Don’t skip a beat!
As health care providers, we need to be sharp and at the top of our game, so in turn, athletes can be at the top of their game. Before the competitiveness can be unleashed, we have to make sure that we pay attention to those things that can detrimentally impede their abilities to perform optimally.
Let’s take a moment to identify some of those necessary things that should be addressed during their pre-participation examination - specifically when it comes to their cardiovascular health.
History - Ask These Questions
Family history of unexplained death before 35 YO?
Exertional chest pain?
Exertional syncope?
Exercise intolerance?
Why would you ask these specific questions? Because you want to rule any possibility of having hypertrophic cardiomyopathy (HCM) - the most common cause of sudden cardiac death in young athletes. Let me re-phrase it … it’s the #1 Cardiac Killer In Athletes!
HCM is characterized by a thickened left ventricular wall. This anatomical variant results in less volume of blood flow being delivered throughout the body, detrimentally putting the body in harms ways. In an attempt to accommodate to this inefficiency, the heart goes haywire and quivers rapidly and inadequately (aka. ventricle fibrillation), resulting in cardiac arrest.
Now, if an individual starts off with only a suboptimal volume of blood flow at rest, imagine what the heart will have to go through during activities and exercise!
Since this condition commonly goes unrecognized, it’s in the athlete/patient’s best interest to capture any indicators that could suggest this being a possibly. It’s just good practice trying to catch something before it actually happens - being aware and being prepared … because you never know who’s life you can save.
Click here for a history form that addresses these vital pre-activity clearance questions all health care practitioners should consider.
Blood Pressure
Definitely a no-brainer task. It’s one of the vital signs clinicians take, so it just makes sense to do it during a pre-participation examination.
Here’s some quick steps to getting the proper resting baseline blood pressure reading (of course it’ll be more challenging when you’re trying to pump out 9 thousand athletes in a 2 hour time span):
First take the blood pressure on each arm
The arm that has the higher reading will be taken a second and third time
Have 1-2 minutes between checks
Calculate the average of the 3 readings to get the resting baseline blood pressure
If the average reading sits at or above 180/110 mmHg, then an alarm should set off !! This is an absolute contraindication to exercise. It’s something that needs to be worked up by a specialist prior to participating in any physical activity or exercise, period. (this is where you imagine a mic being dropped)
DID YOU KNOW … that the hypertension marker has changed?
The marker for hypertension is no longer 140/90 mmHg as it has been for like … decades. In 2017, the figure changed! The new threshold of high blood pressure is now 130/80 mmHg… yeah, that’s 10 increments lower! Although just a guideline, due to this tailored threshold, more people have graduated into the hypertension category (plug in the “hitting the forehead” emoji here). If you don’t believe me, read more about it here, and here.
Also, if you’re a fanatic over the world of blood pressure and want to know more about the details, read more about it here.
Auscultation
Another no-brainer. This is probably the most common cardiac task folks see clinicians perform on TV shows and movie screens; and unfortunately, it’s all too often the ONLY task clinicians will perform besides its other common counterpart, the blood pressure reading.
So what are we listening for during auscultation anyways?
Unusual heart sounds of course! You’re checking for something that doesn’t sound like the normal rhythmic “lub dub” sound. Questionable sounds described as a “whooshing” noise may indicate the presence of a murmur - a sign that an underlying heart complication or other similar pathology may be apparent. These abnormal sounds are created from turbulent blood flow.
TBH, it may takes years and years fine tuning your auscultation skills to be able to recognize the most subtle of sounds, so keep that head up, stethoscope locked in, and ears alert as you practice the perfection of this craft. If any abnormal heart sounds are noticed, refer out. An echocardiogram is usually the modality of choice to further evaluate the questionable sound.
Here’s a cool resource if you’re interested in fine tuning your skills more in the art of auscultating: www.easyauscultation.com
UE & LE Pulses
This is one that I don’t hear too often being performed, but it’s definitely another important task competent providers need to perform. Here’s the secret on how it’s performed:
Find and monitor the integrity of the ipsilateral radial and femoral pulses
Check and note for synchrony of the pulses
Then, check and note synchrony of the contralateral radial and femoral pulses
If the upper extremity pulse is not in synchrony with the ipsilateral lower extremity pulse, then this is a positive finding! Be suspect of a possible coarctation of the aorta. A plethora of additional diagnostic tests can be performed to confirm suspicion.
Coarctation of the aorta is a restriction, or pinching, usually at the arch of the aorta. As a result, the heart must work harder to push blood through the itty bitty tunnel which can delay the blood flow to the lower extremities, hence the lack of synchrony between the upper and lower extremity pulses. Unfortunately, this condition increases blood pressure, damages the blood vessels, causes headaches, increases the risk of internal bleeding and strokes, and is responsible for other uninviting symptoms.
Now imagine the amount of stress being placed on the heart when exhaustive exercises and activities are added! That’s why it’s crucial to be aware of this condition, and to explore for its potential existence. Your athletes will thank you for it, and you can sleep more comfortably knowing you checked for it.
Marfan’s Characteristics
What the heck is Marfan’s? It’s the most common inherited connective tissue disorder that’s commonly associated with aortic root dissections. This is where the inner layer of the blood vessel tears and separates apart (aka. dissects) from the adjacent layers. As blood rushes through the tunnel, it rips open a larger tear, magnifies the separation between layers, and creates a false channel. This exponentially increases the risk of an aortic rupture. Yikes!
Lucky for the athletes, we as health care providers, can physically see, and identify, someone who is showing characteristics and traits of Marfan’s.
So what are we looking for? How can we identify someone that potentially has this condition? Think long and lanky. Kind of like Abraham Lincoln or Michael Phelps-type stature. To be more specific, here’s a quick list of characteristics to look for:
General
Tall and thin
Skin striae (stretch marks - on a skinny person? kind of odd if you ask me, right?)
Joint hypermobility
Wing span 1.05 longer than height
Head
Dolichocephalia (thin, narrowed head)
Myopia (nearsightedness - can’t see far)
Ectopia lentis (dislocated lens - looks like a contact coming out of the eye)
High-arched palate
Body
Pectus excavatum/carinatum (funnel chest - caves in/pigeon chest - pokes out)
Scoliosis (lateral deviation of spine > 20 degrees - visualized on radiographs)
Upper Extremities
Lack of elbow extension (<170 degrees)
Arachnodactyly (long skinny fingers and toes)
Lower Extremities
Genu recurvatum (but limited elbow extension … interesting)
Pes planus (flat-footed)
Other
Recurring abdominal hernias
Spontaneous pneumothorax
For those that like orthopedic test, here’s a couple you can try:
A. Thumb Sign B. Wrist Sign (click image for resource)
(+) Thumb Sign
Tuck the thumb towards the pinky side. It’s positive if the thumb sticks out from the ulnar side of the palm.
(+) Wrist Sign
Wrap your pinky and thumb around the wrist. It’s a positive if they touch and overlap.
If you are suspecting your athlete is showing characteristics of Marfan, then document your findings and refer them out to a clinician that is able to further evaluate these characteristics, manage their condition, and determine the restrictions for activities. In the meantime, if interested in knowing more about this condition, check out the Marfan Foundation website.
So there you have it! The 5 cardiac checks that should be done during a pre-participation physical examination. The mindful practitioner should be able to identify potential problems before they become a major issue. Knowing, preparing, and identifying potential hazards can be the difference between your success and failure, and an individual’s life or death.
Thanks for being curious and taking the time to read this! Hope it added value to your life and equips you to become better than you were yesterday!
Dr. Joe Jaime, DC, DACBSP®, ATC, CSCS®, FRC®ms, CES
Just a disclaimer that I’m not a cardiologist or an expert in this field. Just sharing information that I’ve learned, picked up, and researched through this process of becoming … a better clinician!