The Ultimate Guide to Preventing and Treating MMA Injuries: Featuring advice from UFC Hall of Famers Randy Couture, Ken Shamrock, Bas Rutten, Pat Miletich, Dan Severn and more! (2016)

CONCUSSIONS

The face of a fighter often tells their biography. Broken noses and cauliflower ears are usually tell-tale signs of a career in combat sports. These common injuries, however, are often only superficial. Much of the damage of a career in a combat sport such as MMA is under the surface. Concussion and brain injury are serious issues and more attention needs to be paid to the symptoms fighters experience. Instead of seeking treatment after a concussion, fighters chalk it up to simple run-of-the-mill injury and try to go on with their usual routine, even when something feels off.

MMA legend and pioneer Frank Shamrock admits to misunderstanding the severity of brain injuries as he describes his fight against Yuki Kondo in 1996 at Pancrase in Japan: “After 12 exhausting minutes of non-stop fighting, Yuki kicked me in the face and knocked me backwards. I fell through the second rope and hit my head on the metal floor. It knocked me out for about two seconds and they called the fight. That’s the only time I ever got knocked out. I got up and felt woozy. I was sick to my stomach. I recovered pretty quickly and went out that night and had a good time. The next morning, I woke up and starting walking out of my hotel room. When I went to grab the doorknob, I found it was two inches to the left of where I grabbed. All that day in Japan, it kept happening. I flew home the next day and it still kept happening.”

Another unfortunate example of not recognizing the symptoms of a concussion occurred at UFC 17. At that event, Lion’s Den fighter Pete Williams fought former UFC Heavyweight Champion Mark Coleman in the main event. Pete’s perfectly placed kick was the first-ever head-kick KO in UFC and has become one of the top knockouts in UFC history. Not long after the knockout, it seemed as though Mark had recovered, and neither Mark nor his team recognized the symptoms of a concussion until later that night. “I remember getting knocked out by Pete Williams. I got hit right in the kisser, and I’ll tell you, he knocked “The Hammer” down. I was out cold for what felt like a good two minutes or so, but I got back up and left the Octagon. Back in the locker room, I was talking to my family for at least an hour when I suddenly stopped and looked at my dad and asked him why Big John stopped the fight. Up until then, I couldn’t remember. And then things suddenly became clear again. My brain snapped back on. I had been talking to everyone for an hour, and no one realized my brain wasn’t working completely.”

In recent years, a lot of media attention has been focused on concussions in all sports. The brain is a soft-tissue organ encased in a hard, bony skull. A direct impact to the head such as a kick, a punch, or even a fall backwards onto the canvas imparts energy into the brain and skull. When this happens, the skull can either move faster or slower than the brain. When the skull eventually stops moving, conservation of momentum causes the brain to continue to move towards the skull. With enough force, the brain can slam into the skull (called a “coup” injury). Sometimes the brain even bounces back and hits the opposite side of the skull as well (a “contrecoup” injury).

As the brain smashes up against the skull, small areas of nerve connection can tear or stretch. Injured cells also release stimulating chemical signals that excite other nerve cells. The result is a chaotic highway of altered brain signaling, in which some cells die and others perform poorly for extended periods of time. And while those cells attempt to heal, a second injury (termed “second-impact syndrome”) can be all the more deadly. That’s why an athlete who suffers a concussion must be removed from a game. And not all concussions are caused by a knockout. Taking a lot of punishment standing up or even being “out on your feet” can result in either a concussion or “sub-concussive” episode even if the fighter doesn’t lose via an actual KO. Famed MMA and Muay Thai coach Mark DellaGrotte remarks that, “It’s more than just the guy who gets knocked out that you need to worry about. Sometimes the worst punches aren’t the ones that knock you out, because at least with a knockout it’s definitive. A lot of damage that these guys suffer is often overlooked. At least with a knockout, you see something you need to address.”

AWARENESS IS VITAL TO YOUR CAREER

Awareness that concussions can occur with or without a knockout, especially in boxing or MMA, is something important to understand. Strikeforce champion Gilbert Melendez recalls his experience with concussion symptoms without ever getting knocked out. “I’ve been knocked out once in practice, by Jake Shields, about eight to 10 years ago. With that knockout, I didn’t have any headache or symptoms. But then I had a fight where I never went out, but afterwards I had a concussion. My head hurt and I had nausea. The symptoms lasted one week. Now, I try to avoid heavy sparring. In my younger years, I sparred more. But now I don’t need to bang so hard. The smart people with a good coach will limit their sparring. And I tell people that’s why you need a coach. When you are your own head coach, it’s hard to limit yourself.”

Keeping watch for concussion symptoms needs to continue well after the fight is over. In his rubber match with Andrei Arlovski at UFC 61, Tim Sylvia defeated “The Pit Bull” via unanimous decision to retain his UFC Heavyweight Championship. Arlovski is known as a hard striker, and despite not getting knocked out during the battle, Tim felt the effects of a concussion that night. “I think I have had a couple concussions, but the worst one I had was against Arlovski. We went the distance, and I went to bed that night. In the middle of the night, I got up to use the bathroom and had a head-rush and passed out right on the bathroom floor. I came to, went to try to go to bed, but passed out again and fell face first right back on the floor. My girlfriend found me on the floor and called the paramedics. The ambulance rushed me to the hospital and the doctor told me I had a concussion. I had to follow no contact for six months.”

After a knockout or a concussion, a fighter may feel disoriented or confused. This is part of a post-concussion syndrome of multiple symptoms that may take anywhere from only a few seconds to as long as weeks or months to resolve. The symptoms may even develop or get worse over time, which is why it is imperative to look out for these symptoms after any knockout, even in training. Because the symptoms may not be overtly noticeable right away, ringside physicians should make it a point to talk to the fighters before their bouts, so they have a baseline of how they normally speak to use as a comparison later on after the fight. Coaches and training partners can do the same. Famed UFC announcer and kickboxer Bruce Buffer describes his own experience with sparring too hard too often, resulting in slurred speech — which can be a real problem for the “Voice of the Octagon.” “Concussions are a scary thing. When I went to my doctor at 32 with what I felt was my second concussion from heavy sparring, he immediately told me to stop as the symptoms of slurred speech I experienced would potentially become much worse and possibly permanent if I continued. Plus it probably was not my first concussion; so I stopped contact and just trained non-contact from that point on.”

Recognition of a concussion requires vigilance and familiarity with symptoms. Below is a list of concussion symptoms that may appear right after a knockout and others that may take some time to develop and appear.

Symptoms that may appear promptly after injury:

· Confusion

· Amnesia

· Headache

· Dizziness

· Ringing in the ears

· Nausea or vomiting

· Slurred speech

· Fatigue

Symptoms that may appear later:

· Memory or concentration problems

· Sensitivity to light and noise

· Sleep disturbances

· Irritability

· Depression

MMA legend Renzo Gracie has experienced some of these symptoms, having been knocked out twice in his career, “once by Dan Henderson and once against Matt Hughes. When it happened, I didn’t feel anything. The lights just went off. I didn’t have headaches or amnesia. But I know guys who have had those. I know one fighter who fought and finished a fight and didn’t even remember what happened afterwards. That’s scary.” Former UFC fighter, King of the Cage Middleweight Champion, and world-class grappler Dean Lister weighs in: “I have had several concussions in my life. Some were from American football and others were from getting hit in the head in boxing and MMA. They are a mysterious thing to me. Sometimes they hurt badly right away but even then you usually won’t know the true effects until later. I have had times, even for a few weeks, where I felt off balance and felt like collapsing. This is not to be underrated at all and can be serious. In hindsight, now that we know more about concussions, I should have seen a doctor right away. If anyone has these symptoms, please be very careful and please do not subject yourself to more abuse involving the brain. Yes, this means no sparring in boxing or kickboxing until cleared by a doctor trained in concussions. Not being aware of these symptoms and not educating yourself can be more dangerous than almost anything in MMA.”

You may think your brain is doing fine, or you may not notice the small changes in mood, concentration, or reaction time. Or maybe your significant other tells you that you are forgetting things more often. These are all signs of long-term brain injury, and we are just starting to understand the causes. There is currently no standard test such as a blood sample or lumbar tap to detect levels of brain injury. However, an MRI may pick up brain changes that you were not aware of that can and should be monitored for changes by a brain injury physician.

Renzo Gracie understands that knockouts are a part of the sport, but he believes a fighter is most at risk for head injury during training sessions. “When it comes to getting knocked out in training, don’t be a tough guy who gets knocked out and then keeps training. In fact, I think it’s the training time that is the most dangerous. You train every day for a fight, but the actual fight is only 35 minutes long. As a coach, I noticed that once a guy gets knocked out, he gets knocked out a lot easier after that. A lot of coaches think they need to push a fighter 100% of the time. A fighter doesn’t need to be hit every day. I look at the Russians training only 75-80% and then go on to win. The coach has an obligation to look at a fighter and make sure their career is long. This includes limiting their head injuries.”

WEAR HEADGEAR

While head strikes are part of the game, unnecessary concussions are not. Prevention begins with wearing appropriate headgear while training under adequate supervision. Coach Mike Winkeljohn, head striking-coach for Greg Jackson’s elite team of fighters, including UFC champions Jon Jones and Holly Holm, says that prevention of head trauma goes beyond just the fighter — it involves the whole team, coaches included. “Coaches need to communicate with the fighters and watch the fighters and their energy levels. If they are getting tired and aren’t performing, they’re done. They are not proving anything other than how tough they are, and it’s not benefiting anyone, especially the fighter. One of the biggest mistakes fighters make while training is they spar hard too much. They try to do too much in one day, get tired, and then their hands drop down. When their hands drop down, they take more trauma to head.”

LIMIT SPARRING

In addition to wearing headgear, being smart about how often and when you spar can help prevent concussions and head injuries. As Winkeljohn recommends, “In our camp, we only spar hard one time a week. During our camps, we used to spar hard twice a week. Then we noticed more knockouts and knockdowns later in the week. When guys spar hard, it affects them all week, and all kinds of injuries can happen. I have also noticed that with too much hard sparring, their focus and reaction time goes down and guys get tired easily. You also have to be a responsible training partner. I am a big believer in full-speed training, but once you hurt someone, you need to let up. Fighters always want to fight, so it’s the guys around them that need to help them focus on the long term. The people around them should be held accountable.”

Jackson-Winkeljohn MMA fighter Carlos Condit has limited his sparring as he has grown as a fighter. “This is something I have been thinking a lot about the last four to five years. Growing up, I would spar as much as I could, most of the time without headgear. Fighters like to fight, and even if it’s a sparring session, it turns into a fight. It’s good to have that fire inside you, but you need to hold yourself back. The more wars you have in the gym, the shorter your career. At Jackson’s MMA, we only spar hard, all out, once every one to two weeks. Instead, we do heavy-intensity grappling with lots of movement. If we do add strikes, we put on the smaller MMA gloves, so no one is swinging too hard.”

GOING LIVE AND GOING HARD

Josh Barnett has a long history in MMA, including victories in Pride and defeating Randy Couture at age 24 for the UFC Heavyweight Championship. During that time, he has developed a practical philosophy on balancing hard or live training with knockouts. “In this sport, you will get hurt. You will get knocked out and get a concussion. I stepped into this knowing that. But you can limit the damage you receive. You have to go live during training, but you can go 70% or you can do drills where you let one guy win, which helps technique and preparation for a full-on fight. Without contact, you can’t find that level of relaxation where you can avoid injury when you are out there. Contact helps you deal with your opponent’s aggression better and teaches you to [reduce the intensity of] a punch by slipping it or taking some of the power out of it by rolling with the punch. That can’t happen without live training. If I am sparring, I think ‘Do I need to hit this guy in the head as hard a possible?’ Usually the answer is ‘no.’ I can hit them harder in the body, but when I hit the face and head, I hit 60-70%. Knocking out my partner doesn’t help me train — and then I lose a training partner.”

Andy Foster is a former professional mixed martial artist and the executive director of the California State Athletic Commission, California’s MMA regulatory body. As a former fighter who now looks at things from a regulatory and safety standpoint, he knows that every knockdown or knockout needs to be properly addressed. “If you are knocked down from a strike you should take some time off from sparring. If you are actually ‘knocked out,’ stop training and consult your physician immediately before returning. Once, when I was just simply knocked down during training, I saw my doctor and couldn’t actually return to training for three weeks.”

LOSING YOUR CHIN

Cesar Gracie, who has coached top fighters such as the Diaz brothers, Gilbert Melendez, and Jake Shields, warns against going out there and swinging for the fences all the time. Because once you get knocked out and “lose your chin,” there is no coming back. You can go from a top guy or champion to a low-level guy quickly. “The fans love guys who get in there and bang, but you have to be careful with the head damage you take. If you are going to spar, you need to spar light. There are a lot of tough-guy sayings about getting used to having your bell rung, but you don’t need to get used to getting hit hard in the head. When it comes to your brain, it doesn’t get stronger from getting hit. It only can get hurt. I have always been a fan of the intelligent fighter. I am a fan of the sport, but I don’t want people to get beat up by over-sparring. And once your chin goes, it’s gone. There’s nothing you can do about it. Now all of a sudden you get hit with punches you could take before and suddenly the lights start going off. You get knocked out by easier punches.”

Founder of the successful MMA camp American Kickboxing Academy, Javier Mendez, takes knockdowns in training seriously. “We spar Monday, Wednesday, and Friday, and unless you have a fight coming up, or we need you for something specific, we keep you out of the hard contact room and in the technique room. Most of our fighters elect to go one or two of those days with the smaller gloves, which we use to promote lighter contact. As a coach or trainer, you have to watch out for knockdowns. In our camp, if a fighter gets knocked down, it’s an automatic 30-day suspension from sparring in our gym unless you get cleared from a doctor. I would rather be safe than sorry and use physicians as our number one resource for injury advice.”

AVOID SPARRING WITH HEAVIER OPPONENTS

Another training condition that puts fighters at risk of injury, especially excessive head trauma, is having fighters of largely different weight classes spar. While it may be good practice and an ego booster to fight a larger opponent, being significantly outweighed can lead to unnecessary heavy blows. Don Frye, MMA veteran and winner of two UFC tournaments, including the Ultimate Ultimate 1996 tournament, sees this as a common mistake trainers make. “I have seen trainers at gyms do some dangerous things. One of these is having guys spar with more than 25-50 pounds difference. When an athlete becomes tired or hurt and can’t raise his arms to fully protect his head and chin, it puts him at risk, and it’s amplified [when fighting] bigger guys. Granted I am old school, but even I know better than that!”

BASELINE TESTING LIKE THE PROS

Fighters may also consider getting baseline neurocognitive testing, which is what athletes in the NFL and NCAA do. This allows doctors and trainers to assess where a fighter or other athlete is in their recovery from a concussion and whether they are back at their baseline. You may not notice the subtle symptoms that these tests look for. The pendulum of treatment for concussions has swung in a different direction than previous generations. For a long time, athletes with concussions were instructed to lie quietly in a dark room and be woken up in the middle of the night. Current research suggests that the brain does need rest, but complete isolation is detrimental to a recovering brain. Most concussion specialists work with an athlete to determine how and when their symptoms arise and slowly push the limits as they feel comfortable until they can return to full competition.

PRACTICAL ADVICE FROM A VETERAN

UFC tournament champion and Pride veteran Guy Mezger has spent several years working with professionals on brain health. “I consult with the Carrick Brain Center in Dallas and I am seeing more and more contact athletes being treated there. MMA athletes generally take fewer blows to the head during a match than most other fighting athletes, but it’s the training that is the real killer.” Some of Mezger’s ideas for maintaining a healthy brain for the MMA athlete include:

· Do not use sparring as your method of conditioning. Work on technique specifics while sparring, but stay fresh. Use other training methods for conditioning such as Thai pad work, focus mitt work, bag work, sprinting, or high-intensity intervals.

· Save the really hard contact fighting for the actual fight. Don’t wear your brain (and body) out in the gym.

· Strengthen your neck. A strong neck can be a shock absorber for the head.

· Cut massively down on alcohol, all drugs, and late-night partying. Make a decision to either be a fighter or a partier. It will undoubtedly cost you in the long run if you try to be both.

· Be nutritionally sound. There are a lot of nutritional supplements and foods that are brain protective in nature.

· If you do get your bell rung, be sure to get checked out and take the adequate time off. You do not want to sustain an injury in training and carry that over into the fight itself, putting yourself at further risk.

· Get to know a good neurologist and get CT scans or MRIs if prescribed. Often times you don’t know what’s brewing under the surface.

Guy’s last point is particularly important as we slowly begin to understand the long-term consequences of traumatic brain injury. You may think your brain is doing fine, or you may not notice the small changes in mood, concentration, or reaction time. Or maybe your significant other tells you that you are forgetting things more often. These are all signs of long-term brain injury, whose causes we are just starting to understand. There is currently no standard simple test such as a blood sample or lumbar tap to detect levels of brain injury. However, an MRI may pick up brain changes that you were not aware of that can and should be monitored for changes by a brain injury physician.

PROLONGING YOUR CAREER — AND YOUR LIFE

Advocates for fighter health realize concussions are a big issue those involved in the sport need to address, especially as the earlier generations retire. As they get older, the signs of long-term traumatic brain injury can become significant. Understanding the long-term effects of traumatic brain injury and how we can limit them is something that is an active area of research, but until we have developed a test to detect levels of brain injury, simply being aware that there are long-term consequences is a first step in the right direction. “Big John” McCarthy, one of the sport’s top referees inside the Octagon, is also an advocate for fighter safety and rule formation outside the cage. “The single most impactful injury to a combat sport athlete is usually a concussion. Although the fan sees things differently, anyone who has been affected by a concussion, especially fighters who are now retired and willing to put their shield of invincibility down, will tell you about the adverse effects that head trauma can bring into their lives. A fan sees a fighter break a leg or an arm, or dislocate an elbow, and they become almost ill at the sight of the injury. But many of the injuries in MMA do not carry the long-lasting effect that a concussion can carry.

“The fan sees a fighter get knocked unconscious and they get concerned for the fighter, but as soon as the fighter stands up and begins walking around, everyone feels better about the situation because they think, ‘The fighter’s okay.’ It’s a nice thought, but the truth is, the fighter is far from okay. If a fighter breaks their arm, everyone understands why they are out of the gym for the next eight weeks while their injury heals, but if a fighter is knocked out, we have no problem seeing them back in the gym one week after their fight. This, simply put, is crazy. Often times, a fighter who has received a concussion should be taking as much, if not more, time off for their injury than the fighter who suffers a more visible injury. Significant head trauma is arguably the most serious injury a fighter can absorb in their career. It changes their career. It changes their abilities in and out of the cage, and sometimes, it changes them as a person for the rest of their lives.”

Big John brings up an excellent point. Many fighters and trainers have expressed the importance of prolonging your career, but many fighters only think about their next fight and not their life once they retire. Repeated head injury can lead to forgetfulness and mood disorders. The media is full of stories of NFL players or other athletes who suffered concussions throughout their career and ended up in deep states of depression, which in some cases led to suicide. This is certainly a tragic issue and is being investigated from a scientific standpoint. Autopsies of many of these athletes have found signs of chronic brain damage that may have led to their changes in personality. This may be a result of frontal lobe dysfunction — a reduction in the activity of the brain’s front lobe, which usually limits our aggression and acts as a filter to our actions. We used to refer to chronic brain damage from combat sports as either dementia pugilistica, or punch-drunk syndrome, but now we refer to it as chronic traumatic encephalopathy, or CTE.

X-rays of Ken Shamrock’s neck showing surgically fused cervical vertebrae.

PHOTO COURTESY OF KEN SHAMROCK

While we can begin to identify and recognize the clinical signs of CTE, it is only with an autopsy that we can definitively diagnose it. Scientists are looking into other ways to detect this type of brain damage, but until we have those tools available, athletes need to realize that long-term traumatic brain damage can lead to depression, forgetfulness, aggression, and other personality changes long after their MMA career is over. Sparring hard too much can make you lose your chin and can lead to shorter fights while inside the ring, but holding back during practice will undoubtedly help you lengthen your career and live a more fulfilled life outside the Octagon.

KEEP YOUR NECK STRONG

Mike Winkeljohn says one of the most important things fighters can do to prevent knockouts and improve their ability to take a punch is to strengthen their neck muscles. But there is a fine line between strengthening the neck and putting yourself at risk for injury. “I have noticed the guys that do the best with neck exercises use slow, controlled movements.” Retired MMA fighter Frank Shamrock agrees with keeping things light when dealing with the neck. “The best neck strengthening exercises are the ones that use only a little resistance.”

When a fighter is hit in the head, significant forces are transmitted through the neck. Years of hard training and fighting can lead to deterioration of the cartilage and the cervical spine (discs in the neck), which can result in narrowing of the joint spaces, pain, and/or nerve impingement. Ken Shamrock is just one example of many fighters who have had to undergo surgical fusion of the cervical spine after years of pain.

Keeping your neck muscles strong may help prevent the traumatic forces a fighter’s neck sees from wearing away the cartilage between the vertebrae. Ken credits his strong neck muscles with the longevity of his entire athletic career, not just MMA. “The only reason I was able to play football and become a pro fighter was because I made the areas of my injuries stronger so the muscle protected the site of my injury, including my neck muscles. Even after my career, I can’t stop training because the areas of my body I have injured before become weak and then those same areas become more of a problem for me.” Ken brings up a point that other chapters will explore, namely building up the muscles around a potentially injured area, not only to protect it, but to rehab an injury as well.

Pat Miletich has also had life-changing neck and spinal cord injuries from MMA. “While I was training to fight Frank Trigg, I got hit with a left hook. I immediately felt a crunch and the left side of my body went numb. I finished the round with my right hand. When I went to the doctor, an MRI showed my spinal canal was narrow, and it didn’t leave a lot of room left for my spinal cord. I still have a lot of mobility but cannot take blunt force trauma to the forehead. I feel paralyzed when that happens. That’s the reason I don’t even spar anymore. It’s not worth the risk of permanent injury. But I did learn some good exercises for strengthening my neck muscles. Sometimes I take my tongue and push it against roof of my mouth, which helps to activate the muscles. I use heavy bands for resisted movement, and I also push my head against a swiss exercise ball.”

When doing neck exercises, a fighter should be careful of the more traditional exercises that have you putting your weight on the crown of your head. UFC legendary champion Randy Couture has some advice on this: “As far as your neck is concerned, avoid any and all exercises that put you on the crown of your head and compress the cervical spine. Long term, this puts stress on the cervical discs, which may cause them to degenerate, creating nerve and neck issues. Regular stretching can prevent and alleviate some of these issues.”

NECK STRENGTHENING EXERCISES

Strengthening your neck may help with brain injury prevention, but putting too much weight on your neck can lead to long-term damage. As Golden Glove winner and UFC Heavyweight Stipe Miocic demonstrates, you can use your own body to create resistance to make your neck muscles stronger.

Place your hand on the sides of your head, in front, or behind and push for resistance.

Lie on your side and lift your head sideways up against gravity.

Push an exercise ball against a wall sideways or backwards.

Push your head at an angle against the ball and rotate your head for rotational resistance. This also mimics strike avoidance.