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Panel discusses the management of musculoskeletal injuries, concussion by ringside physicians

Issue: May 2014

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While the popularity of boxing is diminishing in the United States, combat sports —particularly mixed martial arts or unlimited fighting— has become a multi-million dollar sport.

Mixed martial art (MMA) combat sport or “cage fighting” is a combination of wrestling and boxing. With this sport, the boxing gloves are taken off and the combatants punish their opponents by multiple punches resulting in concussion and broken bones. Significant injuries to the extremities may occur when a joint is placed in an extended position, in particular, the elbow with so-called “joint lock” or “submission hold.” The combatant may “tap out,” that is give up before a significant injury occurs. When a concussion occurs, the match is stopped and cannot be restarted. The final large injury category of injury is a “choke out,” where both carotid arteries are simultaneously compressed shutting off the blood supply to the brain resulting in the athlete losing consciousness. When athletes are aware they may be losing consciousness, they can “tap out” or the referee can stop the bout. Concussion is common in all sports, but the submission holds and the “choke out” are unique to MMA.

Orthopedics Today has assembled a panel of physicians with extensive experience in boxing and MMA. Robert C. Cantu, MD, is an internationally recognized leader in the management of concussions in all sports. Joseph Estwanik, MD, founder and president of the Association of Ringside Physicians (ARP), has been physician to the U.S. Olympic Boxing Team and published a textbook on combat sports. Richard N. Weinstein, MD, MBA, the medical director of the International Boxing Federation and an orthopedic surgeon, has extensive experience at all levels of professional and amateur boxing and mixed martial combined sports.

John A. Bergfeld, MD
Moderator

John A. Bergfeld, MD: Describe the ARP and its goals, educational activities and accreditation program.

Joseph J. Estwanik, MD: When I first agreed to “cover” a boxing event in 1980, it was immediately obvious that these dedicated athletes were deprived of the sports medicine standards of technology that were, even then, customary within traditional team sports. In their world, their “doc” was a cut man. Because boxing was no longer a collegiate sport as it was in the 1950s and 1960s, their divorce from the academic milieu deprived boxing of the evolving principles of sports medicine care standards within professional, collegiate and high school sporting events. I rapidly realized that simply laterally transferring current standards of care could significantly impact safety and performance.

The ARP, in its current structure, began about 12 years ago. After several years of subcommittee effort by 15 highly experienced ringside physicians from five countries, an ARP certification exam is now available. The American College of Sports Medicine partnered to coordinate a validated, PhD-monitored, psychometrically validated exam available globally. To quote one of our members, “A doctor at ringside is not the same as a ringside physician.” The variety and overlap of skills necessary for care and decision-making broadly encompass many specialties. In my opinion, a “soccer doc” will be uncomfortable and unprepared to sit ringside in the “hot seat.”

As in all sports, the pre-bout history and exam, instantaneous decisions at ringside and predictive knowledge of mechanisms of injury are unique to boxing and even more technical within the MMA. Ringside medicine occupies a knowledge base compatible with a medical subspecialty.

The ARP seeks consultation and collegiality of established sports medicine organizations to supplement their respect and guidance for these highly dedicated athletes. They have been deprived of traditional team sport advances. Ancillary health care providers, such as athletic trainers and physical therapists, are being recruited to extend care into their gyms, dojos and training facilities.

The billion-dollar industries of MMA and boxing also influence the aerobic training programs of fitness and recreational exercisers. Coverage of the combat arts requires not only a knowledge of first–aid, but also a working knowledge and refined expertise in immediate aid. This year’s ARP annual course will occur at the Vdara Hotel in Las Vegas from Oct. 30-Nov. 1 with CME credits provided. For more information, visit http://associationofringsidephysicians.org.

As an organization, the ARP has been vocal and prominent in our recent statements on athlete safety, which has apparently caused diverse attention on multiple media outlets. The ARP supports and recommends:

• the general elimination of therapeutic use exemptions for testosterone replacement therapy in professional combat sport athletes;
• the continued use of headgear in amateur boxing as well as efforts to improve the effectiveness of the headgear; and
• the use of dual arch (upper and lower) mouthpieces for the protection of the teeth and temporo-mandibular joints.

Bergfeld: What is the role of the ringside physician in boxing or MMA matches?

Estwanik: The skill set of a ringside physician begins with knowledge of the rules, common injuries and etiquette of boxing and MMA. A nurtured sliding scale of tolerance for gravity of injury exposure between professional, amateur and youth participation requires experience and a mature confidence based upon sport specific “radar.” Non-orthopedic injuries of the face, eye, skin, laceration management and concussion management stretch beyond bone and joint. Being a weight-category sport like wresting, significant abuses of weight loss, making weight, 24-hour body weight regains of up to 25 pounds, highlight ongoing, unsolved and unregulated abuses.

Bergfeld: How are concussions managed in the amateur and professional boxing and MMA?

Robert C. Cantu, MD: Wrongly, I believe concussions are managed differently in professional boxing and MMA and, to a lesser extent, in amateur boxing and MMA than in other sports. The standard in football and other collision sports is to immediately remove an athlete from the contest or practice if a concussion is diagnosed or cannot be ruled out. In especially professional boxing, athletes are usually allowed to continue if they seem alert answering questions, appear to have normal balance, can protect themselves and continue to throw punches. This is because tradition is hard to overcome. I believe the standard should be the same in all sports as the brain should not be absorbing more punishment if concussed.

Bergfeld: What are your thoughts on the athlete returning to fighting after a concussion, i.e., the standing 8 count?

Cantu: I am not in favor of the standing 8 count if it allows fighters to continue after being concussed just because they seem to be quickly recovering. I do not believe a thorough assessment for concussion can be carried out in 8 seconds.

Bergfeld: What are your thoughts about a boxer returning after being knocked out?

Cantu: In amateur boxing, a boxer has a mandatory 30-day restriction from sparring in the gym or fighting if the referee stops a contest due to head blows but there is no loss of consciousness (LOC). If there is less than 2 minutes of LOC, then it is a 90-day restriction. If there is an LOC greater than 2 minutes, then it is an 180-day restriction. In professional boxing, this can vary by state. My feeling is these should be minimum guidelines and, of course, boxers must have totally recovered from the concussion before they resume sparring.

Bergfeld: Is the choke-out maneuver a dangerous maneuver?

Cantu: The choke-out maneuver is not dangerous if the referee quickly sees it and stops the contest. There have been rare reports of carotid artery dissection but there have also been rare deaths from subdural hematoma and dysautoregulation (second impact) syndrome.

Bergfeld: How do you become a ringside physician?

Richard N. Weinstein, MD, MBA: Physicians who work at ringside range from orthopedic sports medicine specialists, to neurologists, ENTs, ophthalmologists to emergency room physicians. Not only do all of the physicians at the fight need to know the basics of ringside medicine, but they also depend on each other for specialized evaluations and treatments. More than in many other sports, working ringside requires mentoring to understand what to do. In New York, we have at least three physicians at every fight and new physicians need to be trained for several fights before they can work ringside. The physician has the responsibility to stop a fight when appropriate, but we also owe it to the athletes and the fans to know when to allow a fight to continue.

Bergfeld: What do ringside physicians have at the ringside?

Weinstein: We always have an ambulance and emergency medical technicians. They have backboards, cervical collars and intubation equipment. Before the fight starts, we make sure the nearest level 1 trauma center is aware of the fight and a neurosurgeon and other specialists are available. I always have suturing equipment and local anesthesia. We have blood pressure cuffs, pen lights and stethoscopes as well. Most importantly, I always have lots of gloves and 4x4s.

Bergfeld: How is working ringside different than being a physician for other sports?

Weinstein: Unlike many other sports that physicians cover, boxing and MMA require many different skills for which we are not typically trained. We need to look for concussions and know how to deal with significant lacerations and bleeding outside the operating room. We need to perform pre-fight physicals looking not only for musculoskeletal problems, but also signs of chronic and acute neuropsychological injury. During a fight, we need to make a determination of whether to stop the fight when one of the combatants is hurt. We need to treat the fighter acutely and decide if the injuries are severe enough to warrant transfer to the hospital. Ringside medicine is one of the few sports where the physician may have to decide to stop the competition.

Bergfeld: When do you stop a fight?

Weinstein: Most of the fights that need to be stopped are done by the referees. As the ringside physician, it is critical to establish a relationship with the referees before the fight. In MMA and rarely in boxing, the fighter can quit or “tap out.” In New York and most other states, the physician can stop a fight. When do I stop a fight? There are two simple reasons to stop a fight. One is if the boxer cannot adequately defend himself. This includes inability to use one or both arms, such as suspecting a hand fracture or shoulder dislocation. Also, if there is a leg injury where the combatant cannot move well enough to avoid getting hit. The second reason I stop a fight is if the combatant cannot see out of one or both eyes. If the fighter cannot see a punch coming, then it is too dangerous to continue fighting. It is not uncommon to have a laceration right above the eye that bleeds profusely into that eye. I am often impressed with the cut man’s ability to stop bleeding in the 1 minute between rounds with pressure and adrenaline/Vaseline. More often than not, a fighter and his corner men will not want the fight stopped. As the physician at ringside, I have to be willing to stop the fight despite their protests — and their protests can be adamant.

Bergfeld: How does being a ringside physician differ from being a physician covering other sports?

Weinstein: Ringside medicine is one of the only sports where we examine every athlete before competition, during competition and after competition. We require mandatory blood tests for hepatitis and HIV as well as brain scans, EKGs and fully physical and mental exam. A physician sits in each corner and has to watch the fight looking for injuries as well as signs of injuries. We need to be ready to jump in the ring to protect the fighter from further injury.

Bergfeld: What are the most common injuries seen at ringside?

Weinstein: The most common injuries are lacerations. Fractures and dislocations are uncommon but do include facial fractures including orbital, mandibular and nasal fractures. Hand fractures are not common, but do occur. In MMA, we see extremity fractures and dislocations often from submission holds where the fighter does not tap out in time. Soft tissue injuries are common, but are usually contusions. I have seen distal bicep tears and rotator cuff injuries, but these are rare. Large bone fractures are rare, but can occur in MMA with kicking and blocking. Hand injuries are common, but usually are just contusions of the second and third metacarpophalangeal joints. Chronic hand injuries in experienced boxers can lead to boxer’s knuckle and metacarpal bossing, both of which may require surgical treatment. In one study, of all the MMA injuries, 13.5% were hand injuries second only to facial lacerations. Increasing age of fighters and increased number of rounds fought in boxing lead to higher likelihood of injury.

Bergfeld: What is the significance of submission holds in MMA?

Weinstein: Submission holds are when one of the fighters stresses the opponent’s joint beyond the normal position. Common holds are elbow hyperextensions, “knee locks” and “ankle locks.” These locks stress the joint capsule and supporting ligaments and if continued will lead to joint dislocations or fractures. An ankle lock is forced plantar hyperflexion and may dislocate the ankle. A heel hook locks the ankle and provides torsional stress through the knee and can result in tears of the MCL or ACL. MMA requires good referees and smart fighters who know when to stop the fight before serious injury occurs. As an orthopedist at ringside, it is distressing to watch a joint being stretched beyond its limits.

There are some specific rules for MMA that help protect the combatants. It is illegal to do small joint manipulations. Strikes to the back of the head and kicking to the head of a downed opponent are also banned. Fighters are allowed to “tap out” which is critical when placed in a submission hold or choke to prevent a potentially devastating injury.

Bergfeld: Should orthopedists be ringside?

Weinstein: The fighters are amazing athletes and it is an honor work with them. The amount of cardiovascular conditioning it takes to throw punches and dance around the ring while getting hit is insane. We are knowledgeable in trauma and sports and uniquely qualified to help protect these fighters. It is usually an exciting night out working at the fights and being in the corner, and we are the right people to help these athletes.