The popular combat sports considered in this article are boxing, karate, wrestling and judo. Although these sports produce relatively few injuries compared to others, until recently karate has had a high incidence of disabling injury (Weightman and Browne, 1975; McLatchie, 1976; McLatchie and Fitzgerald, 1979). The injuries can be serious often necessitating a long period off sport or work before recovery is complete. The range of injury produced by these sports is wide – from a bruise to a brain injury – but certain of them carry particular risks. These sports and their resultant injuries are now considered in detail and the mechanism, emergency treatment, and possible methods of prevention discussed.
The ‘noble art’ has been an attraction since Greek and Roman times. Boxing mania was so intense at the end of the eighteenth century that even the storming of the Bastille was relegated to the back pages of the London papers because it clashed with a popular heavyweight contest! Although extremely popular until the Second
World War the sport lost prestige and now only about 7 000 bouts are staged in the United Kingdom per year.
It has always been a target for criticism by both the lay public and, in particular, by the medical profession because of the injuries which can occur in the course of a bout or as a result of continued participation in the sport. The very nature of boxing in which two contestants confront each other and attempt to land blows on a particular target must of necessity cause injury. Such injuries can be reduced to a minimum by improvement in equipment and technique but there will always remain a number of injuries which will require prompt and adequate medical attention.
The instruments of attack, the hands, and the target of attack, the head, are the most common sites of injury; indeed injury to other areas or organs is rare.
Head injury is the most important boxing injury. The ‘punch drunk’ syndrome was first described by Mart-land in 1928, since when medical supervision has been mandatory. The efficacy of this is such that boxing now ranks eleventh as a cause of serious injury in sport (Weightman and Browne, 1975). Regular medical examinations of professional boxers, including electroencephalography, are now carried out. If a boxer is ‘knocked out’, a minimum period of four weeks must elapse before he can take part in further bouts.
When death occurs following head injury it is nearly always due to intracranial bleeding and, according to Green (1978), subdural haemorrhage into one of the middle cranial fossa is the most common finding. These bleeds are thought to be due to prolonged battering and for this reason most amateur bouts last only three rounds whereas professional bouts still last ten to fifteen rounds.
Previously traumatic encephalopathy or ‘punch drunkenness’ was commonly seen in the slugging boxer or sparring partners (Williams and Sperryn, 1976). Its onset is insidious and clinical signs are difficult to detect. The deterioration in the boxer can best be observed in the ring. His movements are slowed, he stands on a broad base and with impaired reflexes he is less able to avoid a blow. At a later stage he seems drunk. He is fatuous, emotionally labile and has slurred speech. Memory and intellect become impaired and eventually even moral sense is lost. Pathologically there is progressive ventricular dilatation with diffuse cerebellar and cerebral neuronal degeneration. The neurological features have been ascribed to petechial haemorrhages in or near the brainstem and to the diffuse cerebral changes already described. Repeated minor trauma is thought to be the cause (Roberts, 1969).
Orbital and eye injuries
Serious eye injury is rare but cases of retinal detachment, paralytic diplopia (double vision) and optic atrophy have all been reported (Doggart, 1965; Rugg-Gunn, 1965). Following such injuries retirement is mandatory. The eye injury most commonly encountered is due to head butting or from the boxing gloves; this results in cither abrasion or laceration of the cornea or peri-orbital cuts, I.e. cuts around the region of the eye. The diagnosis of corneal abrasion can be made by instilling into the eye, a drop of fluorescein which stains the abrasion. Most small abrasions heal in two to three days and a pad may be worn for that period. Peri-orbital cuts may require suture thus forcing withdrawal from the bout.
Nose bleeds and nasal fractures with dislocations of the nasal septum are fairly common. These produce the typical boxer’s nose with considerable cosmetic deformity. Fractures of the mandible and facial bones do occur but are also unusual. Haematoma of the pinna, I.e. the broad upper part of the external ear, producing ‘cauliflower ear’ is also unusual because early aspiration and the injection of proteolytic enzymes allows early resolution.
Fracture or fracture-dislocation of the base of the first metacarpal is a common injury. The reasons for this are the position of the thumb in a separate compartment of the glove coupled with poor technique in delivering a blow; it may also occur through heavy contact with the ring floor. These injuries require manipulative reduction and occasionally surgical treatment because they are unstable injuries. The necks of the second and fifth metacarpal bones are the next most commonly sustained fractures. After reduction three to four weeks’ immobilisation in a dorsal slab is all that is required.
Prompt medical attention and better informed refer-eeing has contributed much to the reduction in the incidence of boxing injuries. This must be maintained and improved to defend the sport against adverse criticism.
Karate is one of the oriental martial arts and has become very popular as a sport in recent years mafnly through the film industry and television. It is estimated that there are 28 000 people who practise the various styles of karate in Great Britain today. Until 1977 the. British team held the world title.
Contests are of two types: controlled and full contact. In the controlled or traditional sport a competition lasts only two or three minutes. Points are scored when a blow – either a punch or a kick – breaks through an opponent’s defence to reach his head, face or trunk. A half-point or a whole point is scored, depending on the power of the blow and the part of the target to which it is delivered. Punches and kicks are ‘pulled’ before contact is made so, theoretically, injury should be rare. The full contact sport is self-explanatory with rounds of three minutes duration like boxing.
Injuries do occur but especially in the controlled sport. Many are accidental due to poor control or judgement; some are intentional. They fall into three main groups: 1. Cranio-facial and cervical injuries 2. Visceral injuries 3. Limb injuries.
Cranio-facial and cervical injuries
Lacerations, abrasions, nose bleeds and black eyes are common and only cause withdrawal from the contest when bleeding is persistent or the eye is closed due to peri-orbital swelling. Steristrip or sutures to lacerations and adrenalin packs for serious nose bleeds are effective methods of treatment. Nasal fracture can occur and present with the features of ‘boxer’s nose’. Fracture of the malar bone has been reported by Serres et al (1973) – the affected man presented with a palpable depression on the right side of his face and suffered from double vision. He also had paresthesia (tingling) due to nerve entrapment over the affected side of his face. After the cheek bone was elevated the symptoms settled.
Concussion and skull fracture are the most worrying head injuries. Both can be caused by uncontrolled blows but also by the occiput striking a hard floor after a fall. Therefore, padded flooring is essential at all competitions. Cervical injury, in the form of dislocation, has occurred when spinning kicks have been used. Many associations have now outlawed such manoeuvres and their use in competition is actively discouraged .
The thoracic viscera can be damaged from direct blows producing a pneumothorax (lung collapse). The abdominal viscera are also vulnerable. Cantwell and King (1973) reported a single case of subcapsular haematoma of the liver in a woman who had received a combination of blows to the right subcostal region during her second karate lesson. She became ill six weeks later and a laparotomy (exploration of the abdomen) was performed. This revealed a large stellate laceration of the capsule on the dome of the right lobe of the liver. An organising haematoma with 1500ml of altered blood was aspirated.
Splenic rupture has been observed following heavy round house kicks to the left posterior and lower thoracic region. The patients so affected became profoundly shocked. Splenectomy was indicated in both cases (McLatchie, 1979). Renal trauma from the same technique also occurs but to date only haematuria has been observed with no renal damage evident on intravenous urography.
Blows to the solar plexus are common but recovery is rapid in almost every case (30 to 90 seconds). However, one case of acute traumatic pancreatitis with a serum amylase of greater than 12 000 International Units has occurred. The patient recovered with conservative treatment (McLatchie, 1979a).
Testicular injury, due to uncontrolled kicks, is acutely painful and forces retirement from competition. The use of proper groin guards diminishes this risk. Those injured have the consolation that their opponent is disqualified for using an illegal technique. Spontaneous recovery is the rule.
Injuries to the limbs
Peripheral nerve injuries are occasionally seen (McLatchie, 1977); the nerve affected is the ulnar nerve at the elbow and its deep branch in the hand. The lesion results from attempts to block kicks or from hardening the hands on firm objects (Nieman and Swan, 1971). The radial nerve is also injured by high kicks to the middle third of the upper arm. Footsweeps occasionally produce superficial peroneal nerve palsy, the foot striking the leg in the region of the fibular neck. Paresthesia over the distribution of the nerve results, but weakness and wasting of muscle groups have also been reported. Recovery time varies from hours to weeks but is complete.
Digital dislocations and sprains occur during attempts to parry blows when the affected digit is hyperextended. If no fracture is suspected reduction should be carried out and immobilisation in a boxing glove bandage allows the participant to continue fighting.
Thumb injuries are also common. ‘Gamekeeper’s thumb’ and ‘karate thumb’ (McLatchie, 1977) both occur as well as the previously mentioned Bennett’s fracture dislocation. In ‘gamekeeper’s thumb’ the ulnar collateral ligament is avulsed from the base of the proximal phalanx with the wedge of bone. In ‘karate thumb’ it is the radial collateral ligament which is affected. The former requires surgical fixation since it is potentially unstable, the latter requires conservative treatment. Puncher’s knuckle (Sperryn, 1973) is seen in many karatekae who toughen their fists on firm pads.
Fascial compartment compression of the leg and quadriceps haematoma are a serious group of injuries noted especially in the Kyokushinkai knock-down style. (This is one of the five original Japanese karate styles in which a score is recorded if one knocks down his opponent. Therefore, low hard kicks to the shins and thighs of the opponent are practised in order to weaken him.) Severe bruising of the large muscles of the thighs can be a chronic source of pain if subsequent calcification, myositis ossificans, occurs. Traumatic anterior tibial compartment syndrome (fascial compartment compression) may require surgical treatment since the viability of the limb is threatened. Ice packs, elevation and bandaging the limb considerably relieves pain and reduces swelling. Withdrawal from the competition is mandatory.
Knee injuries are also quite common in karatekae. In performing a technique such as the roundhouse kick there is a degree of rotation on a fixed tibia which produces tears of the menisci. This mechanism is similar to that of football knee injuries. The patient usually presents with a history of pain, usually in the medial joint compartment and occasionally jamming of the knee. On examination a small effusion is often found. If the symptoms become chronic, meniscectomy is sometimes necessary.
Through the Martial Arts Commission, medical cover is now available at karate competitions. Rules regarding fitness to compete are laid down with the result that the incidence of injury has been considerably reduced (McLatchie and Morris, 1977). Recommendations for medical officers attending karate contests are described in detail elsewhere (McLatchie, 1979b).
Judo, the way of gentleness, has been popular in Great Britain for more than thirty years. It is an Olympic sport and an effective method of self-defence. Serious injury is indeed rare and results most often from the floor techniques in which the opponent can be strangled unconscious if he does not submit.
It is popular among children, in whom a special type of sprain which is known as ‘pulled elbow’ may be found. In this condition the radial head is pulled out of its annular ligament. The symptoms are pain and tenderness over the radial head associated with limitation of pronation and supination. Treatment is simple: firm alternate pronation and supination with the elbow held at a right-angle allows the radial head to ‘click’ back into position. Post-traumatic sequelae do not occur.
A much more serious but very rare elbow injury can occur, the mechanism of which is a fall with the elbow hyperextended and the forearm pronated. It is a serious fracture-dislocation often confused with the more common Monteggia fracture. The lesion consists of a fracture of the radial head or neck with associated olecranon fracture and/or dislocation of the elbow joint. The treatment is surgical and prognosis unfortunately poor, osteoarthrosis being a late sequel .
Other minor injuries which occur include scratches, mat burns and minor soft tissue sprains. It is not usual for these to prevent further participation. If breakfalls are inadequately performed there is the possibility of cervical injury . The judoka must therefore learn how to breakfall efficiently before taking part in randori (free fighting) in which dislocations of both minor and major joints such as the shoulder and the elbow have been witnessed (Williams and Sperryn, 1976).
Wrestling is one of the oldest known sports. At amateur level two styles, Graeco-Roman and freestyle, are practised. In the Graeco-Roman style the use of the legs is forbidden and only holds above the waist allowed. Freestyle permits the use of any fair hold and has a code of rules which describes such holds. Current medical control is efficient. The contestants have to undergo pre-match medical examination and to maintain adequate hygiene, namely, be clean shaven with short hair and short nails. Serious injury is rare and even in the professional sport, with no holds barred, there have only been two deaths in Great Britain during the last 40 years (Green, 1978). One of these was due to myocardial infarction and the other to a serious head injury.
A well-known hazard in this sport is cervical injury. This can occur if one contestant falls heavily on his opponent when he is ‘bridging’ . Gabashvili (1971) reported four deaths from cervical injury but none have been reported in Great Britain. Strict adherence to the rules is vital if such injuries are to be avoided. As in boxing and karate, fractures and fracture dislocations of the metacarpo-phalangeal joints of the thumb are common, requiring surgical intervention to produce a stable joint.
Chronic injuries are also seen and these usually affect the shoulders with innumerable minor muscle sprains, and the knees where meniscus and ligamentous injuries occur and are a source of persistent trouble. They often present with effusion, laxity and pain.
The Sumo wrestlers of Japan present an interesting range of injuries. In this professional sport the participants are ‘reared’ from a young age in establishments known as ‘stables’ to prepare them for their sport. They eat a special high fat diet and, unlike other Japanese, grow very tall and become enormously obese. Their training is intensive. Their hands are subjected to repeated trauma against padded posts as they practise their training techniques. As a result of this, stiffness of the metacarpophalangeal and proximal phalangeal joints of the fingers and thumbs occurs. They are also said to present with a ‘punch drunk’ like syndrome in later life due to repeated concussions from butting each other in competition. Some are also reported to be partially sighted as a result of this. They have short lives, usually to the mid-forties, with a higher incidence of pancreatitis and myocardial infarction than the general population.
PREVENTION OF INJURY
In the combat sports many injuries result when a competitor is tiring; therefore, cardiovascular fitness is especially important. The acquisition of skill through persistent practice decreases the risk of injury. It allows the individual to read the situation and realise the risk involved. It also allows the development of efficient movement patterns to the level of conditioned reflexes. Efficient warm-up is probably another factor which reduces the possibility of injury. The exact mechanism of this is not known but it may help to ‘settle the nerves’ and to prime muscle groups for action.
Protective clothing is advised in the martial arts, especially in karate. The use of gumshields, groin guards and pads for the fists, shins and feet has markedly reduced the incidence of injury in this sport (McLatchie, 1977). In boxing too, facial injury is lessened by wearing a proper fitting gumshield. The use of headgear in sparring and a padded or sprung flooring contributes much to the prevention of serious head injury (Schmid et al, 1968). For wrestling and judo, padded flooring is also in use.
Control of the competition by a strict referee is vital. The competitors should be aware of the rules and the referee’s judgement should be upheld by the governing body of the sport. The combat area is not an excuse for assault. Illegal moves should be penalised by disqualification; in no sport is injury more likely to result than in the combat sports if illegal techniques are resorted to.
In summary a participant should be fit, skilful, informed of the rules of his sport, controlled and he should wear recommended protective clothing.
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