FIFA PRE-COMPETITION MEDICAL ASSESSMENT

(PCMA)

PLAYER:

SURNAME: ____________________ FIRST NAME:__________________

DATE OF BIRTH: __________________________ (DAY / MONTH / YEAR)

NATIONAL TEAM: __________________________________________

LOCAL CLUB: _____________________________________________

COUNTRY OF CLUB: ________________________________________

1. COMPETITION HISTORY
Position on the field goalkeeper defender
midfielder striker

Dominant leg left right both

Number of matches in the last 12 months ______________

2. MEDICAL HISTORY

2.1 PRESENT AND PAST COMPLAINTS

yes, within yes, prior to
General no the last 4 weeks the last 4 weeks
Flu-like symptoms
Infections (esp. viral)
Rheumatic fever
Heat illness
Concussion
Allergies to food, insects
Allergies to drugs
within the last 4 weeks prior to last 4 weeks
Heart and lung no at rest……during/after at rest…during/after
exercise exercise
Chest pain or tightness
Shortness of breath
Asthma
Cough
Bronchitis
Palpitations / Arrhythmias
Other heart problems
Dizziness
Syncope
yes, within yes, prior to
no the last 4 weeks the last 4 weeks
Hypertension
Heart murmur
Abnormal lipid profile
Seizures, epilepsy
Advised to give up sport
More quickly tired than
team mates
Diarrhoea illness

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Musculoskeletal system

Severe injury leading to more than four weeks of limited participation or absence from
play/training:
right –left latest occurrence
no groin strain when?_______ (year)
strain of m. quadriceps femoris when?_______ (year)
strain of hamstring when?_______ (year)
ligament injury of the knee when?_______ (year)
ligament injury of the ankle when?_______ (year)
others, please specify:______________ when?_______ (year)
For others please provide diagnosis:___________________________________

Operations of the musculoskeletal system:

right –left latest operation
no hip joint when?_______ (year)
groin (due to pubalgia) when?_______ (year)
knee ligaments when?_______ (year)
knee meniscus or cartilage when?_______ (year)
Achilles tendon when?_______ (year)
ankle joint when?_______ (year)
other operations when?_______ (year)
For others please provide
diagnosis:___________________________________

Current complaints, aches or pain:

no yes, please specify body parts
right -left
head / face shoulder hip
cervical spine upper arm groin
thoracic spine elbow thigh
lumbar spine forearm knee
sternum / ribs wrist lower leg
abdomen hand Achilles tendon
pelvis / sacrum fingers ankle
foot, toe

Current diagnosis and treatment:

right left
no pubalgia rest physiotherapy surgery
hamstring strain rest physiotherapy surgery
quadriceps strain rest physiotherapy surgery
knee sprain rest physiotherapy surgery
meniscus lesion rest physiotherapy surgery
tendinosis of Achilles tendon rest physiotherapy surgery
ankle sprain rest physiotherapy surgery
concussion rest physiotherapy surgery
low back pain rest physiotherapy surgery
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2.2 FAMILY HISTORY (MALE RELATIVES < 55 YEARS, FEMALE RELATIVES < 65 YEARS)
no father mother sibling other
Sudden cardiac death
Sudden infant death
Coronary heart disease
Cardiomyopathy
Hypertension
Recurrent syncope
Arrhythmias
Heart transplantation
Heart surgery
Pacemaker/Defibrillator
Marfan syndrome
Unexplained drowning
Unexplained car accident
Stroke
Diabetes
Cancer
Others (arthritis etc.)

2.3 ROUTINE MEDICATION WITHIN LAST 12 MONTHS

no yes
Non-steroidal anti inflammatory drugs
Asthma medication
Antihypertensive drugs
Lipid lowering drugs
Antidiabetic drugs
Psychotropic drugs
Other ____________________________

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3. GENERAL PHYSICAL EXAMINATION
Height ______ cm/______ inch Weight: ______kg/______ lbs

Thyroid gland normal abnormal

Lymph nodes/spleen normal abnormal

Lungs
Percussion normal abnormal

Breath sounds normal abnormal

Abdomen
Palpation normal abnormal

Marfan Criteria
no yes, please specify:
chest deformities
long arms and legs
flat footedness
scoliosis
lens dislocation
other: _______________________

4. CARDIOVASCULAR SYSTEM

Rhythm normal arrhythmic

Heart sounds normal abnormal, please specify:

split
paradoxically split
3rd heart sound
4th heart sound

Heart murmurs no yes, please specify:

systolic - intensity: ____/6
diastolic - intensity: ____/6
clicks
changes during Valsalva manoeuvre
changes when abruptly stands up

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Peripheral oedema no yes

Jugular veins (45° position) normal abnormal

Hepato-jugular reflux no yes

Blood vessels
Peripheral pulses palpable not palpable

Delay in femoral pulses no yes

Vascular bruits no yes

Varicose veins no yes

Heart rate after 5 Minutes rest

______ /min

Blood Pressure in Supine Position after 5 minutes rest

Right arm ___ / ___ mmHg

Left arm ___ / ___ mmHg

Ankle ___ / ___ mmHg

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4.1 12-LEAD RESTING ECG* IN SUPINE POSITION AFTER 5 MINUTES REST
* Please attach copy

Heart rate ______ /min

Rhythm/Conduction normal abnormal, please specify:

premature ventricular beats
premature supraventricular beats
supraventricular tachycardia
ventricular arrhythmia
atrial flutter/fibrillation
delta wave
atrio-ventricular block, please specify:
first degree
second degree type I
second degree type II
third degree

Time indices PQ ______ ms

QRS ______ ms broader in V1, V2
QTc ______ ms

Atrial enlargement no yes, left (negative portion of the P wave in lead

V1≥0.1mV in depth and ≥0.04 s in duration)
yes, right (peaked P wave in leads II and III or
V1≥0.25mV in amplitude)

Depolarisation / QRS complex

Axis normal abnormal (≥+120° or -30° to -90°)

Voltage normal abnormal

LV hypertrophy no yes

Q Waves normal abnormal (>0.04 s in duration or >25% of height

of ensuing R wave or QS pattern in two or more
leads)

Bundle Branch Block no yes, please specify:

complete (>0.12 s) left
complete (>0.12 s) right
incomplete left anterior
incomplete left posterior
incomplete right

R wave normal pathologic R or R’ wave in lead V1

(≥ 0.5mV in amplitude + R/S ratio ≥1)
others

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Repolarisation (ST-segment, T waves, QT-interval)

normal abnormal, please specify:

Lead
I II III aVR aVL AVF V1 V2 V3 V4 V5 V6
ST-depression
ST-elevation
T-wave flattening
T-wave inversion

Summarising assessment of ECG normal abnormal

4.2 ECHOCARDIOGRAPHY (normal values of general population)

* Please provide CD-rom/DVD with loops

Body surface area (BSA):______ m2

Left ventricle (LV)

End-diastolic diameter ______ cm

(normal values: ♀ <3.2 cm/m², ♂ <3.1cm/m²)

End-systolic diameter ______ cm

End-diastolic interventricular septum thickness ______ cm

(normal values: ♀ <0.9 cm/m², ♂ <1.0cm/m²)

Diastolic posterior wall thickness ______ cm

(normal values: ♀ <0.9 cm/m², ♂ <1.0cm/m²)

LV Diastolic volume ______ ml

(normal values: ♀, ♂ <75 ml/m²)

LV Systolic volume ______ ml

(normal values: ♀, ♂ <30 ml/m²)

LVMMI (LV mass/BSA; linear method) ______ g/m²

(normal values: ♀ <95 g/m²), ♂ <115 g/m²)

Systolic function
Mitral anterior movement ______ mm

Fractional shortening (endocardial) ______ %

(normal values: ♀ >27 %, ♂ > 25 %)

Ejection fraction (Simpson biplane or area length method) ______ %

(normal value: ≥ 55%)

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Regional wall motion normal abnormal

Diastolic function E Wave ______ cm/s

A Wave ______ cm/s

(E/A ratio) ______

Deceleration time ______ ms

E’ (Tissue Doppler) septal ______ cm/s

lateral wall ______ cm/s

E/E’ ______

Left atrium

Diameter (M-mode, parasternal long axis) ______ cm

Area (4-chamber view) ______ cm²

(normal value: <20 cm²)

Volume (in Simpson or area length method) ______ ml/m²

(normal values: ♀, ♂ < 28ml/m²)

Right atrium/Inferior Vena cava

Area (4-chamber view) ______ cm²

(normal: <20 cm²)

IVC diameter ______ cm

Respiratory variability of the IVC >50% <50%

Right ventricle

Mid-RV diameter (4-chamber view, RVD 2) ______ cm (normal value: < 3.3 cm)

Base-to-apex length (4-chamber view, RVD 3) ______ cm (normal value: <7.9 cm)

Fac (fractional area change) ______ % (normal value: > 32%)

TAM (tricuspidal anterior motion) ______ mm

Systolic RV/RA gradient ______ mmHg

Regional wall motion normal abnormal

Local aneurysm no yes

Hypertrophy no yes

Free wall thickness _____ cm (normal: < 0.5 cm)

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Cardiac valves

Aortic valve normal abnormal

Mitral valve normal abnormal
Tricuspid valve normal abnormal
Pulmonal valve normal abnormal

Specify abnormalities: ____________________________________________

Aortic root diameter (AoD, Sinus Valsalva) ______ cm

Aorta ascendens ______ cm

Summarising assessment of echocardiography normal abnormal

5. BLOOD RESULTS (FASTING)

Haemoglobin ______ mg/dL

Haematocrit ______ %
Erythrocytes ______ mg/dL
Thrombocytes ______ mg/dL
Leukocytes ______ mg/dL
Sodium ______ mmol/L
Potassium ______ mmol/L
Creatinine ______ µmol/l
Cholesterol (total) ______ mmol/L
LDL Cholesterol ______ mmol/L
HDL Cholesterol ______ mmol/L
Triglycerides ______ mmol/l
Glucose ______ mmol/l
C-reactive Protein ______ mg/l

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6. MUSCULOSKELETAL SYSTEM
6.1 SPINAL COLUMN AND PELVIC LEVEL

Spine form normal flat

hyperkyphosis
hyperlordosis
scoliosis

Pelvic level even _____cm lower right left

Sacroiliac joint normal abnormal

Cervical rotation
right ______° painful no yes
left ______° painful no yes

Spinal flexion
Distance fingertips to floor _____cm

6.2 EXAMINATION OF HIP, GROIN AND THIGH

Flexibility of the hip

Flexion (passive)
right normal limited ______° painful no yes
left normal limited ______° painful no yes
Extension (passive)
right normal limited ______° painful no yes
left normal limited ______° painful no yes

Inward rotation (in 90° flexion)

right ______° painful no yes
left ______° painful no yes

Outward rotation (in 90° flexion)

right ______° painful no yes
left ______° painful no yes

Abduction
right ______° painful no yes
left ______° painful no yes

Tenderness on groin palpation

right no pubis inguinal canal
left no pubis inguinal canal

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Hernia
right no yes, please specify________________________________
left no yes, please specify________________________________

Muscles
Adductors
right normal shortened painful: no yes
left normal shortened painful: no yes
Hamstrings
right normal shortened painful: no yes
left normal shortened painful: no yes
Iliopsoas
right normal shortened painful: no yes
left normal shortened painful: no yes
Rectus femoris
right normal shortened painful: no yes
left normal shortened painful: no yes
Tensor fascia latae muscle (iliotibial band)
right normal shortened painful: no yes
left normal shortened painful: no yes

6.3 EXAMINATION OF KNEE

Knee joint axis
right normal genu varum genu valgum
left normal genu varum genu valgum

Flexion (passive)
right normal limited ______° painful no yes
left normal limited ______° painful no yes

Extension (passive)
right 0° limited ______° painful no yes
hyper-extension ______°
left 0° limited ______° painful no yes
hyper-extension ______°

Lachman test
right normal + ++ +++
left normal + ++ +++

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Anterior drawer sign (knee joint in 90° flexion)
right normal + ++ +++
left normal + ++ +++

Posterior drawer sign (knee joint in 90° flexion)

right normal + ++ +++
left normal + ++ +++

Valgus stress, in extension

right normal + ++ +++
left normal + ++ +++

Valgus stress, in 30° flexion

right normal + ++ +++
left normal + ++ +++

Varus stress, in extension

right normal + ++ +++
left normal + ++ +++

Varus stress, in 30° flexion

right normal + ++ +++
left normal + ++ +++

6.4 EXAMINATION OF LOWER LEG, ANKLE AND FOOT

Tenderness of Achilles tendon

right no yes
left no yes

Anterior drawer sign

right normal + ++ +++
left normal + ++ +++

Dorsi flexion
right ______° painful no yes
left ______° painful no yes

Plantar flexion
right ______° painful no yes
left ______° painful no yes

Total supination
right normal decreased increased
left normal decreased increased

Total pronation
right normal decreased increased
left normal decreased increased
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Metatarsophalangeal joint
right normal pathological
left normal pathological

7. SUMMARISING ASSESSMENT
Medical history
Normal
Eligible for football, follow-up required,
please specify:__________________
Play not recommended
please specify: ______________________________________

Clinical examination
Normal
Eligible for football, follow-up required,
please specify:__________________
Play not recommended
please specify: ______________________________________

Orthopaedic examination
Normal
Eligible for football, follow-up required,
please specify:__________________
Play not recommended
please specify: ______________________________________

12-lead resting ECG

Normal
Eligible for football, follow-up required,
please specify:__________________
Play not recommended
please specify: ______________________________________

Echocardiography
Normal
Eligible for football, follow-up required,
please specify:__________________
Play not recommended
please specify: ______________________________________

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 Other findings
Normal
Eligible for football, follow-up required,
please specify:__________________
Play not recommended
please specify: ______________________________________

ELIGIBILITY FOR COMPETITIVE FOOTBALL yes no

8. EXAMINING PHYSICIAN AND INSTITUTION

Name of the examining physician: ___________________________________________________

Address: ________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Phone No.: ______________________________ Fax No: _________________________________

Email ___________________________________________________________________________

Date:_______________________ Signature: ___________________________________________

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