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1. From the Olympic Games to Mixed Martial Arts: What Are the Medical Risks With Combative Sports? Randall R Wroble MD FACSM
Sportsmedicine Grant
Columbus OH
2. Understanding epidemiology is crucial in establishing risk factors and developing strategies for injury prevention
3. Outline General considerations
Sport-specific observations
Thematic issues
4. Key Messages Injury rates are high but comparable to other contact sports
Uniquely wide variety of injuries and issues
More research is needed to design effective prevention strategies
5. General Considerations
6. The Sports - Styles Striking-based
Boxing
Karate – more hand techniques
Kickboxing
Taekwondo – more kicking techniques
Wushu
Grappling-based
Judo
Wrestling
Mixed - MMA
Weapons-based - kendo
7. The Sports - Participation Estimated 6.9 million adults and children in US alone
Estimated 75 million participants worldwide
30-40% female
Olympics – boxing, judo, taekwondo, wrestling
8. Limitations of Current Research Epidemiologic work is scarce if not unavailable for the majority of disciplines
Inconsistencies in
Injury definition
Data collection and methods
Study design
Most studies are case series – tournaments
9. Limitations of Current Research Even within the individual sports, rules vary
Type of contact
Zone of contact
Padding/protective equipment
10. Limitations of Current Research Data especially lacking in females and children
All of these adversely affect validity of available data
Risk factors thus not well-delineated
11. General Epidemiological Statements Across All Sports Exposure is similar
Time in practice >> time in competition
Injury incidence: practice > competition
Injury rate: competition >> practice
12. General Epidemiological Statements Across All Sports Most injuries are mild – contusion, lacerations, sprains and incur little or no time loss
Defender hurt more often than attacker
Head injuries are greatest concern
Lower extremity injury rates higher in taekwondo, wushu, kickboxing
More injuries occur without protective equipment
Sparring/fighting is most common setting
13. Overall Injury Rates (Injuries/100 Participants) Boxing 21-42
Judo 13-24
Karate 34-38
Taekwondo 6-20
Wrestling (HS) 23-50
Wrestling (College) 19-288
14. Sport-specific Observations
15. Boxing Overall rate
171-250/1000 AE (Zazryn, Bledsoe)
Amateur and female injury rates lower than in male professionals
Most common – epistaxis and lacerations
16. Sport-specific Considerations - Boxing Acute head injuries 27-93% of reported injuries
KO and TKO rate has decreased in Olympics
24% in 1988
1.5% in 2004
Chronic brain injury
Eye – retinal detachment
Boxer’s knuckle – chronic synovitis of 2nd or 3rd MCP joints
Subluxation of extensor tendons due to sagittal band damage
May require surgical repair
17. Judo Injury rates
123/1000 AE (Barrault)
Sport-specific considerations
Throws – upper extremity injuries
28-37% of injuries in kids (Pieter)
39-47% of injuries in adults (Pieter)
Choke holds – case reports of stroke
18. Karate Injury rate
53/100 participants (McLatchie)
Protective equipment
gloves, mouthguards, shin and foot pads
19. Sport-specific Considerations - Karate Injuries most common to head/neck/face
51-90% of injuries in kids (Pieter)
Concussion – 1.6/1000 AE (Stricevic)
0.9-5.4% of all injuries
Hand techniques (punching)result in more upper extremity injuries
72% from punches
14% from kicks
20. Kickboxing Injury rate
110 injuries/1000 AE (Zazryn)
Protective equipment
Varies by style and level but in general includes gloves, mouthguards, and groin protectors
21. Kickboxing Concussions
Pro - 17% of injuries 19.2/1000 AE (Zazryn)
Amateur – 62% of all injuries
Shin injuries – 23% of injuries, less when shin guards used
22. MMA Fighters most commonly come from wrestling, kickboxing, or jujitsu background
23. MMA Major changes in rules - weight classes, rounds, time limits, equipment
Outlawed head butting, hair pulling, pinching, eye gouging, etc
Match end
35% submission “Tap out”
34% TKO
24% decision
3% KO – comparable to taekwondo, but lower than boxing or kickboxing
2% physician stopped fight
24. Submission Holds Most common – elbow lock
25. MMA Injury rates – similar to other disciplines
Overall – 236/1000 AE
Concussion – 15.4 – 48.3/1000 AE (Ngai, Buse)
Protective equipment – mouth guard, groin protector, gloves – thinly padded with palm and fingers free
26. Taekwondo Injury rate
21-168/1000 AE (Pieter)
Protective equipment
Headgear required
27. Sport-specific Considerations - Taekwondo Concussion – 7.3/1000 AE (Zemper)
4.3-7.5% of all injuries
Newer rules - more points for head blows
Appears to have resulted in more concussions
Kicking techniques result in more lower extremity injuries
37-65% of injuries in kids (Pieter)
8-69% of injuries in adults (Pieter)
28. Wrestling Styles
Freestyle
Greco-Roman
American folkstyle – HS and College
Match length differs by style and level
29. Wrestling Injury rates
HS – 23-50 injuries/100 wrestlers
Higher in college
Lower in youth wrestling
Very limited international data
Injuries to knee most common
Unique patterns
Skin infections
“Cauliflower ear”
30. Combative Sports Issues Making weight
Acute and chronic head injury
Blood borne infection
Auricular hematoma
Skin infection
Eye injury
Musculoskeletal injuries
31. Making Weight
32. Making Weight Weight matching
Creates equity
Reduces injury risk
Allows broad size range of competitors
Weight cutting occurs to gain advantage in power and strength
33. Making Weight Weigh-in protocol – varies considerably by style and level
Weight control programs - 1998
HS and college require weight certification
Based on body composition
Euhydrated body fat minimums
5% college male, 7% HS male
12-14% female
Max wt loss of 1.5%/wk
International (FILA) wrestling and other combat sports do not regulate weight loss
34. Making Weight Prevalence – data limited primarily to wrestling
College wrestling – positive effect of rule changes
Steen (1990) – 87% of college wrestlers lost 5 kg weekly 15 times during a season
Oppliger et al (2003) – average weekly wt loss – 2.9kg
HS wrestling – rule changes had smaller effect
70% of wrestlers cutting weight
No data on female athletes
Judo – 70-80% reduce weight
35. Making Weight - Methods Recommended techniques
Slow, log-term weight reduction
Modest short term dehydration
High volume exercise
Nutritional education
Not recommended/illegal
Severe dehydration
Fasting
Sauna, plastic/rubber suits
Laxatives, diuretics
36. Making Weight - Physiologic Effects Dehydration impairs cardiovascular and thermoregulatory function
Heat illness – 3 college wrestlers deaths in 1998
Short duration, high intensity activity less affected
Lose lean mass not just fat
Immune function?
37. Making Weight - Performance Effects Does weight loss increase chance of success?
Debate not settled
Study results mixed
College – Horswill – no
HS –Wroble – yes
Adolescents – Alderman - yes
38. Acute and Chronic Head Injury
39. Acute Brain Injury Occur more in boxing than in any other sport
Similar but lower rates in all other full contact disciplines
Repeated deliberate blows to head
Punches, kicks
Deaths due to subdural hematoma
Boxing - 659 reported 1915-1996
40. Concussion Rates Pro boxers - 16-70% of all injuries (Zazryn)
Amateur boxers - 6.5-52% of all injuries (Zazryn)
Karate - 0.9-5.4% of all injuries
Taekwondo – 4.3-7.5% of all injuries
Kickboxing – 62.5% of all injuries
Martial arts – 25% of all competition injuries (Roh, Pieter)
63% of all injuries in 18 yr questionnaire study (Birrer)
41. Adult Concussion Rates/100 Participants Boxing 14.0-44.7
Karate 0.4-2.8
Taekwondo 0.2-5.2
42. Chronic Brain Injury Chronic traumatic encephalopathy
Incidence – data limited
Amateur < pro
Most are case reports
Est. 9-25% in pro boxers
Roberts – 17% ex-boxers have CNS SX
Only one case report in combat sports outside of boxing
43. Chronic Traumatic Encephalopathy Mechanism – numerous subconcussive and/or concussive blows to head
Diagnosis – difficult
Delayed onset
Would have developed anyway
Confounding variables
EtOH, drug use
Other head trauma
44. Chronic Traumatic Encephalopathy Symptoms – variable
Motor impairment
Balance, coordination, parkinsonism
Cognitive impairment
Attention, memory
One third of cases progressive
Dose-response curve is unknown
45. Chronic Traumatic Encephalopathy - Risk Factors Increasing age
Amateur < pro
Shorter bouts
Headgear
More padded gloves
Mandatory suspension after head injury
46. Chronic Traumatic Encephalopathy - Risk Factors Increasing exposure
Number of bouts (>150)
Career > 10 yrs
Less exposure now so incidence likely will decrease
Career length shorter
Mean career length 19 to 5 yrs
Bout number less: mean 336 to 13
Apolipoprotein E4 genotype
47. Chronic Traumatic Encephalopathy - Prevention Glove weight – heavier more padded gloves
Headgear, mouthguards
Better instruction and training – coaches, refs, players
Rule changes to reduce head blows
Limiting exposure
48. Chronic Traumatic Encephalopathy - Prevention Surveillance and supervision – more detailed neurologic evaluation
Annual medical checks
Pre-bout screening – CT or MRI
Neuropsychological testing
Identify high risk fighters
49. Blood Borne Infection
50. Blood Borne Infection - Transmission High risk sports
Boxing, wrestling, MMA
Bleeding wounds – no cases reported of HIV transmission
Doping & drug abuse
Travel in endemic areas
51. Blood Borne Infection Hepatitis, HIV
50-100x more risk of transmitting HBV
HIV susceptible to disinfectants and drying
HBV resistant to drying, simple detergents and alcohol and is stable on environmental surfaces, concentration in blood higher
Outbreak in Sumo club – 5/10 athletes
52. Blood Borne Infection - Prevention Universal blood precautions
Proper protective equipment – mouthguards, headgear
Vaccination for HBV – safe, 95% effective
Recommended for children and high risk athletes
53. Blood Borne Infection - Testing Widespread mandatory screening generally not recommended
Voluntary testing recommended for high risk athletes
USA Boxing & USA Wrestling – known infected athletes barred from competition
Pro boxing – most states require negative tests
54. Control of Bleeding Amateur boxing – no medication allowed
Pro boxing – any topical substance is allowed
Time limits
Boxing – 1 minute between rounds
HS wrestling – 5 minutes cumulative
International wrestling – 2 minutes
Judo – disqualified after 3rd attempt
Methods – “The Cutman”
Vaseline
Avitene, Gelfoam, surgicel
55. Auricular Hematoma
56. Auricular Hematoma Wrestling
1.7-23.4% of all injuries
Direct trauma or abrasion
Head or knee
Incidence reduced with headgear 51 to 35%
Only 5% of coaches require headgear at practice
Amateur boxing – extremely rare with headgear
57. Skin Infection
58. Skin Infection Incidence – 6-26% of reported injuries in wrestling
Multiple reported outbreaks
Risk factors
Sweating, abrasions, close physical contact
59. Skin Infection Problems
Lack of awareness/dermatologic knowledge
Doctor “shopping”
Medical issues
Severe - limb or life threatening
Complications – e.g. Herpes keratitis
Cost of treatment
60. Skin Infection - Bacterial Impetigo – more common in HS wrestlers
CA-MRSA
Cellulitis
Folliculitis
Furunculosis
61. Skin Infection - Fungal Tinea corporis
70% of HS wrestling skin infections
35-40% prevalence in judo athletes
Duration of treatment – in dispute
62. Skin Infection - Viral Herpes gladiatorum– HSV-1
Transmission risk – 30%
Up to 30% asymptomatic carriers
Reported incidence higher in college than HS
63. Skin Infection - Prevention Skin checks
Barrier creams
Hygiene
Prophylaxis
Tinea and herpes
64. Eye Injury
65. Eye Injury Studies limited except in boxing
Retinal detachment, hyphema, cataracts
58% of boxers have “vision-threatening” injuries (Giovinazzo)
18% of wrestling injuries in one study but 90% were periorbital lacerations and corneal abrasions
66. Eye Injury - Preventive Measures Mandatory eye exam at regular intervals
Amateur boxing – retinal tear or detachment disqualifies
Improved documentation and record keeping
Training ringside physicians
Thumbless gloves?
67. Musculoskeletal Injuries - Knee Injuries in Wrestling Lateral meniscus tear
Other contact sports, incidence of meniscal tears
Medial 4x lateral
In wrestling
Medial = lateral
Cruciate ligaments tears uncommon
68. Musculoskeletal Injuries - Knee Injuries in Wrestling Prepatellar bursitis
Rarely reported in other sports
21% of all knee injuries
Often recurrent
Occasionally septic
Deceiving presentation
69. Key Messages
70. Injury Rates Are High Comparable to other contact sports
Studies limited, results highly variable
Medical coverage vital
Teaching opportunity
71. Unique Variety of Issues Expertise required beyond musculoskeletal system
Sport-specific knowledge base
Incredible crucible of clinical material
72. More and Better Research Is Needed to Design Effective Prevention Strategies Prevention strategies have proven effective but are limited in scope at present
Wrestling weight loss rules
Boxing oversight
73. Examine each sport individually
Standardization of injury definition
Extend study population across age, competition level, weight, and gender
Define safe level of exposure
Examine training injuries
Further identification of risk factors
Protective equipment – effectiveness & lifespan
74. But most of all… get involved!
75. Thank You
76. Starting Points for Prevention Strategies
77. The Athlete Proper training
Technique
Hygiene
Limits on weight reduction
Size/ability matching
78. The Sport Standardization and enforcement of rules
Re-evaluate rules allowing blows to head
Adequate supervision
Coaching & officials education – injuries and prevention
Protective equipment
Headgear
Mouthguard
Ear guards
Sparring gloves
Shin pads
Chest/groin protector
79. Environment Removal/padding of hazards
Adequate space
Appropriate temperature/humidity
Quality mats
Mat disinfection
80. Health Support System PPE
Medical coverage – ambulance at boxing matches
Injury tracking
Emergency protocols
Precise treatment protocols
Proper rehabilitation
Strict RTP criteria