Congratulations to Humza Baig, OMS-IV; Syed Rahman, OMS-IV; and Ahad Khatri, OMS-IV, second place winners of the 2026 Namey/Burnett Award. Sponsored by the ACOFP Foundation, with winners selected by the ACOFP Health & Wellness Committee, the Namey/Burnett Preventive Medicine Writing Award honors the memory of Joseph J. Namey, DO, FACOFP, and John H. Burnett, DO, FACOFP—dedicated advocates for osteopathic medicine—and recognizes the best preventive medicine blog posts submitted by osteopathic family medicine students and residents.

Introduction

As the academic sports season approaches, primary care providers often observe a notable increase in young athletes seeking preparticipation physical examinations (PPEs), highlighting the importance of these examinations in promoting safe athletic participation. The primary objective of these is to optimize the athlete's health and ensure safe play in sports. However, research indicates that up to 29% of adolescents experience sports-related injuries, even with this measure in place.1 This raises the critical question: what additional measures can be implemented to enhance injury prevention?

Osteopathic physicians, with their extensive training in the musculoskeletal system – averaging 122 hours of preclinical training – are uniquely positioned to apply their expertise in osteopathic principles and preventative care in this regard.2 This specialized knowledge provides significant opportunities to address and potentially reduce the prevalence of sports-related injuries in youth athletes.

This paper aims to explore the most common sports injuries, particularly sprains and strains,3 and highlight the opportunities for physicians to identify misalignments, assess joint laxity and muscle imbalances, and provide targeted education to young athletes. By addressing these factors, osteopathic physicians may reduce the risk of injury and improve athletic performance.

Background and Current Limitations

The American Academy of Pediatrics (AAP) emphasizes the importance of PPEs in identifying pre-existing medical conditions or risk factors that may compromise athletes’ ability to participate safely in sports.4,5 However, there is significant potential to enhance the musculoskeletal component of these evaluations. This aspect, which often lacks the time and depth required to detect somatic dysfunctions, represents an area where osteopathic physicians' expertise and knowledge in osteopathic manipulative medicine (OMM) could be invaluable. Integrating osteopathic diagnostic and treatment techniques into PPEs could enhance their role as a preventive tool, allowing for more effective identification of joint instability, misalignments, and muscle imbalances, thereby improving the overall care of young athletes.

Recommendations

As recommended by the AAP and the American Academy of Family Physicians (AAFP), the PPE includes assessments of cardiovascular, pulmonary, neurological, and musculoskeletal systems. Specifically, the musculoskeletal evaluation focuses on the spine, extremities, and weight-bearing joints to detect prior injuries or abnormalities, without diagnosing somatic dysfunction, and provides immediate treatment. This gap highlights the unique opportunity for osteopathic family physicians to deliver preventive health measures for athletes.6

Osteopathic physicians can incorporate their training in musculoskeletal modalities into PPEs to improve patient outcomes through several detailed approaches and recommendations. Firstly, they can provide a comprehensive structural examination. This involves taking a detailed history and conducting a physical exam, identifying pre-existing conditions such as joint instability, muscle imbalances, and flexibility issues that may predispose young athletes to injuries. The AAFP emphasizes the importance of these competencies in musculoskeletal and sports medicine during residency training.6

Secondly, with the information ascertained from the history and physical, osteopathic physicians can provide injury prevention counseling. This would involve teaching athletes proper techniques, emphasizing the importance of gradual acclimation to training intensity, and using protective equipment. These strategies can help prevent muscle strains and sprains, as “cold muscles” make the muscles stiffer and less elastic, decreasing susceptibility to injury.7

Thirdly, osteopathic physicians can utilize manipulative treatments, such as Muscle Energy, Counterstrain, Balanced Ligamentous Tension, and Myofascial Release, to address somatic dysfunctions during the physical examination. These techniques can improve circulation to the targeted areas and enhance biomechanics, leading to a overall risk of reduction injury.

Finally, there is the opportunity to collaborate with interdisciplinary teams. Working with athletic trainers, physical therapists, and nutritionists, osteopathic physicians can develop a comprehensive care plan tailored to the needs of athletes. Such collaboration ensures that all aspects of the individual's well-being, health, and athletic performance are addressed.8

Below are some examples of how these strategies can be integrated to significantly enhance the effectiveness of PPEs and contribute to better health modalities for athletes.

Practical Examples of Prevention Strategies

Achilles tendinopathy is an overuse injury commonly seen in athletes participating in sports that involve running and jumping. Repetitive microtrauma, overloading of the Achilles tendon, and inadequate rest are associated with a failed healing response characterized by degeneration.9 The main structure involved is the Achilles tendon; however, it is not uncommon for the gastrocnemius and soleus muscles to be involved. OMT can be beneficial in managing Achilles tendinopathy. Techniques such as Balanced Ligamentous Tension and Myofascial Release can enhance tissue flexibility, alleviate pain, and improve circulation to the affected area.10 The integrative approach of utilizing these techniques aims to address the biomechanical dysfunctions in the individual and improve the mechanics of the lower extremities, preventing further injury. By improving the flexibility and strength of the Achilles tendon and the associated structures, OMT can reduce the risk of tendinopathy and enhance athletic performance. Additionally, a structured home stretch and exercise program can be prescribed to prevent further development of tendinopathy.

Another example is plantar fasciitis, primarily caused by mechanical overload of the plantar fascia due to excessive tension and stress. This can occur due to factors such as flat feet, prolonged standing, and overuse, which is particularly relevant for younger athletes who may be in circumstances of lengthy training.11-13 The primary structure involved is the plantar fascia, a thick band of connective tissue from the calcaneus to the metatarsal heads. The windlass mechanism states how the plantar fascia wraps around the metatarsals to support the foot during weight-bearing activities.14 The Achilles tendon and gastrocnemius-soleus complex can also be implicated in plantar fasciitis.15 Techniques such as Myofascial Release of the foot, calcaneus joint mobilization, and soft tissue stretching of the plantar fascia are commonly used.16 In young athletes, this would improve the biomechanics of the foot and lower extremities, thereby relieving stress on the plantar fascia. Identifying issues such as tightness in the Achilles, pes planus, or excessive foot pronation during physical exams and examining range of motion, gait, and alignment benefits young athletes by improving overall musculoskeletal health and performance.17,18

Patellofemoral Pain Syndrome (PFPS) is a common musculoskeletal condition among athletes, most commonly associated with the overuse and imbalance of knee stabilizer muscles, particularly between the vastus lateralis and medialis. It leads to abnormal patellar tracking and symptoms such as joint effusions and crepitus.19 Conservative treatments have included NSAIDs and activity modifications. However, OMT provides a unique adjunct to these interventions, targeting the somatic dysfunctions underlying PFPS. Techniques, including post-isometric relaxation for the vastus medialis, may enhance treatment outcomes.20 These can be conducted in a physician’s office, with a follow-up prescription of exercises and stretches to strengthen the hip abductors, external rotators, and the vastus medialis. The dynamic utilization of these can help correct malalignments of the lower extremities, thereby improving patellar tracking and alleviating symptoms of PFPS.

Conclusion

Incorporating a holistic approach to address somatic dysfunctions, including OMT, stretching, and strengthening exercises, promotes lifelong behaviors associated with improved health outcomes. Additionally, educating patients and their families about common patterns of sports-related injuries and emphasizing the importance of proper nutrition and dietary modifications when necessary has demonstrated positive effects at the public health level. The osteopathic philosophy, emphasizing a multifaceted and individualized approach, offers a significant opportunity for the long-term prevention and resolution of sports-related injuries.

The musculoskeletal component of the PPE aligns closely with a standard OMM visit, which includes identifying somatic dysfunctions, joint abnormalities, and asymmetry of anatomical landmarks, as well as assessing motion restrictions and soft tissue abnormalities.21 Additionally, gait analysis, often overlooked in standard PPEs, is a crucial component of an OMM visit, as it helps identify developmental disorders and leg length discrepancies that could influence an athlete’s performance and injury risk.22 While the current PPE typically lasts 20 to 30 minutes and provides a basic assessment, incorporating a more detailed musculoskeletal examination with OMM techniques would enhance its utility as a preventive tool.

We propose extending the standard PPE to include a comprehensive musculoskeletal evaluation emphasizing OMM techniques, such as soft tissue therapy, Myofascial Release, and Muscle Energy. While this modification would extend the PPE duration to approximately one hour, it has the potential to offer immediate therapeutic benefits, improve detection of biomechanical dysfunctions, and better prepare young athletes for optimized training and performance. 23-24

References

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  7. Strains and Sprains (for Teens) - Nemours KidsHealth. kidshealth.org. https://kidshealth.org/en/teens/strains-sprains.html

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  10. Ross G, Macfarlane C, Vaughan B. Combined osteopathy and exercise management of Achilles tendinopathy in an athlete. The Journal of Sports Medicine and Physical Fitness. 2017;58(1-2). doi:https://doi.org/10.23736/s0022-4707.17.06817-7

  11. Goff JD, Crawford R. Diagnosis and treatment of plantar fasciitis. American Family Physician. 2011;84(6):676-682. https://pubmed.ncbi.nlm.nih.gov/21916393/

  12. Wearing SC, Smeathers JE, Urry SR, Hennig EM, Hills AP. The pathomechanics of plantar fasciitis. Sports Medicine (Auckland, NZ). 2006;36(7):585-611. doi:https://doi.org/10.2165/00007256-200636070-00004

  13. Rabadi D, Seo S, Wong B, Chung D, Rai V, Agrawal DK. Immunopathogenesis, early Detection, current therapies and prevention of plantar Fasciitis: A concise review. International Immunopharmacology. 2022;110:109023. doi:https://doi.org/10.1016/j.intimp.2022.109023

  14. Bolgla LA, Malone TR. Plantar fasciitis and the windlass mechanism: a biomechanical link to clinical practice. Journal of Athletic Training. 2004;39(1):77-82. https://pubmed.ncbi.nlm.nih.gov/16558682/

  15. Ryskalin L, Morucci G, Soldani P, Gesi M. Do the fasciae of the soleus have a role in plantar fasciitis? Clinical Anatomy. Published online August 4, 2023. doi:https://doi.org/10.1002/ca.24102

  16. Gabriel A, Konrad A, Roidl A, et al. Myofascial Treatment Techniques on the Plantar Surface Influence Functional Performance in the Dorsal Kinetic Chain. Journal of Sports Science and Medicine. Published online November 8, 2021:13-22. doi:https://doi.org/10.52082/jssm.2022.13

  17. Bolin DJ. The Application of Osteopathic Treatments to Pediatric Sports Injuries. Pediatric Clinics of North America. 2010;57(3):775-794. doi:https://doi.org/10.1016/j.pcl.2010.02.002

  18. Middleton JA, Kolodin EL. Plantar fasciitis-heel pain in athletes. Journal of athletic training. 1992;27(1):70-75. https://pubmed.ncbi.nlm.nih.gov/16558136/

  19. Biabanimoghadam M, Motealleh A, Cowan SM. Core muscle recruitment pattern during voluntary heel raises is different between patients with patellofemoral pain and healthy individuals. The Knee. 2016;23(3):382-386. doi:https://doi.org/10.1016/j.knee.2016.01.008

  20. Seffinger MA. Foundations of Osteopathic Medicine: Philosophy, Science, Clinical Applications, and Research, 4e. Lippincott Williams & Wilkins, a Wolters Kluwer business; 2018. Accessed October 6, 2024. https://osteopathicmedicine.lwwhealthlibrary.com/book.aspx?bookid=2582&sectionid=0

  21. Smith J, Laskowski ER. The Preparticipation Physical Examination: Mayo Clinic Experience With 2,739 Examinations. Mayo Clinic Proceedings. 1998;73(5):419-429. doi:https://doi.org/10.1016/s0025-6196(11)63723-3

  22. Balyakina ES, Hansen MM, Mason D. Development of Osteopathic Neuromusculoskeletal Medicine (ONMM) residency curriculum guidelines to meet Accreditation Council for Graduate Medical Education (ACGME) milestones. Journal of Osteopathic Medicine. 2022;122(4):175-185. doi:https://doi.org/10.1515/jom-2021-0122

  23. Cooper L, Harper R, Wham GS, et al. Appropriate Medical Care Standards for Organizations Sponsoring Athletic Activity for the Secondary School–Aged Athlete: A Summary Statement. Journal of Athletic Training. 2019;54(7):741-748. doi:https://doi.org/10.4085/1062-6050-544-18

  24. Beran MC, Awan H, Rowley D, Samora JB, Griesser MJ, Bishop JY. Assessment of Musculoskeletal Physical Examination Skills and Attitudes of Orthopaedic Residents. Journal of Bone and Joint Surgery. 2012;94(6):e36. doi:https://doi.org/10.2106/jbjs.k.00518

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