Pre-Season Evaluation in Sport

Original Editor - Wanda van Niekerk based on the course by James Laskin

Top Contributors - Wanda van Niekerk and Jess Bell  

Goals and Objectives of the Pre-Season Evaluation[edit | edit source]

The overall goal of the Pre-Season Evaluation (PSE) or Preparticipation Exam is to ensure the health and safety of an athlete in training and competition. It is a screening tool to assess athletes for injuries, illness or other factors that may put the athlete or others at risk. This tool is designed to be inclusive and not to just exclude athletes from participation. Only about 0.3% to 1.3% of athletes are reported to be denied clearance to participate, and 3.2% to 13.9% of athletes require further assessment before being allowed to participate.[1]

The PSE is not a substitute for regular health assessments by the athlete's primary care physician, BUT for many athletes, the PSE may be their only access to a medical caregiver and it may be the most extensive, focused health examination they will have.

Primary and secondary objectives of the PSE are listed in Table 1.

Table 1. Primary and secondary objectives of the pre-season evaluation in sport.
Primary Objectives Secondary Objectives
  • Identification of:
    • pre-existing conditions
    • correctable conditions
    • conditions that may limit participation
    • conditions that may lead to injury
    • areas of poor physical conditioning
    • poor exercise tolerance and the risk for heat intolerance
    • joint problems
  • Meeting administrative requirements in a country, state or sports association
  • Initiation of rehabilitation
  • Determining the current health status of the athlete
  • May be the ONLY opportunity a sports clinician has to assess the athlete and discuss relevant health issues such as immunisation, substance abuse and birth control
  • Opportunity to counsel athletes on health-related issues
  • Assess growth development in children and adolescents
  • Assess the athlete's fitness and performance levels
  • Help identify weaknesses that may increase the risk of injury

Exercise is Medicine[edit | edit source]

The American College of Sports Medicine (ACSM) has created the global initiative "Exercise is Medicine" (EIM). Regular exercise improves the health of people and prevents many non-communicable diseases. An active lifestyle is not only relevant to elite athletes, but to all people. The ACSM created a pre-participation screening algorithm. Download the infographic from here.


You can also read these articles:

More information can also be found here: Exercise is Medicine

Administration of PSE[edit | edit source]

Timing and Frequency[edit | edit source]

Ideally, the PSE should be performed at least 6 weeks prior to the start of practice. This allows for adequate time to identify and address any issues that arise during the assessment. The recommended frequency of the PSE is once a year. However various medical associations have different recommendations.[5] For example[5]:

  • American Heart Association - every 2 years during maturation
  • American Academy of Pediatrics - every year until the age of 21 years
  • American Academy of Family Physicians - every 1 to 3 years
  • Preparticipation Physical Evaluation 5th edition writing group - every 2 to 3 years with annual comprehensive questionnaire updates

The frequency can be flexible depending on the history of the athlete, their age, the type of sport or activity, etc.[6]

PSE Team and Setting[edit | edit source]

Often, only one sports clinician (for example a physiotherapist) performs the PSE, but it can also be performed by a multidisciplinary team of various professionals. The PSE can be performed with just the individual athlete present or in a multi-person and multi-stage set-up. Typically individual assessments will be performed at the clinician's consulting rooms. Different models of multi-stage setups can be used. Table 2 summarises the advantages and disadvantages of multi-stage evaluations.

Table 2. Disadvantages and advantages of multi-stage pre-season evaluations.
Disadvantages Advantages
  • Large space required
  • Hurried, noisy with minimal privacy
  • Difficulty with certain examinations
  • Continuity of care easily lost
  • Problems noted may not be followed up
  • In young athletes, there may be a lack of communication with parents
  • Inconsistencies between evaluators
  • Varying levels of training/experience of evaluators
  • Cost-effective
  • Efficient
  • Easy to screen a large number of athletes
  • Specialised personnel at each station
  • Good communication with athletic staff since coach, physician, physiotherapist, athletic trainers are usually part of the evaluation team

This article provides the sports physical therapist's perspective on preparticipation screening: Preparticipation screening–the sports physical therapy perspective. [7]

Components of the Pre-Season Evaluation[edit | edit source]

Medical History[edit | edit source]

  • Questionnaires are often used
  • Medical and family history should be included[8]
    • Kurowski and Chandran[9] reported that an athlete's personal and family history reveals 64-78% of conditions that could prohibit or alter sports participation - showing that history-taking is a sensitive tool.[9] Furthermore, it has been reported that 88% of general medical conditions can be detected from the history alone and 67-75% of musculoskeletal conditions pertinent to sports participation can be detected.[8]
Table 3. List of medical conditions included in an athlete's history.
Medical Conditions Included in History

Allergies to medications


Birth defects



Eating disorders


Heart murmur

Heart problems

Heat problems



High blood pressure

Kidney disease




Menstrual history

Mental disorders



Rheumatic fever


Sickle cell trait or disease


Vital Signs[edit | edit source]

  • Blood pressure
  • Heart rate
  • Weight / height
  • Respiration rate
  • Pulse oximetry (SpO2)
Table 3. Calculation of the Physical Activity Vital Sign.
Questions Answer
  1. On average, how many days per week do you engage in moderate to vigorous physical activity (like a brisk walk)?
  2. On average, how many minutes do you engage in physical activity at this level?
______ days

______ minutes

Total minutes per week of physical activity (multiply #1 by #2) ___ minutes per week

Eye Examination[edit | edit source]

  • Visual acuity should be assessed as poor vision may lead to a decrease in performance and injuries
    • Snellen eye chart is used
      • Download a Snellen eye chart and directions for use here
  • In sports where there is a high risk of eye injuries, eye protection is key
  • Traumatic eye injuries are the leading cause of noncongenital blindness in people younger than 20 years[11]
  • Sports with a high risk of eye injury include sports played with a ball, bat, puck, stick or racquet (e.g. lacrosse, hockey, baseball, basketball, softball) or sports where participants are likely to be hit (martial arts)[11]
  • A functionally one-eyed athlete has a best corrected visual acuity of 20 / 40 or worse in the affected eye[11]
    • Functionally one-eyed athletes should wear protective eyewear in all sports, regardless of the level of risk involved[11]
  • Read more: Eye Injuries

Musculoskeletal Examination[edit | edit source]

  • Address any concerns from the subjective history
  • Assess:
    • posture
    • asymmetry
    • upper and lower quadrant screens
    • joint-specific examinations if indicated
  • Further assessment as required includes:
    • active/passive range of motion
    • special tests
    • reflexes
    • sensation
    • palpation

Read more: Screening in Sport - Musculoskeletal Screening

Neurological Examination[edit | edit source]

Screen for[1]:

  • history of previous concussion/head injuries
  • seizure disorders
  • headaches
  • recurrent stingers or burners
  • prior transient quadriparesis or cervical cord neuropraxia

Cardiovascular Examination[edit | edit source]

  • This is an important part of the PSE:
    • sports clinicians need to address cardiovascular concerns in the personal history of the athlete (specific questions about exertional chest pain, unexplained syncope, excessive exertional and unexplained dyspnea or fatigue, prior recognition of heart murmur and elevated systemic blood pressure)
    • if any of the above are positive, referral to a physician or cardiologist is necessary before the athlete can be cleared for sport and physical activity
    • a family history of premature death before age 50 due to heart disease needs to be considered, as well as disability from heart disease in close relatives
  • Sudden cardiac death in athletes affects 1 - 3/100 000 competitive athletes younger than 35 years.
    • frequent causes are hypertrophic cardiomyopathy, arrhythmogenic cardiomyopathy, coronary artery disease in older athletes and channelopathies in children[12]
  • Recommended readings:

Pulmonary Examination[edit | edit source]

  • This is often done in conjunction with the cardiovascular examination
  • Conditions that require further investigation:
    • abnormal coughing, shortness of breath, breath sounds
    • asthma
    • exercise-induced bronchospasm
    • pulmonary insufficiency

Other Medical Examinations[edit | edit source]

  • Mental health screening
  • Urogenital exam
  • Gastrointestinal exam
  • Integumentary exam

Special Considerations[edit | edit source]

These can arise from questionnaires completed, or through discussions and developing a rapport with the athlete.

  • Substance abuse
  • Female athlete triad
  • Relative energy deficiency in sport
  • Post Covid complications
  • Transgender athletes
  • Athletes with a disability
  • Suspected intentional trauma

Recommended Reading: The Preparticipation physical evaluation.[8]

Determining Clearance[edit | edit source]

Clearance Considerations[edit | edit source]

  • Is the athlete at risk?
  • Are others at risk?
  • Is participation safe during treatment?
  • Can limited participation be allowed?
  • Can the athlete be cleared for certain sports?

Clearance Categories[edit | edit source]

  • Passed
    • No reservations, clear for all sports
  • Passed with conditions
    • Athlete has a medical problem and needs follow-up
    • Follow-up must be prior to activities
  • Passed with reservations
    • No collision sports
    • No contact sports
  • Failed with reservations
    • Not cleared for requested sport
    • Contact not permitted; non-contact allowed
  • Failed with conditions
    • Can be reconsidered after the condition has been addressed
  • Failed
    • Unconditional
    • Cannot be cleared for any sport or any level of competition

Resources[edit | edit source]

  • Application of ACSM's Updated Exercise Preparticipation Health Screening Algorithm


References[edit | edit source]

  1. 1.0 1.1 Douglas W, Siddiqi AR. Preparticipation Evaluation. Essential Sports Medicine: A Clinical Guide for Students and Residents. 2021:45-73.
  2. Kiara Spooner. ACSM Pre-Participation Screening Algorithm. Available from: [last accessed 25/02/2023]
  3. Magal M, Riebe D. New preparticipation health screening recommendations: what exercise professionals need to know. ACSM's Health & Fitness Journal. 2016 May 1;20(3):22-7.
  4. Riebe D, Franklin BA, Thompson PD, Garber CE, Whitfield GP, Magal M, Pescatello LS. Updating ACSM's Recommendations for Exercise Preparticipation Health Screening. Medicine and science in sports and exercise. 2015 Nov;47(11):2473-9.
  5. 5.0 5.1 Maloy W, Schroeder J, Rhodehouse B. Athlete Preparticipation Physical Evaluation. Sports Medicine and Arthroscopy Review. 2021 Dec 3;29(4):200-6.
  6. Laskin, J. Pre-Season Evaluation in Sport. Course. Plus, 2023
  7. Sanders B, Blackburn TA, Boucher B. Preparticipation screening–the sports physical therapy perspective. International journal of sports physical therapy. 2013 Apr;8(2):180.
  8. 8.0 8.1 8.2 MacDonald J, Schaefer M, Stumph J. The Preparticipation Physical Evaluation. American family physician. 2021 May 1;103(9):539-46.
  9. 9.0 9.1 Kurowski K, Chandran S. The preparticipation athletic evaluation. American family physician. 2000 May 1;61(9):2683-90.
  10. Golightly YM, Allen KD, Ambrose KR, Stiller JL, Evenson KR, Voisin C, Hootman JM, Callahan LF. Physical Activity as a Vital Sign: A Systematic Review. Preventing Chronic Disease. 2017 Nov 30;14:E123-.
  11. 11.0 11.1 11.2 11.3 Toldi JP, Thomas JL. Evaluation and management of sports-related eye injuries. Current sports medicine reports. 2020 Jan 1;19(1):29-34.
  12. Robles AG, Palamà Z, Nesti M, Tunzi RM, Delise P, Cavarretta E, Penco M, Romano S, Sciarra L. Sport Related Sudden Death: The Importance of Primary and Secondary Prevention. Journal of Clinical Medicine. 2022 Aug 11;11(16):4683.
  13. Crawford MH. Screening athletes for heart disease. Heart. 2007 Jul 1;93(7):875-9.
  14. Hajduczok AG, Ruge M, Emery MS. Risk Factors for Sudden Death in Athletes, Is There a Role for Screening?. Current Cardiovascular Risk Reports. 2022 Oct;16(10):97-109.
  15. Aspetar. Sudden Cardiac Arrest in Sports. Available from: [last accessed 27/01/2023]
  16. Aspetar. Why do super-fit, young athletes suffer sudden cardiac arrest? Available from: [last accessed 27/01/2023]
  17. ACSM. Application of ACSM's Updated Exercise Preparticipation Health Screening Algorithm. Available from: [last accessed 25/01/2023]