The Special Olympics is a program that allows physically and mentally challenged persons of all levels of ability to take part in organized athletic events.¹ The First International Special Olympics Games were held at Soldier Field, Chicago, in 1968. Since then, millions of children and adults have participated in Special Olympics events.

Before athletes can take part in Special Olympics events, an application form must be completed. In addition to questions on demographics, this form asks for information concerning specific medical problems. In particular, information is requested about cervical spine radiographs and atlantoaxial instability in athletes with Down syndrome. Special Olympics athletes must also undergo a preparticipation physical examination by a licensed examiner every three years.

One review² found that sports-significant abnormalities were noted in 39 percent of Special Olympics athletes who underwent preparticipation physical examinations. The most common abnormalities were vision loss and seizures (31 percent). The majority of the abnormal findings (71 percent) were reported by questionnaire. In these athletes, sports-significant abnormalities were defined as vision loss in one or both eyes, or other eye abnormalities sufficient to warrant recommending the use of polycarbonate lenses for participation in sports carrying a risk of eye injury; history of seizures; need for a wheelchair to take part in sports activities; possible atlantoaxial instability or subluxation; unilateral kidney or undescended testis requiring protection during participation in contact sports; heart disease severe enough to limit sports participation; orthopedic abnormality limiting participation; and other medical conditions limiting activity or warranting further evaluation before permission to participate could be granted.

At the 1995 Special Olympic World Summer Games, comprehensive vision screening was conducted to determine the prevalence of visual anomalies in this select group.³ The athletes were tested for visual acuity, refractive error, oculomotor skills, stereopsis, color vision, contrast sensitivity, eye-hand coordination, eye-foot coordination, and overall ocular health. The most commonly reported abnormality was poor visual acuity.

Spontaneous or traumatic subluxation of the cervical spine is a potential risk in athletes with Down syndrome.⁴ Therefore, these athletes must undergo a neck examination performed by a physician, and radiographs of the cervical spine in full extension and flexion must be obtained and evaluated. Until the radiographic findings are known, athletes with Down syndrome and cervical subluxation are restricted from training or competing in specific sports and activities, including alpine skiing, butterfly stroke, diving, diving starts in swimming, equestrian sports, gymnastics, high jump, pentathlon, soccer, and squat lifting.

In one study,⁵ 29 athletes with Down syndrome were examined with lateral radiographs of the cervical spine (flexion and extension) over a four-month period before they participated in the Missouri Special Olympics. Seven other persons with Down syndrome were also examined. Spinal abnormalities were found in 14 (40 percent) of these athletes, with atlantoaxial subluxation being the most common abnormal finding. Based on the radiographic studies, six athletes (18 percent) were advised against taking part in the Special Olympics.

The natural history of cervical spine instability is unknown, and controlled long-term longitudinal studies are lacking.⁶ The impression of most observers is that the majority of patients with cervical spine instability remain entirely asymptomatic. At least 85 percent of patients with Down syndrome who have an atlanto-dens interval of 5 mm or more have no neurologic symptoms.⁷ The current literature does not provide scientific evidence for or against screening these patients with plain radiographs of the cervical spine. At present, the Special Olympics still requires such radiographs in this group of athletes.

The Special Olympics preparticipation physical examination can serve as an opportunity for the family physician to provide assistance to a group of athletes with special physical and emotional needs. This examination allows the physician to review the athlete's medical condition, including prescribed medications and their potential side effects. It is also a time to discuss the physical demands of the proposed activity and the assistance that may be necessary for participation.