Combat Sports Medicine: Martial Arts Injuries How Practitioners Should Identify them and Administer...

Combat Sports Medicine: Martial Arts Injuries How Practitioners Should Identify them and Administer First Aid Julian Perez, MD Primary Care/Sports Medicine Shoshin Ryu National Seminar Boise, ID August, 2015

Back in the old days

Return to Sport

Evidence Based Martial Arts Big Idea! Thanks Conieris Sensei

Epidemiology of MMA injuries 2010-2013 U.S. Armed Forces: All comers, 21 Musculoskeletal (MSK) injuries/ 10,000 Person years (P-Yrs) Among new recruits in basic training in combat sports, 780/10,000 P-yrs Sprains, strains, contusions most common Concussions/Head injuries = 3.9% Skull/facial fractures, intracranial bleeds = 2.1% Hand/wrist fractures more common in boxers Wrestling had more open wounds and dislocations

Senseis medical bag 4x4 Gauze pads Pen light Tampons (for nose bleeds) Band aids Q-tips Athletic tape Horseshoe-shaped felt 4 elastic wrap (Ace) Non-stick dressings Antibiotic ointment or vaseline Medical Gloves 3 Aluminum SAM splint Triangle bandage for compression or sling Quart-sized freezer-quality zip lock bags for ice application to sprains/strains Salt/sugar dry mix/tablets Scissors Blister pads Nail clipper

General rules for safe training General Below the neck rule Adequate frequent hydration (Q20 min) Evenly matched Uke Tap out or deal w/ injury Overuse injuries Over training/burn out Proper nutrition for performance 3:1 rule Pediatric concerns Growth plates Avulsion injuries Heat stress Growing pains Asthma attacks Psychiatry of young athletes

Overheating: Men vs. Women Less muscle mass = less heat production Less sweat production (50-75% of mens) Women have higher SA/Body Mass ratio so dissipate better by radiation Confers advantage in hot/humid environments **Obese folks have lower SA/Body mass thus higher risk for heat illness

Fluids: Ins and Outs Baseline 8 glasses fluid/day average person Increase fluids in 24 hrs prior to competition 400-600mL about 2-3 hrs prior to exercise 150-350mL about 5-10 min prior to exercise 150-350mL Q15-20 min during exercise Check urine color. May need more!! Thirsty? Too late. Already 1-2% dehydrated Voiding every 30-45 min? Too much in.

The PRICE of Martial Arts Injuries Protect from further injury. Splint, sling, remove from training Rest gives time to heal Ice first 48-72 hours to reduce swelling Compression reduce swelling w/ ACE wrap Elevation reduce swelling. Above heart. NSAIDS (Non-steroidal anti-inflammatories) falling out of favor for acute injuries in lieu of neutral inflammatory management (massage). Use should be limited to first 48 hrs at most if used at all.

Case #1 Uke attempts to kick Tori in groin. Tori expertly blocks with cross block, bringing knees together, then scooping Toris leg and performing osotogari on remaining leg. Uke hits ground hard and bounces head off mat. No loss of consciousness, but his wind knocked out, it takes Uke about 5 minutes to regain breath and composure. Later in class Uke has to sit out with dizziness and a head ache.

Concussions Mild Traumatic Brain Injury mTBI

Concussion Definition Acute Transient alteration of Brain function, caused by Impulsive force resulting in Supply/demand imbalance in brain biochemistry that Manifest as typical symptoms

Impulsive force To head To body Can happen anywhere!

Symptoms Immediate Disorientation Impaired motor function slow, uncoordinated Altered or slow speech Difficulty processing new information Memory deficit antegrade and retrograde amnesia* Delayed (over hours/days) Headache Dizziness Head pressure In a fog Out of it Im not right Tired, want to sleep Light/sound intolerance Emotionally labile (esp kids)

Do you have to get knocked out to have a concussion? Not out Knocked out

Does gear prevent concussions? No!

Concussion Summary Concussions are acute, reversible brain conditions caused by impulsive force resulting in supply/demand imbalance in brain that manifest in typical symptoms of HA, dizziness, poor balance, fogginess Neurobiochemical changes last 7-10 days on average Trust your intuition When in doubt, sit them out YOUR JOB IS TO PREVENT FURTHER INJURY TO BRAIN No same day return to play No benefit to strict rest in youth Have practitioner see a medical professional trained in concussion management (medical doctor, athletic trainer, nurse practitioner or physician assistant) to be cleared for return to sport

2014 J Sports Medicine: Head trauma in Mixed Martial Arts 2006-2012 MMA UFC matches reviewed for mechanism of TKO and KO as well as injuries that happened after LOC (loss of consciousness) KO rate: 6.5/100 athlete-exposures(AEs)(13% matches) TKO rate: 9.5/100 AEs (19% matches) Total match-ending head trauma 16/100 AEs 32% matches

Anatomy of a KO Factors that contribute to KOs: Middle weight and heavy weight classes Earlier time in a round Earlier round in a match Older age victim Repetitive strikes Prior KO put fighter at risk for subsequent KO All KOs were direct blow to head, 54% to mandible

Collateral damage In 30 seconds prior to TKO decision, fighters sustained average 18.5 strikes (Range 5-46) with 92% of those to the HEAD. Lesson learned: 1.Head trauma ends 1/3 fights 2.Fighters are head hunters 3.When faced with overwhelming firepower, move your head or cover up and expect to get hit while you find an escape route 4.Roundhouse punch/elbow/kick to jaw early = KO 5.Pick fights with OLD GUYS!

Concussion: What not to miss! Subdural hematoma Symptoms: altered mental status, severe headache, speech difficulties, all getting worse rapidly. What to do: Call 911 NO NSAIDS or Aspirin

Concussion: What not to miss! Cervical spine injury Symptoms: neck pain and radiation to both arms or legs either temporary or lasting What to do? Lie down, immobilize neck Call 911 for medic evaluation/transport. Neck immobilization demo

Concussion: What not to miss! Heat stroke Symptoms: altered mental status, abnormally dry skin given conditions, skin hot to touch, pinpoint pupils What to do: Get temperature down ASAP! Remove clothing, ice bags in axilla and groin, dunk in ice water if possible, call 911 for transport

Kids Physiology Higher surface area:body mass ratios Allows for efficient heat dissipation by radiation Children sweat less Require greater core temperature increases to trigger sweating Acclimatize more slowly Produce more metabolic heat per mass unit than adults. Children also may lack adequate blood flow for both muscles and cooling needs because cardiac output at a given metabolic rate is lower.

Bottom line for kids No training in hot environments (over 95F) No training in midday sun Frequent water/rest breaks in heat they need to be reminded to drink Flavored drinks may help get fluids in If its too hot outside, move training indoors If its too hotreschedule

Heat illness prevention Heat acclimatization, or the gradual increase in exercise intensity in a warm environment over 10-14 days, has been shown effective in reducing one's chances of heat-related illness Evidence category C Athletes should avoid exercising when the heat index is elevated (> 40 degrees Celsius or >104 degrees Fahrenheit is dangerous for heat-related illness, with >106 degrees Fahrenheit or 41 degrees Celsius causing high risk of EHS)

Heat illness prevention Increased environmental humidity reduces evaporative cooling Avoid intense activity during/close to illness Athletic clothing should be loose to allow for air flow to the skin and thus better convective cooling. Change when soaked w/ sweat. Proper hydration during exercise and good physical fitness also lower one's chances of exertional heat stroke EDUCATION OF STUDENTS AND SENSEIS

Case #2 During competitive randori bout, Tori catches Uke in a beautiful hip throw but to avoid losing, Uke tries to avoid fall using other arm. He falls on an outstretched hand and his elbow buckles. Intense pain and when he hits ground he grabs elbow That doesnt look so bad Remarks Tori

Injuries in Judo. Br J Sports Med 2013 Sprains, Strains, Contusions of knee, shoulder, fingers most common injuries with rate of 13- 29% Being thrown = most common injury mechanism (70% injuries) Severe injuries were to brain and spine almost all during throw Shoulder/elbow dislocation most common in Uke trying to avoid throw by fall on outstretched hand

Elbow injuries Elbow fractures are not always obvious radial head, supracondylar fractures. Palpate bones for pain. Elbow dislocations lock out Elbow sprains can move Remove from training Ice SAM splint and sling Send to doctor for XR evaluate Needs clearance to return

Case #3 Johnnys first day in class. He is learning to roll and dives (literally) right in from standing and doesnt put his hands out. Lands on his shoulder and feels a pop and pain. You look at him and see this

AC joint separation PRICE Sling If tented skin, see doctor for XR Most of the time nothing to do aside from rest until pain resolves Very few need surgery unless skin torn or tense

AC separation: What not to miss! Collar bone fracture Hurts like hell and swells and bruises more Point tender over bone, not joint +/- deformity What to do? Remove from training, sling arm, ice, send to doctor for XR and return to train clearance

AC separation: What not to miss! Dislocated shoulder Look for: squared off shoulder and Uke holding arm in a lot of pain What to do: Reduce ASAP and if cant get back in easily, send to ER for reduction Needs clearance for return to train Shoulder reduction demo

Case #4 Tori and Uke are training on kick blocks. Tori throws vicious roundhouse at Ukes midsection. Uke puts light hands out to tap leg and catches foot on tip of finger Immediate pain reflex and finger deformity

Case #4 continued Tori had bad aim and technique. He hits Uke with his toes and feels/hears a crack and lots of pain. Goes to ground grabbing foot

Canadian Martial Arts Injury Survey BMC Public Health, 2010 Karate injuries were the most prominent (32.5% [299/920]), while injuries due to tai chi were least reported (0.5%) The most serious injuries were recorded in kung fu (40% [6/15]); aikido and jujitsu had the lowest percentages Fractures were the most common injury reported, nearly half of which were reported in karate (72/189). These injuries were most serious in karate; 74% (53/72) were admitted or required follow-up care. More female subjects sustained self-inflicted injuries (41.0% [118/288]), such as fractured limbs from a fall or foot injuries from dropped weapons. The highest number of self-inflicted injuries was reported in the youngest age group;

Dislocated/Fractured digit (little toe or any finger) Most are reduced by injured person grabbing hand while in pain Safe to do gentle traction and straightening Splint Sit out PRICE Send to doctor for XR

Case #5 Right after Sensei relocates his students finger and buddy tapes it, he throws him back in the ring for more pummeling! Tori takes Uke to the ground and gets him into side mount. Uke shrimps out and in the process jams his thumb

J of Hand Surgery, 2013 Injury prevalence study of many arts The hand/wrist was the most common area injured (53%), followed by the shoulder/upper arm (27%) and the forearm/elbow (19%). Joint sprains/muscle strains were the most frequent injuries reported overall (47%), followed by abrasions/bruises (26%). Dislocations of the upper extremity were reported by 47% of participants while fractures occurred in 39%. Surgeries were required for 30% of participants

Thumb ulnar collateral ligament sprain Unless completely ruptured, can be taped or splinted and most will heal Ice after class High risk to injure again Taping demo If Uke has no strength in hand send to doctor for XR and evaluation.

Case #6 Sensei sends in 2 more attackers in to beat up Uke! Uke did not listen the day Sensei told him to keep his foot flat when moving on the ground. While up on his ball of foot, an attacker falls onto Ukes heel and Uke feels burning pain in his great toe joint. Arrow=impact

Turf toe (Great toe plantar plate injury) PRICE Remove from mat Very painful Long recovery Grades of injury Disabling pain needs to be evaluated by medical professional and protected/taped when returns to train

Case #7 Sensei tapes Uke up and sends him in again w/ advice to do foot sweep Tori next time she tries to toss him with a hip throw. Uke tries the sweep but ends up planting Toris forefoot into mat while she comes in for throw and turns her ankle hearing a pop.

Lateral ankle sprain Excruciatingly painful Swell rapidly PRICE Remove from training Consider ER/MD if cant bear wt Horseshoe felt under ACE wrap for compression Ice Q20 min every 3-4 hours for 2-3 days Get them moving ankle ASAP within 72 hrs

Lateral ankle sprains #2 reason for musculoskeletal ER visits behind back pain Repeat sprains can lead to chronic instability and ankle arthritis Should tape/brace ankle for up to a year after bad sprain while training Critical to retrain tendons for proprioception Athletes do WORSE if you immobilize too long

Joint sprains: What not to miss! ACL tear - The most common mechanism of injury was a fall, throw or jump (32.7% [301/920]). Tori loses balance in uchi mata or Uke suffers hard shot to weight-bearing knee w/ osoto-gari. Usually hear/feel pop Swells almost immediately. Hurts like hell. Cant bear weight What to do: PRICE (SAM splint knee) and send to doctor for evaluation. Needs clearance for return to train

Case #8 After composing herself with a freshly sprained ankle, Tori, like an injured bear, lashes out at Uke with a swift kick to the &@!!s...uh, groin.... &@!!s...uh, groin Uke goes to ground

Testicular contusion PRICEkinda.. Definitely protect remove from training temporarily Ice if swelling If excruciating pain lasts more than 30 minutes, send to ER for evaluation to rule out testicular fracture or torsion

What not to miss Spleen, liver, kidney injury Cant train for 4 wks after Mono infection Achy belly pain referring to one shoulder Rapid decrease in mental function due to blood loss and decreased blood pressure What to do: Lie down face up, lift legs, call 911 for urgent transport Requires MD permission for return to train

Case #9 Uke, now having had insult added to injury pulls out a cheap move and pokes Tori in the eye 3 Stooges style. She goes to ground

Corneal abrasion Hurts, can swell a bit, eye may turn red. Persistent sensation of foreign body common. Have injured person irrigate eye copiously to wash out any foreign bodies Dont patch eye. Associated w/ higher risk of infection. Use dark glasses for sensitivity. Can irrigate at home with sterile saline from pharmacy. Most will heal up in 72 hrs. If not feeling better in 72 hrs, see doctor

Corneal abrasion: What not to miss! Just kidding

Corneal abrasion: What not to miss! Hyphema blood in anterior chamber. EMERGENCY Can result in Permanent vision loss Remove from mat, patch eye, sit up Straight to ER

Case #10 And just to finish it off in style, Tori hauls off and punches Uke right in the nose, bloodying him up. Sensei congratulates them on a good clean fight and applies first aid to Uke.

N Am J of Sports Phys Therapy, 2009 55 subjects, 207 injuries Low belt ranks had significantly more injuries more than any other belt rank, resulting in more than two times higher injury rate. The most common body region injured was the head/neck/face (38.2%), followed by the lower extremities (30.4%), upper extremities (22.7%), torso (8.2%), and groin (0.5%). Injuries to the nose (6.3%), shoulder (6.3%), and toe (6.3%) were the most common. The most common type of injury was contusions (29.4%), followed by strains (16.2%), sprains (14.9%), and abrasions (10.1%).

Epistaxis Remove from training. Universal precautions with blood on mat Decide if this is something you can handle in dojo i.e. gushing blood or trouble breathing needs to go to ER Deformity of nose? No Place tampon into nare Cool down head and neck

2 Illegal moves in MMA Ideas for what we should do more of! Mixed Martial Arts: Injury Patterns and Issues for the Ringside Physician. Seidenberg, Peter; MD, FAAFP Current Sports Medicine Reports. 10(3):147-150, May/June 2011. DOI: 10.1249/JSR.0b013e31821cc952 TABLE 1. Actions prohibited by the unified rules of mixed martial arts.

Summary Top injuries are contusions (bruises), joint sprains and strains of muscles Upper extremities #1 site Head #2 site PRICE avoid further injury Concussion: When in doubt, sit them out Sensei should have a first aid kit Safety first, train smart, have fun!

Thank you!..sir, May I have another!

Combat Sports Medicine: Martial Arts Injuries How Practitioners Should Identify them and Administer...

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