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Invited Commentary

COVID-19 and the School-based Mass Preparticipation Physical Evaluation: The Anvil That Broke the Camel's Back?

Cunningham, Andrew MD, CAQSM

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Current Sports Medicine Reports: August 2020 - Volume 19 - Issue 8 - p 284-285
doi: 10.1249/JSR.0000000000000734
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It is 10 a.m. and I have just completed my second virtual meeting for the day on yet another digital platform I did not know existed 2 months ago. After weeding through emails, I review my upcoming schedule for the month to remove events that have already been or are likely to be canceled. The next event on the chopping block: the “physical night” at the local high school for which I have volunteered. Typically, I bring a group of 4 to 6 residents and we perform 100 to 150 preparticipation physical evaluations (PPE) in a matter of 2 h. These examinations fulfill the yearly physical examination requirement of our state high school athletic governing body. This event serves as both a fundraiser for the school athletic department and a convenient service for local athletes who, for whatever reason, did not have their examination performed by their primary care provider. These mass PPE events are so common that they are both a rite of passage for the residents I bring with me and the athletes that are being examined. Currently, to hold this event would be in clear violation of our state's “stay-at-home” order and would contradict the U.S. Centers for Disease Control and Prevention's social distancing guidelines. It will need to be canceled. Despite knowing that these guidelines will eventually be relaxed, I cannot help but ask myself: is the school performed mass PPE dead? I follow up my initial thought with another question: is that a bad thing?

The PPE for high school athletes is ubiquitous. It is required in some part by nearly every state and the District of Columbia. Despite this common requirement, there is very little data to support its use as a cost-effective screening tool for any particular metric (1,2). Furthermore, many providers misinterpret the purpose of the PPE as simply to identify athletes at risk of sudden cardiac death (SCD). Much of the literature has focused on adding a screening electrocardiogram to the PPE to improve its utility but this intervention in the United States high school population is of questionable benefit. Given the rarity of SCD in high school athletes in general, it is reasonable to view this as a pricey solution in search of a problem (3–5). In recent years, there have been calls to end the required PPE altogether (2,6). While this drastic measure is controversial and not personally supported by me, the assertion that the PPE is not data driven is valid. Further, the benefits of performing the examination in a crowded gym in “cattle call” fashion likely exacerbate its deficiencies. Recent recommendation updates state that PPE is best performed in the athlete's medical home by their primary care provider and discourages the performance of the examination in retail clinics or at schools as a fundraiser (1). These updates, however, do provide best practice recommendations if a station-based examination is performed. Despite these recommendations, many providers may be ambivalent about their content or unaware they exist. These recommendations did not seem to decrease the requests for my services at many local schools before the COVID-19 pandemic. In my experience, despite my skepticism of the mass event PPE, they did not dissuade me from agreeing to participate.

However, the climate has clearly changed. Although most states have relaxed social distancing guidelines to some extent, the idea of holding a mass event PPE still seems premature and ill-conceived. Aside from the poor optics of such an event, personal protective equipment requirements and logistics are prohibitive. No one knows what the landscape will look like for the 2020 to 2021 school year in regard to reopening schools let alone extracurricular activities, such as organized athletics. Mass PPEs will likely take a year off. The National Federation of High School Associations Sports Medicine Advisory Committee has recommended loosening PPE requirements for the upcoming school year and has recommended that an interval history form will suffice (7). The final decision, however, will rest with each state. In my home state, the Michigan High School Athletic Association has adopted these recommendations. While these changes seem pragmatic, they are not being met with universal praise by all stakeholders. In my discussions with some high schools, they worry about liability. Some primary care advocacy groups have expressed concerns of the impact this may have on clinical volume as the mandated examination may be the only reason many adolescents visit their physician in a given year. While I tend to agree with this assumption, I am unaware of any published data to support the claim.

It is my belief that family physicians, pediatricians, and primary care sports medicine physicians should unite in support of the PPE 5 recommendations and encourage our state governing bodies to ease recommendations on frequency of the PPE to every 2 to 3 years while moving to make the mass PPE a relic. We should be encouraging our athletes to have these examinations done by their primary care provider in a medical home and not providing a subpar alternative. Loosening requirements in states that require yearly PPEs would allow athletes more time to have their examination done under the guise of primary care in a medical home where other preventive health can be adequately addressed in accordance with accepted recommendations (8). Ideally, every adolescent should be seen yearly for a preventive care visit in accordance with the American Academy of Pediatrics' recommendations but accomplishing this through a low value required examination may not be the right answer.

The author declares no conflict of interest and does not have any financial disclosures.


1. American Academy of Pediatrics, American Academy of Family Physicians, American College of Sports Medicine. Preparticipation Physical Evaluation. 5th ed. Elk Grove Village (IL): American Academy of Pediatrics; 2019.
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7. National Federation of State and High School Associations and Sports Medicine Advisory Committee. Statement of PPE and athletic participation: ramifications of the COVID-19 pandemic. [cited 2020 May 27]. Available from:
8. American Academy of Pediatrics Committee on Practice and Ambulatory Medicine and Bright Futures Periodicity Schedule Workgroup. 2017 recommendations for preventive pediatric healthcare. Pediatrics. 2017; 139:e20170254.
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