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)

LACERATIONS — AKA “CUTS”

Veteran UFC trainer Mark DellaGrotte recounts his experience with his UFC fighter Marcus Davis and his bouts with recurrent lacerations: “Marcus Davis’s problem is his buildup of scar tissue. He was always getting cut in training and in fights. That’s actually how cutman Jacob ‘Stitch’ Duran and I became such good friends. I would always be in Marcus’s corner and knew we would be needing the services of a cutman. I knew we would need some good cut work and preventative work with things such as the enswell [a handheld, curved metal compression block that helps compress the hematoma to help with swelling]. Most people don’t realize that before entering MMA, Davis had close to 100 boxing matches where he had built up a lot of scar tissue. We knew he would get cut in a fight.”

It’s important fighters know that facial lacerations don’t just affect the match you’re fighting in the Octagon, but that the consequences could be long term. When scar tissue builds up cut after cut, even punches during practice could prove damaging. As DellaGrotte explains, “During our training camps for [Marcus] Davis, we would have him wear big Battlestar Galactica-like headgear. His training partners would use 18 oz gloves instead of 16 oz gloves for extra padding. Everyone had to be bundled up like a little kid in winter to prevent additional damage, some of which could prevent him from being able to fight in his next bout.”

Besides knockouts and submissions, significant cuts and bleeding are common reasons for a fight to be stopped. They are also the reason why skilled cutmen are sought after. Despite weeks or months of training, a bad cut can stop a fight as quickly as an unseen right hook or a rear naked choke. Fortunately, the long-term effects of most cuts are considerably less than the drama they create during a bout. Unless they are in certain high-risk areas, which we will examine later, it is rare for a cut to have any serious functional consequences after the fight. However, if you do accumulate a lot of scar tissue from repeated cuts and bleeding, you may end up becoming a fighter that bleeds more easily in a fight.

Cuts occur through the direct transfer of energy from a strike, which is usually absorbed by the harder bony structures. However, the skin and subcutaneous (under the skin) structures are often caught in the middle and can be damaged either by being crushed in the energy “blast” such as in a head-butt or by being sheared as a glove moves across the skin. In essence, the skin is spread apart as the underlying bone pushes out against the soft tissue. Sometimes, the visible cut is just the tip of the iceberg.

THE TWO TYPES OF BLEEDING

Bleeding can be classified as arterial or venous. Arterial bleeding results from damage to arteries, which are the vessels in the outflow track from the heart and thus have a pulsatile quality and can bleed in greater quantities more quickly. During a fight, you may see the distinct droplet spray-pattern on the canvas of an arterial bleed. Venous bleeding occurs when veins are damaged. Veins are the vessels that return the blood to the heart and therefore are under less pressure. Venous bleeds are often slower and non-pulsatile. These appear more as a long drip coming off the fighter’s nose or a pool on the canvas. Some areas of the face are more prone to serious injuries than others. Legendary boxing and MMA cutman Jacob “Stitch” Duran likes to point out one area in particular that causes a lot of bleeding: “That big vein that we all have between our eyes; when they pop that one, I know that I’ve got my job cut out.”

DANGER ZONES AND REASONS TO STOP A FIGHT

Cuts around the eyebrow can cause bleeding that affects a fighter’s vision and ability to protect themself. They can also damage important nerves. If the cut is deep enough above the eyebrow, it can lead to damage of the supraorbital nerve. The same can be said for below the eye, where the infraorbital nerve lies. These nerves supply feeling from the skin near the top of the head down to the upper eyelid and from the upper lip to the lower eyelid, respectively. A cut on the actual eyelid always has a risk of being particularly dangerous to underlying structures. An important structure called the nasolacrimal duct runs from the area between the eye and the nose to just under the eye. If this area is damaged, the normal ability for tears to hydrate the eye can be inhibited, leading to significant long-term eyes issues. And remember, if the cut is severe enough for a ringside doctor to stop a fight, it certainly should be enough to stop a sparring match during training.

Some of the reasons a ringside physician may stop a fight due to a cut include:

1. Significant arterial bleeding resulting in rapid and continuing blood loss.

2. Exposure of underlying nerves or bone (including broken bones).

3. Vision impairment. A cut may affect a fighter’s vision, either from bleeding or the location of the laceration.

4. The location of the cut. The eyelid and the eye area near the nose are high-risk areas and can result in irreparable damage.

Stitch has seen how lacerations can stop fights and knows that if you can’t stop the bleeding, then the fight should be over. “If it’s a real big, old, nasty, gnarly cut that’s above the eyebrow or something that may get you into nerve-damage territory, then it might be time to call it. But it’s usually more a case of blood getting into a fighter’s eye more than anything else. If you work on it for that one minute you get between rounds and he goes out and right off the bat it’s gushing blood again, and it’s going into his eyes and he’s starting to wipe his eyes, and you give it another shot and it’s just not working, then it might be time to go ahead and call that a night for the fighter, so he can come back the next day.”

Do any cuts stick out in Stitch’s mind? There is one story he likes to tell. “When BJ Penn fought Joe Stevenson, we were in England at UFC 80. I was working BJ Penn’s corner and Joe Stevenson ended up with a big gash between his eyes. He was bleeding like a pig and they stopped the fight. As cutmen, we get assigned to a specific corner for the night. Back in the dressing room, Joe kept asking, ‘Where was Stitch? Where’s Stitch?’ You see, those guys look up to what we do as cutmen. I think, especially of all the cutmen, they have a lot of confidence in me and that was just a nice little gesture. It was nice that he made that kind of comment.”

Compression is the cutman’s best friend. Stitch will tell you, the easiest method to reduce bleeding of any kind, including lacerations, is simple pressure. Applying gauze and pressure is the most reliable method to allow the blood to clot and reduce blood flow out of the wound. The reason behind this is that if blood is flowing, it can’t begin the process of solidifying into a clot. Compression helps stabilize the blood flow and allows the blood to coagulate, which prevents further bleeding. The enswell is an example of a device cutmen can use to help compress bleeding wounds to encourage clotting, but not all cutmen are using these devices properly. As Stitch explains, “I also see a lot of the guys working with the enswells trying to move the hematoma [a pocket of clotted blood under the skin] around. In fact, as I was coming up through the ranks I was told to get that clot and try to move it to the side. But talking with the ringside doctors now that know the business, what you’re doing is just moving that blood into tissue that is not damaged. And it eventually comes right back. So direct pressure with a cold compress closes up most blood vessels, and that’s really the basic principle we work with. Compression is what guys are doing right.”

Some cutmen will employ epinephrine (adrenaline), which is a medicine that causes blood vessels to constrict and thus limit how much blood can flow out. This often requires a prescription and the legal use of it varies by jurisdiction. They may mix it with Vaseline and put it on a fighter’s face between rounds. Other compounds that can reduce blood flow include seaweed extracts and synthetic thrombin, which is a chemical in the blood-clotting process. Many fighters have also described using store-bought superglue, but this practice cannot be endorsed as safe by any medical professional.

Stitch also notes that one thing that may make bleeding worse is taking anti-inflammatories, as they may increase the risk for bleeding. Aspirin and anti-inflammatories such as ibuprofen have a theoretical disadvantage in that they may reduce the blood’s efficiency in clotting. “One of the things that I always ask the guys is what kind of medications they’re on and if they are taking any anti-inflammatories. When they get banged up, I know that’ll make my job a little bit harder.”

Both prevention and good work by cutmen during a bout are important. Mark DellaGrotte, one of the UFC’s top trainers, recalls one fight he was cornering that sticks out in his mind, “Joe Lauzon versus Mac Danzig. In rounds 1 to 2, Joe got a large hematoma, like a potato, and came back lumped up and swollen. Rather than use the enswell, they send him back out with a big hematoma and he gets cut there and starts to bleed. Just because there aren’t cuts actively bleeding doesn’t mean that you can’t use things like the enswell or Vaseline to prevent the cut from happening or getting worse.”

STITCHING CUTS AND THE NORMAL HEALING PROCESS

If a laceration is deep enough, it will need to be stitched, which should occur in the hands of a trained physician. The skin has several layers to it, and a suture job that seeks to close a very deep, jagged wound to merely stop the bleeding, and doesn’t address the underlying layers, may result in skin that is scarred and less strong than skin that is properly repaired and healed. Several prominent fighters have sought out plastic surgeons to help them deal with the years of scar tissue that have built up under their skin from years of cuts.

Nick Diaz’s coach Cesar Gracie has battled with Nick’s cuts and sought out such treatment. “Nick’s biggest problem was getting cut. Nick has very sharp bones on his eyebrows so he gets cut very easily. The bone pushes on the skin from the inside. He actually had plastic surgery in Las Vegas to grind down the bone.”

Deciding when to return to contact training depends on where the laceration is in the healing process. Normal skin follows a regular pattern for healing. At two weeks, the skin is about 20% as strong as its pre-injury level. By five weeks, it is about 50% healed. By 10 weeks, it is about 80% of pre-injury strength and may stay at that level forever. It is a safe bet to say that a minimum of six weeks is required before a significantly deep laceration is healed enough for the fighter to return to sparring. If it was a particularly deep cut, up to three months may be required before full contact resumes.

PREVENTING INFECTION

One of the primary functions of skin is to prevent infections. A break in the skin means a risk for bacteria to invade and create an infection, which can rapidly get out of control. Sometimes they can lead to the well-known staph infection. Stitch, cutman for both the UFC and boxing’s world-champion Klitschko brothers, remarks on how important keeping wounds clean is to the health of a fighter: “Right now I look at a lot of the cutmen out there and the first thing I always do is tell those guys that the swabs we use to apply epine [short for epinephrine] on the cut need to stay clean. You’ll see these cutmen put the swabs in the fighter’s mouths and they put them in their ears. And the first thing I tell them is to keep them sanitary and watch where they put them.”

The most effective way to prevent infection after a cut is to keep the injury site as clean as possible. Although it may seem as though fixing cuts is a cosmetic procedure, there could be serious consequences should an infection appear. In Dean Lister’s experience, care should be taken both before and after a laceration occurs: “To help prevent cuts before sparring hard, you need to Vaseline the high-risk areas thoroughly, especially around the ridges of the eyebrows and under the eyes where the cuts are most likely to occur. After receiving a cut, which happens in MMA and boxing of course, please seek medical attention, especially if stitches are needed. After that, you will probably get more attention from the ladies! But most importantly, keep the threat of infection to a minimum and be sure to keep the area very clean.” Neosporin is one over-the-counter option that has both anti-bacterial and anti-fungal medications. It is good to keep a healing laceration covered if it’s in an area where it will be rubbed a lot, such as by clothing. And don’t forget the effectiveness of simple soap and water for keeping the bacteria away! As we will see later in the book, skin infections can have serious consequences.

HEADGEAR AND VASELINE — ADVICE FROM THE PROS

As Mark DellaGrotte points out, wearing appropriate padding during training can help lengthen your career by reducing the amount of trauma and facial injury that builds up. UFC champion Sean “The Muscle Shark” Sherk also understands the importance of preventing lacerations, not just during fights but also in training. Sometimes the danger is worse if the guy you are training with isn’t well trained. “My worst cut I can remember was from a knee when I shot in on a guy during a training camp. I ended up needing to miss my fight 10 days after. I needed 60 stitches. In fact, I get cut under the chin a lot — as most wrestlers do. I would even have to duct tape it. My advice is be careful who you train with. Your injury risk probably triples when guys are hacks and don’t know what they are doing. And wear headgear. I know you can’t hide your whole body, and you need to know what it’s like to feel a hard shot, but you also need to be smart and protect yourself!”

When it comes to preventing cuts, Cesar Gracie points to headgear: “I have noticed that kickboxers at my academy don’t like headgear, but for boxers, it’s natural and they always use it, so it’s an interesting combo in MMA. For the guys that don’t want to wear it, I remind them that their livelihood is fighting. If you get cut and have to pull out of the fight, it’s going to come out of your pocket. If you want to be a professional, you need to wear headgear. I also always apply Vaseline to my fighters. And more importantly, make sure to check and reapply every two to three rounds.”

Don Frye has had two significant lacerations that he can remember, and he has his own tips for fighters that seem to come straight from working on a ranch. “During the Ultimate Ultimate 2 in 1996, Tank Abbott busted my eye to the bone in the finals. I have had that same eye split open with a head-butt against another guy. My advice to avoid getting cut? Make sure to use Vaseline. Maybe even use some butter balm to soften the skin like we do with cows. When you train for a long time on the mats, your feet become dry and cracked and this stuff can help moisten them, too. It helps get you back in the saddle.”

Headgear during training not only protects from hand strikes, but also from inadvertent head-butts. UFC champion Matt Serra, the only man to knock out Georges St-Pierre, has had some experience with inadvertent head-butts. “In the last fight of my career, in the opening round, I was throwing some hands against Chris Lytle. We crashed heads and I got head-butted. I needed a bunch of stitches. Head-butts are dangerous and should be avoided in training. When training, even if it’s just wrestling, at least one guy needs to wear headgear to prevent head-butts. They can really cut people open.”

THE DANGER OF ELBOW STRIKES

Padded protection shouldn’t just be limited to the head. In the Octagon, UFC champion Jon Jones is known for his devastating elbows, which can slice open an opponent in the blink of an eye. Jones practices these strikes with an elbow routine under the supervision of Greg Jackson and Mike Winkeljohn. Because elbows can be so dangerous, Jon wears elbow pads while sparring. “Jon is good enough where he can actually just tap a guy with his elbow, but even he wears pads while training. It protects him, his training partners, and our team. All guys should use them,” says Winkeljohn.

SUMMARY OF ZONES

1. tarsal plate, lacrimal sac

2. vermilion border

3. supraorbital/supratrochlear nerves

4. nasal bridge

5. infraorbital nerve

6. nasolabial fold with facial artery

7. superficial temporal artery, facial nerve (at the zygomatic bone)

8. facial artery at masseter

9. mental nerve

Zones of concern for lacerations. gray means watch closely during a fight and dark gray means stop the fight.

Coach and former UFC champion Josh Barnett also sees elbows as especially dangerous during training. “To avoid cuts, I don’t allow anyone to throw elbows unless they have nice secured elbow pads, and then they are allowed to just touch their partner. No hammering. If you can’t avoid hammering them, you don’t have the skill. If I can’t control my opponent and then perform the finishing strike without hurting them, then I need to work on that technique. If you do get cut, give it time to heal. I know it sucks sitting on the sideline, but you can do other things so it doesn’t get opened back up.”