Many sports have neurologic injury from incidental head contact; however, combat sports allow head contact, and a potential exists for acute and chronic neurologic injuries. Although each combat sport differs in which regions of the body can be used for contact, they are similar in competitor exposure time. Their acute injury rates are similar; thus their injuries can appropriately be considered together. Injuries of all types occur in combat sports, with injuries in between one fifth to one half of all fights in boxing, karate, and tae kwon do. Most boxing injuries are to the head and neck region. In other combat sports, the head and neck region are the second (after the lower limbs) or the first most common injury site.
Boxing and other combat sports (including kickboxing, contact karate, tae kwon do, judo, and the like) are different from other sporting pursuits because the head is a legitimate place of contact. Other sporting activities have incidental contact to the head that may result in neurological injury; however, the rules and close settings associated with combat sports allow contact to the head region, and thus a potential for neurological injuries of both an acute and chronic nature exists. Although each combat sport is different in terms of which regions of the body can be used for contact and how scoring is conducted, they are similar in terms of the exposure time experienced by competitors, and in many cases competitors will compete in more than one combat sport style in their lifetimes. Additionally, it has been shown that acute injury rates during competition are similar between professional boxing and other combat sports, indicating that these groups are appropriate to consider together for injury purposes.
Injuries of all types occur to combat sport participants, with between one fifth to one half of all fights in boxing, karate, and tae kwon do resulting in an injury. In boxing, the majority of these injuries are to the head and neck region, with studies in other combat sports consistently reporting the head and neck region as the first or, more often, the second most common site of injury (following the lower limbs).
Mechanisms of neurological injuries in combat sports
The mechanism of neurological injury varies depending upon the combat sport discipline. In boxing, head injuries generally occur because of contact between the fist and head, head and head, or head and some part of the boxing ring. In other combat sport disciplines, head contact can occur in all of those manners, and also as a result of striking other surfaces (the palms, fingers, elbows, legs, feet, and so forth). In boxing it is thought that the more serious neurological injuries result from punches that cause rotational movements of the head, whereas in the other combat sports it is believed that these injuries result from incorrect throwing techniques (judo), or erroneous kicks, especially those involving rotation. A number of factors that affect the outcome of neurological injury in combat sports have been assessed in a laboratory setting. These include the region of the head that receives the contact, the magnitude, force, and direction of the contact, the use of gloves and their associated weights, and the use of any other barriers for protection (eg, headgear) whose use depends on the combat sport rules. The impact of these factors during competition, however, is yet to be determined because of difficulties measuring the effect occurring with two moving people.
Acute neurological injuries
Acute neurological injuries (ANI) occurring to combat sport participants have been studied extensively, especially in the sport of boxing. Numerous case studies of particular ANI types have been published (for example, a number of case reports relating to vertebral or carotid artery dissections exist in the combat sport literature); however, the ANI leading to fatalities and those of concussion have been the focus of the majority of the literature, and are discussed here.
Fatalities Resulting from Combat Sport Participation
Deaths as a result of participation in combat sports have received plenty of media attention; however, validated epidemiological data are less commonly reported. Although there is no doubt that some deaths do occur, the frequency and circumstances of these deaths are not available from any formal international, validated dataset. Instead, many of the reported fatality data have been obtained from a combination of media sources, industry reports, and coronial inquests, and rarely are these deaths reported as anything other than individual case reports that offer little information on how those deaths may represent all combat sport participations.
Deaths to boxing participants have been reported in a more comprehensive manner than deaths as a result of any other combat sport type. In fact, very limited data exist for deaths occurring in other combat sports. Although a small number of deaths in other combat sports have been the subject of a few case reports, rates of death in those sports certainly cannot be determined based upon the available literature. The majority of deaths from boxing participation result from a subdural hematoma, and are often associated with an immediate loss of consciousness during a fight. Subdural hematomas have also been reported in judo and tae kwon do.
The most comprehensive review of boxing fatalities was published in 1998 based upon newspaper sources. That review included deaths that had occurred “worldwide” that had been reported in newspapers since World War I. To the end of 1996, the review stated that 659 boxing-fatalities had been recorded, for an average of fewer than 9 deaths per year over the 78-year period.
Despite the addition of better reporting over the more recent decades of that study, a reduced death rate in boxing was seen, most likely resulting from a real decrease in the number of deaths rather than a decrease in the number of active boxers over the time period. It is also probable that the data from the newspaper records may have been inaccurate, and that the earlier reports may have misrepresented deaths as being caused by boxing. The published work of Ryan is supplemented by an online database of boxing deaths that have occurred worldwide since the 19th century. Similar decreases in the number of deaths in recent times have been shown in that dataset, although without population numbers in either of these datasets, information related to the risk of death caused by boxing participation cannot be ascertained. In Australia, a recent review of 20 years of professional boxing competition data determined a death rate for that cohort of 0.2 per 100 bouts.
When attempting to compare the number of fatalities occurring as a result of combat sport participation as opposed to other sports, a paucity of data exists. One study calculating fatality rates during sporting activities in England and Wales included boxing within the 8 years of data collection. In that study, climbing sports (<793), air sports (>640), and motor (146) or water sports (67.5) dominated the estimated fatality rate per 100 million participation days. Boxing and wrestling were reported in one category, with three fatal incidents over the 8 years studied, rating it the tenth most common cause of sport or recreation death, with a fatality rate of 5.2 per 100 million participation days. This rate was one third of that of the only other contact sport in the top ten of this list—rugby.
Concussions in Combat Sports
Concussions in the combat sports are the subject of major methodological differences in reporting and definition. Depending on the combat sport being described, concussions may be reported in a number of different ways. For example, in boxing a concussion could be reported as a direct medical diagnosis from the ringside physician, or could be inferred as a result of either a knockout (KO), technical knockout (TKO), or the referee stopping the contest as a result of a head injury (RSC-H). As a result of these discrepancies in defining a concussion, reported incidences of boxing-related concussions vary greatly. For professional boxers, the literature reports that between 15.9% and 69.7% of all injuries are ANI. In amateur boxing, studies have reported the incidence of ANI to be between 6.5% and 51.6% of all injuries.
In terms of other combat sports, medically reported concussions occur infrequently. In adult karate competition concussions have been reported to account for between 0.9% and 5.4% of all injuries. In studies of younger karate competitors or studies in which age was not specified or various ages were studied, concussions have been reported to account for between 1.2% and 8.8% of all injuries. In adult tae kwon do competitions, between 4.3% and 7.5% of injuries are concussions. For younger tae kwon do participants, concussion accounts for 8.6% to 24.4% of all injuries. In kickboxing, a high incidence of concussion has been reported, both for amateur and professional competition (65.2% and 17.5%, respectively). In other studies that have documented concussion rates in various martial arts, between 1.1% and 2.5% of injuries are concussions.
Concussion rates per 100 participants and per 1000 athletic exposures (whereby one bout is equal to two athletic exposures) are shown in Tables 1 and 2 , respectively. The majority of the studies used to determine these concussion rates have involved prospective data collection; however, they have reported prospective data only for concussions that occurred during competition. No prospective collection has thus far determined rates of concussion occurring during training or sparring times, and the studies that report such retrospective data are hindered by issues related to recall. This is an area of research need within the combat sports.
| Reference | Participants, Setting Injury Occurred | Injury Rate Per 100 Participants |
|---|---|---|
| Tae kwon do | ||
| Beis et al | Adults, competition | 0.2 |
| Oler et al | Children, competition | 0.3 |
| Oler et al | Adults, competition | 0.4 |
| Pieter et al | Children, competition | 0.5 |
| Beis et al | Children, competition | 0.6 |
| Pieter et al | Adults, competition | 0.8 |
| Pieter and Zemper | Children, competition | 0.9 |
| Pieter and Zemper | Adults, competition | 1.2 |
| Koh et al | Adults, competition | 1.4 |
| Pieter et al | Adults, competition | 5.2 |
| Koh and Cassidy | Children, competition | 9.8 |
| Karate | ||
| Stricevic et al | Adults, competition | 0.4 |
| Destombe et al | Not specified, not specified | 0.5 |
| Zetaruk et al | Adults, competition | 0.9 |
| Critchley et al | Various, competition | 0.9 |
| McLatchie et al | Not specified, not specified | 2.8 |
| Martial arts | ||
| Birrer | Various, not specified | 0.3 |
| Buschbacher and Shay | Not specified, not specified | 1.7 |
| Birrer and Birrer | Not specified, competition | 3.5 |
| Boxing | ||
| Welch et al | Adults (amateur), competition | 14.0 |
| Porter and O’Brien | Various (amateur), various | 20.4 |
| McCown, 1958 | Adults (professional), competition | 21.0 |
| Jordan and Campbell | Adults (professional), competition | 41.5 |
| Zazryn et al 2006 | Adults (both), various | 44.7 |
| Reference | Participants, Setting Injury Occurred | Injury Rate per 1000 Athletic Exposures |
|---|---|---|
| Tae kwon do | ||
| Beis et al | Adults, competition | 0.7 |
| Pieter et al | Children, competition | 3.1 |
| Beis et al | Children, competition | 3.2 |
| Pieter et al | Adults, competition | 4.5 |
| Zemper and Pieter | Adults, competition | 4.6 |
| Pieter and Zemper | Adults, competition | 5.5 |
| Pieter and Zemper | Children, competition | 5.0 |
| Kazemi and Pieter | Adults, competition | 6.9 |
| Koh et al | Adults, competition | 7.9 |
| Pieter et al | Adults, competition | 13.4 |
| Koh and Cassidy, a | Children, competition | 50.2 |
| Karate | ||
| Stricevic et al | Adults, competition | 1.6 |
| Critchley et al | Various, competition | 3.4 |
| Arriaza and Leyes | Adults, competition | 6.0 |
| McLatchie | Not specified, competition | 11.9 |
| Kick boxing | ||
| Zazryn et al | Adults (professional), competition | 19.2 |
| Buse and Wood | Adults (military), competition | 101.4 |
| Boxing | ||
| Porter and O’Brien | Various (amateur), competition | 11.4 |
| Estwanik et al | Adults (amateur), competition | 77.7 |
| Bledsoe et al | Adults (professional), competition | 186.1 |
| Zazryn et al | Adults (professional), competition | 250.6 |
Acute neurological injuries
Acute neurological injuries (ANI) occurring to combat sport participants have been studied extensively, especially in the sport of boxing. Numerous case studies of particular ANI types have been published (for example, a number of case reports relating to vertebral or carotid artery dissections exist in the combat sport literature); however, the ANI leading to fatalities and those of concussion have been the focus of the majority of the literature, and are discussed here.
Fatalities Resulting from Combat Sport Participation
Deaths as a result of participation in combat sports have received plenty of media attention; however, validated epidemiological data are less commonly reported. Although there is no doubt that some deaths do occur, the frequency and circumstances of these deaths are not available from any formal international, validated dataset. Instead, many of the reported fatality data have been obtained from a combination of media sources, industry reports, and coronial inquests, and rarely are these deaths reported as anything other than individual case reports that offer little information on how those deaths may represent all combat sport participations.
Deaths to boxing participants have been reported in a more comprehensive manner than deaths as a result of any other combat sport type. In fact, very limited data exist for deaths occurring in other combat sports. Although a small number of deaths in other combat sports have been the subject of a few case reports, rates of death in those sports certainly cannot be determined based upon the available literature. The majority of deaths from boxing participation result from a subdural hematoma, and are often associated with an immediate loss of consciousness during a fight. Subdural hematomas have also been reported in judo and tae kwon do.
The most comprehensive review of boxing fatalities was published in 1998 based upon newspaper sources. That review included deaths that had occurred “worldwide” that had been reported in newspapers since World War I. To the end of 1996, the review stated that 659 boxing-fatalities had been recorded, for an average of fewer than 9 deaths per year over the 78-year period.
Despite the addition of better reporting over the more recent decades of that study, a reduced death rate in boxing was seen, most likely resulting from a real decrease in the number of deaths rather than a decrease in the number of active boxers over the time period. It is also probable that the data from the newspaper records may have been inaccurate, and that the earlier reports may have misrepresented deaths as being caused by boxing. The published work of Ryan is supplemented by an online database of boxing deaths that have occurred worldwide since the 19th century. Similar decreases in the number of deaths in recent times have been shown in that dataset, although without population numbers in either of these datasets, information related to the risk of death caused by boxing participation cannot be ascertained. In Australia, a recent review of 20 years of professional boxing competition data determined a death rate for that cohort of 0.2 per 100 bouts.
When attempting to compare the number of fatalities occurring as a result of combat sport participation as opposed to other sports, a paucity of data exists. One study calculating fatality rates during sporting activities in England and Wales included boxing within the 8 years of data collection. In that study, climbing sports (<793), air sports (>640), and motor (146) or water sports (67.5) dominated the estimated fatality rate per 100 million participation days. Boxing and wrestling were reported in one category, with three fatal incidents over the 8 years studied, rating it the tenth most common cause of sport or recreation death, with a fatality rate of 5.2 per 100 million participation days. This rate was one third of that of the only other contact sport in the top ten of this list—rugby.
Concussions in Combat Sports
Concussions in the combat sports are the subject of major methodological differences in reporting and definition. Depending on the combat sport being described, concussions may be reported in a number of different ways. For example, in boxing a concussion could be reported as a direct medical diagnosis from the ringside physician, or could be inferred as a result of either a knockout (KO), technical knockout (TKO), or the referee stopping the contest as a result of a head injury (RSC-H). As a result of these discrepancies in defining a concussion, reported incidences of boxing-related concussions vary greatly. For professional boxers, the literature reports that between 15.9% and 69.7% of all injuries are ANI. In amateur boxing, studies have reported the incidence of ANI to be between 6.5% and 51.6% of all injuries.
In terms of other combat sports, medically reported concussions occur infrequently. In adult karate competition concussions have been reported to account for between 0.9% and 5.4% of all injuries. In studies of younger karate competitors or studies in which age was not specified or various ages were studied, concussions have been reported to account for between 1.2% and 8.8% of all injuries. In adult tae kwon do competitions, between 4.3% and 7.5% of injuries are concussions. For younger tae kwon do participants, concussion accounts for 8.6% to 24.4% of all injuries. In kickboxing, a high incidence of concussion has been reported, both for amateur and professional competition (65.2% and 17.5%, respectively). In other studies that have documented concussion rates in various martial arts, between 1.1% and 2.5% of injuries are concussions.
Concussion rates per 100 participants and per 1000 athletic exposures (whereby one bout is equal to two athletic exposures) are shown in Tables 1 and 2 , respectively. The majority of the studies used to determine these concussion rates have involved prospective data collection; however, they have reported prospective data only for concussions that occurred during competition. No prospective collection has thus far determined rates of concussion occurring during training or sparring times, and the studies that report such retrospective data are hindered by issues related to recall. This is an area of research need within the combat sports.
| Reference | Participants, Setting Injury Occurred | Injury Rate Per 100 Participants |
|---|---|---|
| Tae kwon do | ||
| Beis et al | Adults, competition | 0.2 |
| Oler et al | Children, competition | 0.3 |
| Oler et al | Adults, competition | 0.4 |
| Pieter et al | Children, competition | 0.5 |
| Beis et al | Children, competition | 0.6 |
| Pieter et al | Adults, competition | 0.8 |
| Pieter and Zemper | Children, competition | 0.9 |
| Pieter and Zemper | Adults, competition | 1.2 |
| Koh et al | Adults, competition | 1.4 |
| Pieter et al | Adults, competition | 5.2 |
| Koh and Cassidy | Children, competition | 9.8 |
| Karate | ||
| Stricevic et al | Adults, competition | 0.4 |
| Destombe et al | Not specified, not specified | 0.5 |
| Zetaruk et al | Adults, competition | 0.9 |
| Critchley et al | Various, competition | 0.9 |
| McLatchie et al | Not specified, not specified | 2.8 |
| Martial arts | ||
| Birrer | Various, not specified | 0.3 |
| Buschbacher and Shay | Not specified, not specified | 1.7 |
| Birrer and Birrer | Not specified, competition | 3.5 |
| Boxing | ||
| Welch et al | Adults (amateur), competition | 14.0 |
| Porter and O’Brien | Various (amateur), various | 20.4 |
| McCown, 1958 | Adults (professional), competition | 21.0 |
| Jordan and Campbell | Adults (professional), competition | 41.5 |
| Zazryn et al 2006 | Adults (both), various | 44.7 |
| Reference | Participants, Setting Injury Occurred | Injury Rate per 1000 Athletic Exposures |
|---|---|---|
| Tae kwon do | ||
| Beis et al | Adults, competition | 0.7 |
| Pieter et al | Children, competition | 3.1 |
| Beis et al | Children, competition | 3.2 |
| Pieter et al | Adults, competition | 4.5 |
| Zemper and Pieter | Adults, competition | 4.6 |
| Pieter and Zemper | Adults, competition | 5.5 |
| Pieter and Zemper | Children, competition | 5.0 |
| Kazemi and Pieter | Adults, competition | 6.9 |
| Koh et al | Adults, competition | 7.9 |
| Pieter et al | Adults, competition | 13.4 |
| Koh and Cassidy, a | Children, competition | 50.2 |
| Karate | ||
| Stricevic et al | Adults, competition | 1.6 |
| Critchley et al | Various, competition | 3.4 |
| Arriaza and Leyes | Adults, competition | 6.0 |
| McLatchie | Not specified, competition | 11.9 |
| Kick boxing | ||
| Zazryn et al | Adults (professional), competition | 19.2 |
| Buse and Wood | Adults (military), competition | 101.4 |
| Boxing | ||
| Porter and O’Brien | Various (amateur), competition | 11.4 |
| Estwanik et al | Adults (amateur), competition | 77.7 |
| Bledsoe et al | Adults (professional), competition | 186.1 |
| Zazryn et al | Adults (professional), competition | 250.6 |
Related posts:
Spinal Injuries in Sports
Peripheral Nerve Injuries Attributable to Sport and Recreation
Concussion in the National Football League: An Overview for Neurologists
Sleep, Recovery, and Performance: The New Frontier in High-Performance Athletics
Neurologic Injuries from Scuba Diving
Peripheral Nerve Injuries in Baseball Players
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