Mixed martial arts (MMA)—a combination of fighting arts including wrestling, boxing, and jiujitsu—is arguably the world’s most rapidly growing sport. Although the sport may seem foreign to some doctors and elicit an unsubstantiated negative response, today’s MMA competitor is a well-rounded, multidimensional athlete who may need orthopaedic care.

To adequately treat the MMA athlete, an orthopaedic surgeon should understand the needs and culture of the sport as well as the medical issues the athletes face. Many MMA athletes do not have insurance or an “off-season” in which to recover. Being very body-conscious, they frequently seek holistic approaches to treatment. In addition, the MMA athlete may be at higher risk for concussions and may use rapid and unsafe weight cutting techniques. Like all professional athletes, a small subset may also abuse performance-enhancing drugs (PEDs) and testosterone.

Background and evolution
Although evidence of similar forms of unarmed combat contests can be traced back to the original Olympics, today’s MMA largely evolved from the Brazilian tradition of Vale Tudo (or “anything goes”) in the early 1900s. The Japanese fighting form jiujitsu was adapted by the Gracie family into a Brazilian form that stressed technique over strength. These ground techniques rely on joint locks and choke holds to make an opponent submit through a verbal or physical “tapout.”

The original “Ultimate Fighting Championship” (UFC) was partly an effort to market Gracie jiujitsu to North American audiences. In this multifight, single-night tournament, practitioners of different martial arts would face off to prove the superiority of their fighting form. With few rules and no time limits, rounds, or weight-classes, the UFC incited a wave of criticism. Detractors called the sport barbaric, comparing it to a human version of cockfighting.

In response, the UFC—along with knowledgeable ringside physicians and referees—began to establish weight classes, rounds, and a point-based judging system. These changes enhanced fighter safety, and states began to regulate the sport. Soon the disciplines of the fighters began to evolve as well. Instead of training in only one discipline, athletes began to train in multiple fighting forms, leading to the term “mixed martial arts.”

MMA involves both stand-up and ground work. Stand-up fighting entails punches, kicks, knees, and elbows. (Elbows to the back of the head and kicking/kneeing a downed opponent in the head are illegal.) Ground work is often a combination of wrestling and jiujitsu or another submission-based martial art. While on the ground, fighters will attempt to lure their opponents into positions that will allow them to apply a joint lock or choke hold.

Today’s MMA athlete, culture
Today’s MMA athlete focuses on a wide variety of martial arts disciplines as well as strength and conditioning. Due to the individual nature of the sport, athletes may not have athletic trainers, physical therapists, or team physicians, although some employ a nutritionist. As a result, MMA athletes may seek advice from fellow fighters, boxing or jiu-jitsu coaches, or health professionals who train at the same gym.

Because these athletes often do not have health insurance, they may seek cheap, often temporizing treatments that may not be in their best interests. The lack of an off-season to recuperate, the lure of a larger payday, and a focus on moving up the ranks mean that athletes may ignore the advice of ringside or clinic doctors. In fact, because each state regulates its own MMA events and no centralized records or database exist, an athlete may be suspended by a ringside doctor only to fight in another state before the suspension is completed.

Many MMA athletes have wrestling or other backgrounds that rely on more “holistic” approaches to limit interventions by doctors and avoid surgery. As a result, many of these athletes shun orthopaedic surgeons in favor of chiropractors or Eastern medical practitioners. Although alternative treatments may have a role, orthopaedic surgeons need to educate MMA athletes on the value of orthopaedic sports medicine.

However, orthopaedic surgeons cannot assume that MMA athletes have the same “luxuries” afforded to other athletes with a defined season for recovery or that the physical needs of the MMA athlete are interchangeable with those of other athletes. For example, MMA athletes must be able to perform deep knee flexion while grappling on the ground, block low kicks with their shins, or pivot on one leg while kicking with the other.

Common orthopaedic injuries
MMA athletes are at risk for a wide variety of musculoskeletal injuries. During a fight, an MMA athlete may experience lacerations, orbital fractures, metacarpal fractures, or other striking-related injuries. Because the lightweight gloves are also fingerless, inadvertent eye-pokes may occur. Athletes have also sustained shoulder dislocations and tibial fractures.

Many joint-locks require hyperextension of the affected joint. Such hyperextension can lead to injury during training or before a referee can stop a fight. Elbows and knees are most at risk for hyperextension injuries although shoulder dislocation or labral tears from cranking the shoulder in an awkward position are also common. In addition, MMA athletes often sustain injuries to the anterior cruciate ligament (ACL) or meniscus.

Knee and shoulder injuries commonly occur during training camp or practice, because the athletes are using grappling and take-down techniques rather than sparring or stand-up striking. These often include meniscal or ligament injuries in the knee and labral, rotator cuff, or acromioclavicular joint injuries in the shoulder. Because many MMA athletes also lift weights for strength and conditioning, overuse injuries may occur.

Other injuries include hyperextension injuries of the elbow capsule and ligaments or foot sprains from getting caught on the mat or during a scramble. During competition or in the training camp leading up to the fight, striking becomes a more regular training routine, and metacarpal fractures and finger dislocations tend to occur with increasing frequency.

The athlete’s needs and the pressures of the sport need to be considered when recommending treatment. For example, an ACL allograft may allow a quicker rehabilitation (which the MMA athlete will seek), but increase the risk of re-rupture (given the intense nature of the sport and its training). Similarly, a metacarpal fracture may be immobilized but the pressure to continue to train may limit the athlete’s compliance. Frank discussions about treatments and options to work around the injury are necessary.

Treating physicians must also consider the athlete’s schedule. An athlete who misses a scheduled fight will not get paid and may lose the weeks of training he has invested to that point. After the fight, the athlete will have more time for possible surgery and recovery.

MMA medical issues
Besides musculoskeletal injuries, other medical issues that the orthopaedist may encounter include the abuse of PEDs, rapid and unsafe weight loss, and concussion or mild traumatic brain injury. As with other professional athletes, MMA fighters may seek any advantage over their opponents they can find. Unfortunately, that sometimes leads them to abuse PEDs. Anabolic steroids and human growth hormone are of particular concern, but the abuse of testosterone has also been a hot topic.

As television marketing and physicians’ prescriptions of testosterone have increased, so has the abuse of Testosterone Replacement Therapy (TRT). Some MMA athletes may seek out a physician to approve a Therapeutic Use Exemption (TUE) to allow them to use TRT. In many cases, previous abuse of anabolic steroids has limited the athlete’s testosterone, which is then used as “proof” that the athlete requires a TUE.

State commissions understand the need to test athletes for TRT abuse, but funding for these tests is often limited. Some states, including Nevada and California, have effectively banned the use of TRT by athletes. It behooves physicians to educate athletes directly on the dangers of PEDs and TRT abuse.

Another medical issue faced by MMA athletes is rapid and unsafe weight loss. Rules on when a fighter weighs in vary by state for amateurs, but professionals usually weigh-in the day before a fight. Wrestlers, boxers, and MMA athletes will often dehydrate themselves for 5 to 7 days before a fight to meet weigh-in limits. Immediately afterward, they will rehydrate, often gaining 5 to 20 pounds. This rapid weight loss and dehydration puts them at significant risk for kidney failure, cardiovascular strain, neurocognitive dysfunction, and a host of other pathologies.

Studies have shown that many athletes are still dehydrated by the time the fight starts, and very few meet the limits of their weight class. Several weight-loss-related deaths in the 1990s led the National Collegiate Athletic Association to move wrestling weigh-ins to match day and to regulate how quickly and how much weight a wrestler can cut. Furthermore, this dehydration may limit cerebrospinal fluid volumes, thus reducing the cushion for impact from head blows.

Although MMA gloves are lighter and the fights are shorter than in boxing, MMA fighters are still at significant risk for concussion and long-term mild traumatic brain injury. In fact, most of the accumulated brain injury may occur during training for a fight. Many athletes may not even know that a knockout involves a concussion.

Education on the long-term risk of hard sparring as well as on the impact of multiple subconcussive episodes is important, especially for young athletes entering the sport. More research is required to understand the effects of long-term exposure in earlier generations of MMA fighters.

As MMA becomes more popular, we as orthopaedic surgeons will see more of its athletes in our practices. By understanding the athlete’s needs and the sport’s culture, we can build a bridge between orthopaedics and MMA, while educating and providing better care for these athletes.

Jonathan Gelber, MD, MS, is an orthopaedic surgeon and founder of the Mixed Martial Arts Research Society. For more information or to join the society, please visit mmastudy.org