General Principles
Overview
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The popularity of mixed martial arts (MMA) has grown tremendously in the last 20 years.
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Despite this incredible growth, there is still a paucity of information about the common injuries and proper ringside management of these athletes.
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Often, sports medicine physicians will be asked to cover an MMA competition.
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It can be overwhelming without any basic understanding of either the sport or the ringside considerations for the evaluation and management of MMA competitors.
Pertinent History
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The Ultimate Fighting Championship is the largest organization in MMA.
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It was founded in 1993 and has continued to grow in size and influence, having acquired former rivals such as World Extreme Cagefighting, Pride, and Strikeforce.
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Other organizations actively promoting MMA are Bellator, World Series of Fighting, One Fighting Championship, and Invicta FC.
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MMA is defined as a combative sport between two individuals occurring in a ring or cage that utilizes fighting techniques from a variety of martial arts, including jujitsu, wrestling, boxing, kickboxing and other martial arts.
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MMA must follow the Unified Rules of MMA, which were developed to give some standardization to the competition and to hopefully make the sport safer for its participants.
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These rules mandate that there are two contestants in each match who are paired by promoters and approved by the state commissions.
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Bouts will typically be three or five rounds, with championship bouts most often being scheduled for five rounds.
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Each round is 3 or 5 minutes in duration.
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Terminology
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Bouts can be declared by KO (knockout), TKO (technical knockout), submission, referee stoppage, doctor stoppage, corner stoppage, disqualification, or a judge’s decision.
KO: A competitor is knocked down and deemed unconscious or disoriented.
TKO: The referee stops the bout when one competitor is unable to intelligibly defend himself/herself.
Submission: One of the fighters signals to the referee, via either a tap or a verbal cue, that he or she no longer wants to continue.
Referee Stoppage: The referee calls an end to the competition for any reason other than a TKO.
Doctor Stoppage: The ringside physician determines that it is unsafe for one of the combatants to continue due to an injury.
Corner Stoppage: The combatant’s corner “throws in the towel” to signify that they no longer want their competitor to continue fighting.
Disqualification: One of the combatants is disqualified due to a rules violation.
Decision: The specified number of rounds is successfully completed. The decision is based upon the ringside judges’ scorecards.
Rules
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There are considerable variations in the rules and ringside physician’s responsibilities from state to state; it is critical to be familiar with the rules specific to the area in which the competition is held.
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Clarification on specific state rules, as well as the Unified Rules of MMA, is provided by the Association of Boxing Commission ( www.abcboxing.com ).
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Most states will require that an individual obtain a separate license from the medical board to serve as a ringside physician.
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Although there is now a new additional certification from the American College of Sports Medicine/Association of Ringside Physicians, states do not mandate any proof of knowledge or experience to sit as a ringside physician. Most simply require an additional fee.
Weight Classes
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MMA competitors are divided into seven weight classes:
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Flyweight—up to 125 lbs
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Bantamweight—over 125 to 135 lbs
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Featherweight—over 135 to 145 lbs
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Lightweight—over 145 to 155 lbs
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Welterweight—over 155 to 170 lbs
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Middleweight—over 170 to 185 lbs
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Light Heavyweight—over 185 to 205 lbs
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Heavyweight—over 205 to 265 lbs
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Super Heavyweight—over 265 lbs
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Equipment and Safety Issues
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Competitors wear 4–6 oz open-finger gloves, which allow for greater punch velocity and lesser impact dissipation than 16 oz gloves ( Fig. 89.1 ).
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It is thought that these gloves do more to protect the hands of the striker and decrease the risk of lacerations.
Figure 89.1
Gloves.
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Competitors are also instructed to wear a protective cup and a mouth guard.
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Shoes and a “gi” are not permitted ( Fig. 89.2 ).
Figure 89.2
Mixed martial arts gi: this type of uniform is not permitted in the UFC.
Regulation
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It is important for the covering ringside physicians to understand the rules and regulations that are specific to the state in which they practice.
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Currently, New York and Connecticut do not sanction MMA competitions.
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There can be variations in the prefight examination requirements from state to state.
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The ringside physician can consult the Association of Boxing Commission’s website at the following address for specific state requirements: www.abcboxing.com/medical_requirements.html
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Specific state contacts can be found at the following address: www.abcboxing.com/commission_contacts.html
Prefight Coverage and Examination
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Most often, prefight physical examinations are completed the day prior to the competition at the time of weigh-ins. However, sometimes the logistics of coverage mandate that the examination be completed the day of the competition.
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When preparing to cover an MMA competition, it is important for the physician to review the contents of the medical bag.
Unique Environmental and Nutritional Issues
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Dehydration is an important consideration during the prefight physical examination.
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The Committee Report on Unified Rules of MMA states, “Athletes shall be examined at the prefight examination to screen for an excessive or extreme weight loss practices leading to dehydration.”
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There are no more specific guidelines that are stated on how to accomplish this, and specific practices are not defined; it also does not specify who is charged with doing this screening.
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There are no programs in place like in college wrestling to prevent and monitor excessive weight loss/dehydration.
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There is no section on the prefight physical examination addressing fluid status and weight loss.
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Same day weigh-ins are difficult in MMA because of the potential financial losses from pay-per-view audience reduction if an individual does not make weight and is thus removed from the fight card the day of the fight.
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See Box 89.1 for the hydration study in MMA fighters.
Box 89.1
Hydration Study in MMA Fighters *
* Fighters were weighed at the official weigh-in (24 hours before the bout) and then re-weighed about 22 hours later (2 hours before the bout). Fighters provided a urine sample at each of these times and had a skin fold analysis to determine body density during the official weigh-in.
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Body mass increased 4.4% in the 22-hour period before the competition.
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Similar to a body mass increase in college wrestlers before new rule implementation (4.9%).
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After the rule change, college wrestlers now have 1.2% weight gain.
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39% significantly dehydrated 2 hours before event (USG >1.021)
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11% seriously dehydrated (USG >1.030)
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23% well hydrated (USG <1.010)
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It is yet to be determined if these findings will influence rule changes with respect to hydration and weight loss.
Data from Jetton AM, Lawrence MM, Meucci M, et al. Dehydration and acute weight gain in mixed martial arts fighters before competition. J Strength Cond Res . 2013;27(5):1322-1326.
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Day-of-Fight Considerations, Match Coverage, and Injury Patterns
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Important considerations for an Emergency Action Plan:
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The physician needs to ensure that they have a reserved a seat ringside with an unobstructed view and easy access to the ring if they are called to enter.
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Medical team: If you do cover a competition by yourself, it may need to be temporarily suspended if you need to attend to an injured fighter. This delay may not be acceptable to ringside fans or the television audience.
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It is imperative for the physician to introduce themselves to the EMS team and cover specific responsibilities.
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If the physician provides laceration repair or intravenous fluid replacement therapy, it is important to arrange for appropriate follow up after the competition.
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Where is the nearest hospital?
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It is important to meet with the referee before the competition to review responsibilities and to provide an opportunity to ask any questions.
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During the competition, the physician may be asked to enter the ring, but one may not do so unless summoned by the referee.
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If the physician is asked to enter the ring during the competition, the physician may examine the fighter but not treat him/her.
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For example, the physician can wipe away blood to examine a cut, but one may not actively treat the laceration.
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The physician can only determine if the fighter is able to continue or if he/she should be disqualified for medical reasons.
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It is important to take control of the situation.
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Often, the competitor’s corner men will attempt to enter the ring to assist their teammate who is down.
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This action must be clearly prohibited as moving an injured fighter carries risk if not paying attention to potential cervical spine precautions.
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The establishment of a unified team approach, where each individual clearly knows his/her responsibilities, is paramount to the maintenance of fighter safety.
Laceration Management
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Some teams and/or promoters will provide a “cutman” for the competitors.
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The experience of cutmen varies greatly.
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Cutmen do not replace a physician’s medical expertise with respect to deciding whether or not a fighter is qualified to continue or whether or not a fighter should be disqualified due to a laceration.
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If the physician is asked to tend to a laceration, the physician may only treat the laceration in-between rounds.
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Applying pressure with sterile gauze or a large cotton swab is the best first-line treatment.
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Also consider petroleum jelly.
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The only substances that are permitted for administration are a solution of adrenaline 1:1000, Avetine, or Thrombin.
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An enswell is another helpful instrument to have in your medical bag ( Fig. 89.3 ); it is a frozen piece of steel that can help reduce swelling and contusions on the face or around the eyes.
Figure 89.3
Enswell.
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The presence of periorbital lacerations or contusions that obstruct vision form potential grounds to disqualify a fighter.
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Epistaxis is also common.
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Application of direct pressure is typically effective; also, consider petroleum jelly.
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Observe for presence of septal hematoma or nasal fracture ( Fig. 89.4 )
