The American Journal of Sports

Medicine
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Battle Scars
Bruce Reider
Am J Sports Med 2014 42: 1287
DOI: 10.1177/0363546514535717
The online version of this article can be found at:
http://ajs.sagepub.com/content/42/6/1287

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Editorial

Battle Scars
MMA promoter in North America, agreed to a set of Unified Rules that was approved by the New Jersey Athletic
Commission, leading to its current sanctioned status in
almost all US states.10,11 Although these rules prohibit
a number of ungentlemanly or unladylike behaviors such
as biting, eye-gouging, using abusive language, or inserting a finger into any orifice or wound,14 they still leave
the door open to a vast array of violent actions that fight
fans crave.
MMA fighters compete with a minimum of equipment:
shorts, a mouth guard, a chest protector for women, a groin
protector for men, and lightweight, fingerless gloves.13,14
The duration of fights is set at 3 to 5 rounds of 5 minutes
each, but they are often terminated early by knockout
(KO), submission of a combatant (tapping out), stoppage
by a corner or attending physician, or technical knockout
(TKO), which occurs when the referee judges that a fighter
is unable to logically or safely defend him or herself.8,14
The medical implications of MMA were recently summarized in a systematic review published in our open-access
affiliate, the Orthopaedic Journal of Sports Medicine.10
Combining the results of 5 studies into a meta-analysis,
this review found that the composite injury rate was an
impressive 229 (95% CI, 110-474) per 1000 athletic exposures. The portion of injuries sustained by the head was
high, varying from 67% to a whopping 78%. Laceration
(37%-59%), fracture (7%-43%), and concussion (4%-20%)
were the most common injury types. The wide ranges in
the injury statistics reflect considerable variability among
studies in the methods of collecting data and defining
injury, which was usually the purview of the ringside physician. A common weakness of these studies was a lack of
detail in the documentation of injury severity.
Not surprisingly, this review found that losing fighters
sustained 3 times as many injuries as winners. In addition,
bouts that ended in KOs or TKOs or fights that were settled by the judges decision were associated with injury
rates more than twice that of bouts that ended with the
submission of a combatant. Since fighters had a longer
exposure to injury in bouts that went the distance, contests
settled by judges decision actually had a lower injury rate
than those ending in submission, when the injury rate was
calculated by minutes of exposure. These findings seem to
suggest that the risk of injury is lower when the fighters
are more evenly matched. While the authors acknowledged
that differences in methodology make it difficult to compare studies of diverse sports with confidence, the injury
rate that they obtained was far above that reported for
other popular combat sports such as judo, taekwondo,
and amateur boxing, and placed MMA in competition
with professional boxing for most injuries per 1000 athletic
exposures.
In any activity that features repeated blows to the head,
the potential for concussion or other brain injury is always

And he carries the reminders

Of evry glove that laid him down.
The Boxer;
Words and Music by Paul Simon*
Warrior, a 2011 film directed by Gavin OConnor, is the fictional tale of Paddy Coughlin and his 2 estranged sons, set
against a background of mixed martial arts (MMA) competition. Paddy is a recovering alcoholic approaching his
1000th day of sobriety, but his recent reformation cannot
undo the damage that years of drunkenness have wrought
upon his children. United only by their disdain for their
father and their hatred of each other, the brothers present
a striking outward contrast: Tommy, a hulking and brutal
champion wrestler and ex-Marine; Brendan, a wiry high
school physics teacher with a wife and 2 adorable daughters. Underneath, they are more nuanced and reminiscent
of each other: Tommy is emotionally wounded and vulnerable, while Brendan vents his buried frustrations through
amateur cage fighting.
Unwittingly, the 2 young men have embarked on a violent collision course. Lured by extravagant prize money
that they both desperately need, Tommy and Brendan
punch and wheedle their separate ways into the Sparta
MMA challenge. Staged amid the neon and glitz of the
Atlantic City casinos, this self-styled War on the Shore
will pit 16 leading middleweight MMA fighters against
each other in a single-elimination tournament format. To
gain the $5 million winner-take-all prize, a fighter must
triumph in 4 punishing bouts in a single weekend. As the
narrative builds to the inevitable final confrontation,
Tommy and Brendan conquer their opponents in disparate
fashion: Tommy by viciously pummeling his adversaries
into unconsciousness within seconds, Brendan by enduring
round after round of painful pounding and near-suffocation
until finally trapping each unwary rival in a submission
hold.
Although Warrior is a work of fiction, MMA is a very
real presence in the world of sport and entertainment.
Introduced in North America in the early 1990s, MMA
evokes the ancient Greek tradition of pankration, a competitive sport and combat technique that combined elements
of boxing and wrestling.13 In its early incarnation, MMA
created such a firestorm of criticism that it was banned
in 40 US states, with politicians as prominent as Senator
John McCain calling for its prohibition.3,10,11,13 Just
when MMA appeared on the verge of extinction in the
US, Ultimate Fighting Championship (UFC), the largest
*1968 Paul Simon (BMI).
The American Journal of Sports Medicine, Vol. 42, No. 6
DOI: 10.1177/0363546514535717
2014 American Orthopaedic Society for Sports Medicine

1287
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1288 Editorial

The American Journal of Sports Medicine

a concern. In the MMA literature, the definition and analysis of concussion have varied greatly among individual
reports.3,5,7,11,13,15 Sometimes only a knockout was accepted
as evidence of concussion or severe concussion,7,11,15 while
at least 1 study did not classify KOs or TKOs as injuries at
all.3 Without detailed information about the athletes neurocognitive status or pattern of recovery, conclusions about
concussion rates have generally relied on inference,5 the
recorded assessment of the ringside physician,3,6,11,15 or
the recollections of individual fighters.13
In this issue of the American Journal of Sports Medicine, Hutchison and colleagues8 report the results of their
extensive analysis of head trauma in professional MMA.
This is a timely study, since a recent article has reported
diffusion tensor imaging abnormalities suggestive of
microscopic brain damage in boxers and MMA fighters.16
The authors painstakingly analyzed the publicly available
scorecards and video recordings of 844 UFC MMA contests
that ended in KO or TKO from 2006 to 2012. The scorecards reported the official outcomes of the bouts, while
the complete fight videos, when obtainable, were analyzed
using a scoring tool whose reliability had been previously
documented.9 From the official scorecard outcomes, the
authors determined that competitors 35 years or older
had an increased risk of sustaining a KO or TKO, and
each previous KO increased the risk of sustaining a subsequent KO (odds ratio = 1.30). The longer a fight lasted, the
less likely it was to end in a KO or TKO, perhaps also suggesting that these outcomes were less likely among evenly
matched fighters.
Video analysis was restricted to 142 events for which
digital recordings were publicly available. Scrutiny was
focused on the 30 seconds prior to match stoppage caused
by KOs, or by TKOs that resulted from repetitive strikes
to the head. Of the 65 fighters who were KOd, 41 sustained a second subsequent head impact, usually by striking the floor with their occiput. On average, KOd
competitors received about 5 to 6 head strikes in the 30 seconds before the knockout blow and an additional 2 or 3
head strikes between the KO-strike and match stoppage.
Among 179 TKOs analyzed, 161 were judged to be the
result of repetitive strikes, and videos were available for
77 of these. In the 30 seconds prior to match stoppage,
the TKOd fighter received an average of 17 head strikes,
with a range of 5 to 46. Combining KOs and TKOs, the
authors calculated an incidence of match-ending head
trauma of 15.9 per 100 exposures, or 31.9% of matches.
Without data from actual examinations of the fighters,
the diagnostic implications of these findings remain somewhat speculative. Should all matches ending in head
trauma be assumed to involve a concussion or other brain
injury? Since only a minority of concussions result in
unconsciousness, limiting the diagnosis of concussion to
KOs would likely underestimate the incidence of such injuries. Although the authors acknowledge that they cannot
confidently classify as concussions all TKOs following
repetitive head strikes, a judgment by the referee that
a fighter is unable to intelligently defend him or herself
after repetitive head strikes is highly suggestive that
some form of cognitive impairment was present.

Athletic competitions in which rendering ones opponent

unconscious is considered a highly desirable outcome have
become repugnant to many physicians. Medical societies in
Australia,2 Canada,6 the United Kingdom,17 and the United
States1 have all called for a ban on MMA, although such position statements do not seem to have much effect on the
spreading popularity of MMA competition. Perhaps more
practically, Hutchison and colleagues propose possible interventions to mitigate the likelihood or the severity of head
trauma, including better protective equipment, more rapid
intervention by the referee following KOs and the introduction of a boxing-style 10-count when a combatant is
knocked to the floor by a head strike. Certainly, new studies
based on more complete data than offered by ringside assessments and video analysis would also be desirable.
One of the legendary heroes of the ancient Greek sport of
pankration was Arrhichion, who died while successfully
defending his title at the 54th Olympiad. Despite being
caught in a choke-hold, Arrhichion refused to surrender. As
he suffocated, the renowned pankratiast forced his opponent
into submission by dislocating his ankle.4,12 Arrhichions
corpse was honored as the Olympic champion. In Warrior,
Paddys immersion in an audio recording of Moby Dick, the
story of a man whose crazed obsession leads him and his followers down an inexorable path to self-destruction, runs
through the narrative like a leitmotif and seems an apt metaphor for the fate of all 3 protagonists. Despondent over his
inability to reconnect with his sons, Paddy nearly drinks
himself to death, while Tommy and Brendan come close to
killing each other in their climactic dual. Ultimately, they
all survive, and their love for each other is rekindled by their
near-death experience.
Legendary heroes are often triumphant in death, and
fictional characters are frequently healed and reborn
through extreme hardship. Real people may also be transformed and ennobled by suffering, although few would voluntarily choose that route to self-improvement. By their
heroic efforts, MMA fighters may gain both gold and glory.
As medical professionals dedicated to the well-being of
athletes, we are called upon to question the price of that
glory.

Bruce Reider, MD
Chicago, Illinois

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Battle Scars

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