Remember getting your sports physical before high school tryouts? Every year, you’d visit your doctor for that mandatory exam: height, weight, blood pressure, the stethoscope to the chest, maybe some movement and muscular tests. Your doctor would sign the form, and you would be cleared to play. It was just part of being an athlete.
When you arrived at college, the stakes got higher, and so did the medical oversight. College teams typically had team physicians who evaluated players before the season to ensure they were fit for practice and competition. And if you made it to the professional level, organizations such as FIFA, MLB, NBA, NFL, NHL, etc., all employ extensive preparticipation exams (PPEs) for their athletes.
However, there’s an interesting gap: most recreational fitness events may recommend consulting your physician to ensure you are healthy to compete, but they do not mandate any medical exam. Marathons, triathlons, Hyrox events — you can sign up, pay your entry fee, sign a waiver, and participate in the event.
Historically, CrossFit has followed the same approach. However, the sport of CrossFit is not a recreational fitness event. The CrossFit Open is, but the CrossFit Games are not. The Games are an elite competition featuring the fittest athletes on Earth, pushing the boundaries of human performance across diverse physical demands, from heavy lifts to long-distance events, from gymnastics to swimming. Our athletes train year-round at the highest levels, and when they step onto the competition floor, they’re operating at the absolute edge of their capabilities.
To better safeguard our athletes and set a new benchmark for athlete health, we are moving beyond traditional practices and implementing a new standard for pre-competition medical evaluation. Beginning in 2026, all CrossFit Games athletes will need to complete a new standard: a mandatory preparticipation exam (PPE).
Why This Matters
The overarching purpose of the PPE is to identify conditions that may put the athlete at unreasonable risk of death or catastrophic injury, with the potential to modify and reduce risk through individualized management (1). Additionally, understanding the medical landscape helps us make informed decisions about athlete safety. Our goal is not to restrict an athlete, but to provide a more comprehensive risk assessment that will help you, as a CrossFit Games athlete, understand any underlying conditions that could put you at risk.
Sudden cardiac death, while rare, is a devastating and tragic event, counterintuitive to the common association between athletic activity and good health. In a comprehensive study of NCAA athletes over 20 years, researchers identified 143 cases of sudden cardiac death from 2002 to 2022, with an incidence rate of one in 63,682 athlete-years (2). Male athletes and those competing in high-intensity sports, such as NCAA Division I basketball, had a higher incidence rate (one in 8,188 athlete-years). The most common underlying causes included autopsy-negative sudden unexplained death (19.5%), possible cardiomyopathy (16.9%), and hypertrophic cardiomyopathy (12.7%). Research on U.S. marathon and half-marathon runners found 176 sudden cardiac arrests among 29 million participants from 2010 to 2023, approximately one event per 166,667 participants (3). Where causes could be determined, coronary artery disease was most common.
These statistics aren’t meant to alarm; they’re meant to inform. Elite athletic performance places unique demands on the cardiovascular system, and experts agree that pre-competition health evaluation helps optimize safe participation in sport (4).
The Preparticipation Examination (PPE)
A comprehensive PPE has become the standard across high school, collegiate, and professional sports. It is intended to be a comprehensive evaluation to not only identify potential high-risk features for participation in sport, but also to provide opportunities for the athlete to (1):
- Ensure current health problems are managed appropriately
- Identify conditions that serve as barriers to performance
- Assess for characteristics that may place the athlete at risk for future injury or disease
- Review medications and/or supplements, including addressing possible Therapeutic Use Exemption (TUE) requests
- Educate the athlete regarding health risks, health-related behavior, and pertinent issues regarding safe play in sport
An integral part of any PPE is a cardiovascular risk assessment using a comprehensive personal and family history and physical examination, such as the American Heart Association (AHA) 14-point recommendations (5) and/or the Preparticipation Physical Evaluation Monograph, Fifth Edition (PPE-5). These assessments include information such as:
- Medical history: Questions about cardiac symptoms such as exertion-related dizziness, loss of consciousness, chest pain, or palpitations, plus family history of genetic heart conditions
- Physical examination: Looking for clinical signs of conditions like hypertrophic cardiomyopathy (HCM) and Marfan syndrome
Beyond cardiac screening, the PPE serves another crucial function in identifying medical conditions that require management or monitoring during competition. Athletes with Type 1 or Type 2 diabetes may be at risk for hypoglycemia. Those with a history of bone-stress fractures or exertional heat illness may need further testing or additional management strategies before and during competition to prevent further injury. Athletes with sickle cell trait, a genetic condition affecting red blood cells, may face an increased risk of significant rhabdomyolysis during high-intensity exercise and may benefit from early identification and responsive medical support.
The goal isn’t to exclude athletes; it’s to ensure both athletes and medical teams are fully informed and prepared (6).
The 2026 CrossFit Games Standard
Starting in 2026, all athletes who qualify for the CrossFit Games will be required to undergo a medical preparticipation history and physical examination with a licensed physician before competing. The examination should address, at a minimum, the AHA 14-point examination (note, the PPE-5 is inclusive of the AHA 14 points), plus any additional studies deemed necessary by their physician (7). Further cardiac testing, such as an ECG or a heart ultrasound, if performed, should be guided by physicians with expert knowledge in sports cardiology. Athletes should also discuss any medical conditions, medications, or other concerns that may be affected by competition or environmental conditions.
Leading the Way
We recognize that implementing this requirement places CrossFit in a unique position within the competitive fitness landscape. Most functional fitness competitions don’t require a preparticipation exam. The CrossFit Games have always been about pushing boundaries, not only in athletic performance, but also in how we approach the sport itself.
Recognizing the unique demands of elite competition and to better safeguard our athletes, we are setting a new benchmark for athlete health by requiring comprehensive preparticipation exams.
The CrossFit Games showcase the pinnacle of fitness. Ensuring our athletes can compete safely at that level isn’t just responsible, it’s essential. Starting in 2026, we’re making that commitment to our athletes and our community.
References
- Hainline B, Drezner JA, Baggish A et al. Interassociation consensus statement on cardiovascular care of college student-athletes. J Am Coll Cardiol 2016;67:2981–2995.
- Petek BJ, Churchill TW, Moulson N et al. Sudden Cardiac Death in National Collegiate Athletic Association Athletes: A 20-Year Study. Circulation 2024;149:80–90.
- Kim JH, Rim AJ, Miller JT et al. Cardiac Arrest During Long-Distance Running Races. Jama 2025.
- Drezner JA, O’Connor FG, Harmon KG et al. AMSSM Position Statement on Cardiovascular Preparticipation Screening in Athletes: Current evidence, knowledge gaps, recommendations and future directions. British journal of sports medicine 2017;51:153–167.
- Maron BJ, Friedman RA, Kligfield P et al. Assessment of the 12-lead electrocardiogram as a screening test for detection of cardiovascular disease in healthy general populations of young people (12-25 years of age): a scientific statement from the American Heart Association and the American College of Cardiology. J Am Coll Cardiol 2014;64:1479–514.
- Kim JH, Baggish AL, Levine BD et al. Clinical Considerations for Competitive Sports Participation for Athletes With Cardiovascular Abnormalities: A Scientific Statement From the American Heart Association and American College of Cardiology. Circulation 2025.
- 7. Blank ZJ, Spicer RL, Robinson JA. Preparticipation State Cardiac Screening Forms for Athletes. Pediatrics 2022;151.
Disclaimer: The opinions expressed in this article are the authors’ own and do not reflect the views of any organizations with which they are affiliated.