S2k-Guideline – Sports Pre-Participation Evaluation of the German Society of Sports Medicine and Prevention

The purpose of this derivative version is to highlight and disseminate the core recommendations to clinicians, sports practitioners, and policy makers in the German-speaking health and sports sector.The benefits of physical activity are undisputed. However, adverse events can occur in rare cases, particularly during high-intensity or prolonged exercise.
During physical activity, at-risk patients can experience major cardiac events, whereas adverse events affecting the musculoskeletal system are more common but less severe. A sports pre-participation evaluation (PPE) is designed to detect at-risk individuals and prevent potentially fatal events in apparently healthy adults.
Therefore, a new guideline for conducting PPEs was developed through a consensus process involving 16 medical societies and sports associations based on previously published guidelines and consensus papers. Sports medicine physicians and potential participants were surveyed to assess the content, feasibility, and acceptability of the recommendations.
Based on 20 recommendations developed and agreed upon by these entities, the PPE includes taking individuals’ personal, family, and sports histories, as well as a physical examination. The need for additional examinations (e.g., laboratory parameters, echocardiography, or stress tests) is determined based on the findings. The effect of implementing this guideline should be examined in future research.

Key Words: Health, Recommendations, Pre-Participation Examination, Diagnostics, Screening

This article is based on the original publication in Sports Medicine: Joisten C, Hirschmüller A,et al. Sports Preparticipation Evaluation for Healthy Adults: A Consensus-Based German Guideline. Sports Med (2025). doi.org/10.1007/s40279-025-02230-5 (9).
The health benefits of physical activity for all ages and genders are undisputed including the prevention and treatment of chronic diseases (3, 13). However, people with pre-existing conditions or undiagnosed illnesses, especially those taking part in unfamiliar, high-intensity, and/or prolonged physical activities, may be at risk for health problems, such as sports injuries and, less commonly, cardiac events (5, 12,14). Therefore, a sports pre-participation evaluation (PPE) is recommended before starting or resuming physical activity. The goal is to identify individuals at risk and maximize their safety during exercise. Additionally, a PPE can provide the basis for training-related advices according to the FITT-VP principle (frequency, intensity, time, type, and scope of training, as well as progression), or it can be used to assess cardiorespiratory and muscular fitness in order to evaluate performance or health status (6, 10).

Currently, few guidelines exist for recreational athletes, beginners, and those returning to exercise. To address this gap, the German Society for Sports Medicine and Prevention (Deutsche Gesellschaft für Sportmedizin und Prävention, DGSP) developed a consensus-based guideline (7, 9). The guideline is intended for healthy adults both disabled and non-disabled, who exercise or wish to begin (or resume) exercising. This includes individuals who have recovered from illnesses such as cancer and/or joint injuries. Considering the relevant recommendations, the PPE can also be used to advise individuals with chronic conditions, such as type 1 diabetes or rheumatoid arthritis. However, these guidelines are not intended for competitive athletes or children/adolescents.
The rationale for developing the guideline was therefore twofold: First, to improve the safety when participating in sports by providing physicians with a structured evaluation process to identify individuals at an increased risk of adverse events exercise-relates, particularly cardiovascular incidents. Secondly, to ensure feasibility and acceptance, the focus was on a pragmatic, resource-sensitive and consensus-based approach that can be applied in primary care and sports medicine practices (9).

The recommendations are based on a systematic review of 35 existing guidelines and consensus statements comprising 305 recommendations. Of these, only 12.8% were directly supported by primary study evidence (55 studies, mostly of levels 3–4), with the majority being expert-based. This evidence gap highlights the need for a formal, transparent consensus process involving a wide range of medical specialties. The process was contributed to by German medical societies and sports associations, representing specialties such as cardiology, internal medicine, orthopaedics, pulmonology, general practice and sports medicine. Additionally, feedback from two large online surveys of physicians and potential participants informed the feasibility and acceptability of the recommendations, ensuring that the guideline reflects expert knowledge and user perspectives (7). All recommendations were developed using the structured AWMF S2k classification and formal consensus procedures, ensuring strong or moderate agreement among the participating societies (14). This inclusive approach is particularly relevant given the ongoing debate on the cost-effectiveness and clinical utility of PPEs for adults. The resulting guideline is therefore a unique, interdisciplinary and practical contribution to preventive sports medicine.
By integrating evidence, expert consensus and stakeholder perspectives, this guideline addresses a critical gap in preventive care. It provides physicians with a clear, practical framework for PPEs in apparently healthy adults, aiming to reduce exercise-related risks and support long-term engagement in physical activity, which is a cornerstone of health promotion.

For this publication, we have summarized and abridged the overall guideline (9), the guideline report and publications derived from it (7,9,14).

These guidelines were developed using the methodology based on the AWMF guidelines (8, 14). A detailed description can be found in the guideline report (https://register.awmf.org/de/leitlinien/detail/066-002). The participating professional societies are listed in Box 1. The following aspects were considered when assigning recommendation grades: clinical expertise of the guideline group, quality of identified evidence, benefit-risk assessment, cost-benefit assessment, and views of affected citizens (i.e., study participants) and sports physicians, as collected through surveys. The assessment of the strength or degree of consensus is summarized in Table 1. The extensive rationale behind the strength of a recommendation can be found in the background texts of the publications (7, 9, 14), and in the full version at register.awmf.org/de/leitlinien/detail/066-002 . On pages 207-210 of this Short Communication, the recommendations of the guideline are presented in tabular form.

The benefits of regular physical activity far outweigh the risks (2,4, 15). However, participating in sports is associated with an increased short-term risk of injuries and cardiovascular complications. Nevertheless, fatal events, such as sudden cardiac death or acute myocardial infarction, are rare, but possible (2, 12). Therefore, a preparticipation examination (PPE) aims to identify individuals at risk and prevent serious events during or after exercise. While existing guidelines primarily focus on examining (elite) athletes, this consensus-based guideline is designed to assess healthy adults who wish to (re)start intense exercise or training. However, there is currently insufficient robust or specific evidence on the positive effects of such examinations on patient-relevant outcomes or their optimal sensitivity/specificity, this guideline attempts to reconcile expert knowledge, feasibility in medical practice, and available evidence.
Additionally, the content of PPEs should inform exercise counseling (e.g., FITT-VP) to promote meaningful physical activity. Physical fitness is also an important factor in assessing health status (10, 11). In addition to general exercise counseling, preventive advice on avoiding stress-related damage and injuries can be given. This approach aims to enable safe and inclusive access, rather than creating additional barriers to participation in sports.
The challenge in introducing PPEs to a broader population lies in the requirement of the need for knowledge and skills in various medical disciplines. For instance, the musculoskeletal and cardiovascular systems of the individual must be examined. Although the EU includes sports medicine specialization in its physician guidelines, this qualification is generally unavailable. In Germany, sports medicine knowledge is primarily taught through a course system and, to a lesser extent, at sports medicine institutes.

Strengths and Limitations
A key strength of this guideline is that its recommendations are based on a summary of numerous professional societies‘ and associations‘ guidelines and consensus papers. Surveying healthcare professionals and potential participants/patients provided a user perspective and enriched the discussions. 
A major limitation of this guideline was the scarcity of available data. The available literature primarily refers to elite-level athletes and is based on expert opinions, recommendations not controlled trials. Additionally, there are no intervention studies supporting injury risk screening (1). Currently, no cost-benefit analyses or number needed to prevent (NNP)  have been conducted for this PPE. Such evidence is only available in the context of competitive sports. Therefore, population-based studies are urgently needed to demonstrate the benefits of PPE in identifying and registries at-risk individuals and in promoting and advising physical activity in the general population.

This consensus-based guideline has been developed to provide a solid foundation for evidence-based PPE. The recommendations are intended to help physicians identify individuals at risk of injury or fatal events before they participate in intense physical activity. If abnormalities identified, the relevant specialists (e.g., orthopedists and sports cardiologists) should be consulted. These examinations can also document a person’s health status and facilitate counseling results of these according to the FITT principle. Future studies should investigate the feasibility of this guideline in different regions, including those with limited resources, and its effectiveness in preventing harmful or potentially fatal events.

Acknowledgement
We would like to thank the DGSP for the opportunity to develop this guideline. We would also like to thank Dr Jessica Breuing, Sandra Jaax, Dr Nadja Koensgen (IFOM) and Dr Monika Nothacker (AWMF) for their additional support and Francesca Greco for her critical review of the language. Our special thanks go to the participants in the surveys.

Contributors 
CJ conceived the idea for the consensus statement. CJ, AH, AN and BW formed the consensus groups. CJ, BW, AN, AH, AC, CR, KK led the working groups. KG and AW ensured compliance with the predefined guideline methodology. All authors were included in the development of the recommendations. They contributed to reviewing and giving feedback on each iteration of the consensus draft. All authors read and approved the final version of the manuscript.

Funding 
The authors have not received a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. The guideline-development process was not supported financially; all members of the working groups were volunteers. The IFOM received funding from the lead professional organisation (DGSP) for the preparation of the synopsis and the implementation of the surveys, but there was no further financial support. 

Data Availability Statement
The data presented in this study are available on reasonable 
request from the corresponding author.

Competing Interests
Information on the management of potential conflicts of interest are listed in the supplementary material (S1). Below, only relevant competing interests are listed: CJ, BW, AN, TS are members of the DGSP executive board. CK is the head of the DGSP office. AH, MC, TK, KR, AN, FM, HS, CR, FM, KK, PP, AC are members of the DGSP scientific board/experts. KR is owner of a software company for metabolic endurance diagnostics (Ergonizer Software e.K., Germany). TS received research funding from an ergometer manufacturer (Ergoline GmbH, Germany).
All other authors declare that they have no competing interests.

Patient Consent for Publication
Not applicable.

Ethics Approval 
Not applicable.

Abbreviations
ACSM: American College of Sports Medicine
AWMF: Association of Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften)
Arriba: Define the task jointly, subjective risk, objective risk, information about prevention options, assessing the options, agreeing on how to proceed (Aufgabe gemeinsam definieren, Risiko subjektiv, Risiko objektiv, Information über Präventionsmöglichkeiten, Bewertung der Möglichkeiten, Absprache über weiteres Vorgehen)
COPD: Chronic obstructive pulmonary disease
CPET: Cardiopulmonary exercise testing 
DEGAM: German Society for General Practice and Family Medicine (Deutsche Gesellschaft für Allgemeinmedizin und Familienmedizin)
DGSP: German Society of Sports Medicine and Prevention (Deutsche Gesellschaft für Sportmedizin und Prävention)
ECG: Electrocardiogram 
IFOM: Institute for Research in Operative Medicine 
MET: Metabolic equivalent
PAD: Peripheral artery disease
PPE: Sports pre-participation evaluation
RED-S: Relative energy deficit in sport
TTE: Transthoracic echocardiography

A new guideline for sports pre-participation evaluation (PPE) was developed by 16 medical societies awnd sports associations to identify at-risk individuals and prevent severe events during physical activity.
The guideline is based on 20 recommendations covering personal, family, and sports history, physical examination, and – if indicated – further diagnostics such as lab tests, echocardiography, or exercise testing.
The aim is to enhance the safety of physically active individuals, with future studies needed to evaluate the guideline’s effectiveness.

Recommendations 1-5:

Recommendations 6-11:

Recommendations 12-17:

Recommendations 18-20: