The FIFA pre-competition medical assessment (PCMA) divides the medical history into three sections: general, orthopaedic, and cardiovascular.
- General history
- Before the medical history, players should be briefly asked for their position, their dominant leg and the number of matches they have played in the last 12 months. These initial questions help to indicate the physical and mental demands on a player as exerted by their individual responsibilities within the team, the level of play, and the training and match schedules.
The general medical history covers the personal and family history of a player, and includes standard questions on general health (e.g. allergies and medication use). It should include questions aimed at detecting risk factors manifested through any suspicious symptoms in the past and present, particularly with respect to exercise. It has been suggested that a proper medical history alone may identify (or at least lead to a suspicion of) up to 75% of the problems that affect athletes. 6
- Orthopaedic history
- Knowledge of the medical history of the musculoskeletal system may help to identify risk factors for injury. The player should be asked about previous injuries, especially those leading to a time-loss of more than four weeks, and about any operations on the musculoskeletal system. It should be determined whether or not the player suffers from any current complaints, aches or pains; whether there are known diagnoses; and what treatment is applied for these.
- Cardiovascular history
- In the following sections, the principal diagnostic tools of cardiac assessment, together with the specific requirements and pitfalls of their performance, are discussed. Any cardiac assessment in football should be performed by a sufficiently trained, experienced and skilled physician to reliably identify the clinical symptoms and signs associated with critical cardiovascular disease in sport.
The Lausanne Recommendations, issued under the umbrella of the Medical Commission of the International Olympic Committee (IOC), offer guidance regarding history taking and cardiac screening. The recommendations suggest that the athlete be asked about the presence of exertional chest pain or discomfort, syncope/periods of unconsciousness or near-syncope, irregular heartbeats or palpitations, and the presence of shortness of breath or fatigue out of proportion to the degree of exertion.
As the most common causes of sudden cardiac death (SCD) in sports are inherited diseases, family history is of great importance in identifying players at risk. Family history is considered positive when a close relative has suffered from premature heart attack or sudden death (<55 years of age in males and <65 years in females), or when cardiomyopathy, Marfan syndrome, long QT syndrome, Brugada syndrome (or other rare conduction anomaly), coronary artery disease or any other disabling cardiovascular diseases run in the family. Note that conduction anomalies (long and short QT syndrome, Brugada syndrome, pre-excitation syndromes like Wolff-Parkinson-White, etc.) are “pure” ECG diagnoses with possible symptoms leading to their suspicion: syncope, palpitations, frequent irregular beats. In contrast, cardiomyopathies may often have related resting ECG alterations, particularly ones of the T-wave, but the ECG is more of a tool for finding the diagnosis than evidence itself. Usually, the final diagnosis of cardiomyopathies is made using imaging techniques like echocardiography or cardiac magnet resonance imaging (MRI).
There are two disease entities which are particularly difficult to detect even with this sophisticated PCMA screening: coronary anomalies and myocarditis. Coronary anomalies may lead to ischemia during exercise and, thus, to symptoms like angina pectoris or undue dyspnea. When an affected player does not report such symptoms, only an exercise ECG (ST-segment depression or intensity-dependent occurrence of ectopic beats) or sometimes a meticulously conducted echocardiography can lead to the diagnosis which is typically confirmed by invasive (catheter) examinations. A myocarditis usually is not present during the PCMA but develops on the basis of an infectious disease with a spread of viruses, bacteria or other pathogens. The most effective means to prevent SCD due to myocarditis is probably a thorough diagnosis and management of any infection and advice to players not to train and compete with symptoms indicative of acute infectous diseases. Apart from myocardial biopsy (the gold standard of diagnosis) unspecific ECG irregularities, echocardiographic findings and delayed gadolinium enhancement in cardiac MRI may lead to a myocarditis diagnosis in an acutely affected player.
Dr Tim Meyer
Sports and Exercise Physician