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DOI: 10.1177/0363546514535717 2014 42: 1287Am J Sports Med

Bruce ReiderBattle Scars

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Battle Scars

And he carries the remindersOf evry glove that laid him down.

The Boxer;Words and Music by Paul Simon*

Warrior, a 2011 film directed by Gavin OConnor, is the fic-tional tale of Paddy Coughlin and his 2 estranged sons, setagainst a background of mixed martial arts (MMA) compe-tition. Paddy is a recovering alcoholic approaching his1000th day of sobriety, but his recent reformation cannotundo the damage that years of drunkenness have wroughtupon his children. United only by their disdain for theirfather and their hatred of each other, the brothers presenta striking outward contrast: Tommy, a hulking and brutalchampion wrestler and ex-Marine; Brendan, a wiry highschool physics teacher with a wife and 2 adorable daugh-ters. Underneath, they are more nuanced and reminiscentof each other: Tommy is emotionally wounded and vulner-able, while Brendan vents his buried frustrations throughamateur cage fighting.

Unwittingly, the 2 young men have embarked on a vio-lent collision course. Lured by extravagant prize moneythat they both desperately need, Tommy and Brendanpunch and wheedle their separate ways into the SpartaMMA challenge. Staged amid the neon and glitz of theAtlantic City casinos, this self-styled War on the Shorewill pit 16 leading middleweight MMA fighters againsteach other in a single-elimination tournament format. Togain the $5 million winner-take-all prize, a fighter musttriumph in 4 punishing bouts in a single weekend. As thenarrative builds to the inevitable final confrontation,Tommy and Brendan conquer their opponents in disparatefashion: Tommy by viciously pummeling his adversariesinto unconsciousness within seconds, Brendan by enduringround after round of painful pounding and near-suffocationuntil finally trapping each unwary rival in a submissionhold.

Although Warrior is a work of fiction, MMA is a veryreal presence in the world of sport and entertainment.Introduced in North America in the early 1990s, MMAevokes the ancient Greek tradition of pankration, a compet-itive sport and combat technique that combined elementsof boxing and wrestling.13 In its early incarnation, MMAcreated such a firestorm of criticism that it was bannedin 40 US states, with politicians as prominent as SenatorJohn McCain calling for its prohibition.3,10,11,13 Justwhen MMA appeared on the verge of extinction in theUS, Ultimate Fighting Championship (UFC), the largest

MMA promoter in North America, agreed to a set of Uni-fied Rules that was approved by the New Jersey AthleticCommission, leading to its current sanctioned status inalmost all US states.10,11 Although these rules prohibita number of ungentlemanly or unladylike behaviors suchas biting, eye-gouging, using abusive language, or insert-ing a finger into any orifice or wound,14 they still leavethe door open to a vast array of violent actions that fightfans crave.

MMA fighters compete with a minimum of equipment:shorts, a mouth guard, a chest protector for women, a groinprotector for men, and lightweight, fingerless gloves.13,14

The duration of fights is set at 3 to 5 rounds of 5 minuteseach, but they are often terminated early by knockout(KO), submission of a combatant (tapping out), stoppageby a corner or attending physician, or technical knockout(TKO), which occurs when the referee judges that a fighteris unable to logically or safely defend him or herself.8,14

The medical implications of MMA were recently summa-rized in a systematic review published in our open-accessaffiliate, 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 animpressive 229 (95% CI, 110-474) per 1000 athletic expo-sures. The portion of injuries sustained by the head washigh, 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 inthe injury statistics reflect considerable variability amongstudies in the methods of collecting data and defininginjury, which was usually the purview of the ringside physi-cian. A common weakness of these studies was a lack ofdetail in the documentation of injury severity.

Not surprisingly, this review found that losing fighterssustained 3 times as many injuries as winners. In addition,bouts that ended in KOs or TKOs or fights that were set-tled by the judges decision were associated with injuryrates more than twice that of bouts that ended with thesubmission of a combatant. Since fighters had a longerexposure to injury in bouts that went the distance, contestssettled by judges decision actually had a lower injury ratethan those ending in submission, when the injury rate wascalculated by minutes of exposure. These findings seem tosuggest that the risk of injury is lower when the fightersare more evenly matched. While the authors acknowledgedthat differences in methodology make it difficult to com-pare studies of diverse sports with confidence, the injuryrate that they obtained was far above that reported forother popular combat sports such as judo, taekwondo,and amateur boxing, and placed MMA in competitionwith professional boxing for most injuries per 1000 athleticexposures.

In any activity that features repeated blows to the head,the potential for concussion or other brain injury is always

Editorial

The American Journal of Sports Medicine, Vol. 42, No. 6DOI: 10.1177/0363546514535717 2014 American Orthopaedic Society for Sports Medicine

*1968 Paul Simon (BMI).

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a concern. In the MMA literature, the definition and analy-sis of concussion have varied greatly among individualreports.3,5,7,11,13,15 Sometimes only a knockout was acceptedas evidence of concussion or severe concussion,7,11,15 whileat least 1 study did not classify KOs or TKOs as injuries atall.3 Without detailed information about the athletes neuro-cognitive status or pattern of recovery, conclusions aboutconcussion rates have generally relied on inference,5 therecorded assessment of the ringside physician,3,6,11,15 orthe recollections of individual fighters.13

In this issue of the American Journal of Sports Medi-cine, Hutchison and colleagues8 report the results of theirextensive analysis of head trauma in professional MMA.This is a timely study, since a recent article has reporteddiffusion tensor imaging abnormalities suggestive ofmicroscopic brain damage in boxers and MMA fighters.16

The authors painstakingly analyzed the publicly availablescorecards and video recordings of 844 UFC MMA conteststhat ended in KO or TKO from 2006 to 2012. The score-cards reported the official outcomes of the bouts, whilethe complete fight videos, when obtainable, were analyzedusing a scoring tool whose reliability had been previouslydocumented.9 From the official scorecard outcomes, theauthors determined that competitors 35 years or olderhad an increased risk of sustaining a KO or TKO, andeach previous KO increased the risk of sustaining a subse-quent KO (odds ratio = 1.30). The longer a fight lasted, theless likely it was to end in a KO or TKO, perhaps also sug-gesting that these outcomes were less likely among evenlymatched fighters.

Video analysis was restricted to 142 events for whichdigital recordings were publicly available. Scrutiny wasfocused on the 30 seconds prior to match stoppage causedby KOs, or by TKOs that resulted from repetitive strikesto the head. Of the 65 fighters who were KOd, 41 sus-tained a second subsequent head impact, usually by strik-ing the floor with their occiput. On average, KOdcompetitors received about 5 to 6 head strikes in the 30 sec-onds before the knockout blow and an additional 2 or 3head strikes between the KO-strike and match stoppage.Among 179 TKOs analyzed, 161 were judged to be theresult of repetitive strikes, and videos were available for77 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, theauthors calculated an incidence of match-ending headtrauma 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 some-what speculative. Should all matches ending in headtrauma be assumed to involve a concussion or other braininjury? Since only a minority of concussions result inunconsciousness, limiting the diagnosis of concussion toKOs would likely underestimate the incidence of such inju-ries. Although the authors acknowledge that they cannotconfidently classify as concussions all TKOs followingrepetitive head strikes, a judgment by the referee thata fighter is unable to intelligently defend him or herselfafter repetitive head strikes is highly suggestive thatsome form of cognitive impairment was present.

Athletic competitions in which rendering ones opponentunconscious is considered a highly desirable outcome havebecome repugnant to many physicians. Medical societies inAustralia,2 Canada,6 the United Kingdom,17 and the UnitedStates1 have all called for a ban onMMA, although such posi-tion statements do not seem to have much effect on thespreading popularity of MMA competition. Perhaps morepractically, Hutchison and colleagues propose possible inter-ventions to mitigate the likelihood or the severity of headtrauma, including better protective equipment, more rapidintervention by the referee following KOs and the introduc-tion of a boxing-style 10-count when a combatant isknocked to the floor by a head strike. Certainly, new studiesbased on more complete data than offered by ringside assess-ments and video analysis would also be desirable.

One of the legendary heroes of the ancient Greek sport ofpankration was Arrhichion, who died while successfullydefending his title at the 54th Olympiad. Despite beingcaught in a choke-hold, Arrhichion refused to surrender. Ashe suffocated, the renowned pankratiast forced his opponentinto submission by dislocating his ankle.4,12 Arrhichionscorpse was honored as the Olympic champion. In Warrior,Paddys immersion in an audio recording of Moby Dick, thestory of a man whose crazed obsession leads him and his fol-lowers down an inexorable path to self-destruction, runsthrough the narrative like a leitmotif and seems an apt met-aphor for the fate of all 3 protagonists. Despondent over hisinability to reconnect with his sons, Paddy nearly drinkshimself to death, while Tommy and Brendan come close tokilling each other in their climactic dual. Ultimately, theyall survive, and their love for each other is rekindled by theirnear-death experience.

Legendary heroes are often triumphant in death, andfictional characters are frequently healed and rebornthrough extreme hardship. Real people may also be trans-formed and ennobled by suffering, although few would vol-untarily choose that route to self-improvement. By theirheroic efforts, MMA fighters may gain both gold and glory.As medical professionals dedicated to the well-being ofathletes, we are called upon to question the price of thatglory.

Bruce Reider, MDChicago, Illinois

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