The sports eligibility exam: what it looks for, and what it misses in a teenage athlete

It requires five tests set out in the Italian ministerial decree of 18 February 1982: medical examination, full urinalysis, ECG at rest, ECG after exercise, and spirography. It is a cardiac screening programme, and on its own target it works — in the Veneto region the incidence of sudden cardiovascular death in screened athletes fell by 89% (Corrado et al., 2006; 55 deaths, 50 of them male, mean age 23.3 years). It is not a screening of adolescent athlete health: cycle, energy availability, iron and bone are not on the list.

Every year, before she can play, an athlete visits a clinic and leaves with a certificate. Italian law has required five tests since 1982 — medical examination, full urinalysis, ECG at rest and after exercise, spirography — and they were designed to catch one thing: the cardiac conditions that cause sudden death. On that target the Veneto data show an 89% drop in incidence. But none of the five covers the menstrual cycle, energy availability, iron or bone health: the things that, statistically, are far more likely to stop a 14-year-old. What the certificate covers, what it does not, and which questions are worth bringing into the room.

Every year, before she can take the field, an athlete goes to a clinic. They take her blood pressure, have her step up and down, attach the electrodes, and at the end she leaves with a piece of paper. That paper is the condition for playing, and in Italy it has existed for more than forty years.

That is good news: few countries have a mandatory, recurring health contact with every boy and girl who competes. The problem is not that the exam exists, and it is not that it does its job badly. The problem is that the exam does exactly the job it was designed for in 1982 — and that job is a single one.

Key points

  • Five tests are mandatory, set out in the ministerial decree of 18 February 1982: medical examination, full urinalysis, ECG at rest, ECG after exercise, spirography.
  • The same decree gives the doctor the power to request further tests "on reasoned clinical suspicion": the list is a minimum, not a ceiling.
  • On its own target the screening works: in the Veneto region the incidence of sudden cardiovascular death in screened athletes fell from 4.19 to 0.87 per 100,000 person-years between 1979 and 2004 (-89%), while in unscreened non-athletes it stayed flat (Corrado et al., 2006).
  • That result was measured in a population that was almost entirely male and adult: of the 55 deaths among athletes, 50 were male and the mean age was 23.3 years.
  • None of the five tests covers the menstrual cycle, energy availability, iron or bone health.
  • Wherever screening forms have been counted, the questions about periods are missing: across 287 forms from NCAA Division I universities, only 9% contained at least 9 of the 12 questions recommended for the Female Athlete Triad, and 44% contained 4 or fewer (Mencias et al., 2012; college athletes, predominantly adults).

What does Italian law require the eligibility exam to include?

Five tests, listed in a decree from 1982. The governing rule is the Italian Ministry of Health decree of 18 February 1982, "Rules for the health protection of competitive sports activity", published in the Official Gazette no. 63 of 5 March 1982. Anyone taking part in competitive sport must undergo, "beforehand and periodically", a check of specific fitness for the sport practised, and the required tests are:

Test What it looks at
Medical examination History-taking and general physical examination
Full urinalysis Kidney function, metabolic markers
ECG at rest The heart's electrical activity at baseline
ECG after exercise The heart's electrical response to load
Spirography Respiratory volumes and flows

Tests and intervals vary by discipline according to the tables annexed to the decree, and it is the national sports federation or recognised body that determines which athletes count as competitive.

One detail of the rule matters more than it looks, and it is worth stating up front because it carries the rest of this article: the examining doctor has the power to request further specialist and instrumental tests on reasoned clinical suspicion. The list of five is a mandatory minimum, not a maximum. Everything outside the list is not forbidden — it is simply not guaranteed, and depends on what that doctor, in those ten minutes, has the means and the reason to suspect.

Does the Italian screening programme work?

On the problem it was built for, the available data say yes. The reference study is a population analysis carried out in the Veneto region on people aged 12-35 between 1979 and 2004, comparing trends in sudden cardiovascular death in screened athletes and in unscreened non-athletes (Corrado et al., 2006).

Among athletes, incidence fell from 4.19 per 100,000 person-years in the pre-screening period (1979-1981) to 2.35 in the early screening phase (1982-1992) and 0.87 in the late phase (1993-2004): an 89% decline. In the non-athletic population, over the same span, incidence barely moved: 0.77, then 0.79, then 0.81. It is the comparison between the two curves — one falling, the other flat — that makes the result interesting.

Two limitations have to travel with the number, though, because without them it gets used to say more than it says.

The first is a matter of design: this is an observational study of trends over time, not an experiment. Observing that a curve falls after a programme is introduced is consistent with the programme working, but does not demonstrate it the way a randomised comparison would — and on an event this rare, nobody has ever been able to run one.

The second limitation bears directly on the readers of this site. Of the 55 deaths recorded among athletes across the whole period, 50 were male and 5 female, with a mean age of 23.3 years. The pillar of the Italian sports exam, in other words, was validated in a population made overwhelmingly of adult men. That does not make it useless for a 14-year-old — a heart is a heart — but it says something precise about which problem the system was designed to see, and who its designers had in mind.

What does the exam miss in a teenage athlete?

The three things most likely, statistically, to stop her. Go back to the table of five tests and try to find, inside it:

This is not a polemical list, it is a reading of the actual one. And the point is not that the decree should have included them — in 1982 RED-S had not yet been defined, and the literature on female athlete health was a fraction of what it is now. The point is that today, when a family walks out of the clinic holding a certificate, that piece of paper says something much narrower than it appears to say.

Because it is precisely the uncovered territory that is dense with things that actually happen. Low energy availability is the mechanism the International Olympic Committee consensus statement describes as affecting bone health, the endocrine system, metabolism and mental health (Mountjoy et al., 2023). Iron deficiency is one of the commonest conditions in adolescent girls who train, with measurable effects on fatigue. Stress fractures have bone health and energy availability as their principal determinants. None of those three pathways runs through an electrocardiogram.

Does the form ask about periods?

Wherever someone has gone and counted the questions, the answer is: far less than you would expect.

The first piece of evidence comes from athletes of exactly the age discussed here. In an analysis of the preparticipation evaluation forms of 207 Ohio high school athletes, the proportion with menstrual dysfunction detected by the questionnaire was 7%, with a mean age at menarche of 11.94 years and 11.51 menses per year. The authors do not present that 7% as good news: they compare it with much higher published estimates and conclude that the likeliest explanation lies in the limitations of the questionnaire, not in a genuinely low prevalence (Fischer and Young, 2014).

The second piece concerns older athletes, and should be labelled as such: across 287 forms collected from 257 NCAA Division I universities (74% of those invited), only 25 institutions (9%) included at least 9 of the 12 questions recommended by the Female Athlete Triad Coalition for primary screening, while 127 (44%) included 4 or fewer. The questions omitted from more than 40% of forms were the most uncomfortable and the most informative ones: losing weight to meet a sport's aesthetic requirements, using vomiting, diuretics or laxatives to lose weight, and the number of menses in the past 12 months (Mencias et al., 2012). In the same study, 100% of universities required a preparticipation evaluation for incoming athletes, but only 32% required one annually for returning athletes.

These two studies come from a different system to Italy's: in the United States preparticipation evaluation revolves around a completed form, whereas Italy has an in-person medical examination with mandatory instrumental tests. They are not transferable as prevalence estimates. But the mechanism they describe crosses both systems without difficulty: if the question is not in the protocol, the answer depends on who is sitting opposite you — and in a clinic with a full schedule, "depends on who is sitting opposite you" means, for some girls, that nobody will ask.

It is worth adding the piece this site documents elsewhere: even when the question does come, the silence already has a history. Only 11% of athletes discuss menstrual matters with the person who coaches them — 4% if that person is a man — and 88% learned about it on their own (Höök et al., 2022; mixed-age sample). Being asked in a clinic is not the same as being asked at the side of a pitch, but the difficulty of naming things travels with the girl, not with the room.

Why should a cycle matter to whoever signs a certificate?

Because it is one of the few pieces of information that summarise many things at once. A regular cycle is no guarantee of health, but a cycle that disappears in an athlete who trains is dense clinical information: it can accompany low energy availability, it is one of the three components of the Female Athlete Triad, and it is associated with reduced bone health in a window of life when bone mass is still being built.

The figures on how common this is come from mixed-age populations, and should be read that way. In the study of 1,086 Swedish and Norwegian athletes, 22% reported an episode of amenorrhoea, and roughly one in five had nobody in their sporting environment to discuss it with; only 3% had access to a gynaecologist through their sport (Höök et al., 2022). In the systematic review of 60 studies and 6,380 athletes not using hormonal contraception, dysmenorrhoea was the most prevalent menstrual disorder at 32.3%, with a range across studies from 7.8% to 85.6% (Taim et al., 2023).

None of this asks a sports doctor to become a gynaecologist. It asks for something more modest: that the question gets asked, and that when the answer is "I haven't had one in eight months", that sentence ends up somewhere rather than staying in the room.

What should you bring to the eligibility exam?

Three pieces of information prepared in advance, because time in the clinic is short and memory is unreliable. These are not tests to demand or diagnoses to propose: they are the data that make it possible for the doctor to exercise the power the decree gives them.

1. The cycle history, in two lines. Whether periods have started and when; how many in the past twelve months; whether any months were skipped and how many. This is exactly the item most often omitted from American forms (Mencias et al., 2012) and not a mandatory field in the Italian protocol. You do not need a clinical diary: you need a number.

2. The real training load. Hours per week, across how many sports, with how many consecutive weeks without a break. It is the denominator of any reasoning about energy availability, and no test on the list measures it. On how that number weighs on a growing body, this site has a page on early specialisation.

3. The signals that repeat. Fatigue out of proportion to the load, injuries that keep returning to the same site, performance dropping without explanation, previous fractures. These are the three or four facts that, lined up, can constitute the "reasoned clinical suspicion" that opens the door to one more test.

A note on tone, because it matters: none of these three should be brought in as a request for a service. They should be brought in as information. The difference between "I'd like you to test her ferritin" and "she has been tired for months and her periods are heavy" is that the second sentence puts the doctor in the position of deciding, which is their job.

What can a club do?

Three concrete things, none of which requires clinical expertise or money.

Remind athletes about the appointment, don't just file the certificate. Many clubs treat the certificate as an administrative task: it arrives, it gets filed, the date gets checked. But that piece of paper is also the only recurring health appointment many girls have in those years. A club can add one line to the reminder: "before you go, if there's something you've been noticing for months, write it on a note and take it with you".

Don't ask what is in it. The certificate a club receives says eligible or not eligible; the clinical information stays between the athlete, her family and the doctor. Asking for details is both wrong and counterproductive: willingness to name symptoms grows where nobody claims a right to know them. It is the same logic by which team signals should be read in aggregate rather than individually.

Know that the certificate does not cover what you see in the gym. An athlete with valid clearance can be struggling, and the person who coaches her sees her three times a week while the doctor sees her once a year. An athlete skipping meals, getting injured constantly, permanently tired, or whose words about her own body shift in tone, is saying something no electrocardiogram will record. The right response is not a diagnosis: it is pointing her towards someone who can look at the whole picture.

What BAB does here

BAB does not replace any clinical pathway and does not produce clinical assessments. It does something simpler and complementary to the certificate: it gives athletes a way to record how they are doing over time — energy, sleep, pain, cycle — and gives staff an aggregated, anonymous reading of team signals, without any girl having to expose herself in front of the group.

The value, next to the exam, is in the frequency. A certificate photographs one day; a season is made of two hundred. When the annual appointment comes round, walking in with "over the last three months her period has been skipped twice and the fatigue increased after the March tournament" is very different from trying to reconstruct it from memory in ten minutes.

When to see a professional

Some situations do not wait for a certificate to expire. A cycle absent for three months or more in a girl who previously had regular periods, periods that have never appeared by age fifteen, persistent fatigue out of proportion to the training load, localised bone pain that worsens with activity, or a relationship with food that becomes a source of anxiety: all are reasons to speak to a paediatrician, family doctor or sports physician without waiting, regardless of whether clearance has been granted.

The certificate is not a deadline beyond which nothing can happen. It is a screening programme, with a declared target and precise boundaries — and knowing those boundaries is the best way to use it well.

Sources

This article is for information only and does not constitute medical advice, a clinical assessment, or any statement on fitness or unfitness to practise sport, which is solely the responsibility of the competent physician. A cycle absent for three months or more, periods that have never appeared by age fifteen, persistent fatigue out of proportion to the training load, localised bone pain that worsens with activity, or a relationship with food that becomes a source of anxiety should be raised with a paediatrician, family doctor or sports physician, without waiting for the certificate to expire.

What exactly does the Italian competitive sports eligibility exam involve?

The tests are set out in the Italian Ministry of Health decree of 18 February 1982, and there are five: medical examination, full urinalysis, ECG at rest, ECG after exercise, and spirography — with tests and intervals varying by sport according to the tables annexed to the decree. The same decree gives the examining doctor the power to request further specialist and instrumental tests on reasoned clinical suspicion: the list is a mandatory minimum, not a ceiling.

Why does the Italian sports exam include an ECG?

Because Italian screening was built to catch the cardiac conditions that can cause sudden death in a young person who trains, and it has been required by law since 1982. The most-cited outcome data come from the Veneto region: between 1979 and 2004 the incidence of sudden cardiovascular death in screened athletes fell from 4.19 to 0.87 per 100,000 person-years, an 89% decline, while in the unscreened non-athletic population it stayed flat (Corrado et al., 2006). It should be read for what it is: an observational study of trends over time, not an experiment — and of the 55 deaths recorded among athletes, 50 were male and the mean age was 23.3 years.

Does the eligibility exam check an athlete's menstrual cycle?

Not among the mandatory tests. The five tests required by the 1982 decree are cardiac, respiratory and urinary: none of them concerns menstrual history. If anything is asked, it happens inside the general history-taking, and so depends on the individual doctor's time and awareness. It is not forbidden to ask — it is simply not prescribed, and what is not prescribed is not guaranteed.

Does an eligibility certificate mean the athlete is healthy?

It means no contraindications to practising that sport competitively emerged from the tests required. That is a narrower statement than 'she is healthy'. An athlete with low iron, with a cycle that has been absent for months, or in low energy availability can be cleared without any of those three problems being detected, because no test on the list looks for them.

Do screening forms actually ask teenage athletes about their periods?

Far less than you would expect, and the data show it wherever someone has counted the questions. In an analysis of the forms of 207 Ohio high school athletes, the rate of menstrual dysfunction picked up by the questionnaire was 7%: the authors themselves point to the limitations of the form, rather than a genuinely low prevalence, as the likeliest explanation (Fischer and Young, 2014). Across NCAA Division I universities, of 287 forms collected only 9% contained at least 9 of the 12 questions recommended for Female Athlete Triad screening, while 44% contained 4 or fewer; among the items omitted from more than 40% of forms was the number of menses in the past 12 months (Mencias et al., 2012 — college athletes, so predominantly adults).

What can a parent ask at the sports eligibility exam?

Three simple things that no test on the list covers and that move the conversation where it needs to go: whether periods have started and whether they have been regular since; whether food intake matches the training load; and whether there is any reason, in this girl's history, to look at iron. These are questions a doctor may choose to follow up — the 1982 decree explicitly allows further tests on reasoned clinical suspicion — but somebody almost always has to raise them first.

How long does the eligibility certificate last, and at what age is it needed?

The interval is set out in the tables annexed to the decree of 18 February 1982 and varies by sport; the requirement applies to anyone doing competitive sport, a status defined by the national sports federations or recognised bodies. For athletes aged 13-17 this means, in practice, a recurring medical appointment — often the only regular health contact a girl has in those years. Which is another reason to arrive with something to ask.

Should a cycle that disappears be reported to the sports doctor?

Yes — not because it is an emergency, but because it is a signal no test in the exam would go looking for. An absent cycle in an athlete who trains can accompany low energy availability, RED-S, which the International Olympic Committee consensus statement describes as affecting bone, the endocrine system, metabolism and mental health (Mountjoy et al., 2023). In the study of 1,086 Swedish and Norwegian athletes, 22% reported an episode of amenorrhoea and roughly one in five had nobody in their sporting environment to discuss it with (Höök et al., 2022; mixed-age sample, adults and adolescents together). A cycle that disappears is not a sign of good training: it is clinical information, and it belongs with a healthcare professional.

Does the eligibility exam replace the paediatrician or family doctor?

No, and confusing the two is the most expensive misunderstanding here. The eligibility exam answers a narrow administrative question — can this person practise this sport competitively? — using the tests the rules require. The overall health of an adolescent who is growing, training and menstruating is a different conversation, on a different timescale and with different people. The certificate is not a report card on health status: it is the outcome of a screening programme with a declared target.

Why is iron not on the list of mandatory tests?

Because the 1982 battery was built around acute cardiovascular risk, not around the factors that limit a teenage athlete's health and performance across a season. Full urinalysis is there; a blood count and ferritin are not. This is not an oversight to be corrected here: it follows from how the aim of the screening was defined more than forty years ago. Anyone with reason to suspect a deficiency — fatigue out of proportion to the load, heavy periods, a diet without meat — needs to raise it, because the list alone will not get there.