danlos syndrome - vascular form*


Qualified no

Marfan syndrome*

Mitral valve prolapse*

Anthracycline use*


Qualified yes

Vasculitis/vascular disease 

   Kawasaki disease*

   Pulmonary hypertension*

Consultation with a cardiologist is recommended. Athlete needs individual evaluation to assess risk on the basis of disease activity, pathologic changes, and medical regimen. Qualified yes

Cerebral palsy*

The athlete needs an evaluation.

Qualified yes

Diabetes mellitus*

If the diabetes is well controlled, the athlete can play in all sports with proper attention to diet, hydration, and insulin therapy. Particular attention is needed for activities that last 30 minutes or more.


Diarrhea, infectious§

Unless the disease is mild, no participation is permitted because diarrhea may increase the risk of dehydration and heat illness. (See Fever, below.)

Qualified no

Eating disorders

Patients need both medical and psychiatric assessments before sports participation.

Qualified yes

Functionally one-eyed athlete, loss of an eye, detached retina, previous eye surgery, or serious eye injury

A functionally 1-eyed athlete has a best-corrected visual acuity (BCVA) of better than 20/40 in the worse eye. These athletes could experience a significant disability if the better eye is either seriously injured or suffers a loss of the vision in the eye. Athletes who have previously undergone eye surgery or who have had a serious eye injury may be at increased risk of injury because of weakened eye tissue. Use of eye guards approved by ASTM International (formerly the American Society for Testing and Materials [ASTM]) and other protective equipment may allow the athlete to participate in most sports, but this approach must be judged on an individual basis.

Qualified yes

Conjunctivitis, infectious Athletes with active infectious conjunctivitis should be excluded from swimming. Qualified no


Fever can increase cardiopulmonary effort, reduce maximum exercise capacity, make heat illness more likely, and increase orthostatic hypotension during exercise. In rare cases, fever may accompany myocarditis or other infections that may make exercise dangerous.



Malabsorption syndrome*

    Celiac and cystic fibrosis*

Short bowel syndrome*

Athlete needs individual assessment for general malnutrition or specific deficits resulting in coagulation or other defects. With appropriate treatment, these deficits can be treated adequately to permit normal activities.  Qualified yes

Heat illness, history of

Due to the increased likelihood of recurrence, the athlete needs an individual assessment to determine the presence of predisposing conditions and to arrange a prevention strategy.

Qualified yes

Hepatitis C All athletes should receive hepatitis B vaccination before participation. Because of the apparent minimal risk to others, all sports may be played as an athlete's state of health allows. For all athletes, skin lesions should be covered properly, and athletic personnel should use universal precautions when handling blood or body fluids. Yes

Human immunodeficiency virus (HIV) infection§

All sports may be played, as allowed by the patient's state of health, due to the apparent minimal risk to others. In all athletes, skin lesions should be properly covered, and athletic personnel should use universal precautions when handling blood or body fluids.


Kidney, absence of one

The athlete with one kidney needs individual assessment and counseling with regard to contact/collision sports, with a discussion of the risks of contact sports, suggesting limited participation.

Qualified yes

Liver, enlarged

If the liver is acutely enlarged, athletic participation should be avoided because of a risk of rupture. If the liver is chronically enlarged, individual assessment is needed before engaging in contact/collision or limited contact sports.

Qualified yes


The athlete needs an individual assessment.

Qualified yes

Musculoskeletal disorders

The athlete needs an individual assessment.

Qualified yes

History of serious head or spine trauma, severe or repeated concussions, or craniotomy

The athlete needs an individual assessment for participation in contact/collision or limited contact sports and also for noncontact sports if deficits in judgment or cognition are present. Recent research supports a conservative approach to the management of concussions.[22]

Qualified yes

Seizure disorder, well controlled

The risk of convulsions during sports participation is minimal.


Seizure disorder, poorly controlled

The athlete needs an individual assessment before participation in contact/collision or limited contact sports. Due to the risk a convulsion poses to the athlete or to others, the following noncontact sports should be avoided: archery, riflery, swimming, weight lifting or power lifting, strength training, and sports involving heights.

Qualified yes


Obese persons need careful acclimatization and hydration due to the risk of heat illness.

Qualified yes

Organ transplant recipient*

The athlete needs an individual assessment.

Qualified yes

Ovary, absence of one

The risk of severe injury to the remaining ovary is minimal.


Pregnancy/postpartum The athlete needs an individual assessment. As pregnancy progresses, modifications to usual exercise routines will become necessary. Activities with high risk of falling or abdominal trauma should be avoided. Scuba diving and activities posing risk of altitude sickness should also be avoided. After the birth, physiological and morphologic changes of pregnancy take 4 to 6 weeks to return to baseline. Qualified yes

Pulmonary compromise, including cystic fibrosis*

The athlete needs an individual assessment, but generally, all sports may be played if oxygenation remains satisfactory during a graded exercise test. Patients with cystic fibrosis need acclimatization and good hydration to reduce the risk of heat illness.

Qualified yes


With proper medication and education, only athletes with the most severe asthma need to modify their participation.


Acute upper respiratory tract infection

Upper respiratory tract obstruction may affect pulmonary function. Athletes, with the exception of those with mild disease, need an individual assessment. (See Fever, above.)

Qualified yes

Juvenile rheumatoid arthritis 

Athletes with systemic or polyarticular juvenile rheumatoid arthritis and history of cervical spine involvement need radiographs of vertebrae C1 and C2 to assess risk of spinal cord injury. Athletes with systemic or HLA-B27-associated arthritis require cardiovascular assessment for possible cardiac complications during exercise. For those with micrognathia (open bite and exposed teeth), mouth guards are helpful. If uveitis is present, risk of eye damage from trauma is increased; ophthalmologic assessment is recommended. If visually impaired, guidelines for functionally 1-eyed athletes should be followed. Qualified yes

Juvenile dermatomyositis, idiopathic myositis*

Systemic lupus erythematosus*

Raynaud phenomenon*

An athlete with juvenile dermatomyositis or systemic lupus erythematosus with cardiac involvement requires cardiology assessment before participation. Athletes receiving systemic corticosteroid therapy are at higher risk of osteoporotic fractures and avascular necrosis, which should be assessed before clearance; those receiving immunosuppressive medications are at higher risk of serious infection. Sports activities should be avoided when myositis is active. Rhabdomyolysis during intensive exercise may cause renal injury in athletes with idiopathic myositis and other myopathies. Sun protection is necessary during outdoor activities in athletes with juvenile dermatomyositis and systemic lupus erythematosus, due to photosensitivity. In Raynaud phenomenon, exposure to the cold presents a risk to hands and feet. Qualified yes

Sickle cell disease

The athlete needs an individual assessment. In general, if the status of the illness permits, the athlete may play all sports except high-exertion, contact/collision sports. Overheating, dehydration, and chilling must be avoided.

Qualified yes

Sickle cell trait

Individuals with the sickle cell trait (AS) are unlikely to have an increased risk of sudden death or other medical problems during athletic participation in most conditions. Exceptions include the most extreme conditions of heat, humidity, and, possibly, increased altitude. Like all athletes, those with the sickle cell trait should be carefully conditioned, acclimatized, and hydrated to reduce any possible risk.


Skin infections, including herpes simplex, molluscum contagiosum, verrucae (warts), staphylococcal and streptococcal infections (furuncles [boils], carbuncles, impetigo, methicillin-resistant Staphylococcus aureus [cellulitis and/or abscesses]), scabies, and tinea 

During the periods in which the patient is contagious, participation in gymnastics with mats, martial arts, wrestling, or other contact/collision or limited-contact sports is not allowed. 

Qualified yes

Spleen, enlarged§

Patients with an acutely enlarged spleen should avoid all sports because of the risk of rupture. Those with chronically enlarged spleens need an individual assessment before playing contact/collision or limited-contact sports.

Qualified yes

Testicle, absent or undescended

Athletes in certain sports may require a protective cup.


Note: This table is designed to be understood by medical and nonmedical personnel. In the 'Explanation' column, a notation that the athlete needs an evaluation means that a physician with appropriate knowledge and experience should determine whether an athlete with the listed medical condition can safely participate in a given sport. Unless otherwise noted, these evaluations are generally recommended because of variations in the severity of disease and in the risk of injury in specific sports.[21]

*Not discussed in text of the AAP source monograph.

†See Table 4 above.

‡Mild, moderate, and severe congenital heart disease are defined elsewhere (36th Bethesda Conference).

§See the AAP recommendation[21] as indicated for qualifications by other commentators.


Disqualification From Sports Participation and Its Implications

The decision to disqualify an athlete from sports participation can be challenging, as multiple factors need to be taken into account. Discussions should involve the athlete, the family (as appropriate), and medical personal, while addressing the specific sport for which the individual seeks medical clearance. When the situation is vague, the guidelines described above (see Clearance for Sports Participation) can help in clinical decision-making about granting clearance.

If cardiac defects are detected, the current criterion standard for decision-making includes a scientific statement by the American Heart Association and American College of Cardiology,[18] as well as multiple task forces from the 36th Bethesda Conference on cardiac anomalies and participation in sports.[23] Articles by Torg[24, 25] are often referenced, as well as those of Torg et al[26, 27, 28] for cases involving congenital or acquired cervical spinal deformities. Fortunately, obscure conditions that may require such referencing are rare, and usually a general guideline such as that of the AAP is most often used. This resource is valuable because the associated categorizations (contact and intensity) can be used to make recommendations for athletes who are denied sports participation.

A pitfall to keep in mind is not discouraging athletes from general sports participation when they are disqualified from a particular sport. Athletes might still be able to compete in other sports and experience the multitude of benefits from participation. Furthermore, an optimistic approach is always important when problems are detected in young and impressionable athletes. Many disqualifying conditions can be resolved or controlled with medical or surgical intervention, enabling future sports participation. In cases where this is not possible, they could be redirected to sports that can provide a healthy and safe athletic experience.



An athletic preparticipation evaluation can be performed efficiently and thoroughly when protocols and tools are in place. Use of a reliable medical history questionnaire and a good screening physical examination are usually adequate to meet these needs. The following issues should always be emphasized:

  • Demographic data (eg, name, age, sex, sport, telephone numbers, current medications, allergies to medications)

  • History of exercise-induced loss of consciousness

  • Family history of sudden cardiac death

  • History of poorly controlled asthma

  • History of recent or previous concussions

  • History of fractures or major musculoskeletal problems

  • History of heat stroke

  • History of environmental anaphylactic reactions, as with insect bites

  • History of loss or dysfunction of one of a pair of organs

  • History of chronic illness requiring regular physician intervention

  • History of drastic weight change

  • For females: menstrual history (menarche, menstrual irregularity, most recent period)

  • Parental signature on history forms for minors

A focused physical examination should emphasize the following:

  • Vital signs (eg, height, weight, BP)

  • Visual acuity

  • Infectious dermatologic conditions

  • Anisocoria

  • Wheezing

  • Heart murmurs or irregular heart rhythms

  • Abdominal organomegaly

If abnormalities are detected during the physical examination, further workup should be pursued as indicated.

Finally, the participation status of the athlete for a specific sport should be determined. The main goals of the athletic preparticipation evaluation are as follows:

  • To discover any abnormalities that places the individual at sport-specific risk of injury

  • To inform the athlete of correctible abnormalities before the start of the sport's season

  • To determine the safety of the athlete's participation

  • To provide a database that team physicians, coaches, and administrators can use for reference

  • To provide a platform of interaction between athletes and physicians

Participation in sports is a benefit to which everyone is entitled. Ensuring an athlete's safety can promote a healthy lifelong habit of physical activity in which the athlete can learn about discipline, teamwork, physical fitness, and camaraderie.