Working With Combat Athletes
Sports that involve fighting are among the most challenging and stressful—not to mention dangerous—competitions. PTs who work with these athletes need to be on top of their own games.
Combat athletes compete in many different sports. While some—such as wrestling, boxing, and karate—have been practiced for hundreds or even thousands of years, others, such as mixed martial arts (MMA) and Brazilian jiu jitsu (BJJ), are new to the scene. (The term “combat sports” describes a competition whose essence consists of direct combat between 2 competing athletes.1 See “Combat Sports and Terminology in Brief” on page 19 for descriptions of different combat sports and definitions of terms.)
Similar to athletes in other pro sports—as well as to tactical athletes, including military personnel, police, and firefighters2—combat sports athletes’ continued employment relies on their physical performance and, ideally, avoiding injury. However, the physical demands of combat sports mean that injuries occur more frequently than in other sports. In MMA, for example, a number of studies have found an injury rate of 24-29 per 100 fight participations.3,4
Both women and men compete in combat athletics. Women compete in judo in the Olympics as well as at other levels; MMA fighter Ronda Rousey was an Olympic judo bronze medalist before transitioning to MMA, where she won the UFC (Ultimate Fighting Championship) women’s bantamweight championship. Holly Holm was a professional boxer and kickboxer before defeating Rousey to win the UFC bantamweight championship. Amanda Nunes, the current MMA bantamweight champion, started training in karate at age 7 and pursued training in boxing at the age of 16. She holds a black belt in BJJ and a brown belt in judo. In fact, many women combat athletes have practiced multiple martial arts.
Physical therapists (PTs) who specialize in working with these athletes focus on minimizing injuries, addressing those that do occur, and extending the careers of the athletes.
Combining Martial Arts and Physical Therapy
Jessica Probst, PT, DPT, founder of ThriveAgain Physical Therapy & Wellness in Washington, DC, fell in love with martial arts as she began her PT education in 1996. She studied jiu jitsu as she was learning about the human body.
“The joint locks [moves designed to make an opponent submit, involving the application of pressure to joints] complemented the details from my physical therapy orthopedics classes,” she says. “My detailed knowledge of the sternocleidomastoid muscles and carotid arteries augmented my chokes [submissions in which pressure is applied to the neck, depriving the brain of blood] to an impressive degree.”
Having experienced rib and thoracic injuries, a second-degree acromioclavicular joint sprain, and multiple finger and toe fractures while performing jiu jitsu, Probst switched to a martial art that would result in less wear and tear on her body. She transitioned to aikido (a defensive art using strikes, throws, and joint locks) in 2005. In 2008, she started Krav Maga (an Israeli military self-defense and fighting system). She now practices Muay Thai—also known as Thai boxing—that involves strikes by both the hands and feet.
Probst began her private practice in 2009 to meet the needs of martial artists and fighters. “I combine my extensive advanced manual therapy training with my martial arts training to provide tailored care,” she says. “I analyze technique and identify the sources of the movement problem from a regional interdependence model. Then I complete manual therapy, stretches, strengthening, and neuromuscular reeducation, and build back up into reintegrating appropriate movement into the specific problem area to maximize performance.”
Over the last decade, Probst has treated hundreds of martial artists and fighters in the Washington, DC, region, some of whom have gone on to win World Kickboxing Association championships, amateur and professional MMA competitions, Muay Thai competitions, and Taekwondo competitions.
While conditions and injuries for combat sports athletes can vary, the most common injuries Probst sees are rib injuries, thoracic restrictions, lower back pain, knee pain (frequently meniscal or at the iliotibial band or medial region), hip impingement and pain, ankle sprains, elbow hyperextension (often among “newbies” to their sport, she says), postconcussion headaches, and chronic whiplash.
She also sees a lot of shoulder impingement syndrome (SIS), which frequently occurs because the athletes have been taught to protect their chin while throwing jabs by “putting on a hoodie”—bringing their shoulders up and forward, as if shrugging into a jacket.
“Many of these patients stay in ‘fight stance,’ continuing to cover their chin as they go to their [daytime or salaried] jobs, and the anterior tipping of the scapula will frequently, over time, cause partial supraspinatus tears if not addressed,” Probst says. “For these patients, my first goal is to fully normalize thoracic mobility, costal mobility, and cervical mobility through manual interventions. Ribs 1-4 are very frequently restricted in these patients. Soft tissue work and stretching instruction usually is needed.”
“I try to retrain by having patients first protract and then upwardly rotate their scapula,” Probst says. “In multiple conversations I’ve had with competitive MMA athletes and Krav Maga black belts, many feel this still provides adequate protection while decreasing the incidence or likelihood of SIS.”
She notes that it’s also important to assess lumbar and hip mobility and lumbopelvic stability, as many of these patients are using their upper body to power their punches instead of rotating through their hips and pelvic girdle, and incorporating their whole body in delivering the strike. For them, Probst says, addressing fighting stance and striking form is crucial.
Lauren (Laurey) Lou, PT, DPT, a physical therapist at the Hospital for Special Surgery in White Plains, New York, started training in Muay Thai and later jiu jitsu, which heightened her passion for working with this population. She also was the lead PT for the Chinese National Wrestling and Judo teams at the Olympic Training Center in Beijing for the athletes prepping for the 2016 Olympic Games in Rio de Janeiro, Brazil. Lou is a board-certified clinical specialist in sports physical therapy.
“The thing I love most about treating combat sports athletes is that there isn’t the same narrow pattern of injuries that you see in other sports—in part because each combat sport is so different,” she says. “Basically, I see 2 types of injuries—acute, from taps and blows, and chronic, from repetitive movements and positions.”
For acute injuries, such as those to the ulnar collateral and medial collateral ligaments, Lou says most combat athletes continue to train during the healing process. “For these folks,” she says, “I’ll use taping to help decrease stress to the area during training, then corrective exercises and strengthening for the structures around the area.”
Regarding chronic injuries, Lou sees a lot of low back and shoulder pain. “Each fighter is different,” she says, “but a large contributing factor I’ve seen is from the fighter’s posture—rounded shoulders, pitched forward—compounded by the dominant patterns in specific types of combat sports such as wrestling, judo, and jiu jitsu.” Lou typically works with those athletes on inner core activation in reciprocal and rotational patterns. This may start with basic functional movement rolling patterns and then progress to more sport-specific positions; for example, standing exercises for a boxer or ground exercises for grapplers.
In addition, Lou observes, “most of these combat sports athletes need a lot of gluteal work. Some of them have super strong glutes, but they can’t access this strength due to the length tension in hip flexion, which is found in the typical fighters’ posture, versus extension. Although being in extension may not be ‘sport specific,’ this is an integral part of the corrective exercises that combat sports athletes must be doing outside of their skills training.”
George J. Davies, PT, DPT, MEd, FAPTA, brings another perspective to the subject. Davies teaches in the PT program at Armstrong Atlantic State University in Savannah, Georgia. He first experienced combat sports while serving in the United States Marine Corps almost 50 years ago. He later earned a black belt in karate and served as a sports medicine consultant to his dojo (the school or facility in which martial arts are practiced), where he developed prevention programs, revised the stretching and warm-up programs, and provided recommendations to any of the martial artists who became injured.
“When the instructors were competing, I would assist them with their conditioning programs and often would work the full-contact events, along with a ring physician, as a cornerman [a coach or trainer who assists a fighter during a bout],” he says. “When more serious injuries occurred, I would provide the appropriate physical therapist services.”
Davies notes that musculotendinous unit (MTU) strains or ruptures can occur in grappling sports because of some of the extreme positions into which the body is forced.
“It’s critical to work on a combination of static, dynamic, and ballistic flexibility of the MTU, with emphasis on end ranges of motion,” he says. “Moreover, performing strengthening and power exercises through the full ROM, particularly with end-ROM strengthening exercises, is critical to try to prevent MTU strains.”
In his practice, Davies sees numerous shoulder anterior subluxations—a problem that, if not treated properly, can become a chronic condition.
“After a short period of immobilization, the patient needs to work on neuromuscular dynamic stability exercises to help the muscles compensate for the instability of the ligaments and the capsule,” he says. “Total body rehabilitation is used, even during the immobilization period. The patient performs cardio exercises, lower extremity strengthening and stretching exercises, core exercises, scapulothoracic exercises, total arm strength exercises, and appropriate glenohumeral and rotator cuff exercises when the timing is appropriate.”
Plyometric exercises for the shoulder complex are performed for power training.
Mixed Martial Arts
As a former professional MMA competitor, Charles E. Rainey, PT, DPT, DSc, MS, a lieutenant commander with the Naval Health Clinic Hawaii, can relate to combat athletes because he experienced many of the same injuries during his competitive years.
MMA is a full-contact combat sport that allows both striking and grappling, while standing and on the ground. It uses techniques from other combat sports and martial arts, including kickboxing, wrestling, and BJJ.
“I have a common line of communication with the athletes because we speak the same language,” Rainey says. “So, when an athlete says he was put into a Kimura [an armlock] and adds, ‘I didn’t tap out quick enough,’ I know which shoulder anatomical structures might have experienced trauma. I also know what physical demands these athletes face day in and day out, and I understand the dynamics of training, rest, and recovery.”
In the realm of MMA, Rainey says the most common injury location is the head and face—predominately the nose, eyes, and jaw regions. This is followed by the lower extremities and then upper extremities.
“The upper and lower extremities tend to follow distal to proximal locations with regard to higher injury rate,” he says. “The hand typically suffers a higher injury rate, followed by the elbow and then the shoulder. The lower extremity follows the same pattern, with the toes having the highest injury rate, followed by the ankle and then the knee. The research shows this across multiple studies.”
Following physical therapy school, Rainey entered the military and was assigned to a special operations SEAL team (a special unit trained for unconventional warfare; “SEAL” is an acronym for SEa Air and Land) command whose physical and mental training regimens were similar to those for MMA athletes. That made it an easy transition.
“SEAL team operators also frequently train in combat sports and MMA, so having an MMA background was valuable in not only serving this population related to military training injuries, but also in addressing their specific combat arts training injuries,” he says.
Ujjwal Shakya, PT, DPT, founder of MMA & Sports Rehab in Arlington, Virginia, brings yet another set of experiences to his patients and clients. Shakya originally is from Nepal and long has been interested in martial arts.
“I have been working with combat sports athletes since I became a PT, partly because my brother-in-law is a professional Muay Thai fighter and I have been studying and treating his injuries for the past 8 years,” he says. “He owns Pentagon Mixed Martial Arts and this terrific opportunity has allowed me to be able to work with many other fighters and combat sports athletes. I myself have been training for the past 5 or 6 years and mainly practice Muay Thai.”
At MMA & Sports Rehab, Shakya says, while injuries vary from sport to sport and person to person, he mainly sees shoulder/neck and hip/knee injuries in the combat athlete population.
“We see a great deal of hip flexor tendinitis as a result of repetitive kicking,” Shakya says. “We have successfully treated this condition with dynamic hip flexor stretching, manual therapy, dry needling, exercises focused on hip abductors, and eccentric hip flexor strengthening exercises.”
He also sees a lot of shoulder impingement/rotator cuff tendinitis because of repetitive punching—particularly “hooks.” For these injuries, he says it’s important to work on rotator cuff and scapular strengthening.
“Cross training is one of the best ways to engage muscles and joints that combat sports athletes don’t use as part of their regular training regimen,” Shakya says. “It’s important to pick another sport or movement that uses different muscle groups to improve muscle balance and overall stability.”
Injuries in Action
Combat sports athletes attempting roundhouse kicks for Muay Thai, MMA, or karate are more prone to meniscal tears, as many martial artists will rotate in weight-bearing through their knee and lower leg instead of pivoting on the ball of their foot. Repeated weight-bearing rotation through the knee can cause significant wear and tear through that joint, say PTs who treat these athletes.
“To avoid this, it is important that the patient has excellent hip external rotation ROM and lumbar mobility,” Probst says. “He or she must also have excellent lumbo-pelvic stability and hip external rotator strength. For these folks, I recommend piriformis, adductor, and hip flexor stretches; clamshell exercises with excellent pelvic stability; and planks and side planks. I frequently do retraining on Pilates rotation discs to retrain deep hip rotators and teach patients how to use their hips and pelvic girdle to rotate instead of rotating through the knee or tibia.”
Lou describes a challenge she encountered while working with a jiu jitsu athlete who has a long history of shoulder impingement, with bilateral labral tears, caused by years in the ring.
“We did rotator cuff and peri-scapular muscle work, deep neck flexor endurance, and pec active releases,” she says. “He got back to 80%, but every time he fought, he’d experience a flare up. Then we started incorporating single-leg strength and balance, lumbo-pelvic stability, and glute strength into his shoulder program. That was the key for him.”
Shakya once treated a fighter who’d had pain at the lower neck/upper thoracic spine with numbness and tingling for 2 months after receiving an improperly executed rear naked choke (a choke applied from an opponent’s back), as his neck was awkwardly twisted.
“He was in a great deal of pain when looking up and was unable to perform push-ups. He saw me 2 months after his original injury. I was able to assess him thoroughly and perform thoracic spine manipulations, dry needling, and myofascial release to improve his symptoms,” Shakya says. “After the first session, he was able to look up without any symptoms and perform 5 push-ups. He was back in full training mode 2 weeks later, following further strengthening and manual therapy treatment.”
Apropos for All
A great deal of what PTs do with combat sports athletes can be applied to other patients as well, these PTs say.
“I spend a lot of time thinking about rotational patterns for my combat athletes—but reciprocal and rotational patterns are very functional for all patients,” Lou says. “A patient who is older and has chronic low back pain needs inner core stability in the presence of rotation as much as your Thai boxing fighter does.”
Everyday activities—using proper movement patterns to bend down to pick something up, putting something on the top shelf, opening a door, carrying a suitcase, walking, stair negotiation—all include a component of rotation or antirotation and a reciprocal pattern.
The clinic at which Davies has practiced for almost 30 years covers approximately 1,700 sporting events a year and works with many college, high school, middle school, youth, and recreational athletes.
“Many of the fundamental treatments are similar,” he says. “Where the divergence occurs is more in the terminal phases of rehabilitation, where it is focused more on specificity of activity. Obviously, someone returning back to activities of daily living does not require the levels of specific training that combat athletes need to return to their activity.”
The PTs interviewed for this article describe combat sports athletes as a highly resilient population who are dedicated and tough-minded in their approach to training and rehab.
“As with any patients, the key to successful treatment is proper education about their body, understanding their symptoms, and effectively treating them,” Shakya says.
Keith Loria is a freelance writer. Additional interviews were conducted by Don Tepper, editor of PT in Motion.
Combat Sports & Terminology in Brief
Here are brief summaries of some of the sports and terms mentioned in this article.
Boxing, both amateur and professional, involves attack and defense with the fists. Boxers wear padded gloves and generally observe the code set forth in the Marquess of Queensberry rules. Matched in weight and ability, boxing contestants try to land blows while attempting to avoid the blows of the opponent. A boxer wins a match either by outscoring the opponent—points can be tallied in several ways—or by rendering the opponent incapable of continuing the match. Bouts range from 3 to 12 rounds, with each round normally lasting 3 minutes.1
Brazilian Jiu-Jitsu (BJJ) is a martial art and combat sport that teaches a smaller person how to defend himself or herself against a larger adversary by using leverage and proper technique. The Gracie family, founders of BJJ, modified judo and traditional Japanese jujutsu to create the art. It contains stand-up maneuvers but is most known for its ground-fighting techniques. Gaining superior positioning—so one can apply the style’s numerous chokes, holds, locks, and joint manipulations to an opponent—is the key in BJJ.2 Fights may be won by submission or by points awarded by the referee.
Chokes are submission moves that apply pressure to the neck, cutting off blood to the brain. A player who does not “tap,” or submit, will lose consciousness.3
Joint Locks are moves that apply pressure to a joint and push it in an “unnatural” direction (ie, locking an arm and forcing an elbow backward). This restricts an opponent’s movement and/or causes him or her to submit due to pain and/or potential for a hyperextension injury or broken bone.
Jujutsu is a Japanese martial art and method of close combat for defeating an armed and armored opponent while using no weapon or only a short weapon. Because striking an armored opponent proved ineffective, practitioners learned that the most efficient methods for neutralizing an enemy took the forms of pins, joint locks, and throws. These techniques were developed around the principle of using an attacker’s energy against him or her, rather than directly opposing it.4
Karate developed out of martial arts forms practiced on Okinawa, an island now part of Japan. The word karate is Japanese for “open hand” (kara means open and te means hand). Te signifies that the main weapon is the body. Instead of an arsenal of swords or guns, the “karateka” cultivates a personal arsenal of punches, kicks, and deflection techniques. Kara relates to the psychology of karate. Karatekas are open to the world around them, making them better equipped to handle any attack.5 Historically, and in some modern styles, grappling, throws, joint locks, restraints, and vital-point strikes also are taught.
Krav Maga is a tactical mixed-martial art/combative and self-defense system that combines boxing, judo, jujitsu, and aikido. It was developed for the Israel Defense Forces and Israeli security forces. The primary goal, to neutralize a threat as quickly as possible, governs all the other principles of Krav Maga. It consists of strikes, holds, and blocks. The fighter looks to combine an offensive movement with every defensive movement.6
MMA (Mixed Martial Arts) is a full-contact sport that allows a variety of fighting styles to be used (including martial and non-martial arts techniques). Striking and grappling techniques, either standing or on the ground, are permitted. The early years of the sport saw a wide variety of traditional styles, but it is now common for fighters to train in multiple styles, creating a more balanced skill set.7 A competitor may win by submitting his or her opponent (forcing the opponent to concede the match), knocking out the opponent, prompting a referee stoppage (technical knockout), accumulating the most points from the judges, or causing an injury that results in a doctor’s stoppage.
Muay Thai or Thai boxing is the Thai national sport. In Muay Thai, competitors fight standing as in Western boxing, but elbows, knees, and kicks strikes are allowed, with the only protection being the gloves. An important part of this fighting style is the clinch (standing wrestle).8
References
- Wallenfeldt EC, Poliakoff M, Hauser T, et al. Boxing. Encyclopaedia Britannica. https://www.britannica.com/sports/boxing. Accessed February 11, 2018.
- Brazilian jiu jitsu. Black Belt Magazine. http://blackbeltmag.com/category/brazilian-jiu-jitsu/. Accessed February 3, 2018.
- Worthington V. What’s that move called? https://breakingmuscle.com/learn/what-s-that-move-called-a-glossary-of-mma-terms. Accessed February 2, 2018.
- Jujutsu https://en.wikipedia.org/wiki/Jujutsu.. Accessed January 29, 2018.
- Harris T. How Karate Works. https://entertainment.howstuffworks.com/karate1.htm. Accessed February 11, 2018.
- McKay B. The Art of Manliness: A Primer on Krav Maga: The Combative System of the Israeli Defense Forces. https://www.artofmanliness.com/2013/07/10/a-primer-on-krav-maga-the-combative-system-of-the-israeli-defense-forces/. Accessed February 11, 2018.
- Types of Martial Arts. Master Chong’s World Class Tae Kwon Do. https://buffalotkd.com/types-of-martial-arts/. Accessed February 2, 2018.
- Muay Thai &Thailand. http://thailand-muaythai.com/en/. Accessed February 3, 2018.
In A Training Camp
John Knarr, PT, MS, ATC, has worked with many individual athletes and sports teams. He runs Elite Physical Therapy in Rehoboth Beach, Delaware.
Serving as a PT during an athlete’s training camp, he says, can be an experience unlike any other. And he should know. He was the PT during the training camp of Wladimir Klitchko, a 2-time world heavyweight champion who competed from 1996 to 2017 and compiled a record of 64-5.
Knarr worked with Klitchko before his 2008 fight with Sultan Ibragimov—which Klitchko would win, regaining his World Boxing Organization heavyweight title.
Knarr recalls, “My first contact [with Klitchko] wasn’t an initial PT evaluation. It was on the phone. We talked to find out if we were compatible, because I’ll be living with the guy for 6 weeks. We do 5 weeks of preparation, a 5-week camp, and then a week of pretty intense media before the fight. Physicians are there ringside, making sure the fighter is coherent. After the fight, I make sure he’s healthy. I check him out for any impact from new or previous injuries. I’m in contact that night and again about a week later. After that, everyone goes their own way. It’s like a band separating after a performance.”
How do you know if everything’s going OK? “When you’re sitting around not doing anything,” Knarr says. “If there’s nothing other than prevention to do, you’re successful.”
In the Military
The military has had various forms of combatives-type training for decades, which in the past 10-15 years have been developed into formal programs in each of the services.
With support from the APTA Sports Physical Therapy Section (SPTS), Richard B. Westrick, PT, DPT, DSc, 3 years ago founded the section’s Tactical Athlete Special Interest Group for PTs working with military, law enforcement, and firefighter tactical professionals. (For more information, see “Protecting the Protectors” in the May 2017 issue of PT in Motion.2) Westrick is an associate professor in the Department of Physical Therapy at the MGH Institute of Health Professions in Boston.
“The various combatives programs comprised martial arts techniques from various disciplines and include grappling, striking, and weapons training,” Westrick says. “For nearly a decade, every military trainee has been required to go through these formal combative training programs, and they may continue to advance through various levels of proficiency during their military career.”
The most significant difference between training and competition for civilian combat sports and training for military warfighters is the potential consequences when hand-to-hand skills may be required, especially in a deployed setting.
Nevertheless, the similarities are great enough that more than a dozen military personnel trained in combatives or specific combat sports have gone on to carve out successful MMA careers. These include Randy Couture (former UFC heavyweight and light-heavyweight champion), Brian Stann, Brandon Vera, Tim Kennedy, and Liz Carmouche.
References
- US Army Combatives—FM 3-25.150, 1-01, Definition of Combatives. http://www.usarmycombatives.com/1-01-definition-of-combatives/. Accessed November 26, 2017.
The Athletes Speak
“I’ve had many injuries that required me to see a PT. I have had a ruptured ligament in a finger, a torn labrum in my shoulder, numerous strained muscles and tendons, pinched nerves, elbow injuries, broken toes, jammed fingers, ‘stuck’ ankles, and many more,” she says. “Combat sports are tough on the body. Seeing a PT can reduce a lot of the injuries or shorten the downtime away from the sport.”
“I was able to easily develop my larger muscles, but often my small muscles were ignored, causing imbalances,” Schmidt says. “Jess had me do so many targeted stretches and exercises while I competed, allowing me to build up those small muscles to be more even and reduce the risk of a repeat injury.”
Kru Vivek Nakarmi has been training and competing in Muay Thai (also known as Thai boxing) since 2004 and is president and founder of Pentagon Mixed Martial Arts in Arlington, Virginia.
He’s fought competitively in various martial arts since the age of 8, and over the years has undergone surgeries to repair torn labrum on both shoulders. He’s also experienced knee injuries, a broken wrist, and injured knuckles from repeated punching; sprained fingers; and a herniated disc.
“As an athlete, extending the life of my body is key to my success as a professional fighter, so it is important to make sure everything is working properly and efficiently,” he says. “A good PT is a key partner in injury treatment and prevention for athletes. Also, it’s important to avoid unnecessary surgery, and physical therapy often provides an effective alternative to surgery.”
Working with Ujjwal Shakya, PT, DPT, has been a critical part of his ability to continue fighting professionally.
“I wouldn’t be where I am today without him,” he says.
Ian McCall is a professional MMA fighter with a 13-6 record. Formerly under contract with the UFC (Ultimate Fighting Championship), he’s now fighting in the Japanese organization Rizin. McCall’s had more than his share of injuries: “I’ve had broken hands twice, dislocated my elbow, and had 4 surgeries on my shoulder. I pulled my hip, pulled my groin, popped my knee, and had rib injuries.”
McCall speaks highly of physical therapy, not only for recovery from injuries but also to extend an athlete’s career. “My advice to other athletes: You definitely need it, including maintenance, preventive maintenance, and rehab. You have to constantly take care of yourself. Have the little things—a pinch in the knee or numbness in your hand—looked at before they become a real problem.”
Mike Suski, meanwhile, started off as a high school wrestler and amateur boxer in Michigan. He soon focused on boxing, compiling a winning record and national recognition that included being named to the US Boxing Team. Along the way, then-business mogul Donald Trump heard about Suski and hired him to be his “boxing bodyguard” at Mar-a-Lago for several years in the 1990s. Suski turned pro, compiled a 12-2 record, and once was ranked Number 10 in the world by the International Boxing Council, 1 of a number of boxing promotions. Suski describes his experiences in his book Small Town Boxer.
During a 12-year career, though, he’d experienced a number of injuries and, unknowingly, also was aggravating them. “Boxing had torn my body up. And after my pro career, I lifted weights and did a lot of running. I had a lot of instability in my joints, and the weights started ripping up my shoulders and lower lumbar. So, my injuries from boxing were made a lot worse.”
He credits physical therapy—especially aquatic physical therapy—with helping him recover.
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