Pre-Participation Evaluations (PPE)


What are the goals and objectives of the pre-participation evaluation?

The overall goal of the pre-participation evaluation (PPE) is to help maintain the health and safety of athletes. Its purpose is not to exclude athletes from participation but to promote safe participation. If not cleared, most athletes can be rehabilitated or redirected to another sport. This goal is achieved by adhering to the evaluation's three primary objectives. The three secondary objectives take advantage of the doctor-athlete contact.

Primary objectives
  • Detect conditions that might predispose the athlete to injury
  • Detect conditions that might be life-threatening or disabling
  • Meet legal and insurance requirements
Secondary objectives
  • Determine general health
  • Counsel on health-related issues
  • Assess fitness level for specific sports

What are the advantages of office-based pre-participation evaluations?

An office-based exam is usually performed by the athlete's primary care doctor. The doctor is familiar with the athlete's medical and family history. The setting is much quieter and allows for the discussion of multiple health issues that are pertinent to adolescents. These include the use of drugs, supplements, and alcohol; sexual activity; and other topics. Immunization history can be reviewed and updated accordingly.

What are the advantages of mass pre-participation evaluations?

These evaluations are less expensive. Multiple specialists can be involved, such as athletic trainers, physical therapists, orthopaedic surgeons, family doctors, and pediatricians who have a special interest in sports medicine.

What are the components of the pre-participation evaluation?

The medical history is the cornerstone of any medical evaluation. A complete history will identify about 75 percent of problems affecting athletes. To increase the information obtained, the athlete and parent should complete the history together before the examination. The recommended baseline history includes the following general information:

  • Medical conditions and diseases
  • Surgeries
  • Hospitalizations
  • Medicines (prescription, over-the-counter, supplements)
  • Allergies (medicines, insects, environmental)
  • Immunization status
  • Menstrual history
  • Psycho-socio-sexual development

Other information about the following should also be included:

  • Cardiovascular (heart)
  • Pulmonary (lungs)
  • Neurologic (nervous system, including the brain)
  • Musculoskeletal
  • Injuries or illness since last exam
  • History of concussions

The PPE is a screening tool that emphasizes the areas of greatest concern in sports participation and areas identified as problems in the history. The recommended standard components of the PPE include the following:

  • Height
  • Weight
  • Pulse
  • Blood pressure
  • Eyes
  • Ear/nose/throat
  • Heart
  • Abdomen
  • Genitalia
  • Skin
  • Musculoskeletal system

What is athletic heart syndrome?

The heart of an athlete undergoes certain functional and morphological (physical size and shape) changes that distinguish it from the heart of non-exercising individuals. These changes represent a normal physiologic response to exercise and not a disease process. The type and degree of change is affected by the type of training — endurance (aerobic) versus strength (isometric). Endurance athletes have an increased left ventricular volume and cardiac output. Strength athletes have an increase in thickness of the heart muscle wall. Endurance athletes have a lower heart rate.

What is the cause of sudden cardiac death syndrome?

Sudden death in the athlete under the age of 35 is most commonly due to congenital heart disease. Usually the athlete is male, has been involved in a variety of sports, and is at the junior high or high school level. Unfortunately, there are usually no preceding symptoms.

How can the athlete at risk for sudden cardiac death syndrome be identified?

The PPE history is designed to identify athletes at risk, such as those with chest pain or heaviness, palpitations, shortness of breath, fainting spells (syncope), or family history of sudden death. Any athlete with these symptoms requires full evaluation. The PPE physical examination might reveal a murmur. The evaluation might include further testing (electrocardiogram [EKG], chest X-ray, stress test, echocardiography) or consultation with a cardiologist.

Test Details

What are the appropriate time, setting and structure of the pre-participation evaluation?

Ideally, the PPE should be performed at least six weeks before pre-season practice, allowing time for correction or rehabilitation of any identified problems. To avoid potential scheduling difficulties, the PPE might be performed at the end of the previous school year.

Opinions vary regarding how often the young athlete should be evaluated. In some high schools, a full annual evaluation is the norm. Another option, followed primarily at the college level, is a complete evaluation at an entry or new level, followed by an interim annual evaluation.

The two most common settings for performing the PPE are the doctor's office or in a station-based screening environment.

What is involved in determining clearance for participation in sports?

The most important and difficult decision in the PPE is determining whether an athlete should be cleared for sports participation. Clearance can be divided into three categories:

  • Unrestricted clearance
  • Clearance after completion of further evaluation or rehabilitation
  • No clearance for certain types of sports or for all sports

When an abnormality or condition is found that might limit an athlete's participation or predispose him or her to further injury, the doctor must consider the following questions:

  • Does the problem place the athlete at increased risk for injury?
  • Is another participant at risk for injury because of the problem?
  • Can the athlete safely participate with treatment?
  • Can limited participation be allowed while treatment is being completed?
  • If clearance is denied only for certain sports or sports categories, in what activities can the athlete safely participate?

To aid in this decision, sports are classified based on degree or level of contact and strenuousness:

  • Contact/collision
  • Limited contact
  • Strenuous, non-contact
  • Moderately strenuous, non-contact
  • Non-strenuous, non-contact

Last reviewed by a Cleveland Clinic medical professional on 08/21/2018.


  • Mirabelli, MH, Devine MJ, Singh J, et al. The Preparticipation Sports Evaluation. Am Fam Physician. 2015 Sep 1;92(5):371-376.
  • Sanders B, Blackburn TA, Boucher B. Preparticipation screening – the sports physical therapy perspective. Int J Sports Phys Ther. 2013 Apr; 8(2): 180–193.
  • American Academy of Pediatrics. The Preparticipation Sports Evaluation. ( Accessed 8/28/2018.

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