Athlete screening is measuring the wrong things in two different ways

Screening programmes fail in two ways. They can flag things that turn out not to matter, generating investigation, anxiety and cost. Or they can not ask about things that do. Two 2026 papers document one of each, in the same population.

The false positives

Cardiac screening in athletes uses the 2017 International Criteria, which sort ECG findings into normal, borderline and abnormal. Borderline findings are the awkward middle: not clearly pathological, but historically enough to trigger further evaluation when two or more appear together.

A study examined 17,685 professional footballers, 84.7% male, who underwent cardiac screening with a 12-lead ECG and echocardiography between 2017 and 2024 [s1].

Borderline ECG findings were present in 1,389 (7.9%) athletes — 8.8% of males and 2.6% of females (P < 0.001) — with right atrial enlargement the most frequent pattern at 5.5% [s1].

The diagnostic yield was close to nothing. Major cardiac pathology was incidentally identified in 2 (1.43%) athletes with isolated left atrial enlargement, against 9 (0.06%) athletes with normal ECGs (P = 0.004) [s1]. The two cases were an anomalous coronary origin and significant aortic root dilatation — and both were unrelated to the ECG findings that prompted the look [s1].

Unrelated. The finding did not point at the disease; the echocardiogram that followed found something else [s1].

All other borderline patterns, and ectopy, revealed no major pathology [s1]. Among 42 athletes with two or more isolated borderline ECG findings — the group current criteria single out for further evaluation — no major conditions were identified [s1].

Minor pathology tracked background rates rather than the ECG. It was found in 18 (1.41%) athletes with isolated borderline findings, 3 (2.07%) with isolated ectopy, and 2.38% of those with two or more borderline findings (P = 0.463), against 212 (1.34%) of athletes with normal ECGs (P = 0.836) [s1].

A test result that identifies a group with the same disease rate as everyone else is not carrying information. The authors conclude that borderline criteria and ventricular ectopy are poor discriminators for major and minor cardiac pathology in athletes, and that borderline changes including two or more findings do not warrant further evaluation and could be considered normal in future iterations of the criteria [s1].

That is a direct recommendation to change guidance, from a cohort of 17,685 [s1]. The counter-argument is that this population is elite professional footballers, who are younger, fitter and more selected than athletes generally, so the underlying disease prevalence is low and yield would be low almost regardless.

The unasked questions

The second paper looks at what athlete screening covers rather than how well it discriminates, in female athletes specifically.

It reviewed 360 studies published between 1990 and 2026, representing 134,506 female participants from recreational to elite sport, and 273 screening tools [s2].

Coverage was concentrated. Mental health accounted for 77 studies (34.1%), disordered eating 33 (14.6%) and body image 30 (13.3%) [s2]. Domains related to female health — menstrual health, pelvic floor health, pregnancy and postpartum, and breast health — were comparatively underrepresented [s2].

Roughly a third of the literature on screening female athletes is about mental health, while the domains specific to being a female athlete are the thin ones [s2]. Menstrual function is a recognised indicator of energy availability and bone health; pelvic floor dysfunction is common in high-impact sport; breast health affects both comfort and participation. These are not niche concerns.

Validation was inconsistent. Half the studies — 180 of 360 (50%) — reported use of at least one validated tool [s2]. Most use was for risk identification, in 323 studies (80.3%) [s2]. Health literacy constructs were explicitly assessed in only 12.5% (n = 45) [s2].

Half of screening research in this population used at least one validated instrument, which means half did not report doing so [s2]. Tool use was also concentrated in professional and elite sport, with limited inclusion of recreational, masters and disability athlete cohorts [s2] — so the group with the least medical support around them is the least studied.

The authors describe health screening in female athletes as fragmented and uneven in domain coverage, with inconsistent validation reporting, and call for integrated, multi-domain and contextually inclusive frameworks [s2].

The shared problem

These are opposite failures with a common cause: screening content set by what is measurable and traditional rather than by what predicts harm.

ECG criteria carry borderline categories because ECGs produce those patterns and someone had to classify them, not because the patterns were shown to predict disease — and now, in 17,685 athletes, they largely do not [s1]. Female athlete screening concentrates on mental health and disordered eating partly because validated instruments for those domains already existed, having been developed for general populations [s2].

Both papers point the same way: screening should be built backwards from outcomes.

What to watch

Whether the next revision of the International Criteria reclassifies borderline findings, including the two-or-more rule, as the football data recommends [s1]. And whether integrated screening frameworks for female athletes are developed and validated in recreational and masters cohorts rather than only in elite sport [s2].

This article describes published research. It is not medical advice.

Sources

• [s1] Diagnostic yield of borderline ECG changes and ectopic beats in football players, British Journal of Sports Medicine, online 2026-08-13.
• [s2] Self-Report Health Screening Tools in Female Athletes: A Systematic Review of Domain Coverage, Validity and Use, Sports Medicine, online 2026-09-04.