Explanation: Athlete (particularly if he or she has Down syndrome or juvenile rheumatoid arthritis with cervical involvement) needs evaluation to assess the risk of spinal cord injury during sports participation, especially when using a trampoline. (American Academy of Pediatrics [AAP], Committee on Injury and Poison Prevention, Committee on Sports Medicine and Fitness, 1999; Maranich, Hamele, & Fairchok, 2006; AAP, Committee on Sports Medicine and Fitness, "Atlanto-axial instability," 1995; American Academy of Family Physicians et al., 2004)

Explanation: Athlete needs evaluation. (Mercer & Densmore, 2005; National Hemophilia Foundation, 2005)

Carditis (inflammation of the heart)

Explanation: Carditis may result in sudden death with exertion.

Hypertension (high blood pressure)

Explanation: Those with hypertension>5 mmHg above the 99th percentile for age, gender, and height should avoid heavy weightlifting and power lifting, bodybuilding, and high-static component sports (see Figure 1 in the original guideline document). Those with sustained hypertension (>95th percentile for age, gender, and height) need evaluation. (National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents, 2004; AAP, 1997; American College of Cardiology Foundation, 36^th Bethesda Conference, 2005) The National High Blood Pressure Education Program Working Group report defined prehypertension and stage 1 and stage 2 hypertension in children and adolescents younger than 18 years of age. (National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents, 2004)

Congenital heart disease (structural heart defects present at birth)

Explanation: Consultation with a cardiologist is recommended. Those who have mild forms may participate fully in most cases; those who have moderate or severe forms or who have undergone surgery need evaluation. The 36th Bethesda Conference (American College of Cardiology Foundation, 36^th Bethesda Conference, 2005) defined mild, moderate, and severe disease for common cardiac lesions.

Dysrhythmia (irregular heart rhythm)

Long-QT syndrome

Malignant ventricular arrhythmias

Symptomatic Wolff-Parkinson-White syndrome

Advanced heart block

Family history of sudden death or previous sudden cardiac event

Implantation of a cardioverter-defibrillator

Explanation: Consultation with a cardiologist is advised. Those with symptoms (chest pain, syncope, near-syncope, dizziness, shortness of breath, or other symptoms of possible dysrhythmia) or evidence of mitral regurgitation on physical examination need evaluation. All others may participate fully. (Maron et al., 2007; AAP, Committee on Sports Medicine and Fitness, "Cardiac dysrhythmias," 1995; Freed et al., 1999)

Heart murmur

Explanation: If the murmur is innocent (does not indicate heart disease), full participation is permitted. Otherwise, athlete needs evaluation (see structural heart disease, especially hypertrophic cardiomyopathy and mitral valve prolapse).

Structural/acquired heart disease

Hypertrophic cardiomyopathy

Coronary artery anomalies

Arrhythmogenic right ventricular cardiomyopathy

Acute rheumatic fever with carditis

Ehlers-Danlos syndrome, vascular form

Marfan syndrome

Mitral valve prolapse

Anthracycline use

Explanation: Consultation with a cardiologist is recommended. The 36th Bethesda Conference provided detailed recommendations. (American College of Cardiology Foundation, 36^th Bethesda Conference, 2005; Maron et al., 2007; Freed et al., 1999; Maron, 2003; Maron, 2002; Pyeritz, 2000) Most of these conditions carry a significant risk of sudden cardiac death associated with intense physical exercise. Hypertrophic cardiomyopathy requires thorough and repeated evaluations, because disease may change manifestations during later adolescence. (American College of Cardiology Foundation, 36^th Bethesda Conference, 2005; Maron et al., 2007; Maron, 2002) Marfan syndrome with an aortic aneurysm also can cause sudden death during intense physical exercise. (Pyeritz, 2000) Athlete who has ever received chemotherapy with anthracyclines may be at increased risk of cardiac problems because of the cardiotoxic effects of the medications, and resistance training in this population should be approached with caution; strength training that avoids isometric contractions may be permitted. (AAP, Council on Sports Medicine, 2008; Steinherz et al., 1991) Athlete needs evaluation.

Vasculitis/vascular disease

Kawasaki disease (coronary artery vasculitis)

Pulmonary hypertension

Explanation: Consultation with a cardiologist is recommended. Athlete needs individual evaluation to assess risk on the basis of disease activity, pathologic changes, and medical regimen. (Newburger et al., 2004)

Explanation: Athlete needs evaluation to assess functional capacity to perform sports-specific activity.

Explanation: All sports can be played with proper attention and appropriate adjustments to diet (particularly carbohydrate intake), blood glucose concentrations, hydration, and insulin therapy. Blood glucose concentrations should be monitored before exercise, every 30 min during continuous exercise, 15 min after completion of exercise, and at bedtime.

Explanation: Unless symptoms are mild and athlete is fully hydrated, no participation is permitted, because diarrhea may increase risk of dehydration and heat illness (see fever).

Explanation: Athlete with an eating disorder needs medical and psychiatric assessment before participation.

Functionally 1-eyed athlete

Loss of an eye

Detached retina or family history of retinal detachment at young age

High myopia

Connective tissue disorder, such as Marfan or Stickler syndrome

Previous intraocular eye surgery or serious eye injury

Explanation: A functionally 1-eyed athlete is defined as having best-corrected visual acuity worse than 20/40 in the poorer-seeing eye. Such an athlete would suffer significant disability if the better eye were seriously injured, as would an athlete with loss of an eye. Specifically, boxing and full-contact martial arts are not recommended for functionally 1-eyed athletes, because eye protection is impractical and/or not permitted. Some athletes who previously underwent intraocular eye surgery or had a serious eye injury may have increased risk of injury because of weakened eye tissue. Availability of eye guards approved by the American Society for Testing and Materials and other protective equipment may allow participation in most sports, but this must be judged on an individual basis. (Gomez, 2003; AAP, Committee of Sports Medicine and Fitness, 2004)

Conjunctivitis, infectious

Explanation: Athlete with active infectious conjunctivitis should be excluded from swimming.

Explanation: Elevated core temperature may be indicative of a pathologic medical condition (infection or disease) that is often manifest by increased resting metabolism and heart rate. Accordingly, during athlete's usual exercise regimen, the presence of fever can result in greater heat storage, decreased heat tolerance, increased risk of heat illness, increased cardiopulmonary effort, reduced maximal exercise capacity, and increased risk of hypotension because of altered vascular tone and dehydration. On rare occasions, fever may accompany myocarditis or other conditions that may make usual exercise dangerous.

Malabsorption syndromes (celiac disease or cystic fibrosis)

Explanation: Athlete needs individual assessment for general malnutrition or specific deficits resulting in coagulation or other defects; with appropriate treatment, these deficits can be treated adequately to permit normal activities.

Short-bowel syndrome or other disorders requiring specialized nutritional support, including parenteral or enteral nutrition

Explanation: Athlete needs individual assessment for collision, contact, or limited-contact sports. Presence of central or peripheral, indwelling, venous catheter may require special considerations for activities and emergency preparedness for unexpected trauma to the device(s).

Explanation: Because of the likelihood of recurrence, athlete needs individual assessment to determine the presence of predisposing conditions and behaviors and to develop a prevention strategy that includes sufficient acclimatization (to the environment and to exercise intensity and duration), conditioning, hydration, and salt intake, as well as other effective measures to improve heat tolerance and to reduce heat injury risk (such as protective equipment and uniform configurations). (AAP, Committee on Sports Medicine and Fitness, 2000; Bergeron et al., 2005)

Explanation: All athletes should receive hepatitis B vaccination before participation. Because of the apparent minimal risk to others, all sports may be played as athlete's state of health allows. For all athletes, skin lesions should be covered properly, and athletic personnel should use universal precautions when handling blood or body fluids with visible blood. (AAP, Committee on Sports Medicine and Fitness, "Human immunodeficiency virus," 1999)

Explanation: Because of the apparent minimal risk to others, all sports may be played as athlete's state of health allows (especially if viral load is undetectable or very low). For all athletes, skin lesions should be covered properly, and athletic personnel should use universal precautions when handling blood or body fluids with visible blood. (AAP, Committee on Sports Medicine and Fitness, "Human immunodeficiency virus," 1999) However, certain sports (such as wrestling and boxing) may create a situation that favors viral transmission (likely bleeding plus skin breaks). If viral load is detectable, then athletes should be advised to avoid such high-contact sports.

Explanation: Athlete needs individual assessment for contact, collision, and limited-contact sports. Protective equipment may reduce risk of injury to the remaining kidney sufficiently to allow participation in most sports, providing such equipment remains in place during activity. (Gomez, 2003)

Explanation: If the liver is acutely enlarged, then participation should be avoided because of risk of rupture. If the liver is chronically enlarged, then individual assessment is needed before collision, contact, or limited-contact sports are played. Patients with chronic liver disease may have changes in liver function that affect stamina, mental status, coagulation, or nutritional status.

Explanation: Athlete needs individual assessment. (Dickerman, 2007)

Explanation: Athlete needs individual assessment.

History of serious head or spine trauma or abnormality, including craniotomy, epidural bleeding, subdural hematoma, intracerebral hemorrhage, second-impact syndrome, vascular malformation, and neck fracture. (AAP, Committee on Injury and Poison Prevention, Committee on Sports Medicine and Fitness, 1999; Maranich, Hamele, & Fairchok, 2006; Wojtys et al., 1999; McCrory et al., 2005; Aubry et al., 2002)

Explanation: Athlete needs individual assessment for collision, contact, or limited-contact sports.

History of simple concussion (mild traumatic brain injury), multiple simple concussions, and/or complex concussion

Explanation: Athlete needs individual assessment. Research supports a conservative approach to concussion management, including no athletic participation while symptomatic or when deficits in judgment or cognition are detected, followed by graduated return to full activity. (Wojtys et al., 1999; McCrory et al., 2005; Aubry et al., 2002; "Concussion," 2006; Guskiewicz et al., 2004)

Myopathies

Explanation: Athlete needs individual assessment.

Recurrent headaches

Explanation: Athlete needs individual assessment. (Lewis et al., 2002)

Recurrent plexopathy (burner or stinger) and cervical cord neuropraxia with persistent defects

Explanation: Athlete needs individual assessment for collision, contact, or limited-contact sports; regaining normal strength is important benchmark for return to play. (Castro, 2003; Weinberg, Rokito, & Silver, 2003)

Seizure disorder, well controlled

Explanation: Risk of seizure during participation is minimal. (Hirtz et al., 2003)

Seizure disorder, poorly controlled

Explanation: Athlete needs individual assessment for collision, contact, or limited-contact sports. The following noncontact sports should be avoided: archery, riflery, swimming, weightlifting, power lifting, strength training, and sports involving heights. In these sports, occurrence of a seizure during activity may pose a risk to self or others. (Hirtz et al., 2003)

Explanation: Because of the increased risk of heat illness and cardiovascular strain, obese athlete particularly needs careful acclimatization (to the environment and to exercise intensity and duration), sufficient hydration, and potential activity and recovery modifications during competition and training. (AAP, Council on Sports Medicine and Fitness and Council on School Health, 2006)

Explanation: Athlete needs individual assessment for contact, collision, and limited-contact sports. In addition to potential risk of infections, some medications (e.g., prednisone) may increase tendency for bruising.

Explanation: Risk of severe injury to remaining ovary is minimal.

Explanation: Athlete needs individual assessment. As pregnancy progresses, modifications to usual exercise routines will become necessary. Activities with high risk of falling or abdominal trauma should be avoided. Scuba diving and activities posing risk of altitude sickness should also be avoided during pregnancy. After the birth, physiological and morphologic changes of pregnancy take 4 to 6 weeks to return to baseline. (American College of Obstetricians and Gynecologists, 2002; Morales, Dumps, & Extermann, 1999)

Pulmonary compromise, including cystic fibrosis

Explanation: Athlete needs individual assessment but, generally, all sports may be played if oxygenation remains satisfactory during graded exercise test. Athletes with cystic fibrosis need acclimatization and good hydration to reduce risk of heat illness.

Asthma

Explanation: With proper medication and education, only athletes with severe asthma need to modify their participation. For those using inhalers, recommend having a written action plan and using a peak flowmeter daily. (National Heart, Lung, and Blood Institute, 2007; American College of Allergy, Asthma, and Immunology, 2006; Storms, 2003; Holzer & Brukner, 2004) Athletes with asthma may encounter risks when scuba diving.

Acute upper respiratory infection

Explanation: Upper respiratory obstruction may affect pulmonary function. Athlete needs individual assessment for all except mild disease (see fever).

Juvenile rheumatoid arthritis

Explanation: Athletes with systemic or polyarticular juvenile rheumatoid arthritis and history of cervical spine involvement need radiographs of vertebrae C1 and C2 to assess risk of spinal cord injury. Athletes with systemic or HLA-B27-associated arthritis require cardiovascular assessment for possible cardiac complications during exercise. For those with micrognathia (open bite and exposed teeth), mouth guards are helpful. If uveitis is present, risk of eye damage from trauma is increased; ophthalmologic assessment is recommended. If visually impaired, guidelines for functionally 1-eyed athletes should be followed. (Giannini & Protas, 1992)

Juvenile dermatomyositis, idiopathic myositis

Systemic lupus erythematosis

Raynaud phenomenon

Explanation: Athlete with juvenile dermatomyositis or systemic lupus erythematosis with cardiac involvement requires cardiology assessment before participation. Athletes receiving systemic corticosteroid therapy are at higher risk of osteoporotic fractures and avascular necrosis, which should be assessed before clearance; those receiving immunosuppressive medications are at higher risk of serious infection. Sports activities should be avoided when myositis is active. Rhabdomyolysis during intensive exercise may cause renal injury in athletes with idiopathic myositis and other myopathies. Because of photosensitivity with juvenile dermatomyositis and systemic lupus erythematosis, sun protection is necessary during outdoor activities. With Raynaud phenomenon, exposure to the cold presents risk to hands and feet. (Tench et al., 2002; Carvalho et al., 2005; Hicks et al., 2002; Clarkson et al., 2006)

Explanation: Athlete needs individual assessment. In general, if illness status permits, all sports may be played; however, any sport or activity that entails overexertion, overheating, dehydration, or chilling should be avoided. Participation at high altitude, especially when not acclimatized, also poses risk of sickle cell crisis.

Explanation: Athletes with sickle cell trait generally do not have increased risk of sudden death or other medical problems during athletic participation under normal environmental conditions. However, when high exertional activity is performed under extreme conditions of heat and humidity or increased altitude, such catastrophic complications have occurred rarely. (Mercer & Densmore, 2005; Pretzlaff, 2002; Kark, 2000; Kerle & Nishimura, 1996; Bergeron et al., 2004) Athletes with sickle cell trait, like all athletes, should be progressively acclimatized to the environment and to the intensity and duration of activities and should be sufficiently hydrated to reduce the risk of exertional heat illness and/or rhabdomyolysis. (Bergeron et al., 2005) According to National Institutes of Health management guidelines, sickle cell trait is not a contraindication to participation in competitive athletics, and there is no requirement for screening before participation. (National Heart, Lung, and Blood Institute, 2002) More research is needed to assess fully potential risks and benefits of screening athletes for sickle cell trait.

Explanation: During contagious periods, participation in gymnastics or cheerleading with mats, martial arts, wrestling, or other collision, contact, or limited-contact sports is not allowed. (Mast & Goodman, 1997; Sevier, 1994; Centers for Disease Control and Prevention [CDC], 2003; CDC, "Community-associated MRSA information for clinicians", 2005.)

Explanation: If the spleen is acutely enlarged, then participation should be avoided because of risk of rupture. If the spleen is chronically enlarged, then individual assessment is needed before collision, contact, or limited-contact sports are played.

Explanation: Certain sports may require a protective cup. (Gomez, 2003)