Summary
Regular physical activity is recommended for people of all ages and should be tailored to each person’s health status, abilities, and goals. For school- and college-aged individuals involved in sports, a pre-participation physical evaluation may be performed to support safe participation by identifying conditions that could increase the risk of injury or other health complications. Athletes of all ages should be counseled on wellness topics, including adequate nutrition, implications of supplement and performance-enhancing drug use, and injury-prevention strategies. While regular exercise offers significant physical and mental health benefits, improper training or excessive exercise may lead to conditions such as overuse injuries and performance-related anxiety. Early recognition and management of exercise-related conditions are critical to maintaining safe, ongoing participation in physical activity.
Preventive care for athletes
- Initial evaluation of individuals beginning a new exercise program or participating in competitive sports (e.g., at school) may include:
- A pre-participation physical examination
- Health and wellness counseling for physical activity, including on nutrition and injury prevention
- Assessment for chronic conditions that may impact exercise potential (see “Physical activity considerations in selected populations”)
- For ongoing management, assess for and treat adverse health conditions associated with exercise (e.g., sports injuries, sports-related concussion, performance-related anxiety).
Pre-participation physical examination
The goal of a pre-participation physical examination is to support safe participation in sports by identifying conditions that could increase the risk of injury or other health complications. [1]
General principles [1][2]
- Ideally, evaluation is recommended:
- ≥ 6 weeks before the start of the activity [1]
- In a regular clinical setting, by the PCP
- Obtain history from the patient and caregivers.
- Diagnostic studies are not routinely indicated.
- Refer to specialists as needed for:
- Additional testing to determine medical eligibility
- Conditions requiring exercise modifications or restrictions
Cardiac testing, such as an ECG, is not routinely indicated as part of the pre-participation evaluation. [3]
Focused history [1][2][3]
-
Past medical and surgical history
- Cardiovascular disease (including heart murmurs) and/or prior cardiac testing
- Neurological disorders (e.g., seizures)
- Concussions
- Diabetes
- Missing organs (e.g., single kidney)
- Asthma or exercise-induced bronchospasm
- Menstrual history
- Eating disorders
- Prior restriction from sports participation
-
Family history
- Cardiovascular disease
- Disability or death due to heart disease at < 50 years of age [3]
- Sudden death at < 35 years of age [1]
- Genetic conditions involving the heart (e.g., hypertrophic cardiomyopathy, long QT syndrome)
- Sickle cell disease or trait
-
Review of systems
- Cardiovascular: syncope; chest pain, palpitations, and/or dyspnea with exertion
- Neurological: paresthesias, weakness
- Musculoskeletal: pain and/or injury
- Dermatologic: rashes
- Medication use: including supplements and performance-enhancing drugs [1]
-
Mental health and substance use screening
- Questionnaires can be used to assess for:
- Depression (e.g., PHQ-9 for adults, PHQ-9 modified for adolescents)
- Anxiety (e.g., GAD-7 for adults, PHQ-A for adolescents)
- Substance abuse (e.g., CRAFFT for adolescents, AUDIT-C for adults)
- Eating disorders (e.g., BEDA-Q) [1]
- For details on screening tools, see:
- Questionnaires can be used to assess for:
Physical examination [1][2]
- Vital signs
- Visual acuity testing
- Pediatric growth patterns
-
Cardiac examination including: [3]
- Auscultation of the heart (while lying down and standing): to detect heart murmurs
- Pulse examination: to identify radiofemoral delay suggestive of aortic coarctation
- Clinical features of Ehlers-Danlos syndrome and Marfan syndrome
Disposition and follow-up
- Make one of the following medical eligibility designations: [1]
- No restrictions
- No restrictions, but follow-up evaluation is required
- Restricted from all activities until additional studies or rehabilitation is performed
- Restricted from specific activities
- Restricted from all activities
- Refer for diagnostic testing and/or specialist referral as needed based on clinical evaluation (e.g., cardiac testing if risk factors for sudden cardiac death in children are present).
Athletes with HIV, hepatitis B, or hepatitis C should not be excluded from sports participation solely on the basis of their infection status. [1]
Health and wellness counseling
Nutrition [4][5]
- Counsel individuals on:
- General nutrition recommendations
- The importance of nutrition and hydration for athletic performance, recovery, and overall health
- Maintaining an appropriate balance between energy intake and expenditure
- Health consequences of inadequate energy balance (e.g., relative energy deficiency in sport)
- Individualize the nature and timing of nutrient and fluid intake based on activity demands. [4]
- Inquire about the use of dietary supplements (e.g., vitamins, minerals, protein supplements). [6]
- Consider referral to a dietitian specialized in sports nutrition for individualized nutrition planning. [4]
Advise children and adolescents to avoid dietary supplements unless recommended by a medical professional. [5]
Performance-enhancing drugs [7]
- Educate patients on the safety, effectiveness, and legality of performance-enhancing drugs and supplements.
- Substances with evidence of efficacy that are generally considered safe include:
- Substances banned by the World Anti-Doping Agency include: [7][8]
- Anabolic androgenic steroids
- Erythropoietin
- Human growth hormone and other growth factors
- Certain stimulants (e.g., methylphenidate, modafinil)
- In patients with current or past use of performance-enhancing drugs, monitor for adverse effects.
- Anabolic steroids: hypertension, hypogonadism, dyslipidemia, mental health conditions
- Human growth hormone: edema, joint pain, carpal tunnel syndrome, diabetes [9]
- Erythropoietin: hypercoagulability
The use of performance-enhancing drugs is more prevalent in recreational athletes than in competitive or elite athletes. [7]
Injury prevention [10]
Strategies to reduce the risk of injury from physical activity include:
- Selecting activities appropriate for an individual's level of fitness, health status, and physical abilities
- Gradual increases in physical activity duration and/or intensity according to ability
- Warm-up and cool-down exercises
- Use of proper technique and protective equipment (e.g., helmets and/or pads, protective eyewear)
- Balanced nutrition and adequate energy intake [4]
- See also:
Physical activity considerations in selected populations
Certain conditions may impact an individual's ability to participate in physical activity. Consider activity modifications and/or increased health monitoring based on the person's health status, e.g.: [10]
- Pregnancy: See “Physical activity during pregnancy.”
- Asthma and/or exercise-induced bronchospasm: See “Treatment of EIB.”
- Osteoarthritis: Perform low-impact activities (e.g., swimming, walking) that do not cause pain.
-
Diabetes [11]
- Monitor blood glucose around the time of exercise.
- Select appropriate footwear and implement other measures to prevent diabetic foot.
- Hypertension: Assess whether medication de-escalation is appropriate as activity increases. [12]
Adverse health conditions related to exercise
Physical activity supports overall health, but excessive exercise or improper technique can cause injuries or other adverse effects.
Inflammation and injury
- Sports-related concussion
- Acute fractures and stress fractures
- Insertional tendinopathies
- Bursitis
- See also “Sports injuries.”
Psychosocial and mental health conditions [13]
- Exercise addiction
- Performance-related anxiety and pressure [14]
- Sleep disorders
- Eating disorders
- Trauma-related disorders
Relative energy deficiency in sport
Definitions [15]
-
Relative energy deficiency in sport (REDs)
- A constellation of symptoms resulting from physiological and/or psychological dysfunction in individuals with inadequate energy intake relative to energy expenditure
- Can affect both male and female athletes
-
Female athlete triad [16]
- A term traditionally used to describe certain features of REDs
-
A constellation of clinical findings in adolescent and young adult female athletes that comprises:
- Relative calorie deficit compared to energy needs, with or without an eating disorder
- Menstrual dysfunction
- Decreased bone density
Unlike the female athlete triad, REDs can occur in both men and women, and encompasses a wider range of adverse health effects due to an imbalance in energy intake and expenditure. [17]
Clinical features [15]
-
General
- Impaired athletic performance
- Impaired neurocognitive function
- Increased susceptibility to infection
- Hunger
- Endocrine
- Psychological
- Gastrointestinal
-
Musculoskeletal
- Clinical features of stress fractures
- Increased susceptibility to injury
REDs is more common in female individuals than in male individuals. [15]
Diagnosis [15]
- Diagnosis is made clinically based on history and physical examination.
- Laboratory and imaging studies may be indicated to exclude alternative diagnoses and support the diagnosis. [15][18]
- Diagnostics for amenorrhea: Findings in REDs are consistent with functional hypothalamic amenorrhea.
- Diagnostics for male hypogonadism: ↓ testosterone (free or total)
- CMP: Electrolyte abnormalities may be present.
- Diagnostics for iron deficiency: to exclude iron deficiency anemia as a cause of symptoms
- Lipid panel: may show hypercholesterolemia
- DEXA scan: ↓ bone mineral density
Use of oral contraceptives can mask the presence of menstrual abnormalities. [2]
Management [15][18]
Management involves a multidisciplinary team with the goal of balancing energy intake with expenditure.[17]
- Refer to a nutritionist for dietary counseling.
- Evaluate the need for changes to sports participation.
- Severe manifestations of REDs (e.g., red flags in eating disorders): Removal from participation and urgent medical evaluation are required.
- Multiple manifestations of REDs: Modifications to training or removal from participation may be necessary.
- Provide management of specific disease manifestations, e.g.:
- Psychotherapy and/or pharmacotherapy for mental health conditions
- Treatment of eating disorders (see “Evaluation of suspected eating disorder”)
- See also “Management of functional hypothalamic amenorrhea.”
Prevention [15][18]
- Educate athletes on the importance of balancing energy intake with activity levels.
- Screen athletes for features of REDs (e.g., during pre-participation physical examinations).