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Care and Treatment of Athletes in MMA and Boxing
John Neidecker, DO, ATC,
FAOASM
AOASM 30th Annual Clinical
Conference
Philadelphia, PA
April 25th, 2015
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Overview
Boxing vs. MMA
Fighter License Process
Typical Event Coverage
Medical Suspensions
Common Injuries
Hot Topics
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Disclosure
Association of Ringside Physicians
Member of the board of directors
International non-profit organization
comprised of experienced ringside
physicians and associates, all devoted to
the common goal of ensuring and
promoting health and safety in combative
sports
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Before we start…
This is the hurt game
The object of these sports is different than
all others
Guidelines that we generally use in sports
medicine may not apply
Few quality studies out there
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Poll
How many of you have covered a
boxing/MMA event?
Which sport do you think is safer, boxing or
MMA?
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Boxing vs. MMA
Similar sports in objective but are very
different
Trying to compare the two is like comparing
hockey to lacrosse
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Boxing History
Some form of boxing
has been around
since 300 BC
Modern boxing has
been around since
the 1860s
Rounds
Gloves
10 count
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MMA History
UFC 1 was held in
1993
The purpose of it was
to determine which
martial art form is the
most dominant
“There are no rules!”
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MMA History
Late 1990s UFC
came under fire
Sen. John McCain
“Human cockfighting”
Sponsors would not
touch it
States started to ban
it
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MMA History
Unified rules created
in 2000
UFC purchased for
$2 million in 2001
The Ultimate Fighter
Griffin vs. Bonnar
August 2005
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Format
Boxing
3-12, 3 minute rounds
1 minute rest in
between
Gloves are 8-10 oz
Welterweight (147 lbs)
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Format
MMA
3-5, 5 minute rounds
1 minute rest in
between
Gloves are 4-6oz
Hand size
Eye injuries
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Ways to win
Boxing
KO
TKO
Decision
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Ways to win
MMA
KO
TKO
Submission
Decision
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Knock downs
Boxing
You have 10 seconds
to get up. If you do
then the fight
continues.
Usually if knocked
down 3 times in a
round the fight is
stopped
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Knock downs
MMA
When a fighter is
knocked down from a
strike his opponent
can continue with his
attack. The knocked
down fighter needs to
be intelligently
defending his/her self
for the bout to
continue.
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Knock downs
MMA
“Intelligently
defending” means that
the fighter is not
“turtling up”. The
downed fighter needs
to be deflecting strikes
or controlling his/her
opponents arms.
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Knock downs
MMA
If the downed fighter
appears unconscious
the referee will stop
the fight immediately.
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Striking
Boxing
Only punching is
allowed
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Striking
MMA
Punching
Kicking
Elbows
Knees
Cuts
Both standing and on
the ground
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Grappling
Boxing
“Tie Up”
Usually happens when
fighters are fatigued or
to try to defend
themselves
Referee usually
breaks it up after a
couple of seconds
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Grappling
MMA
Happens standing
“clinch”
While in the “clinch”
fighters can strike,
and/or attempt to take
their opponent down.
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Grappling
MMA
Happens on the ground
While on the ground
fighters can strike,
attempt a submission
hold, and/or try improve
their position
If no action is happening
– the referee will bring
the fighters back to a
standing position
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Other MMA Rules
Can NOT kick or
knee a “downed”
opponent in the head
Downed is defined as
having at least one
knee or at least one
hand on the ground
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Poll
Which sport do you think is safer, boxing or
MMA?
You are both right!!!
MMA is certainly more dangerous from an
orthopaedic perspective and lacerations.
Boxing is probably more dangerous from a
brain injury perspective, acutely and
chronically
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Otten et al. 2015
Looked at 152 UFC bouts in Nevada in 2007-2009
60.3% had no complaints or injuries post bout
19% of fighters had significant facial laceration or
soft tissue injury
6% of fighters had an orthopedic injury
3% of fighters had a nasal fracture
12% of fighters were sent for head CT
No intracranial pathology
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Baird et al. 2010
Looked at mortalities in professional boxing
from 1950-2007
339 deaths
219 between 1950-1982
120 between 1983-2007
Vast majority of deaths due to brain injury
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Baird et al. 2010
Difference between “15 rd” and “12 rd” eras
Shorter careers and fewer fights
Stricter regulations and better medicine
80% of fatalities involved KO or TKO
KO 62%
TKO 18%
70% KO fatalities happen in rds 6-10
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MMA Fatalities
Since 2001 (Unified Rules)
4 total ring deaths in sanctioned events
3 brain injury related
1 suspected cardiac related
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Hutchison et al. 2014
Looked at 844 bouts from the UFC from
2006-2012
KO rate 12.7%
TKO (due to strikes) rate 19.1%
Submission rate 20.9%
Decision rate 44.5%
Other literature states that KO rates in
professional boxing is less than 5%
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Hutchison et al. 2014
For KOs
Average time between KO-Strike and stoppage
was 3.5 seconds
Loser received an average of 2.6 additional
strikes
For TKOs
30-second interval immediately preceding the
stoppage, loser received an average of 18.5
strikes, 92.3% of these being head strikes
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Boxing vs. MMA
Boxing
120 deaths over 25 years
4.8 deaths per year
MMA
4 deaths over 14 years
0.28 deaths per year
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Data Summary
Death rates in boxing are higher
Death rates in boxing usually associated
with KO or TKO
KO or TKO rates are higher in MMA
What is the difference?
Boxing KO and TKO are usually associated
with more cumulative head trauma
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Future Research
Since MMA is such a young sport - no long
term effect studies available.
The Cleveland Clinic’s Lou Ruvo Center for
Brain Health in Las Vegas
Over 400 fighters registered
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Federal ID Card
All fighters must apply for a Federal ID
Card
General Information
Manager/Promoter/Trainer Information
For Data Base
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State License
Every fighter has to apply for a license in
every state he/she is planning to fight in
Not all state athletic commissions function
equally
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Universal Requirements
Annual Physical Exam
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Universal Requirements
Annual Dilated Eye Exam
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ARP Position Statement
Ocular Guidelines
Fighters should have uncorrected visual acuity of
20/200 or better in each eye
Fighters should have corrected visual acuity of
20/60 in each eye
Absence of major ocular disease
Glaucoma, macular disease, retinal disease
Fighters with only one functioning eye should not
be allowed to fight
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ARP Position Statement
Ocular Surgery Guidelines
Intraocular surgery
Cataract, Retinal Detachment
Should be dealt with on a case by case basis
Refractive Surgery
Radial Keratotomy should not be allowed to
compete
LASIK and PRK allowed to compete
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Universal Requirements
Blood Tests
Every 6 months
Hep B, Hep C
HIV
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ARP Position Statement
Blood- Borne Infectious Disease
Recommend testing every 6 months
HIV ½ serum Ab (with EIA, with confirmation)
HBsAg
HCAb
Disqualify if
+ HIV
+ HBsAg
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ARP Position Statement
Blood-Borne Infectious Disease
Fighter with + HCAb should be disqualified
UNLESS the following conditions are met…
Documented proof of completed treatment
3 consecutive viral load blood test within a 6
month period including a test 2 weeks prior to the
bout
Clearance from an Infectious Disease physician
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State Specific Requirements
Brain Imaging
CT or MRI
Some states require baseline no mater what
Usually every three years
Other states require only if
Older than 35
Extensive losing record
Consecutive losses in a row
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State Specific Requirements
Cardiac Testing
Some states require baseline EKG no mater
what
Other states require EKG only if
Older than 39
Some states require other
Perfusion if older than 39
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State Specific Requirements
Blood Tests
Some states require
CBC
CMP
PT/INR
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ARP Position Statement
Medical Clearance of the over 40 fighter
Recommendations in addition to annual physical,
blood-borne testing and annual eye exam
Initial MRA of the brain
Annual MRI of the brain
Annual EKG and perfusion testing
Annual formal neurocognitive testing
Annual CBC & CMP
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ARP Position Statement
Medical Clearance of the over 40 fighter
If results suggest any deterioration in health
status that fighter should not be granted a
license.
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Female Fighter Requirements
SOME states require
Serum Pregnancy test within 30 days of fight
Urine Pregnancy Test right before fight
Full Gynecological Exam
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Fighter Medical Insurance
Many fighters do not have medical
insurance while training
Mandatory medical coverage by promoter
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Other players - Promoters
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Other Players - Commissions
Commissions purpose
Regulate combat sports for the protection of the
public and to ensure the health and safety of the
combatants.
However
Political
Positions are appointed
No MMA in New York
Make the State money
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Typical Event Coverage
Arrive about 2 hours before the event Physical exam of each fighter/referee before
event
Establish a relationship/normals with each fighter and to look for “red flags”
HR, BP
Face
Eyes
Heart/Lungs/Abdomen/Ribs
Hands/Ortho
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Typical Event Coverage
One or multiple physicians covering
Scout out the area
EMS – Nearest hospital
HAVE A PLAN
AED, O2, Board a must have
If EMS goes and no back up – event should be
stopped until another rig arrives
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Typical Event Coverage
Sit Ringside
Observe
Defending themselves
Style change
Ready to be called in
Know the situation
No fight can start unless a doctor is ringside
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Get to know your refs!!!!
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Typical Event Coverage
Post fight exam
Winners & Losers
Abridged
Depends on # of doctors
Mental Status
Neuro
Eyes
Hands
Address any complains
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Suspensions
Mandatory Minimum Suspensions TKO – 30 days
KO – 60 days
Submission less than 1 minute – 30 days
As ringside physician you can Increase minimum suspension
Issue medical suspension until cleared by
Orthopaedics
Ophthalmology
Neurology
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Suspensions
Excessive Head Trauma
Some states allow for a physician to issue a
medical suspension to a fighter if they have
taken “excessive head trauma” during the course
of the fight.
Even if the fighter is having no complaints and
has a normal post-fight exam
Even if he/she won the fight
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Common Injuries
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Metacarpal Fracture
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Dislocations
It is dislocated?
Fracture???
N/V status?
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Lacerations
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Lacerations
Location, location, location
What to look for
Can the fighter see?
Excessive blood loss
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Lacerations
Repair
On-site vs. hospital
Size
Location
Physician availability
Comfort level
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Eye Trauma
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Eye Trauma
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Eye Trauma
Any loss in vision/movement during/after
fight…
Goes right to the ER
Slit lamp exam
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KO
Immediate Tx
CABs
Eyes
Neck
Oxygen
Be patient
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KO
Post-fight Management
Mental Status
Full Neuro Exam
If a fighter experienced
LOC for a long period
of time – send to the
ER
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Concussions
Post-fight Management
Mental Status
Orientation
Full Neuro Exam
Cognitive
Monitor
Educate
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Concussions
Post-fight Management
TAKE HOME POINT
Fighters do not complain
If a fighter is complaining about concussion
symptoms after a bout I would recommend
sending them to the ER for further evaluation and
imaging
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Hot topics
Therapeutic Use Exemptions
Testosterone Replacement Therapy
ARP issued a statement for ban in Jan, 2014
Nevada voted to ban in Feb, 2014
Some commissions still allow it
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Hot Topics
Weight Loss and Dehydration
Very similar to the crisis that wrestling faced in
the late 1990’s and early 2000’s
Deaths involving weight cutting
Increased risk of head injury?
ARP supports a certification program similar to
wrestling
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Do you want to be a ringside doc?
Get in touch with your state athletic
commission
Requires state medical license
SOME states will have you work under a
experienced ringside physician for a couple
of cards before allowing you to work on
your own
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Association of Ringside Physicians
Mentoring program
Ringside physicians around the country willing to
bring students and residents to events to learn
ringside medicine
Some states are more willing then others
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ARP/ACSM Certified
Certification
Certified Ringside Physician
Minimum requirements and pass a test
Not a requirement, but maybe some day
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Association of Ringside Physicians
Annual Conference
New Orleans
September 25-26
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Association of Ringside Physicians
www.associationofringsidephysicians.org
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References
Varlotta GP, Jordan BD, Medical issues in boxing. Clinics in Sports
Medicine. 2009, Vol. 28; 505-648
Kelly M, Fight Medicine: Diagnosis & Treatment of Combat Sports
Injuries for Boxing, Wrestling & Mixed Martial Arts. 2008
Baird LC, Newman CB, Volk H, et al. Mortality resulting from head
injury in professional boxing. Neurosurg. 2012, Vol. 67; 1444-1450
Hutchenson MG, Lawrence DW, Cuimano MD, et al. Head trauma
in mixed martial arts. Am J Sport Med. 2014, Vol. 20; 1-7
Otten MH, Ghazarian N, Boura J, Ultimate Fighting Championship
Injuries: A two-year retrospective fight injury study. Osteopath
Family Physician. 2015, Vol. 7; 13-18