Musculoskeletal Practices for the Preparticipation Physical Examination

Musculoskeletal Practices for the Preparticipation Physical Examination | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Musculoskeletal Practices for the Preparticipation Physical Examination Connor Corrente, Matthew Silvis, Joseph Murphy, Robert Gallo, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-210629/v2 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 04 Aug, 2021 Read the published version in BMC Sports Science, Medicine and Rehabilitation → Version 2 posted 10 You are reading this latest preprint version Show more versions Abstract Background: Little is known about the musculoskeletal (MSK) exam providers use during the preparticipation physical exam (PPE). The primary aims of this study were to determine current practice with regards to the MSK screening exam, if goals are being met, and if there may be opportunities for improvement. Results: The study had a total of 616 participants with a response rate of 9%. The majority of respondents (82%) were familiar with the 4th Edition PPE Monograph and 80% either moderately or strongly agreed that they use this as a guideline for their MSK screening exam. The 90 second MSK screening test was implemented by 52% of the participants and 13% reported no knowledge of this test. The majority of participants use an orthopedic exam as part of their PPE (82%). 92% of participants felt satisfied that their MSK exam would screen for current injury, while only 42% were satisfied that it effectively screened for future injury. 86% of participants agree that the MSK exam should be performed, while 26% said that they don't perform a physical exam at all. Educationally, 51% received training for the MSK PPE in residency, and 62% had training in fellowship. Conclusions : Most participants believe that the MSK exam should be performed and that it effectively screens for current injuries, but there is variability as to what tests are being utilized despite the majority being familiar with the PPE Monograph. Most providers do not believe that the MSK PPE adequately screens for future injury; an overriding goal of the PPE. Residency or fellowship programs appear to be venues that education may be instituted. Sports Medicine and Kinesiology Musculoskeletal (MSK) Preparticipation Physical Exam (PPE) injury prevention MSK screening exam Figures Figure 1 Background High school athletes suffer an estimated 2 million injuries and require 500,000 doctor visits and 30,000 hospitalizations annually. 1 The High School Sports-Related Injury Surveillance Study showed that ankle and knee injuries were two of the most common high school sports-related injuries, accounting for nearly 30% of all high school sports-related injuries in the 2014-15 school year. 2 Longer-term consequences of sports injuries include predisposition to recurring injuries, earlier sports termination/dropout, and potentially compromised physical and psychological health. 3 The current standard of care for screening athletes at risk for injury and illness is the pre-participation evaluation (PPE), but there has been no conclusive evidence that supports the effectiveness of the musculoskeletal (MSK) PPE to accurately identify or prevent at risk populations from injury. 4 Despite not having a validated screening exam the musculoskeletal portion of the PPE, mostly through the history and review of systems form, has been found to be the most common cause of disqualification for athletes. 5 The primary goal of the Pre-participation Physical Examination as described in the 4th Edition PPE Monograph, which was used at the time of this study, is to (1) screen for conditions that may be life-threatening or disabling, and (2) screen for conditions that may predispose individuals to injury or illness. 6 Currently, there is no standardization for healthcare providers on how the PPE is completed, and there are questions surrounding the effectiveness of the PPE in meeting its objectives to properly screen athletes. In a study completed in 2014, it was found that healthcare providers overall were unaware of the PPE screening guidelines, and that knowledge of the Fourth Edition PPE Monograph led to increased satisfaction with the PPE as a screening tool. 7 Effective screening tests must satisfy 2 requirements as described by the US Preventive Services Task Force: (1) the test must be able to detect abnormalities earlier than without screening and (2) the screening must be accurate. 8 Due to the need to understand more completely how to better screen athletes for MSK injury we designed a survey to gain information from physicians performing PPE’s. Our aims were to understand current physician practices in regard to the MSK screening exam, if physicians who perform PPEs feel the current goals of the PPE are being met, and if there may be opportunities for education in teaching of the MSK screening examination. Our hypothesis is that over 50% of providers are not aware of the 4th Edition PPE monograph, that the goals of the PPE are not being met, and that there is variability in how the MSK screen is performed amongst providers. Methods Following institutional review board approval, members from the American Academy of Family Physicians (AAFP) and the American Medical Society for Sports Medicine (AMSSM) were recruited for the study. Inclusion criteria included current practicing physicians in primary care, primary care sports medicine, and sports orthopedics that perform pre-participation physical examinations as part of his/her practice. Exclusion criteria included providers who are not currently practicing, and individuals that do not perform the PPE as part of their practice. The study utilized a cross-sectional survey-based REDCap instrument for data collection. 3,000 members of the AAFP were mailed postcards that contained a link and scannable QR code for participants to access the survey and 3,871 members of the AMSSM were sent an email that was generated through the organization on two occasions, one month apart, containing a link to the survey. The survey contained a total of 24 questions and was separated into two main sections: a series of questions regarding the demographics of each participant followed by questions pertaining to participants’ MSK screening practices for the PPE. Demographic questions investigated the number of years of clinical practice, specialty of provider, location of practice, and level of athlete (middle school through professional) typically seen. The MSK screening questions involved a variety of Likert scale, multiple select, and yes/no questions exploring providers’ satisfaction that their screen is appropriate for current or future injury, knowledge of the 4th Edition PPE Monograph, what physical exam tests are commonly performed in the PPE, thoughts on the value of the MSK screening exam, and if the PPE is adjusted based on athlete level. Additionally, information regarding the number of PPEs performed per year, most common age group of athletes screened, and facilities in which the PPEs are being performed in was collected. Prior to administration, the survey was reviewed for accuracy by 3 board certified sports medicine physicians (two primary care and one orthopedic), 2 family practice physicians, and 1 certified athletic trainer who were not involved in the creation of the questionnaire. Descriptive statistics were used in the analysis of the data. Results A total of 616 out of 6871 participants (9%) responded to the survey. The majority of participants, 72%, were family medicine physicians with the remaining 28% being composed of orthopedic, internal medicine, emergency medicine, pediatric, and physical medicine and rehabilitation physicians. Participants practiced across 46 states collectively. Variability in the MSK screening exam is depicted in Fig. 1 . The 90 second MSK screening test was implemented by 52% of the participants, the most common among physicians. The majority of participants who perform a MSK exam use an orthopedic exam as part of their PPE (82%). 26% of participants reported that they do not perform a physical exam at all as part of their MSK screening examination, while 86% of participants agree that the MSK exam should be performed. 92% of participants felt satisfied that their MSK examination would screen for current injury, while only 42% were satisfied that it effectively screened for future injury. One of the main barriers to performing portions of the MSK screen was time (46%), while 22% reported lack of evidence for the exam as their reason. Educationally, 51% received training for the MSK PPE in residency, and 62% had training in fellowship. The majority of respondents (82%) were familiar with the 4th Edition PPE Monograph and 80% either moderately or strongly agreed that they use this as a guideline for their MSK screening exam. 13% reported no knowledge of the 90 second MSK screening test that is included in the 4th Edition PPE Monograph. These results are summarized in Table 1 . Table 1 Participant Demographics and PPE Experience Data Total providers contacted 6871 Total responses 616* Practice location (n = 496) Rural Suburban Urban 56 (11.29%) 263 (53.02%) 177 (35.69%) Years practicing (n = 497) 1–5 6–10 11–15 15–20 > 20 184 (37.02%) 96 (19.32%) 65 (13.08%) 54 (10.87%) 98 (19.72%) Primary Practice Setting (n = 616) Outpatient Primary Care General Orthopedics Sports Orthopedics Primary Care Sports Medicine Pediatrics Other 147 (23.86%) 17 (2.76%) 78 (12.66%) 314 (50.97%) 8 (1.30%) 36 (5.84%) Residency Completed (n = 504) Family Medicine Internal Medicine Orthopedic Surgery Emergency Medicine Pediatrics Physical Medicine and Rehabilitation Other 360 (71.43%) 30 (5.95%) 1 (0.20%) 18 (3.57%) 47 (9.33%) 35 (6.94%) 13 (2.58%) Sports Medicine Fellowship Training (n = 496) Yes No 439 (88.51%) 57 (11.49%) Team Physician (n = 495) Yes No 393 (79.39%) 102 (20.61%) Level of Sport Covered (n = 616) High School Club College Professional National Team Other (Dance, military, semi-pro, roller derby, endurance events) 283 (45.94%) 75 (12.18%) 273 (44.32%) 122 (19.81%) 51 (8.28%) 12 (1.95%) Training for PPE (n = 616) Medical School Residency Fellowship Continuing Medical Education PPE Literature Other (undergraduate education, experience, colleagues) 139 (22.56%) 314 (50.97%) 380 (61.69%) 123 (19.97%) 174 (28.25%) 9 (1.46%) Familiarization of 4th Edition PPE Monograph (n = 466) Yes No 383 (82.19%) 83 (17.81%) Use of PPE Monograph as guideline (n = 382) Disagree Strongly Disagree Moderately Disagree Slightly Agree Slightly Agree Moderately Agree Strongly 4 (1.05%) 8 (2.09%) 13 (3.40%) 50 (13.09%) 180 (47.12%) 127 (33.25%) Satisfied with MSK screening exam for CURRENT injury (n = 466) Yes No 431 (92.49%) 35 (7.51%) Satisfied with MSK screening exam for FUTURE injury (n = 466) Yes No 194 (41.63%) 272 (58.37%) Location where PPE is performed most commonly (n = 616) Normal office patient encounter On-field with team Gymnasium Physical Therapy Clinic Athletic Training Room Other 370 (60.06%) 16 (2.60%) 201 (32.63%) 18 (2.92%) 264 (42.86%) 43 (6.98%) Age groups most commonly assessed (years) (n = 466) 25 5 (1.07%) 258 (55.36%) 198 (42.49%) 5 (1.07%) Number of PPE performed yearly (n = 466) 0–25 26–50 51–75 76–100 > 100 63 (13.52%) 77 (16.52%) 68 (14.59%) 54 (11.59%) 204 (43.78%) Discussion There are a variety of approaches that are used for the MSK screening examination during the PPE. Most participants believe that the MSK exam should be performed and that it effectively screens for current injuries, but the majority of providers do not believe that the MSK exam adequately screens for future injury; an overriding goal of the PPE. 6 This data confirmed our perception that the MSK screen does not screen for future injury and that providers do not believe in the predictive ability of the screen. To that end almost a third of respondents reported that they do not perform a physical exam at all. This perception is also in agreement with literature investigating the effectiveness of the MSK PPE, which shows there has been no convincing evidence that the MSK PPE is effective at accurately identifying or preventing at risk athletes from injury. 4 , 9 , 10 Most participants were aware of the 4th Edition PPE Monograph and reported that they primarily use it as their guideline, contradictory to our hypothesis. Even with participants reporting using the monograph as their guideline for the MSK screen, there is still a lot of variability in how the screen is being performed, with half of the participants using the 90 second MSK screening test, 14% using the Functional Movement Screen (FMS), and close to a third not using a physical exam at all for the screen. Approximately 46% of participants reported lack of time as a barrier to performing some portions of the MSK PPE, providing some explanation as to why this variability may exist. Another explanation for the inconsistency could be due to educational differences amongst providers as there was variability in where providers were taught the MSK exam. 51% of respondents received training for the MSK PPE in residency and 62% in fellowship programs, which highlights that standardization in curriculums could improve the quality of MSK screenings provided. Our findings support a lack of understanding of the PPE monograph given the wide variability in MSK screening exam techniques used while being aware of the PPE guidelines. This calls attention to the need for continued standardization of the MSK screening exam, as well as further research to validate objective screening exams for the prevention of MSK injury. Screening exams should be explored to look at the relationships between screening tests and risk factors in relevant populations to determine what tests are appropriate and effective in identifying high-risk populations. 9 A recent study by Teyhen et. al. was able to show in a military population that the sum of a number of risk factors was able to produce a highly sensitive model for identifying those at risk for MSK injury. 11 This highlights that future MSK screenings should not focus on a single screen, but that a multivariate model with multiple risk factors could successfully identify a high-risk population. Injury prevention programs have shown to be effective in reducing injuries in athletes across a range of sports. 12 , 13 , 14 Identifying the high-risk population would provide an opportunity to direct limited prevention resources to the most at-risk individuals with the ultimate goal to reduce overall injury risk. There are several limitations to our study. Our survey was the first that we are aware of that looked to gain provider insight to the MSK exam. As with any questionnaire-based research study, limitations regarding validation of the instrument used is of paramount concern. Validation of a questionnaire requires a process to determine construct, criterion, and content validity, amongst others. We addressed content validity through independent review of the questionnaire by 3 sports medicine physicians (two primary care and one orthopedic), 2 family medicine physicians, and 1 certified athletic trainer not involved in the creation of the questionnaire. Because there are no other instruments available to assess similar information, we were unable to assess criterion validity. Given the sample design of the questionnaire, we did not believe that it was necessary to assess construct validity. 15 The study was also limited due to a low response rate of 9%, however, other web-based survey studies targeting members of the AMSSM had similar response rates. 16 , 17 , 18 Additionally, it is important to note that the response rate is slighter higher than 9% due to crossover of providers being active members of both the AAFP and AMSSM. The low response rate from providers specializing in fields other than family medicine did not allow for further analysis across specialties. Conclusion This study provides evidence for variability in MSK screening practices. It also highlights physician concerns that the goals of the PPE are not being met with the MSK screening. Finally, there may be a need to improve educational efforts in residencies and fellowships. Future steps include creation of a validated MSK screening model, similar to other primary prevention screening models (CAD, Colon cancer, etc.), that accomplishes the goals of the MSK portion of the PPE, which can then be implemented to be a standard part of the PPE exam. List Of Abbreviations MSK (musculoskeletal), PPE (preparticipation physical exam), AAFP (American Academy of Family Physicians), AMSSM (American Medical Society for Sports Medicine), FMS (Functional Movement Screen). Declarations Ethics approval and consent to participate – This study was approved by the Scientific Review Committee of the Department of Family and Community Medicine as well as the Human Subjects Protection Office of the Institutional Review Board at Penn State Milton S. Hershey Medical Center which determined that the research met the criteria for exempt research. No identifiable protected health information (PHI) was accessed, used, or disclosed in this study. Participants were asked to indicate their consent via REDCap, and the survey questionnaire would not begin until consent was given. A copy of the consent was available to download for participants to have on file. Consent for publication – Not applicable Availability of data and material – The datasets generated and/or analyzed during the current study are available in the REDCap repository and available from the corresponding author on reasonable request. Competing interests – The authors declare that they have no competing interests. Funding – Funding was provided by the Department of Family and Community Medicine at Penn State Milton S. Hershey Medical Center to support distribution of postcards for participant recruitment. Authors’ contributions – CC was involved in the development of the IRB and data collection instrument, data analysis and interpretation, and manuscript preparation. CO oversaw all aspects of the study, including study design, data analysis and interpretation, and manuscript preparation. MS, JM, and RG each contributed to study design and manuscript preparation. All authors read and approved the final manuscript. Acknowledgements - Thank you to Alan Adelman, Amanda Taylor Gehman, and Jessica Wright for your support in the development of the study protocol, administrative support, and financial support of this study. Thank you also to our statistician Erik Lehman for providing support in the data analysis of this study. Authors’ information – MS is a board-certified Primary Care Sports Medicine physician, serves as the Division Chief of Primary Care Sports Medicine at Penn State Milton S. Hershey Medical Center, and is the team physician for the Hershey Bears Hockey Club and Hershey High School. JM serves as Director and Assistant Professor of Athletic Training at Lebanon Valley College. RG is a board-certified Orthopedic Sports Medicine physician and serves as the medical director for the Harrisburg Senators baseball team. CO is a Certified Athletic Trainer and board-certified Primary Care Sports Medicine Physician, and serves as the team physician for the Hershey Bears Hockey Club and Lebanon Valley College. References MMWR Weekly. Sports-Related Injuries Among High School Athletes: United States, 2005-2006 School Year. Vol 55. Atlanta, GA: Centers for Disease Control and Prevention; 2006:1037-1040. Comstock R, Currie D, Pierpoint L. Summary Report, National High School Sports-Related Injury Surveillance Study, 2014-2015 School Year. Colorado School of Public Health/University of Colorado Anschutz Medical Campus. http://www.ucdenver.edu/academics/colleges/PublicHealth/research/ResearchProjects/piper/projects/RIO/Documents/Original%20Report_%202014_15.pdf Stracciolini A, Casciano R, Levey Friedman H, Meehan WP, 3rd, Micheli LJ. Pediatric sports injuries: an age comparison of children versus adolescents. Am J Sports Med. 2013;41(8):1922-1929. PMID: 23739684 Andujo, V. D., Fletcher, I. E., & Mcgrew, C. (2020). Musculoskeletal Preparticipation Physical Evaluation—Does it Lead to Decreased Musculoskeletal Morbidity? Current Sports Medicine Reports, 19 (2), 58-69. doi:10.1249/jsr.0000000000000683 Smith, J. Laskowski ER. The preparticipation physical examination: Mayo Clinic experience with 2,739 examinations. Mayo Clin Proc. May 1998;73(5):419-429 Bernhardt, D. T., Roberts, W. O., American Academy of Family Physicians; American Academy of Pediatrics; American College of Sports Medicine; American Medical Society for Sports Medicine; American Orthopaedic Society for Sports Medicine; and American Osteopathic Academy of Sports Medicine. (2010). PPE: Preparticipation Physical Evaluation, 4th Edition . Elk Grove Village, IL: American Academy of Pediatrics. Madsen, N. L., Drezner, J. A., & Salerno, J. C. (2014). The Preparticipation Physical Evaluation. Clinical Journal of Sport Medicine, 24 (2), 142-149. doi:10.1097/jsm.0000000000000008 United States Preventive Services Task Force. Guide to Clinical Preventive Services .Alexandria, VA: International Medical Publishing; 1996. Bahr, R. (2016). Why screening tests to predict injury do not work—and probably never will…: A critical review. British Journal of Sports Medicine, 50 (13), 776-780. doi:10.1136/bjsports-2016-096256 Labotz, M., & Bernhardt, D. T. (2016). Preparticipation physical examination: Is it time to stop doing the sports physical? British Journal of Sports Medicine, 51 (3), 151-152. doi:10.1136/bjsports-2016-096892 Teyhen, D. S., Shaffer, S. W., Goffar, S. L., Kiesel, K., Butler, R. J., Rhon, D. I., & Plisky, P. J. (2020). Identification of Risk Factors Prospectively Associated With Musculoskeletal Injury in a Warrior Athlete Population. Sports Health: A Multidisciplinary Approach, 12 (6), 564-572. doi:10.1177/1941738120902991 Brunner, R., Friesenbichler, B., Casartelli, N. C., Bizzini, M., Maffiuletti, N. A., & Niedermann, K. (2018). Effectiveness of multicomponent lower extremity injury prevention programmes in team-sport athletes: An umbrella review. British Journal of Sports Medicine, 53 (5), 282-288. doi:10.1136/bjsports-2017-098944 Grimm, N. L., Jacobs, J. C., Kim, J., Amendola, A., & Shea, K. G. (2016). Ankle Injury Prevention Programs for Soccer Athletes Are Protective. The Journal of Bone and Joint Surgery, 98 (17), 1436-1443. doi:10.2106/jbjs.15.00933 Thorborg, K., Krommes, K. K., Esteve, E., Clausen, M. B., Bartels, E. M., & Rathleff, M. S. (2017). Effect of specific exercise-based football injury prevention programmes on the overall injury rate in football: A systematic review and meta-analysis of the FIFA 11 and 11+ programmes. British Journal of Sports Medicine, 51 (7), 562-571. doi:10.1136/bjsports-2016-097066 Brophy R, et al . Understanding the meniscus injury and expectations of meniscus surgery in patients for orthopaedic care. Arthroscopy 2015; 31 (12): 2295-300. Stache S, Howell D, Meehan WP 3rd. Concussion Management Practice Patterns Among Sports Medicine Physicians. Clin J Sport Med. 2016 Sep;26(5):381-5. doi: 10.1097/JSM.0000000000000270. PMID: 26584436. Taranto E, Fishman M, Benjamin H, Ross L. Genetic Testing by Sports Medicine Physicians in the United States: Attitudes, Experiences, and Knowledge. Sports (Basel). 2018 Nov 12;6(4):145. doi: 10.3390/sports6040145. PMID: 30424536; PMCID: PMC6315998. Pascale, B., Steele, C., Attipoe, S., O'Connor, F. G. & Deuster, P. A. (2016). Dietary Supplements. Clinical Journal of Sport Medicine, 26(2), 139–144. doi: 10.1097/JSM.0000000000000213. Cite Share Download PDF Status: Published Journal Publication published 04 Aug, 2021 Read the published version in BMC Sports Science, Medicine and Rehabilitation → Version 2 posted Review # 2 received at journal 11 Apr, 2021 Editorial decision: Major revision 11 Apr, 2021 Reviewer # 2 agreed at journal 29 Mar, 2021 Reviewer # 1 agreed at journal 23 Mar, 2021 Review # 1 received at journal 23 Mar, 2021 Editor assigned by journal 22 Mar, 2021 Reviewers invited by journal 22 Mar, 2021 Submission checks completed at journal 22 Mar, 2021 Editor invited by journal 22 Mar, 2021 First submitted to journal 08 Mar, 2021 You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-210629","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[{"code":1,"date":"2021-02-19 22:37:04","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"articleType":"Research article","associatedPublications":[],"authors":[{"id":18960529,"identity":"3a13bd02-2e00-407e-b1e2-596611112a6c","order_by":0,"name":"Connor Corrente","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0003-4620-2559","institution":"Penn State College of Medicine","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Connor","middleName":"","lastName":"Corrente","suffix":""},{"id":18960530,"identity":"1bdf3c17-cf6c-4c10-99d3-a6260e21c446","order_by":1,"name":"Matthew Silvis","email":"","orcid":"","institution":"Penn State Health Milton S Hershey Medical Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Matthew","middleName":"","lastName":"Silvis","suffix":""},{"id":18960531,"identity":"64a1c307-6b39-4921-aaca-914f3cbc265f","order_by":2,"name":"Joseph Murphy","email":"","orcid":"","institution":"Lebanon Valley College","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Joseph","middleName":"","lastName":"Murphy","suffix":""},{"id":18960532,"identity":"84f2cee5-6464-4f96-9c4e-98a49daf27aa","order_by":3,"name":"Robert Gallo","email":"","orcid":"","institution":"Penn State Health Milton S Hershey Medical Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Robert","middleName":"","lastName":"Gallo","suffix":""},{"id":18960533,"identity":"87c5a7e3-f9b3-4b04-b0a9-a8e2d012b6a0","order_by":4,"name":"Cayce Onks","email":"","orcid":"","institution":"Penn State Health Milton S Hershey Medical Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Cayce","middleName":"","lastName":"Onks","suffix":""}],"badges":[],"createdAt":"2021-02-05 17:20:51","currentVersionCode":2,"declarations":"","doi":"10.21203/rs.3.rs-210629/v2","doiUrl":"https://doi.org/10.21203/rs.3.rs-210629/v2","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13102-021-00316-x","type":"published","date":"2021-08-04T15:04:07+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":7460767,"identity":"8a8e5be4-30de-40ea-bb5e-629270efee8a","added_by":"auto","created_at":"2021-03-29 20:14:29","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":41887,"visible":true,"origin":"","legend":"Variability in MSK screening tests used during the PPE","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-210629/v2/90f08ac3bc470527339273da.jpg"},{"id":13683004,"identity":"c58e3d5a-3c23-405a-8072-502e0cf0c36c","added_by":"auto","created_at":"2021-09-17 12:00:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":271619,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-210629/v2/835a810a-a7d1-44c4-84a6-ea2e21174450.pdf"}],"financialInterests":"","formattedTitle":"Musculoskeletal Practices for the Preparticipation Physical Examination","fulltext":[{"header":"Background","content":"\u003cp\u003eHigh school athletes suffer an estimated 2 million injuries and require 500,000 doctor visits and 30,000 hospitalizations annually.\u003csup\u003e1\u003c/sup\u003e The High School Sports-Related Injury Surveillance Study showed that ankle and knee injuries were two of the most common high school sports-related injuries, accounting for nearly 30% of all high school sports-related injuries in the 2014-15 school year.\u003csup\u003e2\u003c/sup\u003e\u0026nbsp; Longer-term consequences of sports injuries include predisposition to recurring injuries, earlier sports termination/dropout, and potentially compromised physical and psychological health.\u003csup\u003e3\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe current standard of care for screening athletes at risk for injury and illness is the pre-participation evaluation (PPE), but there has been no conclusive evidence that supports the effectiveness of the musculoskeletal (MSK) PPE to accurately identify or prevent at risk populations from injury.\u003csup\u003e4\u003c/sup\u003e Despite not having a validated screening exam the musculoskeletal portion of the PPE, mostly through the history and review of systems form, has been found to be the most common cause of disqualification for athletes.\u003csup\u003e5\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThe primary goal of the Pre-participation Physical Examination as described in the 4th Edition PPE Monograph, which was used at the time of this study, is to (1) screen for conditions that may be life-threatening or disabling, and (2) screen for conditions that may predispose individuals to injury or illness.\u003csup\u003e6\u003c/sup\u003e Currently, there is no standardization for healthcare providers on how the PPE is completed, and there are questions surrounding the effectiveness of the PPE in meeting its objectives to properly screen athletes. In a study completed in 2014, it was found that healthcare providers overall were unaware of the PPE screening guidelines, and that knowledge of the Fourth Edition PPE Monograph led to increased satisfaction with the PPE as a screening tool.\u003csup\u003e7\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEffective screening tests must satisfy 2 requirements as described by the US Preventive Services Task Force: (1) the test must be able to detect abnormalities earlier than without screening and (2) the screening must be accurate.\u003csup\u003e8\u003c/sup\u003e Due to the need to understand more completely how to better screen athletes for MSK injury we designed a survey to gain information from physicians performing PPE\u0026rsquo;s. Our aims were to understand current physician practices in regard to the MSK screening exam, if physicians who perform PPEs feel the current goals of the PPE are being met, and if there may be opportunities for education in teaching of the MSK screening examination. Our hypothesis is that over 50% of providers are not aware of the 4th Edition PPE monograph, that the goals of the PPE are not being met, and that there is variability in how the MSK screen is performed amongst providers.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv class=\"Ethics-ToolTip\"\u003eFollowing institutional review board approval, members from the American Academy of Family Physicians (AAFP) and the American Medical Society for Sports Medicine (AMSSM) were recruited for the study.\u003c/div\u003e\n\u003cp\u003eInclusion criteria included current practicing physicians in primary care, primary care sports medicine, and sports orthopedics that perform pre-participation physical examinations as part of his/her practice. Exclusion criteria included providers who are not currently practicing, and individuals that do not perform the PPE as part of their practice.\u003c/p\u003e\n\u003cp\u003eThe study utilized a cross-sectional survey-based REDCap instrument for data collection. 3,000 members of the AAFP were mailed postcards that contained a link and scannable QR code for participants to access the survey and 3,871 members of the AMSSM were sent an email that was generated through the organization on two occasions, one month apart, containing a link to the survey.\u003c/p\u003e\n\u003cp\u003eThe survey contained a total of 24 questions and was separated into two main sections: a series of questions regarding the demographics of each participant followed by questions pertaining to participants\u0026rsquo; MSK screening practices for the PPE. Demographic questions investigated the number of years of clinical practice, specialty of provider, location of practice, and level of athlete (middle school through professional) typically seen. The MSK screening questions involved a variety of Likert scale, multiple select, and yes/no questions exploring providers\u0026rsquo; satisfaction that their screen is appropriate for current or future injury, knowledge of the 4th Edition PPE Monograph, what physical exam tests are commonly performed in the PPE, thoughts on the value of the MSK screening exam, and if the PPE is adjusted based on athlete level. Additionally, information regarding the number of PPEs performed per year, most common age group of athletes screened, and facilities in which the PPEs are being performed in was collected. Prior to administration, the survey was reviewed for accuracy by 3 board certified sports medicine physicians (two primary care and one orthopedic), 2 family practice physicians, and 1 certified athletic trainer who were not involved in the creation of the questionnaire. Descriptive statistics were used in the analysis of the data.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 616 out of 6871 participants (9%) responded to the survey. The majority of participants, 72%, were family medicine physicians with the remaining 28% being composed of orthopedic, internal medicine, emergency medicine, pediatric, and physical medicine and rehabilitation physicians. Participants practiced across 46 states collectively. Variability in the MSK screening exam is depicted in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. The 90 second MSK screening test was implemented by 52% of the participants, the most common among physicians. The majority of participants who perform a MSK exam use an orthopedic exam as part of their PPE (82%). 26% of participants reported that they do not perform a physical exam at all as part of their MSK screening examination, while 86% of participants agree that the MSK exam should be performed. 92% of participants felt satisfied that their MSK examination would screen for current injury, while only 42% were satisfied that it effectively screened for future injury. One of the main barriers to performing portions of the MSK screen was time (46%), while 22% reported lack of evidence for the exam as their reason.\u003c/p\u003e\n\u003cp\u003eEducationally, 51% received training for the MSK PPE in residency, and 62% had training in fellowship. The majority of respondents (82%) were familiar with the 4th Edition PPE Monograph and 80% either moderately or strongly agreed that they use this as a guideline for their MSK screening exam. 13% reported no knowledge of the 90 second MSK screening test that is included in the 4th Edition PPE Monograph. These results are summarized in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eParticipant Demographics and PPE Experience Data\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eTotal providers contacted\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e6871\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTotal responses\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e616*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePractice location (n\u0026thinsp;=\u0026thinsp;496)\u003c/p\u003e\n\u003cp\u003eRural\u003c/p\u003e\n\u003cp\u003eSuburban\u003c/p\u003e\n\u003cp\u003eUrban\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e56 (11.29%)\u003c/p\u003e\n\u003cp\u003e263 (53.02%)\u003c/p\u003e\n\u003cp\u003e177 (35.69%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYears practicing (n\u0026thinsp;=\u0026thinsp;497)\u003c/p\u003e\n\u003cp\u003e1\u0026ndash;5\u003c/p\u003e\n\u003cp\u003e6\u0026ndash;10\u003c/p\u003e\n\u003cp\u003e11\u0026ndash;15\u003c/p\u003e\n\u003cp\u003e15\u0026ndash;20\u003c/p\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;20\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e184 (37.02%)\u003c/p\u003e\n\u003cp\u003e96 (19.32%)\u003c/p\u003e\n\u003cp\u003e65 (13.08%)\u003c/p\u003e\n\u003cp\u003e54 (10.87%)\u003c/p\u003e\n\u003cp\u003e98 (19.72%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePrimary Practice Setting (n\u0026thinsp;=\u0026thinsp;616)\u003c/p\u003e\n\u003cp\u003eOutpatient Primary Care\u003c/p\u003e\n\u003cp\u003eGeneral Orthopedics\u003c/p\u003e\n\u003cp\u003eSports Orthopedics\u003c/p\u003e\n\u003cp\u003ePrimary Care Sports Medicine\u003c/p\u003e\n\u003cp\u003ePediatrics\u003c/p\u003e\n\u003cp\u003eOther\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e147 (23.86%)\u003c/p\u003e\n\u003cp\u003e17 (2.76%)\u003c/p\u003e\n\u003cp\u003e78 (12.66%)\u003c/p\u003e\n\u003cp\u003e314 (50.97%)\u003c/p\u003e\n\u003cp\u003e8 (1.30%)\u003c/p\u003e\n\u003cp\u003e36 (5.84%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eResidency Completed (n\u0026thinsp;=\u0026thinsp;504)\u003c/p\u003e\n\u003cp\u003eFamily Medicine\u003c/p\u003e\n\u003cp\u003eInternal Medicine\u003c/p\u003e\n\u003cp\u003eOrthopedic Surgery\u003c/p\u003e\n\u003cp\u003eEmergency Medicine\u003c/p\u003e\n\u003cp\u003ePediatrics\u003c/p\u003e\n\u003cp\u003ePhysical Medicine and Rehabilitation\u003c/p\u003e\n\u003cp\u003eOther\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e360 (71.43%)\u003c/p\u003e\n\u003cp\u003e30 (5.95%)\u003c/p\u003e\n\u003cp\u003e1 (0.20%)\u003c/p\u003e\n\u003cp\u003e18 (3.57%)\u003c/p\u003e\n\u003cp\u003e47 (9.33%)\u003c/p\u003e\n\u003cp\u003e35 (6.94%)\u003c/p\u003e\n\u003cp\u003e13 (2.58%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSports Medicine Fellowship Training (n\u0026thinsp;=\u0026thinsp;496)\u003c/p\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e439 (88.51%)\u003c/p\u003e\n\u003cp\u003e57 (11.49%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTeam Physician (n\u0026thinsp;=\u0026thinsp;495)\u003c/p\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e393 (79.39%)\u003c/p\u003e\n\u003cp\u003e102 (20.61%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLevel of Sport Covered (n\u0026thinsp;=\u0026thinsp;616)\u003c/p\u003e\n\u003cp\u003eHigh School\u003c/p\u003e\n\u003cp\u003eClub\u003c/p\u003e\n\u003cp\u003eCollege\u003c/p\u003e\n\u003cp\u003eProfessional\u003c/p\u003e\n\u003cp\u003eNational Team\u003c/p\u003e\n\u003cp\u003eOther (Dance, military, semi-pro, roller derby, endurance events)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e283 (45.94%)\u003c/p\u003e\n\u003cp\u003e75 (12.18%)\u003c/p\u003e\n\u003cp\u003e273 (44.32%)\u003c/p\u003e\n\u003cp\u003e122 (19.81%)\u003c/p\u003e\n\u003cp\u003e51 (8.28%)\u003c/p\u003e\n\u003cp\u003e12 (1.95%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTraining for PPE (n\u0026thinsp;=\u0026thinsp;616)\u003c/p\u003e\n\u003cp\u003eMedical School\u003c/p\u003e\n\u003cp\u003eResidency\u003c/p\u003e\n\u003cp\u003eFellowship\u003c/p\u003e\n\u003cp\u003eContinuing Medical Education\u003c/p\u003e\n\u003cp\u003ePPE Literature\u003c/p\u003e\n\u003cp\u003eOther (undergraduate education, experience, colleagues)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e139 (22.56%)\u003c/p\u003e\n\u003cp\u003e314 (50.97%)\u003c/p\u003e\n\u003cp\u003e380 (61.69%)\u003c/p\u003e\n\u003cp\u003e123 (19.97%)\u003c/p\u003e\n\u003cp\u003e174 (28.25%)\u003c/p\u003e\n\u003cp\u003e9 (1.46%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFamiliarization of 4th Edition PPE Monograph (n\u0026thinsp;=\u0026thinsp;466)\u003c/p\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e383 (82.19%)\u003c/p\u003e\n\u003cp\u003e83 (17.81%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUse of PPE Monograph as guideline (n\u0026thinsp;=\u0026thinsp;382)\u003c/p\u003e\n\u003cp\u003eDisagree Strongly\u003c/p\u003e\n\u003cp\u003eDisagree Moderately\u003c/p\u003e\n\u003cp\u003eDisagree Slightly\u003c/p\u003e\n\u003cp\u003eAgree Slightly\u003c/p\u003e\n\u003cp\u003eAgree Moderately\u003c/p\u003e\n\u003cp\u003eAgree Strongly\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (1.05%)\u003c/p\u003e\n\u003cp\u003e8 (2.09%)\u003c/p\u003e\n\u003cp\u003e13 (3.40%)\u003c/p\u003e\n\u003cp\u003e50 (13.09%)\u003c/p\u003e\n\u003cp\u003e180 (47.12%)\u003c/p\u003e\n\u003cp\u003e127 (33.25%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSatisfied with MSK screening exam for CURRENT injury (n\u0026thinsp;=\u0026thinsp;466)\u003c/p\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e431 (92.49%)\u003c/p\u003e\n\u003cp\u003e35 (7.51%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSatisfied with MSK screening exam for FUTURE injury (n\u0026thinsp;=\u0026thinsp;466)\u003c/p\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e194 (41.63%)\u003c/p\u003e\n\u003cp\u003e272 (58.37%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLocation where PPE is performed most commonly (n\u0026thinsp;=\u0026thinsp;616)\u003c/p\u003e\n\u003cp\u003eNormal office patient encounter\u003c/p\u003e\n\u003cp\u003eOn-field with team\u003c/p\u003e\n\u003cp\u003eGymnasium\u003c/p\u003e\n\u003cp\u003ePhysical Therapy Clinic\u003c/p\u003e\n\u003cp\u003eAthletic Training Room\u003c/p\u003e\n\u003cp\u003eOther\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e370 (60.06%)\u003c/p\u003e\n\u003cp\u003e16 (2.60%)\u003c/p\u003e\n\u003cp\u003e201 (32.63%)\u003c/p\u003e\n\u003cp\u003e18 (2.92%)\u003c/p\u003e\n\u003cp\u003e264 (42.86%)\u003c/p\u003e\n\u003cp\u003e43 (6.98%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAge groups most commonly assessed (years) (n\u0026thinsp;=\u0026thinsp;466)\u003c/p\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;12\u003c/p\u003e\n\u003cp\u003e13\u0026ndash;18\u003c/p\u003e\n\u003cp\u003e18\u0026ndash;25\u003c/p\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;25\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (1.07%)\u003c/p\u003e\n\u003cp\u003e258 (55.36%)\u003c/p\u003e\n\u003cp\u003e198 (42.49%)\u003c/p\u003e\n\u003cp\u003e5 (1.07%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNumber of PPE performed yearly (n\u0026thinsp;=\u0026thinsp;466)\u003c/p\u003e\n\u003cp\u003e0\u0026ndash;25\u003c/p\u003e\n\u003cp\u003e26\u0026ndash;50\u003c/p\u003e\n\u003cp\u003e51\u0026ndash;75\u003c/p\u003e\n\u003cp\u003e76\u0026ndash;100\u003c/p\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;100\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e63 (13.52%)\u003c/p\u003e\n\u003cp\u003e77 (16.52%)\u003c/p\u003e\n\u003cp\u003e68 (14.59%)\u003c/p\u003e\n\u003cp\u003e54 (11.59%)\u003c/p\u003e\n\u003cp\u003e204 (43.78%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\u003cbr\u003e"},{"header":"Discussion","content":"\u003cp\u003eThere are a variety of approaches that are used for the MSK screening examination during the PPE. Most participants believe that the MSK exam should be performed and that it effectively screens for current injuries, but the majority of providers do not believe that the MSK exam adequately screens for future injury; an overriding goal of the PPE.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e This data confirmed our perception that the MSK screen does not screen for future injury and that providers do not believe in the predictive ability of the screen. To that end almost a third of respondents reported that they do not perform a physical exam at all. This perception is also in agreement with literature investigating the effectiveness of the MSK PPE, which shows there has been no convincing evidence that the MSK PPE is effective at accurately identifying or preventing at risk athletes from injury.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eMost participants were aware of the 4th Edition PPE Monograph and reported that they primarily use it as their guideline, contradictory to our hypothesis. Even with participants reporting using the monograph as their guideline for the MSK screen, there is still a lot of variability in how the screen is being performed, with half of the participants using the 90 second MSK screening test, 14% using the Functional Movement Screen (FMS), and close to a third not using a physical exam at all for the screen. Approximately 46% of participants reported lack of time as a barrier to performing some portions of the MSK PPE, providing some explanation as to why this variability may exist. Another explanation for the inconsistency could be due to educational differences amongst providers as there was variability in where providers were taught the MSK exam. 51% of respondents received training for the MSK PPE in residency and 62% in fellowship programs, which highlights that standardization in curriculums could improve the quality of MSK screenings provided.\u003c/p\u003e\n\u003cp\u003eOur findings support a lack of understanding of the PPE monograph given the wide variability in MSK screening exam techniques used while being aware of the PPE guidelines. This calls attention to the need for continued standardization of the MSK screening exam, as well as further research to validate objective screening exams for the prevention of MSK injury. Screening exams should be explored to look at the relationships between screening tests and risk factors in relevant populations to determine what tests are appropriate and effective in identifying high-risk populations.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e A recent study by Teyhen et. al. was able to show in a military population that the sum of a number of risk factors was able to produce a highly sensitive model for identifying those at risk for MSK injury.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e This highlights that future MSK screenings should not focus on a single screen, but that a multivariate model with multiple risk factors could successfully identify a high-risk population. Injury prevention programs have shown to be effective in reducing injuries in athletes across a range of sports.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Identifying the high-risk population would provide an opportunity to direct limited prevention resources to the most at-risk individuals with the ultimate goal to reduce overall injury risk.\u003c/p\u003e\n\u003cp\u003eThere are several limitations to our study. Our survey was the first that we are aware of that looked to gain provider insight to the MSK exam. As with any questionnaire-based research study, limitations regarding validation of the instrument used is of paramount concern. Validation of a questionnaire requires a process to determine construct, criterion, and content validity, amongst others. We addressed content validity through independent review of the questionnaire by 3 sports medicine physicians (two primary care and one orthopedic), 2 family medicine physicians, and 1 certified athletic trainer not involved in the creation of the questionnaire. Because there are no other instruments available to assess similar information, we were unable to assess criterion validity. Given the sample design of the questionnaire, we did not believe that it was necessary to assess construct validity.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e The study was also limited due to a low response rate of 9%, however, other web-based survey studies targeting members of the AMSSM had similar response rates.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e Additionally, it is important to note that the response rate is slighter higher than 9% due to crossover of providers being active members of both the AAFP and AMSSM. The low response rate from providers specializing in fields other than family medicine did not allow for further analysis across specialties.\u003c/p\u003e"},{"header":"Conclusion","content":" \u003cp\u003eThis study provides evidence for variability in MSK screening practices. It also highlights physician concerns that the goals of the PPE are not being met with the MSK screening. Finally, there may be a need to improve educational efforts in residencies and fellowships. Future steps include creation of a validated MSK screening model, similar to other primary prevention screening models (CAD, Colon cancer, etc.), that accomplishes the goals of the MSK portion of the PPE, which can then be implemented to be a standard part of the PPE exam.\u003c/p\u003e "},{"header":"List Of Abbreviations","content":"\u003cp\u003e \u003cp\u003eMSK (musculoskeletal), PPE (preparticipation physical exam), AAFP (American Academy of Family Physicians), AMSSM (American Medical Society for Sports Medicine), FMS (Functional Movement Screen).\u003c/p\u003e \u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u0026ndash; This study was approved by the Scientific Review Committee of the Department of Family and Community Medicine as well as the Human Subjects Protection Office of the Institutional Review Board at Penn State Milton S. Hershey Medical Center which determined that the research met the criteria for exempt research. No identifiable protected health information (PHI) was accessed, used, or disclosed in this study. Participants were asked to indicate their consent via REDCap, and the survey questionnaire would not begin until consent was given. A copy of the consent was available to download for participants to have on file.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e \u0026ndash; Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e \u0026ndash; The datasets generated and/or analyzed during the current study are available in the REDCap repository and available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e \u0026ndash; The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e \u0026ndash; Funding was provided by the Department of Family and Community Medicine at Penn State Milton S. Hershey Medical Center to support distribution of postcards for participant recruitment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions \u0026ndash; \u003c/strong\u003eCC was involved in the development of the IRB and data collection instrument, data analysis and interpretation, and manuscript preparation. CO oversaw all aspects of the study, including study design, data analysis and interpretation, and manuscript preparation. MS, JM, and RG each contributed to study design and manuscript preparation. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements - \u003c/strong\u003eThank you to Alan Adelman, Amanda Taylor Gehman, and Jessica Wright for your support in the development of the study protocol, administrative support, and financial support of this study. Thank you also to our statistician Erik Lehman for providing support in the data analysis of this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; information \u0026ndash; \u003c/strong\u003eMS is a board-certified Primary Care Sports Medicine physician, serves as the Division Chief of Primary Care Sports Medicine at Penn State Milton S. Hershey Medical Center, and is the team physician for the Hershey Bears Hockey Club and Hershey High School. JM serves as Director and Assistant Professor of Athletic Training at Lebanon Valley College. RG is a board-certified Orthopedic Sports Medicine physician and serves as the medical director for the Harrisburg Senators baseball team. CO is a Certified Athletic Trainer and board-certified Primary Care Sports Medicine Physician, and serves as the team physician for the Hershey Bears Hockey Club and Lebanon Valley College.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMMWR Weekly. Sports-Related Injuries Among High School Athletes: United States, 2005-2006 School Year. Vol 55. Atlanta, GA: Centers for Disease Control and Prevention; 2006:1037-1040.\u003c/li\u003e\n\u003cli\u003eComstock R, Currie D, Pierpoint L. Summary Report, National High School Sports-Related Injury Surveillance Study, 2014-2015 School Year. Colorado School of Public Health/University of Colorado Anschutz Medical Campus. http://www.ucdenver.edu/academics/colleges/PublicHealth/research/ResearchProjects/piper/projects/RIO/Documents/Original%20Report_%202014_15.pdf\u003c/li\u003e\n\u003cli\u003eStracciolini A, Casciano R, Levey Friedman H, Meehan WP, 3rd, Micheli LJ. Pediatric sports injuries: an age comparison of children versus adolescents. \u003cem\u003eAm J Sports Med. \u003c/em\u003e2013;41(8):1922-1929. PMID: 23739684\u003c/li\u003e\n\u003cli\u003eAndujo, V. D., Fletcher, I. E., \u0026amp; Mcgrew, C. (2020). Musculoskeletal Preparticipation Physical Evaluation\u0026mdash;Does it Lead to Decreased Musculoskeletal Morbidity?\u003cem\u003eCurrent Sports Medicine Reports,\u003c/em\u003e\u0026nbsp;\u003cem\u003e19\u003c/em\u003e(2), 58-69. doi:10.1249/jsr.0000000000000683\u003c/li\u003e\n\u003cli\u003eSmith, J. Laskowski ER. The preparticipation physical examination: Mayo Clinic experience with 2,739 examinations. \u003cem\u003eMayo Clin Proc. \u003c/em\u003eMay 1998;73(5):419-429\u003c/li\u003e\n\u003cli\u003eBernhardt, D. T., Roberts, W. O., American Academy of Family Physicians; American Academy of Pediatrics; American College of Sports Medicine; American Medical Society for Sports Medicine; American Orthopaedic Society for Sports Medicine; and American Osteopathic Academy of Sports Medicine. (2010). \u003cem\u003ePPE: Preparticipation Physical Evaluation, 4th Edition\u003c/em\u003e. Elk Grove Village, IL: American Academy of Pediatrics.\u003c/li\u003e\n\u003cli\u003eMadsen, N. L., Drezner, J. A., \u0026amp; Salerno, J. C. (2014). The Preparticipation Physical Evaluation. \u003cem\u003eClinical Journal of Sport Medicine,\u003c/em\u003e \u003cem\u003e24\u003c/em\u003e(2), 142-149. doi:10.1097/jsm.0000000000000008\u003c/li\u003e\n\u003cli\u003eUnited States Preventive Services Task Force.\u0026nbsp;\u003cem\u003eGuide to Clinical Preventive Services\u003c/em\u003e.Alexandria, VA: International Medical Publishing; 1996.\u003c/li\u003e\n\u003cli\u003eBahr, R. (2016). Why screening tests to predict injury do not work\u0026mdash;and probably never will\u0026hellip;: A critical review.\u0026nbsp;\u003cem\u003eBritish Journal of Sports Medicine,\u003c/em\u003e\u003cem\u003e50\u003c/em\u003e(13), 776-780. doi:10.1136/bjsports-2016-096256\u003c/li\u003e\n\u003cli\u003eLabotz, M., \u0026amp; Bernhardt, D. T. (2016). Preparticipation physical examination: Is it time to stop doing the sports physical?\u0026nbsp;\u003cem\u003eBritish Journal of Sports Medicine,\u003c/em\u003e\u003cem\u003e51\u003c/em\u003e(3), 151-152. doi:10.1136/bjsports-2016-096892\u003c/li\u003e\n\u003cli\u003eTeyhen, D. S., Shaffer, S. W., Goffar, S. L., Kiesel, K., Butler, R. J., Rhon, D. I., \u0026amp; Plisky, P. J. (2020). Identification of Risk Factors Prospectively Associated With Musculoskeletal Injury in a Warrior Athlete Population.\u0026nbsp;\u003cem\u003eSports Health: A Multidisciplinary Approach,\u003c/em\u003e\u003cem\u003e12\u003c/em\u003e(6), 564-572. doi:10.1177/1941738120902991\u003c/li\u003e\n\u003cli\u003eBrunner, R., Friesenbichler, B., Casartelli, N. C., Bizzini, M., Maffiuletti, N. A., \u0026amp; Niedermann, K. (2018). Effectiveness of multicomponent lower extremity injury prevention programmes in team-sport athletes: An umbrella review.\u0026nbsp;\u003cem\u003eBritish Journal of Sports Medicine,\u003c/em\u003e\u003cem\u003e53\u003c/em\u003e(5), 282-288. doi:10.1136/bjsports-2017-098944\u003c/li\u003e\n\u003cli\u003eGrimm, N. L., Jacobs, J. C., Kim, J., Amendola, A., \u0026amp; Shea, K. G. (2016). Ankle Injury Prevention Programs for Soccer Athletes Are Protective.\u0026nbsp;\u003cem\u003eThe Journal of Bone and Joint Surgery,\u003c/em\u003e\u003cem\u003e98\u003c/em\u003e(17), 1436-1443. doi:10.2106/jbjs.15.00933\u003c/li\u003e\n\u003cli\u003eThorborg, K., Krommes, K. K., Esteve, E., Clausen, M. B., Bartels, E. M., \u0026amp; Rathleff, M. S. (2017). Effect of specific exercise-based football injury prevention programmes on the overall injury rate in football: A systematic review and meta-analysis of the FIFA 11 and 11+ programmes.\u0026nbsp;\u003cem\u003eBritish Journal of Sports Medicine,\u003c/em\u003e\u003cem\u003e51\u003c/em\u003e(7), 562-571. doi:10.1136/bjsports-2016-097066\u003c/li\u003e\n\u003cli\u003eBrophy R, \u003cem\u003eet al\u003c/em\u003e. Understanding the meniscus injury and expectations of meniscus surgery in patients for orthopaedic care.\u0026nbsp; \u003cem\u003eArthroscopy \u003c/em\u003e2015; 31 (12):\u0026nbsp; 2295-300.\u003c/li\u003e\n\u003cli\u003eStache S, Howell D, Meehan WP 3rd. Concussion Management Practice Patterns Among Sports Medicine Physicians. Clin J Sport Med. 2016 Sep;26(5):381-5. doi: 10.1097/JSM.0000000000000270. PMID: 26584436.\u003c/li\u003e\n\u003cli\u003eTaranto E, Fishman M, Benjamin H, Ross L. Genetic Testing by Sports Medicine Physicians in the United States: Attitudes, Experiences, and Knowledge. Sports (Basel). 2018 Nov 12;6(4):145. doi: 10.3390/sports6040145. PMID: 30424536; PMCID: PMC6315998.\u003c/li\u003e\n\u003cli\u003ePascale, B., Steele, C., Attipoe, S., O'Connor, F. G. \u0026amp; Deuster, P. A. (2016). Dietary Supplements. Clinical Journal of Sport Medicine, 26(2), 139\u0026ndash;144. doi: 10.1097/JSM.0000000000000213.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-sports-science-medicine-and-rehabilitation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ssmr","sideBox":"Learn more about [BMC Sports Science, Medicine and Rehabilitation](http://bmcsportsscimedrehabil.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ssmr/default.aspx","title":"BMC Sports Science, Medicine and Rehabilitation","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Musculoskeletal (MSK), Preparticipation Physical Exam (PPE), injury prevention, MSK screening exam","lastPublishedDoi":"10.21203/rs.3.rs-210629/v2","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-210629/v2","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eLittle is known about the musculoskeletal (MSK) exam providers use during the preparticipation physical exam (PPE). The primary aims of this study were to determine current practice with regards to the MSK screening exam, if goals are being met, and if there may be opportunities for improvement.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe study had a total of 616 participants with a response rate of 9%. The majority of respondents (82%) were familiar with the 4th Edition PPE Monograph and 80% either moderately or strongly agreed that they use this as a guideline for their MSK screening exam. The 90 second MSK screening test was implemented by 52% of the participants and 13% reported no knowledge of this test. The majority of participants use an orthopedic exam as part of their PPE (82%). 92% of participants felt satisfied that their MSK exam would screen for current injury, while only 42% were satisfied that it effectively screened for future injury. 86% of participants agree that the MSK exam should be performed, while 26% said that they don't perform a physical exam at all. Educationally, 51% received training for the MSK PPE in residency, and 62% had training in fellowship.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: Most participants believe that the MSK exam should be performed and that it effectively screens for current injuries, but there is variability as to what tests are being utilized despite the majority being familiar with the PPE Monograph. Most providers do not believe that the MSK PPE adequately screens for future injury; an overriding goal of the PPE. Residency or fellowship programs appear to be venues that education may be instituted.\u003c/p\u003e","manuscriptTitle":"Musculoskeletal Practices for the Preparticipation Physical Examination","msid":"","msnumber":"","nonDraftVersions":[{"code":2,"date":"2021-03-29 20:12:31","doi":"10.21203/rs.3.rs-210629/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2021-04-12T00:00:00+00:00","index":2,"fulltext":"Recommendation: Accept after discretionary revisions\nForm responses:\n---\n\nComments to Author:\n---\nThank you for submitting your article, I was very happy to review it. I've added some comments / queries that I hope would add some value to the finalised draft.\n\nThe abstract doesn't described the methods or discussion but presents a lot of results. It might help to reduce the results section to allow for a brief explanation of the methods, and a short discussion, before your conclusion.\n\nBackground (line 14) has a reference from 2014-15, is there anything more recent? Line 26 states the PPE is the current standard of care - is this from the reference 4 - or if not can you reference this as it's a central statement to the relevance of your paper. Line 34-38 read slightly unclear to me, perhaps rephrasing would help the reader? You've used PPE at times, and the full wording, sometimes capitalised and sometimes not - a consistent version would be better. Your aims would be better in their own paragraph and you don't typically need a hypothesis in qualitative survey studies, so I would consider removing that part.\n\nMethods look good and well written.\n\nResults are written in two tenses, and should preferably be in the past tense throughout. Page 6 line 12 'variability' should be a new paragraph as you're going onto the next section of your findings.\n\nDiscussion page 7 line 7- 14 doesn't need the hypothesis part in (if you remove from the aims in the background). Line 7 - I don't think you can say it doesn't screen for future injury as you present no data to support that, rather you present data that represents people opinions? I think this needs consideration and removing. In the first few paragraphs you seem to make the point that standardisation of MSK exam is needed, but after you've made the point it doesn't screen for future injuries, then later you conclude a battery of tests are required like CAD etc. This seems slightly contradictory as a thread through the discussion. I think what you're saying is people don't do it as they don't understand it or don't think it works, therefore it should be replaced by a better screening method, not just education and standardising the existing exam?\n\nConclusion doesn't reflect the discussion, unless you change the above discussion points. I think your conclusion reflects what the data says and suggests a reasonable direction for practice / future research, but I don't feel that the discussion thread leads you to that (see above).\n\nOverall, I think this will be a useful article for those involved in PPE to review their practice against a national picture. More so, it should provide the basis for future work that looks to change the methods used in the PPE - moving towards a more targeting battery of tests that are overall more sensitive to future injury risk prediction. Thank you for your article.* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons after the final decision on the manuscript has been made. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please publish my name with my report.**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"decision","content":"Major revision","date":"2021-04-12T00:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2021-03-30T00:00:00+00:00","index":2,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2021-03-24T00:00:00+00:00","index":1,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-03-24T00:00:00+00:00","index":1,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n\nComments to Author:\n---\nThank you for this work. I have the following comments:\nI was not aware of the document you referred to and thus I spent more time on the references then I normally do\nA clear reference to where to find the exam you discuss would be helpful - and I was unable to find reference 10\nbut my search did uncover that there is a version 5 of this exam which I did not see mentioned anywhere in your work - even if version 4 is what you used for your survey you should identify that this is now an older version\nI believe you could find more recent references than you present for #1 and #2.\nI would make the same comment for ref #5 - and if this is the most recent (1998 publication) then you should comment on that\nReference #7 is incomplete on the title\nOn page 7 line 3 - I don't think the exam is meant to screen for future injury - perhaps it is meant to be future risk\nPage 8 line 3 - perhaps there needs to be a discussion about the value of the exam before a standardization of exam\nThere also was no mention of what clinicians are completing - are they completing just a form that says they athlete can compete or are they completing something more specific - if done at a school they are completing something more specific in my experience that may make the PPE you reference unnecessary or redundant or inadequate.\n\nOn your tables\nIs fellowship a mix of family practice and orthopedic surgery\nCould there be more than one answer for sports covered and location of training?\nDid you determine if clinicians who do less then 25 physicals a year are different from the other groups in knowledge?\n\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons after the final decision on the manuscript has been made. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **No**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"editorAssigned","content":"","date":"2021-03-23T00:00:00+00:00","index":"","fulltext":""},{"type":"reviewersInvited","content":"","date":"2021-03-23T00:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2021-03-22T23:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2021-03-22T23:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2021-03-09T00:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-sports-science-medicine-and-rehabilitation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ssmr","sideBox":"Learn more about [BMC Sports Science, Medicine and Rehabilitation](http://bmcsportsscimedrehabil.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ssmr/default.aspx","title":"BMC Sports Science, Medicine and Rehabilitation","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d7d050c8-ddba-45cf-9630-ffd0738c4897","owner":[],"postedDate":"March 29th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":3286334,"name":"Sports Medicine and Kinesiology"}],"tags":[],"updatedAt":"2021-08-22T15:19:24+00:00","versionOfRecord":{"articleIdentity":"rs-210629","link":"https://doi.org/10.1186/s13102-021-00316-x","journal":{"identity":"bmc-sports-science-medicine-and-rehabilitation","isVorOnly":false,"title":"BMC Sports Science, Medicine and Rehabilitation"},"publishedOn":"2021-08-04 15:04:07","publishedOnDateReadable":"August 4th, 2021"},"versionCreatedAt":"2021-03-29 20:12:31","video":"","vorDoi":"10.1186/s13102-021-00316-x","vorDoiUrl":"https://doi.org/10.1186/s13102-021-00316-x","workflowStages":[]},"version":"v2","identity":"rs-210629","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-210629","identity":"rs-210629","version":["v2"]},"buildId":"ApUGefWb6u5IBVtyqm6d5","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}