Many participants train several times per week, year round, without a natural break in training for rehabilitation/recovery.

Emphasis of training is often on personal development, both physical and mental, and not on competition.

Muscle mass and strength are typically not as important as speed, strategy, technique, mental discipline, and flexibility.

Individuals of different levels of training may “spar” (to engage in practice competition with another individual to simulate the actual competition or bout) in practice, exploiting the mismatch in skill levels between participants.

Tae kwon do

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  Three times the injury rate and a four-fold risk of multiple injuries compared with Shotokan karate

  
  
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  More severe injuries and a greater incidence of multiple injuries than other disciplines

Incidence of injury is directly related to the amount of time spent in full-contact sparring, limited-contact sparring, or competition.

A competition setting may also influence the injury rate and severity.

Types of martial arts training include:

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  Kata—detailed choreographed patterns of movements/techniques used by practitioners to practice on their own

  
  
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  Basic hand strikes

  
  
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  Basic kicking

  
  
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  Strength training

  
  
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  Conditioning

  
  
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  Stretching

  
  
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  Flexibility

  
  
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  Breaking—using striking techniques to break boards or bricks

  
  
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  One-step sparring—noncontact sparring during which students practice techniques to be used during free sparring or a competition

  
  
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  Grappling

  
  
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  Ground fighting

  
  
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  Joint locks—grappling technique involving the manipulation of an opponent’s joint in such a way that the joint reaches a maximal degree of motion in order to induce submission or to injure an opponent

  
  
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  Chokes—employed via various mechanisms using the upper or lower extremities to temporarily disrupt the vascular supply to the brain or compress the trachea to prevent breathing

  
  
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  Free sparring—to engage in a practice competition with another individual to simulate the actual competition or bout

  
  
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  Point-scoring competition

  
  
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  Full-contact competition

Mouth guard: Risk of orofacial injury is 1.6–1.8-times greater when mouth guards are not worn. Use does not reduce the risk of concussion.

Headgear: May reduce peak acceleration forces to the head; different brands have varying safety profiles ( Fig. 86.1 )

Protective equipment.

Hand and foot protection: Hand protection (as used in tae kwon do) and foot-padding gear have not been shown to reduce peak acceleration; combination of headgear and hand/foot protection superior to either used alone (see Fig. 86.1 ). Padding may lead to decreased inhibition and poorer control of striking, which may lead to a greater number of blows with a larger amount of force. Hand and foot padding are thought to decrease the amount of superficial injuries, such as lacerations and abrasions, to both the attacker and the defender. Equipment varies with different martial arts.

Padded flooring: Padded flooring may reduce the intensity of a blow by absorbing some of the impact of falls and throws (see Fig. 86.1 ). The surface must be closely monitored for risk factors for fall, such as moisture (water, blood, or perspiration) or gaps between the padding. Mat pads are common reservoirs for fungi and bacteria and therefore must be cared for in a similar manner to wrestling mats in order to prevent the spread of infections (e.g., community-acquired methicillin-resistant Staphylococcus aureus or tinea corporis).

Age is not a reliable predictor of the likelihood of injury, although one study reported decreased incidence of injury in adolescent karate practitioners during elite competitions.

Experience and number of hours of participation appear to be associated with higher rates and severity of injury.

A previous study reported a greater incidence of head injuries and fractures in professional Muay Thai kickboxers when comparing amateurs to beginners.

Individuals with at least 3 years of experience were at twice the risk of injury than less-experienced individuals.

The number of tournaments and months of practice are directly and significantly associated with the likelihood of injury.

Tournament and competitive situations are associated with a lower absolute number of injuries but higher rate of severity compared with noncompetitive situations, possibly secondary to increased aggression in tournament settings.

Informal training sessions are associated with a higher risk and severity of injuries compared with more formal supervised instructions.

Males have higher rates and severity of injuries compared with females, probably related to increased aggressiveness, except in karate, where females have a higher injury rate than do males.

Muay Thai kickboxing participants who compete at a heavier weight are at a higher risk of injury.

In competition, governing bodies of martial arts have established weight classes. Physicians must be aware of their athletes that are attempting to make different weight classes and provide appropriate counseling for weight maintenance.

The American Academy of Orthopedic Surgeons (AAOS) offers these tips for martial arts participants to safely train and compete:

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  Consult with a physician before beginning your conditioning to establish your readiness.

  
  
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  Train under the direction of a martial arts instructor who focuses on form and technique rather than competitive strategy.

  
  
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  Wear appropriate protective gear for your type of activity: e.g., tae kwon do, as a full contact sport, requires a head guard, a body protector, forearm and shin guards, and a groin guard.

  
  
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  Exercises that strengthen rotator cuff muscles and hip adductors/abductors are critical to martial arts for injury prevention, balance, and improved striking ability.

  
  
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  Maintain appropriate breathing techniques when practicing martial arts to avoid injury—breathing out during the contraction portion of any stretching movement, and breathing in during the extension portion of any stretching movement.

General

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  Attending physician must be present when the rules of the competition are reviewed.

  
  
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  It is important to identify yourself and briefly review certain medical considerations.

Prefight examinations

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  Perform in a quiet, well-lit environment.

  
  
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  Enquire about previous and/or recent concussions and “knockouts.”

Match stoppage

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  Typically done by the referee; however, the referee may consult with the physician for medical guidance regarding whether the match should continue.

  
  
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  Typically, intervention will be required for lacerations and bleeding.

Cervical spine injuries

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  Often teammates or coaches will want to attend to their fighter, and they may inappropriately move a fighter with an unstable cervical neck injury.

  
  
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  Review the rationale and need for appropriate cervical spine immobilization with the entire group of participants and their team.

Postfight examinations

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  After a loss or a knockout, the participant may be confused, belligerent, or emotional.

  
  
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  It is important to maintain control of the situation to complete an appropriate examination.

Medical kit suggestions: disposable gloves, gauze, silver nitrate, band aids, suture kits, sling, athletic tape, Coban, nonsteroidal anti-inflammatory drugs (NSAIDs), cold/flu/allergy medication, antidiarrheal medication, shears, petroleum jelly, nasal plugs, bandages, otoscope/ophthalmoscope, tooth saver solution, syringes, needles, lidocaine with/without epinephrine, alcohol swabs, betadine, contact and eye wash solution, splinting material, betadine, oral airway, cervical collar, Epipen, and albuterol

It is critically important to understand the unique aspects of each martial art discipline in order to best predict potential injuries.

Certain martial arts disciplines focus more on contact and sparring, whereas others focus more on technique.

When covering a martial arts competition or evaluating a martial artist, familiarize yourself with the techniques, emphasis, equipment, scoring, and target areas of each discipline in order to anticipate various possible injuries.

Punching: Striking an opponent with a closed fist ( Fig. 86.2 ). Appropriate punching technique places the wrist in slight volar flexion, with the second and third metacarpals aligned with the long bones of the forearm. Contact is made with the second and third metacarpal heads. A “boxer’s fracture” of the fifth metacarpal typically results from poor punching technique, wherein an individual makes contact with the fifth metacarpal head instead of the second and third metacarpal heads. Common injuries from poor punching technique include phalanx fractures, fourth or fifth metacarpal fractures, wrist sprains, extensor tendon injuries, and first metacarpal phalangeal ulnar collateral sprains.

Common techniques in martial arts.

Knife hand chop (“karate chop”): A strike with an open hand during which contact is made with the ulnar aspect of the fifth metacarpal head

Ridge hand (reverse knife hand chop): A strike during which the thumb is tucked into the palm and contact is made with the radial aspect of the second metacarpal head

Spear thrust: Open hand technique during which contact is made with the fingertips of the second, third, and fourth fingers, most commonly targeting the eyes and throat

Hammer fist: Closed-hand strike with the ulnar aspect of the fist

Spinning back fist: The attacker swivels 360 degrees and strikes the opponent with dorsum of the hand and second and third metacarpophalangeal (MCP) joints, employing great power and momentum.

Front snap kick: From a standing position, the hip is flexed up to bring the femur parallel to the floor (see Fig. 86.2 ). The leg is then extended, resulting in the ball of the foot making contact with the defender’s abdomen. Note: If the target is the groin, the foot is plantar flexed and the point of contact is the dorsal aspect of the proximal first metatarsal. If the target is the face, the ankle is dorsiflexed and contact is made with the plantar aspect of the heel.

Side kick: Delivered sideways relative to the position of the person executing the kick; contact is made with the heel targeting the abdomen or face (see Fig. 86.2 ).

Back kick (“donkey kick,” “mule kick,” or “spinning back kick”): Kick is delivered backward, keeping the kicking leg close to the standing leg and striking with the heel. Most often, it is delivered with a spinning motion generating great power.

Roundhouse kick: From the position of the hip flexed up to 90 degrees, the attacker swings his or her lower leg up in a circular motion, striking with the dorsal aspect of the proximal first metatarsal (see Fig. 86.2 ).

Miscellaneous: Certain disciplines of martial arts encourage kicking with the shin opposed to the ball of the foot or instep to reduce the likelihood of injury.

Rear naked choke: Attacker approaches opponent from behind, wrapping his or her arm around the opponent’s neck and then grasping the biceps of his or her other arm. Then, using his or her free hand, the attacker forces the head of the opponent into flexion, resulting in compression of the carotid arteries, temporarily rendering the opponent unconscious (see Fig. 86.2 ).

Triangle choke: Attacker is on his or her back (guard position) and wraps one leg around the neck and shoulder of the opponent with their knee next to the opponent’s neck, the other leg crosses the ankle of the first leg, using the foot of the first leg to lock the second leg into position at the knee (see Fig. 86.2 ).

Guillotine choke: Applied from a standing position or the guard; the attacker faces the opponent and wraps an arm around the opponent’s neck so that his or her humerus is on the dorsal aspect of the neck and their forearm wraps around anteriorly to apply pressure to disrupt the vascular supply to the brain, temporarily rendering the opponent unconscious, or to compress the trachea in order to restrict breathing (see Fig. 86.2 )

Arm bar: A joint lock that hyperextends the elbow joint by placing the opponent’s extended arm over a fulcrum such as an arm, leg, or hip (see Fig. 86.2 ). The opponent is controlled in this position, and if he or she does not tap out, continued force will result in dislocation of the elbow.

Leg lock: A joint lock that is directed at the joints of the leg such as the knee or ankle. A kneebar is similar to an armbar, which aims to forcefully hyperextend the knee of the opponent (see Fig. 86.2 ).

Ankle lock: A submission applied to the opponent wherein the attacker uses his or her arm to secure the opponent’s ankle in his or her armpit. Once the ankle is secured, the attacker leverages his or her hip forward, which forcefully plantar flexes the ankle. The forearm serves as a fulcrum in leveraging and may cause severe pressure on the Achilles tendon.

Miscellaneous: Small joint manipulation is typically prohibited.