Seidenberg, Peter H. MD, FAAFP
Mixed martial arts (MMA) is a combat sport that is quickly expanding its fan base in the United States. Also known as cage fighting, ultimate fighting, and no-holds barred fighting, the sport has its early history from ancient Greece in the Olympic sport Pankration. The event typically culminated the games and featured competitors utilizing various striking and grappling techniques in an effort to overcome the opponent (17).
The sport's more recent history can be traced back to Europe, the Pacific brim, and Japan in the early 1900s. Fighters of various disciplines - from boxing to wrestling to martial arts - were pitted against each other in an attempt to determine which form was the most effective unarmed hand-to-hand combat style. In the 1920s, Vale Tudo competitions emerged in Brazil, which were introduced to the United States in 1993 as Ultimate Fighting Championships. Initially, concerns over the level of violence and severity of injury in MMA events had led to medical organizations and legislators calling for a ban of the sport, which seemingly forced it to an underground status. In an attempt to eliminate the sport's stigma of "fight to the death," the Unified Rules for Mixed Martial Arts were created in 2000 (17).
They improved the reputation of the sport by eliminating the stigma of "fight to the death." Weight classes also were established, and fights were limited to 3 to 5 rounds of 5-min duration each. It required the use of open-fingered gloves to better protect the hands. It banned head butting and other actions that required little skill but could cause significant harm (Table 1). With the adoption of stricter regulations designed to protect participants, the sport now has international acceptance as evidenced in 1999 by the creation of the International Sport Combat Federation (ISCF) as the world's first MMA sanctioning organization. In the United States, the sport is governed by the individual state athletic associations, and additional regulations often are present; however, not all states permit MMA competitions (17).
A fighter may win his match by knock out, decision at the end of regulation time, stoppage by the referee or ringside physician due to injury or due to a fighter's inability to protect himself, submission, or the cornerman throwing in the towel (17).
Injury Patterns in MMA
Few studies have been dedicated to studying the injury patterns in mixed martial arts. However, they give us an excellent point from which to launch. It is commonly thought that the injury patterns in MMA would be similar to other combat sports - boxing, kickboxing, wrestling, and various martial arts. However, since elements of all of these sports are melded together to form MMA, it is possible that the risks of each individual style combined are worse than the individual disciplines alone.
To further clarify the sport's injury patterns, Buse (4) retrospectively examined 642 matches (1,284 athlete encounters). His data show that 72% of matches were ended due to injury. The greatest number (39.4%) was due to closed head trauma, followed by musculoskeletal stress (22.9%), neck choke (19.7%), and miscellaneous trauma (18.0%). The study was limited by its retrospective design and that the severity of the injuries was not able to be clarified. In addition, a neck choke was considered an injury, but we do not know if it was a true injury or just a submission. The musculoskeletal stress also appears to be predominantly stoppages due to submission holds, with the elbow being the most commonly affected joint. Again, we do not know if the stress sustained in the fight resulted in actual injury. Yet, the study does demonstrate that head trauma resulted in the majority of fight stoppage, with a punch to the head being the most common mechanism. The concussion rate was calculated to be 48.3·1,000−1 fight exposures. This rate is 2.5 times greater than that reported in kickboxing (18).
Nagai (10) also performed a retrospective analysis of 5 yr of data regarding MMA injuries. However, in contrast to Buse, his group found the concussion rate in MMA to be less than kickboxing, with a severe concussion rate of 15.4·1,000−1 athlete competition exposures. Yet we do not know from his investigation what the total concussion rate was irrespective of severity. Regardless, the overall injury rate in his study of 1,270 athletes was still quite high (23.6·100−1 fight participations). Lacerations and upper limb injuries were the most common reported in the cohort.
Bledsoe's group (2) was the first to report on injury incidence in MMA. They retrospectively examined 171 matches between 220 different fighters in the Nevada. Injuries were classified based upon the ringside physician's written report. Injuries were 28.6·100−1 fight participations. Facial lacerations followed by hand injuries were the most common to occur. Interestingly, the incidence of concussion was not reported during the study; however, 46.2% of the bouts were stopped due to knock out or technical knock out. If Buse's criteria for closed head trauma is used, Bledsoe's group actually discovered a higher concussion incidence than Buse's study reported (39.2%) (4). A significant limitation of Bledsoe's study was that the injury reporting was based solely upon the ringside physicians' reports. No confirmation of injuries or their severity was possible.
All three of the retrospective analyses found that the mechanism that caused the majority of injuries was striking - either the body region being struck or the body part used to strike (2,4,10). The rate of these injuries appears congruent with other combat sports that utilize striking (3,6,7,11,18,19).
The high rate of head trauma combined with the death of a MMA athlete who sustained numerous nongloved blows to the head (12) resulted in the requirement of gloves during competition. However, biomechanical research on karate gloves (similar to those used in MMA) questions the effectiveness the gloves can have in dissipating the force of a blow to the head (14). In fact, in the last 3 yr, two deaths have been reported in gloved fighters (17). Regardless, given the high risk of head injury, it behooves the ringside physician to have a well established protocol for handling concussion with knowledge of the Third International Conference on Concussion Consensus Statement on Concussion (9), as well as the local state athletic association's regulations. Additionally, written instructions for care of closed head trauma should be available to be given to the caretakers of the concussed athletes. Remember that an unconscious athlete should be assumed to have a cervical spine injury, and Advanced Trauma Life Support principles with cervical spine stabilization protocols must be utilized. It is advisable to practice the management of the athlete with a cervical spine injury with the medical team prior to the event.
Given the frequency of lacerations (2,4,10), the covering physician also should be comfortable suturing simple lacerations. However, in general, it is not recommended that complicated lacerations attempt to be sewn at ringside. The time required to make such extensive repairs distracts the clinician from supervising the other bouts that are still ongoing.
The use of submission holds is very common in MMA. The stress placed on joints during these holds can result in significant ligament injury and even dislocations. As such, the ringside physician should have competence in recognizing which injuries can be managed at the venue and which must be transported to the emergency department. He or she also must be familiar with peripheral neuroanatomy, as pressure point strikes have been reported to cause traumatic neuralgia (8).
Since participants do not wear head gear but grapple in a similar manner to wrestlers, there is a high risk of auricular hematomas. Ringside physicians should be familiar with how to manage this complication (13). This makes the identification of a preexisting cauliflower ear during the prebout examination important so as to prevent overzealous attempts at drainage if an acute hematoma develops over a chronic cauliflower deformity. Other ear injuries reported in MMA include tympanic membrane rupture (5), and as such, an otoscope should be available.
In Pennsylvania, prior to an athlete being permitted to participate in a MMA event, he or she must become licensed in the state to compete. Part of this process includes a preparticipation physical examination and blood work to include HIV and viral hepatitis testing. The Unified Rules for MMA require that each fighter is examined by a physician pre- and postbout. However, the prefight examination can be challenging, as the physician may not have an accurate medical history due to failure of disclosure by the athlete.
Because of the wide variety of injuries that may occur in an MMA fight, it is important to have a medical kit well equipped to meet the challenge. The Team Physician Consensus Statement on sideline preparedness (15) gives a detailed list to be considered. Table 3 lists the author's preferred medical kit for ringside coverage. However, the sports medicine bag does not replace an onsite ambulance with an experienced crew for assistance in emergency stabilization and transport. It is recommended that the physician meet with the emergency medical technicians before the event to practice injury protocols (such as cervical spine) and establish a hand signal and/or two-way radio communication systems to facilitate rapid response to urgent situations. It also is advisable to contact the local emergency department that would receive any potential casualties. Equally important, before agreeing to be a ringside physician, it is prudent for the sports-medicine specialist to ensure that his or her malpractice policy will cover medical supervision of the event.
Yet despite all of the above preparations, the author has found ringside coverage to be very fulfilling. It provides a means to interact with athletes who often have limited physician contact. The rapport built gives a pathway for them to enter into the medical system and enables health counseling to occur, with special attention to the adverse effects of anabolic steroid use (1). Additionally, because of the wide variety of injuries and medical conditions encountered at ringside, it can be an excellent educational forum for sports-medicine fellows and primary-care residents.
Despite the growing popularity of the sport, there is a relative paucity of research concerning the epidemiology of injuries in MMA. The few studies that have been published are largely retrospective in analysis. The author could not locate any prospective MMA injury studies. There is a need for further examination of injury in this sport - both in training and competition. By better understanding the types of injuries that occur in training and competition and what factors predispose these injuries, the sports-medicine community can make evidence-based recommendations to prevent athlete morbidity and mortality. Additionally, although the Unified Rules have been designed to lessen harm to fighters, further investigation is needed to see whether these rule changes have been successful from a medical viewpoint. As scientists, we should seek to make evidence-based intervention and then be able to determine whether our recommendations make a clinically significant improvement in the health of the athletes.
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