KNEE INJURIES AND RETURNING TO THE OCTAGON AFTER SURGERY - 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)

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)

CHAPTER 4

KNEE INJURIES AND RETURNING TO THE OCTAGON AFTER SURGERY

When an athlete has a significant knee injury, whole sports worlds can change. A team can lose their star player for the season. An entire UFC card can be canceled because the headliner was injured. Or the reigning, dominant champion can be knocked out of competition for over a year. One of the most talked about knee injuries in MMA occurred in 2011. While preparing for a fight against Carlos Condit, Georges St-Pierre defended a wrestling takedown attempt by his training partner and felt a pop in his right knee. For weeks prior he had been compensating for other seemingly minor injuries, especially in his right knee, but in this instance it became clear the pop he felt was serious. There was not much swelling on the knee initially, so he tried to continue training. However, he soon found it was difficult for him to walk normally and in the few days afterwards, he continued to feel pain as well as instability. He called his doctor, who suggested he get an MRI in Las Vegas. The MRI revealed he suffered from a torn ACL in his right knee that would require surgery. This injury put the champion out of action for the better part of a year. Most critics felt he would never return to championship form. After all, the list of running backs in the NFL that never returned to the same level of performance after an ACL rupture was ever growing. However, proving that he truly is a champion, GSP had surgery, rehabbed his knee, and went on to defeat then-interim champion Carlos Condit by unanimous decision after a grueling five-round 25-minute bout. As we will see later, Condit had his own experience with an ACL Injury, and St-Pierre’s experience provided him with some advice.

ANATOMY

Understanding the anatomy of the knee is important to understanding its injuries. The knee is composed of the femur (thigh bone), tibia (shin bone), and patella (kneecap). As the connection between the femur and tibia, the knee acts as a hinge allowing the leg to bend. The knee can experience considerable stress when changing levels and shooting in for a takedown, snapping a kick, or quickly moving out of the way of an opponent’s attack.

The femur has two rounded ends that rest on top of the tibia. Since the top of the tibia is relatively flat, the body has adapted to create two semi-circular cushions of cartilage called the menisci (plural for meniscus). The menisci help the femur fit into the tibia as well as provide stability and act as shock absorbers in the knee, distributing force and protecting the surface cartilage from damage.

The knee is also held in place by several ligaments. Ligaments are soft-tissue structures that run from one bone to another. This is in contrast to tendons, which are the ends of muscles that thicken and insert into bones to allow them to pull. Within the center of the knee are two ligaments that cross each other (“cruciate” meaning crossing). The ACL, or anterior (front) cruciate ligament, lies in front, and the PCL, or posterior (back) cruciate ligament, lies in the back. On the inner side of the knee running from the femur to the tibia is the MCL, medial collateral ligament, and on the outer side of the knee running from the femur to the fibula is the LCL, lateral collateral ligament.

ACL INJURIES

Ultimate Fighter 3 finalist Ed Herman knows firsthand what it feels like to rupture his ACL in the Octagon. During his UFC 102 bout against All-American wrestler Aaron Simpson, his knee was forced backwards into an awkward position. “Simpson shot a double leg and then I felt instant pain. It hurt like hell. I didn’t realize how bad it was, so I continued to fight and tried to answer the bell in the second round. When I came out to fight, I threw a kick and there was nothing there underneath me. My knee just buckled. At first, there was almost no swelling, so I thought I sprained it. But then I saw the doctor and we got an MRI. It showed I had torn my ACL.”

HOW THE ACL TEARS

The ACL acts to prevent the tibia from moving forward away from the femur and helps prevent the knee from buckling during sudden changes in direction such as cutting, twisting, or even kicking. The ACL can be injured when one part of the knee suddenly rotates quicker than the other, such as when it is grabbed and twisted during grappling or when a fighter quickly pivots with a planted foot to kick or change direction. In addition, the ACL can also be injured when a fighter’s knee is hit from the side, similar to when a football player hits someone’s knee during a tackle. In fact, since MMA has so many facets, the injuries an MMA fighter sees arches across many sports. ACL injuries are more common in sports such as football where players often need to suddenly stop and change direction, but these injuries commonly strike MMA fighters as well. Baseball players or other overhead athletes often injure their shoulders through overuse injuries, yet MMA fighters injure their shoulders and rotator cuffs as well.

Carlos Condit had a common injury mechanism during his UFC 171 co-main event bout against Tyron Woodley. “In the second round of the fight, I tore my ACL and both menisci. During the round I stepped wrong, and I felt a pretty intense burning and could feel the sensation that my bones shifted. I went down to the guard, the pain improved, and we stood back up. Then, he kicked my other knee from the outside. I went to pivot on the injured knee and my whole knee gave out.”

Front and side views of the knee with ligaments and menisci shown.

CREDIT: JOE KANASZ

ACL RECONSTRUCTION

Like all ligaments, the ACL can either be sprained (partial tear) or ruptured (completely torn). When the ACL is ruptured, the athlete may often hear a “pop” and then experience quick pain and swelling of the knee. They can tell pretty soon something is wrong with their knee and will feel a sense of instability. Complete tears will require surgery to continue participating in sports that require sudden directional changes. A complete tear of the ACL cannot heal on its own, so the surgery is referred to as an ACL “reconstruction,” which means replacing it with a new ACL graft. Different surgeons and different athletes prefer different types of grafts to reconstruct the ACL. Georges St-Pierre underwent reconstruction with his own patellar tendon graft. Cat Zingano, a top female MMA athlete used a cadaver graft. UFC Bantamweight Champion Dominick Cruz had a cadaver graft for his initial surgery and then used his own patellar tendon for his second ACL surgery on the same knee. Ed Herman used his own hamstring graft for his first surgery and a cadaver patellar tendon for the second.

Deciding which ACL graft to use is a topic that has been, and will likely continue to be, hotly debated by surgeons. Large-scale studies have shown that there is likely no difference in re-tear rates between your own hamstring and patellar tendon grafts, but both of these tend to do better than cadaver grafts since they are your own tissue. You can feel your patellar tendon if you bend your knee and feel the front of your leg, just below your kneecap. When a patellar tendon graft is used, a piece of bone is taken out of the patella and another piece is taken from your tibia with a strand of patellar tendon in between. This graft is thought to have the best chance of healing, since it has bone on the ends, which the hamstring graft does not. Unfortunately, a side effect may be pain when kneeling down, something grapplers do all the time. There may also be some weakness in the quadriceps, the muscles that straighten your leg, which could weaken the “snap” of your kick. The potential for kneeling pain is why Herman decided on a hamstring graft with his surgeon. “I didn’t want to use my own patella tendon because my surgeon said there was a risk of sensitivity in the front of the knee and [I could have] trouble kneeling.” The hamstring graft is taken where some of the hamstring tendons wrap around to the front of the knee. The benefit of using a hamstring graft instead of a patellar tendon graft is that the pain of having to take bone with the graft and the subsequent kneeling pain is eliminated. The theoretical downsides are that there is no bone on the ends of the graft for healing into the femur and tibia bones directly and you may lose some of your knee flexion (bending) strength.

The third option is to use a cadaver ligament. This method avoids all the pain of harvesting the graft from your own body (which can be the most painful part of the surgery) and may make your rehab easier. The downside is that there is a risk of disease transmission, although this is significantly lower than in past decades. Since it’s not your own tissue, it may not be the best choice for a younger, elite athlete and some studies have shown it can be four times more likely to fail. However, in Ed Herman’s case, since he already used his hamstring from the injured knee as a graft the first time around, he and his surgeon chose to use a cadaver tendon for the second surgery.

PRE-HAB, REHAB, AND GETTING BACK TO 100%

It’s not only the fighters who are at risk for an ACL rupture in the Octagon. The “Veteran Voice of the Octagon” Bruce Buffer is an announcer known for his exciting spins during his introduction of fighters. At UFC 129 in Toronto, with 55,000 people in the stands, Buffer was getting ready to announce Canadian Georges St-Pierre in front of one of the largest crowds in UFC history. GSP was standing a few feet away, ready to face off against Jake Shields in front of a largely Canadian crowd. Buffer started like he normally does with his trademark “It’s time!” catchphrase and an introduction of Shields, but he really reached deep to announce the name of GSP. Suddenly, GSP bounced forward towards him in excitement and Buffer had to hop back abruptly. This sudden change in direction led to Buffer tearing his ACL.

Buffer is the UFC’s top announcer and has a mind-blowing travel schedule. He delayed his surgery until his schedule allowed him some time off, and in the interim focused on getting his body ready for surgery. He knew he needed to work on not only his post-surgery rehab, but also his pre-surgery “pre-hab.” Bruce recalls, “When I booked my operation a few months ahead of time due to my appearance schedule, my trainer and I trained the leg intensively to make it as strong as possible for my ACL operation and it worked to make a very healthy environment for my doctor to replace my ACL. I even went off pain medication the day after and rehabbed quickly, which I attest to the physical shape I was in going into the operating room.” Focusing on ACL pre-hab is a great way to get ready for an upcoming ACL surgery.

After surgery, the final thing you must face is your post-operative rehabilitation. ACL rehab is not easy and usually takes at least six months, and it will most likely take up to a year until you are feeling close to 100%. Working on your range of motion is one of the first things you will do, then you will begin to focus on your hamstrings, and then work your way up to your quadriceps. The quadriceps are the first to weaken, even before surgery, so it’s important to keep your quadriceps strong before and after your surgery.

Ed Herman knew if he wanted to get back to the UFC, he needed to really focus on his rehab. “I did some intensive rehab. It was hard. I started the day after surgery and was there five days a week. My advice to other fighters recovering from ACL surgery is to hit the rehab hard, but make sure to do it with professionals. And don’t force it. Don’t try and come back to wrestling and sparring too soon.”

Ed brings up a very important topic. Despite excellent outcomes from ACL surgeries, many athletes who have already had an ACL tear will experience another one. A systematic review of studies has shown that within five years of surgery, about 6% of athletes will tear their same ACL and around 12% will tear their other ACL. (1) Three years after returning to championship form from his ACL tear, GSP tore the ACL in his other knee. Three months after his ACL surgery, Ed Herman tore his newly reconstructed ACL. Many of these re-tears within the first year happen because the athlete isn’t fully rehabbed from their knee surgery. Often, they are still favoring their other knee and have limited balance on their operative knee. In fact, one study showed there is an equal (3%) chance of tearing the ACL in either the reconstructed or the “good” knee within just two years of surgery. (2)

Ed recalls his second injury, “When I re-tore it, it was only three months after surgery. I tried to come back too soon. I think I was cleared to do light training. I was further along than anyone at my rehab place had ever seen that soon after surgery. But then again, they aren’t used to dealing with professional athletes. I was doing a skip knee drill. I was holding my training partner’s head in a Thai plum clinch, alternating knees with a light jumping motion to his chest. I came down on the outside of my foot on the soft mats, and boom! I knew I re-tore it right away.” MMA athletes are known for their determination and perseverance. There is no off-season to recover like other sports, so the fighter is often very eager to return to competition, always pushing the boundaries. But it’s important, especially with a big surgery like ACL reconstruction, to give yourself the full recovery time, even if it takes more than a year. The risk of a second surgery, being out even longer, and making your knee worse is not worth the risk of dangerously shortening your rehab period.

UFC Hall of Famer Mark Coleman suffered his first MMA injury at age 31. “[It] was an ACL tear in my right knee. My right knee is my lead knee, which may have made it more susceptible to injury. In 1997, I was 31. I had just won the UFC title in 1996. I had many injuries in wrestling, but nothing that required surgery. I got stuck up in the corner, and a guy put his shoulder in me, and my knee went out. I knew it was a big one. I was out for eight months. Back in 1996, they were getting better with ACL surgery, and I had serious atrophy versus now when they get you moving right away. My first fight was five months later against Pete Williams, and I am not going to blame the loss on my ACL, but my leg was definitely not ready. Back then I was my own coach. I probably should not have taken the fight and it was not a good evening for me. Athletes have an itch. They want to get back in there quickly. And some do, but many end up back on the sideline. Athletes often are strong headed, but they need to listen to their coaches and their doctors. If you want to be wise, you rehab your knee and you get back in there when you are truly ready.”

Patrick Côté underwent ACL surgery and it took him over a year to get back, which is not unexpected. “I had my ACL reconstruction in 2009. It took me a year and a half to be ready to get back in competition. My doc did an amazing job, but it takes time to heal both physically and mentally. Now my knee is 100%.” Patrick brings up another excellent point — a fighter also needs to consider the amount of time it takes to mentally heal from ACL reconstruction. This type of recovery has been shown to be just as important, as some athletes never return to their sport simply out of fear of re-injury. Like most of these athletes, it took UFC veteran and U.S. Army Ranger Tim Kennedy one year to feel fully recovered from his ACL surgery. But he has some advice on how to tell when you are truly recovered and ready to push it. “I tore my ACL wrestling in college and had surgery. At seven months out, I was in the army and jumping out of airplanes, but it took one year until I felt right. I was very disciplined in my rehab and then carried that through my career and continue to strongly focus on injury prevention. Part of coming back from an injury is being mentally ready to push yourself. Until you are dripping sweat and crying from just your workout and forgetting about your leg, that’s when it’s time to really train — when you can forget about surgery and your injury, when you have rehabbed fully, have confidence in your recovery, and forget what it’s like to be afraid.”

After the surgery, sticking to a well-thought-out, guided physical therapy program is the next step in making sure you have a good outcome from ACL reconstructions. Ed points out the importance of working with good physical therapists during your recovery: “Make sure your rehab is guided by professionals who specialize in ACL or other sports surgical rehab. They, along with your surgeon, will help guide you back to where you need to be to get back to fighting.” Tim Kennedy agrees, “If you can, seek out a sports-specific physical therapist who understands your sport. Before you see the physical therapist, see who he has worked with, where he has learned and worked before. Is he known in your sport and your community? Talk to your doctors about who they recommend.”

When Carlos Condit ruptured his ACL, his former opponent Georges St-Pierre reached out to him through their mutual friend Greg Jackson. “GSP contacted me through Greg Jackson. He gave me some advice and part of the message was how important the rehab was. You have to be careful and don’t push it too hard, too fast. As athletes, we are risk takers, we want to push ourselves. But you need to be patient and trust the process. My advice for recovering from injuries is the same as my advice in general for reaching goals, and that is focusing on the small stuff — the day-to-day grind and task at hand, and to do well at that. Whether it’s training for a fight or doing your therapy, it’s the small incremental steps that get you to where you want to be. Having gone through ACL rehab, I took some exercises away from it, including working on stability. I spend a lot of time with my strength and conditioning coach on injury prevention exercises, mobility, and functional movement. It may be boring at times, but it prevents injury.”

THE IMPORTANCE OF MUSCULAR STABILITY

Some MMA athletes have actually been able to avoid surgery during their career by focusing on strengthening the large muscle groups around the knee and working on dynamic (active movement) stability such as plyometrics. If these muscle groups can prevent the athlete from experiencing the “giving way” feeling associated with a ruptured ACL, then reconstruction may not be necessary. Most surgeons, however, will argue that reconstructing the ACL will thwart further irreparable cartilage and meniscus damage. Furthermore, the athlete may not be able to perform at his peak if the knee isn’t 100% stable. This is a significant discussion an athlete should have with his or her doctor.

Former UFC Light Heavyweight Champion Frank Shamrock avoided ACL reconstruction during his career, but not without some limitation: “My biggest knee injury was training for Phil Baroni in 2007 for an event co-promoted by Strikeforce and EliteXC. I was sparring a judo guy and he swept me and I couldn’t walk for a week. The pain and swelling were severe. I tore my ACL. I saw three doctors and they all told me to do the rehab first and then do the surgery, so we could cut the rehab time in half. Rehab was challenging. At three months my knee was stable enough that I could fully train, so the doctor told me I had the option to avoid surgery.”

Shamrock continues, “We focused heavily on balancing, building hamstrings, and loosening up the hip and calves so the knee stayed relaxed. It only bothered me during tennis. I fought about twice more without an ACL. However, it did affect my fighting. It affected my ability to shoot in and close the distance and also to step in and create power. I had to move forward at a more measured pace.”

When it comes to putting your knees at risk, Frank points to shoes as one injury-causing issue during his career: “When I was in Pancrase, the shoe acted as a handle to lock your foot and hurt your knee. The same is true in wrestling when someone grabs your knee and you twist to get out. You can really hurt your knee. Do not let someone hang on your leg!”

Braces can support an injured knee, although sometimes they cannot withstand the forces generated by professional athletes during competition. There are many pictures out there that show a bent brace following a collision between NFL players. Braces come in several functional styles. The compression-sleeve braces help keep the knee warm and remind the athlete to focus on good form, but don’t actually provide any mechanical stability. Hinged braces can help athletes recovering from ligament injuries feel more stable, but there is little evidence they do anything for actual injury prevention during competition. One study showed braces helped protect the MCL of football defensive players, but other than that, it seems they are more of a mental support for the athlete. Frank Shamrock would use his brace to keep his knee warm. However, the master of mind games that he is, he often would put it on the uninjured knee to distract his opponent’s attention!

Ken Shamrock also had significant experience with ACL injuries during his long and impressive MMA career. “I tore my ACL while in Japan training for a fight, and Tra Telligman had to take the fight instead. He ended up getting an upset win over powerful Russian striker Igor Vovchanchyn at Pride 13,” said Ken. “Afterwards, I had many fights with a torn ACL. It was actually torn during my first fight with Tito Ortiz. I had it fixed after that fight. We used a patella tendon graft. With a torn ACL, I felt I lost the ability to shoot and move on the ground for submissions. My training instead focused on stand-up. Once I had surgery, it was hard to get back to shooting, since I hadn’t been doing it for so long. I had to retrain and rehab a lot to get deep knee bends for shooting in. I didn’t do 100% of the rehab that I should have. Other sports don’t need such deep knee bends that wrestling or grappling needs.”

Shamrock goes on to say, “If you don’t focus on those deep range of motion points, you may have a false sense of security. You may be able to do other activities or beat some guys, but it will take 12-15 months to get into those grappling positions you need to be in at the top of your game. You need to test your leg in all positions. Sit on your heels and try and lay back. Lunges are a great exercise to test the stability of the leg and strengthen the knee. These will help you find where you really are.”

MCL AND LCL INJURIES

On either side of the knee are the collateral ligaments: the MCL, medial (inner) collateral ligament, and LCL, lateral (outer) collateral ligament. These collateral ligaments are important in stabilizing the knee when a force is directed from either the inside or outside of the knee. If the knee is hit from the outside aspect of the knee, such as someone diving in for a tackle, the LCL compresses and the MCL stretches, making the MCL the important stabilizer of the knee at that moment. The opposite is true if the knee is hit from a force on the inner side of the knee and directed laterally; there, the LCL becomes tight and acts as the stabilizing ligament. The MCL and LCL can also be injured during grappling, when the knee is forced to bend at an awkward angle.

When the MCL is injured, it is usually sprained, in which some of the fibers stretch or break, but the ligament is not completely ruptured. This usually heals in a matter of weeks. If, however, the MCL completely ruptures, it can still heal on its own because it is enclosed in a sheath and can form a clot that allows reparative cells to lay down new tissue. It is for this reason the MCL rarely requires reparative surgery.

Pat Miletich suffered an MCL injury early in his career: “I was training for my first UFC four-man tournament [UFC 16]. I was up against the wall and my left leg was straight and locked. Two heavyweights were grappling by us and both guys landed on my left leg. I tore my MCL and had no insurance. I couldn’t train. I could only jog on a treadmill. Three and a half months out, I couldn’t bend my knee beyond 90 degrees.

“My wife, who was my girlfriend at the time, had been going to chiropractic college and knew some sports guys. We worked on stability drills and then iced my knee after the drills. A good exercise is to grab on to the side of a weight machine, push your foot down onto a swiss ball and do circular motions with your leg; one way 10 times and then 10 times the other way to build stability and proprioception. I also did leg raises sideways and at different angles while using an ankle weight. I went on to win the tournament.”

When it comes to preventing these types of knee injuries, Pat feels flexibility is important: “It comes down to flexibility. Warm up [legs and knees] correctly, rotate them in circles, work on different angles. I learned this in wrestling. I was very flexible while in kickboxing. But then I didn’t focus on flexibility in MMA. I was thinking I wouldn’t need to kick high. That was a mistake. It certainly made me more prone to injuries during my career.”

Two-time Strikeforce Lightweight Champion Gilbert Melendez has felt the pain of an MCL injury from being kicked on the outer part of the knee. The force caused the inner side of his knee to bend, injuring his MCL. “Everyone should learn how to properly block a kick. I have been kicked from the outside, which stretched my MCL. I was able tape it up, use a brace, and train through it. I could actually feel my knee wobble a little even when walking. It took about three to four weeks to heal. It’s important to have a good tape job, which helps. Part of becoming a martial artist is evolving your game and learning new techniques. I was a boxer with a boxer’s stance and have learned to train more Muay Thai. In Muay Thai, you turn your leg out to raise your knee and block your opponent’s kick with your shin. It can hurt, but it’s better than the kick hitting or stretching your ligaments. It can be simply lifting your knee and having good timing. But it takes practice. Also work on building the muscles around your knee. And watch how trainers properly tape hands, knees, and ankles. I enjoy taping my own joints and take my time doing it. To avoid injuries with kicking, don’t aim for the knees. Aim for above the knee for both your safety and your partner’s. Once, I asked my Muay Thai coach, ‘When will it stop hurting to kick and block?’ and he said, ‘Never.’ So I always wear pads and avoid hitting the joints with my kicks and blocks to minimize the risk of injury.”

The LCL, however, is rarely injured in an isolated incident, although it can certainly happen in MMA. Usually the LCL is injured in a very high-impact injury, such as a car accident, and involves several other structures on the posterior and lateral side of the knee (a posterolateral injury), which can often involve the PCL. Again, like the MCL, it is more commonly sprained than completely ruptured and can usually heal on its own without surgery. However, surgery may be necessary if there is a multi-ligament injury involving the LCL/posterolateral corner and either the ACL or PCL, part of the LCL has pulled off with a fixable piece of bone, or when the knee is rotationally unstable.

PCL INJURIES

Posterior Cruciate Ligaments (PCL) injuries are rare in sports, but are more common in mixed martial arts than in other sports. The PCL is usually injured when a significant force pushes the tibia backwards relative to the femur. In a motor vehicle accident, this may be referred to as a “dashboard injury” as a person hits the dashboard with their knee, driving the tibia backwards. In MMA, when a fighter shoots in towards an opponent, they often drive one or both of their own bent knees onto the mat, putting a backwards force onto the knee, stressing the PCL. Usually, the PCL is just sprained, but repeated sprains or one large force may result in a complete rupture of the PCL. If the PCL is completely ruptured, it may be reconstructed similar to an ACL, but usually it is treated with only rehabilitation, focusing on the quadriceps. Since the job of the PCL is to keep the tibia from moving backwards, strengthening the quadriceps can bring the tibia forward and help avoid PCL surgery. If a fighter continues to have instability despite proper rehabilitation, then a surgery can be offered. UFC heavyweight fighter and K-1 kickboxer Mark Hunt suffered a PCL injury during his fight with Jérôme Le Banner in the K-1 World Grand Prix but was able to avoid surgery for a long time. “It happened in front of eighty thousand people. It sounded like a crack from a whip!” recalls Hunt. “I started as a kick [boxing] fighter and have received more injuries in that sport than in MMA. When I was with K-1 it wasn’t a matter of if you were going to be injured — it was a matter of how much. I actually started MMA because of the PCL injury. I was out for a year. When I came back, I had an offer from Pride. I had six weeks to train for my first fight, so I started doing jiu-jitsu.”

Mark continues, “However, even after my PCL tore, I was still able to fight successfully for 10 more years without needing surgery. Then, when I was training with Antonio ‘Bigfoot’ Silva for my fight with Stefan Struve, he was kicking it, and I found out how bad my leg was. I went to my doctor and got an MRI. It was my PCL. He couldn’t see anything left of it. Now, after surgery and proper rehab, the only lingering effect is I am not as fast moving with the left leg.”

MENISCUS INJURIES

One of the most overlooked, but perhaps most important, injuries related to a fighter’s career is a meniscus injury. The meniscus acts as a shock distributor in the knee, but when it is torn, it can cause pain and result in other parts of the knee, such as the articular cartilage (joint cartilage on the bone), being damaged. Meniscus tears can be either simple or complex. If the meniscus tear is simple, it usually happened from a particular injury, as opposed to complex tears, which result from degeneration over time or repeated injury. Simple meniscus tears that occur in the outer third of the meniscus ring where the blood supply is best are candidates for repair with suture devices. All the other types of meniscus tears are usually shaved down to a smooth rim to prevent the torn flaps from catching within the knee and causing pain and mechanical locking.

UFC Welterweight Champion Matt Serra suffered a torn meniscus, but under the guidance of his doctor, he was able to avoid surgery and rehab his way back into the Octagon and to a historic title shot. “I tore my meniscus around 2006 while rolling jiu-jitsu. My ankle went in towards my chest and I felt a pain in my knee. I had torn my meniscus. Fortunately, my meniscus tear didn’t need surgery. I worked on strengthening my knee and the muscles around it under the direction of my doctor and rehabbed it properly and got through it.

“Shortly after I got hurt, I got a call from the UFC for a fight against Karo Parisyan, who had just beaten Shonie Carter, Nick Diaz, and Chris Lytle. I took the fight, but had to train around my injury. I focused instead on my boxing skills, since my ability to roll was limited. In reality, the injury ended up being a blessing in disguise. By training around my injury, I improved my striking. I ended up losing to Karo, but that loss led me to The Ultimate Fighter (TUF) comeback show, which led to my title shot and KO victory over Georges St-Pierre.”

Matt Serra’s trainer, Ray Longo, recalls a similar story. “Matt hurt his meniscus, but it didn’t need surgery. For the Karo Parisyan fight, we had to take out the jump squats and plyometric exercises that hurt his knee. It was also hard to work his cardio, so I worked on boxing and his exercises were done under the supervision of his doctor. When he lost, I made sure Matt never gave up. The most important thing was to keep Matt mentally in the game, even when he was dropped from the UFC. And then he got that call for TUF: The Comeback, and he seized the opportunity and never lost focus; and the rest, as they say, is history.”

According to his trainer Mark DellaGrotte, Patrick Côté has battled many knee injuries, one of which sticks out in his mind. “In 2008, Côté had hurt his knee going into training camp against Anderson Silva. The bout was scheduled for the world title and Côté didn’t want to pull out, so he continued training through the pain.” In the process, Patrick had a cortisone shot to help with the pain and inflammation. Sometimes a single cortisone shot can help an athlete get through a particular contest, but often the effects are only temporary, as the underlying injury is still there. Some doctors are also wary of repeated cortisone shots, as they can weaken tendons and ligaments and even lead to rupture of these structures.

MARK DELLAGROTTE’S TOP THREE INJURIES HE SEES IN MMA TRAINING

1. Knee Injuries

2. Hand Injuries

3. Skin Infections

Despite the pain, “The Predator” continued training for Anderson Silva. Côté didn’t want to bail on a title fight with Silva. “Up to that point,” Mark continues, “nobody had taken him past the second round and we wanted to put on a great fight. We had taken Silva into deep water where he had not been before. Côté was behind on the score cards, but we managed to take Silva, who was unstoppable at the time, all the way to the third round. Unfortunately, at the start of the third round, Côté’s knee gave out and he dropped to the ground and was unable to continue. Patrick had maybe torn his meniscus even more, and the pain was severe enough that he required surgery. He ended up having a meniscus repair that kept him out of action afterwards for close to a year.” This actually illustrates the dilemma a doctor and an athlete face between shaving or repairing a meniscus. If a meniscus tear is in the right location, it can be repaired in the hopes that it heals and preserves the meniscus. While waiting for the meniscus to heal (which it may not despite having surgery) the fighter will be out of action for several months. With a shaving, since you don’t have to wait for a tear to heal, a fighter can get back quicker, but the shaving also takes away some of the meniscus in the process, limiting its effectiveness as a shock absorber and possibly increasing the risk of arthritis down the road.

Once a meniscus is damaged, it can no longer fully protect the articular cartilage of the knee. If the articular cartilage of the knee is damaged enough, early arthritis can set in and significantly limit a fighter’s career. Since the meniscus is usually damaged with twisting injuries, it is important to keep the knee strong. In addition, untreated ACL injuries have been shown to set people up for meniscus injuries as well.

During the opening bout of the main card of UFC on Fuel TV 5, Duane “Bang” Ludwig, an MMA and Muay Thai veteran, collapsed with a knee injury. MRIs later revealed both a ruptured ACL and torn menisci. Duane’s surgeon elected to repair the menisci and then schedule the ACL reconstruction after the meniscus repairs healed, because meniscus repairs often require the athlete to keep the knee from bending beyond 90 degrees until they heal. Other surgeons may do both surgeries at the same time since the blood in the knee released from the ACL drilling may actually help to heal the meniscus tear repair. Duane’s surgery was done arthroscopically and his meniscus repair and torn ACL were documented.

Ken Shamrock has some advice for fighters who suffer meniscus and other soft-tissue injuries: “Guys need to understand these soft-tissue injuries may not seem like a big deal at the beginning, but in the long run they may see some serious side effects. Don’t ignore your injuries and make sure to talk to the doctor about it. If not treated earlier on, you may end up tearing even more of your meniscus and having more surgeries and pretty soon the majority of it will be gone.”

Dean Lister also has some advice on knee surgery for fighters. “Knee injuries were one of my big curses. If you need surgery, I suggest you just do it. In my case, I delayed surgery on my knee and ended up losing one year of my athletic career simply from denial. On the other hand, if you have an injury that doesn’t need surgery, please don’t be ashamed to practice on the sidelines. That will save your knee from further abuse until it is healed. And more importantly, be careful about the partners you select. A bad training partner can and will make things worse.”

CSAC executive director Andy Foster echoes the importance of having good training partners for avoiding knee injuries. “As a former MMA fighter, I have injured my knees many times while grappling. Make sure you are warmed up before engaging in grappling and/or kickboxing. Also, when training heel hooks, toe holds, and knee bars, make sure that your partner knows to let go immediately and to not actually go for the tap. That’s a key difference. A good training partner with a safe training plan will greatly eliminate knee injuries associated with grappling. Sometimes knee injuries occur when practicing takedowns. I would suggest only practicing takedowns in a wrestling room with qualified trainers. A blown knee can damage a promising combat-sports career. I suggest wearing good equipment and even wrapping your knees for support. In Muay Thai, make sure your partner is trustworthy and does not target the knee or the kneecap. Also be careful with ‘axe-kicks,’ as I have seen ligament hyperextension injuries from these getting blocked. Finally, this is more than obvious but it is worth pointing out: do not spar hard with people you do not know.”

QUADRICEPS AND PATELLAR TENDON INJURIES

At the top of the knee, the quadriceps muscles thicken and condense to form the quadriceps tendon. This tendon can be partially or completely ruptured. Complete ruptures require surgery, but partial ruptures can be healed through proper rehab. In his preparation for UFC Fight For the Troops 3, army veteran Tim Kennedy suffered a partial tear of his quadriceps tendon. “During fight camp, your body fat is low. You are like a thoroughbred horse. You are trained exactly to do what you need to fight three or five 5-minute rounds. I was finishing up my 10-week fight camp and was doing my last strength and conditioning session. My body was at 4% body fat, and I am normally around 8%. I was out on the track running hard, and a lady walked over the track. It was either run over a 65-year-old lady and probably kill her, or try to decelerate in about two meters. I chose to decelerate and just fell to the ground, grabbing my leg and screaming. I partially tore my quadriceps, but I knew I had to fight for the troops. Fortunately, I knocked my opponent out in the first round. I didn’t suffer any further injuries and went straight into rehabbing my knee. First, I rested for two weeks after my fight. Then I began working on linear and lateral movements. I worked on building back up the muscle atrophy with electrical stimulation. I used deep tissue massage. Then I began formal physical therapy.”

As the quadriceps run over the top of the femur, they insert onto the patella (knee cap). The patella is then connected to the tibia by the patellar tendon. The patellar tendon can be partially or completely ruptured or it can become inflamed by repetitive stress. This inflammation of the patellar tendon is called patellar tendonitis. Repetitive jumping or kicking can lead to patellar tendonitis. If the patellar tendon does become inflamed, it can be treated with rest and anti-inflammatories. Some fighters may find a small strap that goes over the end of the tendon to be helpful. If the patellar tendon is completely ruptured, it will need to be surgically repaired.

Tendonitis tends to come from overuse, which may happen later in a fighter’s career. In addition to anti-inflammatories, some doctors may offer a cortisone shot. In his experience, Cesar Gracie’s fighters tend to seek out a cortisone injection when they have an upcoming fight they can’t, or won’t, pull out of. “Tendonitis generally comes in the second part of a guy’s career. There is a lot of pressure for a guy to perform. He has to be ready to go. If he doesn’t fight, he doesn’t get paid and his trainer doesn’t get paid. You may lose your spot in the line to the big fight. Sometimes a cortisone shot is what it takes.” If you are considering a cortisone shot, talk to your doctor and be sure you aren’t using cortisone too much. It’s a temporary solution, so make sure to address whatever the underlying problem is.

Another option under active investigation for tendonitis and partial tendon tears throughout the body is the use of platelet-rich plasma (PRP). With PRP, a small amount of blood is taken from the patient and spun in a centrifuge to separate out the cells from the healing factors and signaling molecules normally circulating in the body’s blood. With the centrifuge, these factors are concentrated down into a small vial, which can then be injected directly into the site of injury in hopes of reducing inflammation and promoting healing. The exact method of healing isn’t fully known and each company’s preparation is a little different, so talk to your doctor about his or her experience with PRP and what the cost to you would be, as it’s not usually covered by insurance.

INJURY PREVENTION

The key to preventing injury to knee ligaments and the meniscus is proper biomechanics of the knee joint. Strengthening the large muscle groups around the knee joint such as the quadriceps and hamstring muscles helps to keep the knee properly aligned when the muscles contract. Exercises such as leg extensions and hamstring curls, which isolate each muscle group, are important for building strength. However, these exercises alone are often not enough to help prevent injury in a dynamic sport.

Improving neuromuscular control is critical for the moments when a fighter suddenly slips, gets tripped, or twists a leg during grappling. The body has a neuromuscular network that works on a subconscious level, similar to our reaction to pulling our hand off a hot stove. We don’t think about it, our muscles just contract and we do it. The same can be applied to knee injuries. If the knee is suddenly tweaked, the large muscle groups may contract quickly to help stabilize it. However, it’s important that the muscles contract in the appropriate sequence. Exercises that help this happen are more dynamic and plyometric exercises such as box jumps, single-leg squats and hops, and shuttle runs. In addition, especially for women, working on proper hip, knee, and foot alignment and positioning while landing from jumps has been shown to prevent ligament injuries.

Besides proper mechanics, a good training environment can help prevent the unexpected knee injury. Well-known striking coach Mike Winkeljohn points out some things he and Greg Jackson have learned while training some of UFC’s top fighters. “Some injuries are just unavoidable. Jon Jones’s knee injury was unavoidable. When Jon hurt his knee, our problem was not enough space. It’s not the one-on-one encounters that hurt most guys in our camp, it’s being blindsided by someone or something. Often our gym gets crowded because everyone wants to be there at the same time, and this can lead to guys rolling into each other and causing injuries. It sounds simple, but it’s important. Also, if mats are too sticky or too spongy, you can’t rotate your grounded foot with your kick or during takedown. That can lead to a lot of torque on your knee. When kicking, such as with a roundhouse, don’t push into the ground. Your ground foot should be hovering ever so slightly. Turn your foot before you kick or rotate with the kick. Send all your force into your opponent, not into the ground.”

UFC Heavyweight and Lightweight Champion Randy Couture echoes this statement, especially during transition drills from standing to grappling. “For takedown and transition drills, watch out for wet or sweaty mat surfaces, overcrowded spaces, and cracks or crevices in flooring. Those can be major causes of injuries with those drills.” Jiu-jitsu world champion and American Top Team (ATT) co-founder Ricardo Liborio thinks the type of mats used can limit injuries. “In Brazil, where we do mostly grappling, the mats are more like the puzzle mats. But here at ATT, for MMA we use the rolling mats since there are less places to get caught. I have seen it often, if the puzzle mats get out of place and a hole opens up you can get your hand or leg caught, especially in wrestling or when you start standing up for MMA and takedowns. Plus, the rolling mats are easier to clean.”

Perhaps the easiest piece of advice for knee and overall injury prevention comes from UFC Welterweight Champion Carlos Newton. “The closest thing to a significant knee injury I have had was when I was younger and doing Brazilian Jiu-Jitsu. My partner was a sambo practitioner and while I was in sidemount, he decided to grab my leg in a knee bar and pull my leg sideways — it left me very tender. I learned in that instant, I wanted to avoid injuries while grappling, to not get knee barred and not to fight a submission attempt while you’re rolling. When grappling, it is important to not let your ego rule. I was able to avoid injury by not pushing through moves in wrestling, judo, and BJJ. Judo is notorious for knee injuries, but you can develop the skill of avoiding risky positions. Not getting injured is actually a skill in itself, and I made sure to develop it. That same skill actually helps avoid opportunities for my opponents to attack. Certain angles of attack and certain positions put you at risk for injury and give your opponents an attacking advantage.”

Greg Nelson, a former NCAA wrestler and the coach of top MMA wrestlers and champions Sean Sherk and Brock Lesnar, sees two things as leading to knee injury during grappling. The first is not knowing the proper technique or reversal of a knee bar, heel hook, or similar move, and the other is an aggressive grappler who attempts to explode out of a bad position. “Knee injuries are pretty common and can happen in both training and fights. Due to the nature of MMA and the intensity of the scrambles, takedowns, and guards, it is easy for a fighter to tweak their knee. Like wrestling, a lot of knee injuries happen when a fighter attempts to win a scramble and fight for top position. I can recount a number of occasions when a fighter had their foot get caught on the mat at a funny angle or their opponent had a hold of it while they quickly jerked their body away. The twisting, combined with quick, jerky movements makes for easy knee tweaks, sprains, or torn cartilage/ligaments. Many of these injuries stem from making an explosive motion without really knowing where they are going to end up. In other words, there is no planned technical response, just a reactionary explosive movement. This is more likely to happen with a very intense individual that is always attempting to be more explosive than technical.

“Leg locks are also a major cause of knee injuries, especially the reverse heel hook. Injuries occur during leg locks when either (1) the attacker quickly hits the lock, be it a heel hook or straight knee bar, and doesn’t give his partner sufficient time to tap, or (2) the fighter who is getting leg locked explosively attempts to get away and in the process damages their own knee. It is crucial during training that those grappling live understand that leg locks directly torque the knee, and they must learn to control their pressure when applying the lock. It’s also vital to learn proper escape techniques and know when to tap when caught. I do not allow new students to do twisting leg locks or knee bars (only Achilles locks and straight ankle locks), making sure they first learn how to properly counter and know when to tap. This is hard when you have two very competitive fighters who are proficient at leg locks.”

Nelson goes on to talk about another area of concern, which happens when an aggressive wrestler-type is relentless in passing the guard. In this scenario, the bottom fighter refuses to open his guard and allows his legs to get into an odd angle, and then the top fighter, in an aggressive and explosive manner, throws his opponent’s legs and drops his weight down onto the bottom opponent. During this type of scenario if the top partner drops quickly and the bottom is not ready … POP! There goes the knee. My instructor, Professor Pedro Sauer, told me never to put your knees in a position that, if the top person were to drop all their weight down suddenly, your knees would not be able to bend naturally.”

During the height of his career, Sean Sherk often overlooked injury prevention, and he suffered the consequences. “Based on my experience, guys don’t do any preventative exercises until it’s too late. I trained pretty hard. If something didn’t hurt, I wouldn’t worry about it. Once something hurt, I would just work through it. If it got to the point where I couldn’t work through it on a regular basis, I would throw a brace on it. Eventually it would be ‘done’ and I would need surgery.”

Having suffered a knee injury before and having had to work to get back from surgery, Tim Kennedy knows the importance of focusing on injury prevention. “I spend about 90 minutes for a training session. Two-thirds of that is dedicated to injury prevention, mostly core and muscle stretching and strengthening. Also doing band work and [working with] training balls. Olympic lifts and sprints are only about one-third of my workout. The vast majority is injury prevention.”

KNEE INJURY PREVENTION EXERCISES

Part of knee injury prevention is maintaining good balance and core strength, while good biomechanics help to keep the hips and knees aligned, avoiding stress on the ligaments. Below are some dynamic control and core strengthening/balance exercises that can help fortify the muscles around the knee and prevent knee injuries.

To work on core strength and balance, you can hold a medicine ball while standing on one foot and rotate to either side.

Repeat using a lunge position.

Have a partner throw the ball to you so you can catch it on one leg, rotate, and throw it back.

Lunges and one-legged squats help keep muscles strong but also help teach the body to keep appropriate alignment. To avoid injury, remember not to bend your knees past 90 degrees. You can also look at your knee from above and make sure you can still see your toes to make sure you haven’t bent your knees too much.

Resistance bands can be placed around the legs for lateral shuffling. Make sure your knees and hips are pointing outward and not inward, which stress the knee ligaments.

Plyometrics and rapid sequence movements help train the body to function in appropriate positions and maintain good form at a rapid pace. These can include box jumps,

lateral one-legged landings,

high-stepping,

lateral shuttle runs,

and running drills where you and your partner cross over each other.

Traditional exercises such as leg press, leg extension, wall squats, and leg curls help to isolate muscle groups.

The leg extension and leg curls are called “open-chain” exercises, because they isolate either the quadriceps or hamstring muscle groups. The leg press and wall squats are called “closed-chain” exercises because they activate both muscle groups together.


1 “Ipsilateral Graft and Contralateral ACL Rupture at Five Years or More Following ACL Reconstruction: A Systematic Review.” Wright RW, Magnussen RA, Dunn WR, Spindler KP. J Bone Joint Surg Am. 2011 Jun 15; 93(12): 1159-65

2 “Risk of Tearing the Intact Anterior Cruciate Ligament in the Contralateral Knee and Rupturing the Anterior Cruciate Ligament Graft During the First 2 Years After Anterior Cruciate Ligament Reconstruction: A Prospective MOON Cohort Study.” Wright RW. Am J Sports Med. 2007 Jul; 35(7): 1131-4