What Happens at a Sports Physical: A Head-to-Toe Walkthrough

Why is the health history the most important part?

Most sports medicine clinicians consider the health history the most critical piece of the PPE — research shows the medical history alone can detect up to 88% of general medical conditions and 67% to 75% of musculoskeletal conditions pertinent to sports participation 1Ref 1Carek PJ, Mainous AG (2021).The Preparticipation Physical Evaluation.Health history detects up to 88% of medical conditions and 67–75% of musculoskeletal conditions; elevated BP and vision problems are the most common PPE abnormalities; less than 2% of athletes are denied clearance. You or your child will typically complete a standardized questionnaire before the visit covering:

• Past or current heart conditions, chest pain with exercise, fainting, or unexplained shortness of breath
• Family history of sudden cardiac death or a relative who died unexpectedly before age 50
• History of concussion, head injuries, or loss of consciousness
• Bone or joint injuries (stress fractures, sprains, prior surgeries)
• Asthma, exercise-induced wheezing, or allergies
• Chronic conditions such as diabetes or epilepsy
• Current medications or supplements
• For female athletes: menstrual history, bone health, and nutritional patterns

A "yes" on any item does not automatically disqualify anyone — it opens a conversation.

What does the physical exam actually cover?

Vital signs: Blood pressure, resting heart rate, height, weight, BMI, and basic vision screening. Elevated blood pressure and visual acuity problems are among the most common abnormalities found during a PPE 1Ref 1Carek PJ, Mainous AG (2021).The Preparticipation Physical Evaluation.Health history detects up to 88% of medical conditions and 67–75% of musculoskeletal conditions; elevated BP and vision problems are the most common PPE abnormalities; less than 2% of athletes are denied clearance.

Heart and lungs: The most medically critical portion. The clinician listens to the heart at rest and may ask the athlete to perform a provocative maneuver (squatting and standing) to bring out sounds that change with position. They listen for murmurs, irregular rhythms, or other sounds that could suggest structural heart disease. The American Heart Association recommends a focused 14-element cardiovascular screening history and physical — rather than routine electrocardiography — for asymptomatic athletes 2Ref 2Maron BJ, Levine BD, Washington RL, Baggish AL, Kovacs RJ, Maron MS (2015).Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 2: Preparticipation Screening for Cardiovascular Disease in Competitive Athletes.AHA/ACC recommendation for a 14-element cardiovascular history-and-physical screening rather than routine ECG in asymptomatic competitive athletes. The lungs are checked for signs of asthma or restriction.

Musculoskeletal exam: The clinician evaluates flexibility, strength, and range of motion — often using a standardized sequence through the neck, shoulders, elbows, wrists, back, hips, knees, and ankles. They check for old injuries that have not fully healed and any asymmetry that might signal a problem.

Abdomen: A brief check for an enlarged spleen, which can rupture during contact sports if swollen from illnesses like mononucleosis.

Skin: A quick look for conditions like ringworm or impetigo that can spread in contact sports.

Neurological: Basic assessment of reflexes, coordination, and any concussion history.

Genitourinary (males): In a full PPE, a brief check for a hernia and, in younger athletes, testicular abnormalities.

What is the clinician actually trying to rule out?

The sports physical exists largely because of a small number of serious but rare conditions that can cause sudden cardiac death in young athletes — including hypertrophic cardiomyopathy (thickening of the heart muscle), congenital coronary artery anomalies, and electrical rhythm abnormalities. Among competitive collegiate athletes, sudden cardiac death is estimated to occur at roughly 1 per 53,000 athlete-years, making it uncommon but worth screening for 3Ref 3Harmon KG, Asif IM, Maleszewski JJ, et al. (2015).Incidence, Cause, and Comparative Frequency of Sudden Cardiac Death in National Collegiate Athletic Association Athletes: A Decade in Review.Sudden cardiac death rate among NCAA athletes approximately 1 per 53,703 athlete-years; cardiovascular causes represent the leading medical cause of death during exertion in collegiate athletes.

Unhealed musculoskeletal injuries that raise re-injury risk are also a focus. Most athletes pass without any concerns. Less than 2% of athletes are denied clearance following PPE, and findings that do come up usually lead to follow-up, not automatic disqualification 1Ref 1Carek PJ, Mainous AG (2021).The Preparticipation Physical Evaluation.Health history detects up to 88% of medical conditions and 67–75% of musculoskeletal conditions; elevated BP and vision problems are the most common PPE abnormalities; less than 2% of athletes are denied clearance.

What are the possible outcomes?

At the end of the exam, the clinician marks one of three outcomes on the form:

• Cleared without restriction: The most common result.
• Cleared with conditions: The athlete can participate but needs follow-up — for example, a cardiology appointment before full clearance, or a brace for a prior injury.
• Not cleared pending evaluation: Something was found that needs more workup before the clinician can sign off. This is uncommon and does not mean disqualification — it means a question needs answering first.

When and where should the PPE happen?

The American Academy of Pediatrics recommends the PPE happen at least six to eight weeks before the start of a season, ideally during the athlete's regular well-child visit with their primary care provider 4Ref 4American Academy of Pediatrics (2024).Sports Physical: When, Where, Who Should Do It?.AAP recommends PPE at least 6–8 weeks before the season, ideally during the well-child visit; discourages mass physicals in gym settings. This timing allows for any follow-up that is needed — an additional cardiac workup, physical therapy, or specialist consultation — before the season begins.

The PPE5 monograph (the fifth edition of the authoritative multi-organization guidance on the PPE) discourages mass physicals in gymnasiums or locker rooms, which lack privacy and the continuity of a medical home. Walk-in and urgent care settings are an option when the primary care office is not available, but the clinician will not have the athlete's background on file.