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)

To the untrained, boxing gloves are worn to protect an opponent’s head from the battering of punching fists. In reality, it’s the hands that need protecting. The hand contains some of the smallest and weakest bones in the body, which strike one of the hardest bones in the body, the cranium. When a punch occurs with enough impact, it’s the small bones of the hand that usually fail (some areas of the facial bones are thinner, and thus they may fracture as well). According to veteran UFC trainer Mark DellaGrotte, hand injuries are some of the most common injuries he sees in his fighters. This chapter will focus on the more common broken bones and dislocations in the hand.

The vast majority of hand injuries that occur with striking sports are either fractures or dislocations. Based on the location of these injuries, treatment may be quite different. If you look at the back of your hand, you will see three sets of knuckles. The first row of knuckles, which is what most people strike with, is where the fingers attach to the palm. This is called the metacarpophalangeal (MCP) joint, because it is where the metacarpal bones (the bones that make up the non-finger part of the hand) attach to the phalangeal bones (the finger bones). The other two rows are called the proximal interphalangeal (PIP) joint and the distal interphalangeal (DIP) joint. The PIP joint is in the middle of the finger, while the DIP joint is closer to the fingernail.

Side view of the finger joints and major tendons.

CREDIT: JOE KANASZ

HAND FRACTURES

Martial arts experts have long known that one of the safest methods of punching is with a straight fist that strikes with the MCP joints of the index and middle fingers. These bones are larger than the other metacarpal bones and are more stable. Inadvertent striking with the small finger knuckle (MCP) either due to poor technique, fatigue, or looping punches can often result in a fracture. This type of injury has been nicknamed “the boxer’s fracture” due to its frequent occurrence among boxers.

A boxer’s fracture or other metacarpal fractures can be very angulated and should be x-rayed and realigned by a professional. Once it is realigned, it must be immobilized in a splint or cast to prevent the angular deformity from occurring before the bone heals. Once the bone heals, there may be a residual bump, but the function of the hand should not be compromised, unless there is a large degree of deformity. If, however, the alignment of the bone cannot be maintained in a splint or cast, a doctor may offer surgery to hold the bone in place with hardware. Hardware may include small screws, a plate and screws, or removable pins placed percutaneously (poked through the skin and drilled into the bone). Fractures between the MCP joint and the PIP joint are often treated in the same manner. This is in contrast to fractures in between the PIP joint to the tip of the finger, as these often do not need surgery. They may need to be realigned with some traction by a professional, but they generally can be buddy taped to the neighboring finger for support.

If a healthcare professional recommends a splint or cast, it should be respected. Once the injury heals, then it will be acceptable to begin a gentle range of motion to overcome the stiffness that may have developed. It’s always better to need therapy for stiffness than to not have a bone or ligament heal properly, which draws the pain out even longer.

If you must continue to train striking technique, there are ways to minimize the pain while training. Josh Barnett trains using the uninjured hand at full power but modifies the other hand accordingly: “One time, I had a training partner and his hand was bothering him, so I worked with him around it. If you throw your hurting power hand, I will make sure to act like it’s not hurt. You can throw it with less power and I will treat it like it’s being thrown with full power. Another thing is, if your knuckles are sore, try some gel padding as a shock absorber. I have found them to work pretty well.”

UFC champion Demetrious Johnson felt the effects of a metacarpal fracture very early in his career. “My very first injury as an amateur was a broken hand,” recalls Demetrious. “The doctors had to pin my index finger metacarpal. Since I was working full-time at a warehouse job, I rehabbed myself. After I got the pin out, I started back slowly. But even when I hit, I could feel the bone rattle. With hand injuries, it’s all about where and how you hit. With my injury, I hit a guy in the head, and the small bone lost to the big bone. To help prevent hand injuries, I wear 16 oz gloves for sparring, so I can protect myself and my training partners. I wear 7 oz gloves for MMA. You should try and pad up as much as you can.”

FINDING THE CONFIDENCE TO HIT HARD AGAIN

Tim Silvia has experienced firsthand the long physical and mental recovery hand fractures can sometimes take. He knows one of the hardest things for a fighter to overcome after a hand injury, even after it’s healed, is confidence — the confidence to start throwing hard punches again. “I have had plates put on the ring finger metacarpals of both hands. As part of my rehab, I squeezed tennis balls to work on my grip strength. It took about six months of training before I felt confident in throwing hard again. Usually I use 18 oz gloves, but after getting hurt, I was using 24 oz until I had the confidence to go back down to 18 oz.”

Cesar Gracie, coach to many top-level UFC fighters, recommends getting hand fractures realigned by a doctor for two reasons: psychological and physical. “With a deformed broken bone, there is a psychological aspect that bothers the fighter — you tend to not throw as hard with that deformed hand. You don’t want that limitation during a fight. And in my experience, they tend to break easier again when they heal at an angle. It’s a traumatic experience when you break something. The pain is sent searing through your whole body. To help prevent injury, you want a professional wrapping your hands. In competition, we prefer both cloth and tape for wrapping. In training we do Mexican-style elastic wraps.”

According to Frank Shamrock, if you’re an MMA athlete and “you got no hands, you got nothing.” This can make hand injuries a real wake-up call to those who don’t take the care to protect their hands. In order to make sure you prevent hand injuries, he recommends two things: wrap your hands and punch with the first two knuckles. Not only does wrapping protect your bones and tendons, it also keeps your hands and wrists strong.

Frank Shamrock continues, “Maintaining a weightlifting regimen keeps my hands and wrists strong. I focus on the muscles that support my hands and wrists. I like exercises that use just hands, like climbing trees. Most people don’t understand why they wrap their hands. It’s to keep everything aligned and distribute the force. I spent the first 10 years of my career punching without wraps until I realized your hands are a limited resource.”

Carlos Newton also understands the importance of building up technique and the appropriate muscles to support your hands in striking. “The biggest mistake guys make when they start training is they buy wraps and boxing gloves and start hitting hard right away. Don’t do that. Start without gloves and wraps and learn how to make a proper fist and have proper technique and alignment. You need to develop these and train lightly to get a feel for balance. My boxing coach has taught me a lot. They say when the pupil is ready, the master will appear. Once you reach a certain level, it’s no longer a question of technique, it then becomes a matter of force. Then you need to glove up and strike hard in practice. If you have bad technique and form and you have only trained with big gloves, then when you go to use the smaller 6 oz MMA gloves, you will get hurt.”

WORKING ON GRIP STRENGTH

Frank’s adopted brother and UFC Hall of Famer Ken Shamrock also experienced a hand injury and touts the importance of hand exercises: “Before my second fight with Tito Ortiz, I was training and blocked a kick with my hand and the kick bent my fingers back. Then I threw a punch, and I broke my first and second metacarpals. I was treated with a cast. To rehab, I did a lot of grip work like squeezing play-dough and grabbing the edge of a newspaper to bring the newspaper into a ball.”

The newspaper ball exercise is actually a well-known exercise among professional grapplers and wrestlers. Retired MMA fighter Pat Miletich recalls hearing stories of a legendarily strong Olympic wrestler named Danny Hodge, who could make applesauce with his bare hands. “I first met Danny Hodge in Oklahoma. I asked him how he got such legendary grip strength and he showed me the newspaper exercise. He said to lay two pages flat on top of each other and then grab them between fingers in the middle of the square and make a little tent. Then gradually ball up a page in each hand. Then unfold them, straighten them, and repeat. I would do it three times a day.”

UFC legend Pat Miletich demonstrating the Danny Hodge newspaper exercise. Flatten out a newspaper and using just your fingertips, draw the paper up into your palm like a tent and then ball the paper up into your fist.

Close-up of how the fingers draw up the newspaper.

PHOTOS COURTESY OF JASON VAUGHN

American Top Team co-founder and jiu-jitsu champion Ricardo Liborio also sees a role for grip strength, especially when practicing grappling with a gi (a traditional martial arts uniform). “There is no doubt that working on your grip helps prevent injuries, especially in jiu-jitsu. What happens in jiu-jitsu is you get the fingers caught in the gi and twisted. Or when guys hold your fingers to try and break a submission attempt. I remember, I was fighting a Japanese opponent in the ADCC [Abu Dhabi Combat Club] tournament and he grabbed my finger and caught it and broke it right away. To work on your grip strength, I have seen gi fabric attached to a string attached to a weight machine. Or you can wrap your gi over a pull-up bar and practice pulling yourself up by grabbing the gi.”

UFC champion Carlos Condit has used several exercises to keep his hands strong. “I definitely like ice for healing, and for grip strength, we use weighted sleds and ropes. Sometimes we fill a bucket with rice, and I put my hand in rice and use it for resistance. You can work on grabbing, pinching, and turning your hand in the rice. I also do pull-ups holding a towel over a pull-up bar to work on different grips. I have also done a little bit of rock climbing for fun and grip strength.”

Don “The Predator” Frye, an MMA veteran, shares a story to remind fighters that protecting your hands needs to happen both inside and outside the cage. Simply put, getting into fights outside the cage can result in a hand fracture, and as Frank mentioned, your hands are a limited resource. “I remember I first broke my hand against Tank Abbott in the finals when I won the Ultimate Ultimate tournament. Back then, they just wrapped the back of the hand. They didn’t wrap the knuckles like they should have. The tape ended before the knuckles. We know better now. But unfortunately, I broke it again one year later. I was walking out a bar with fellow UFC fighter Brian Johnston. At UFC 10 we were opponents, but we became friends. We have been good friends since then. At some point, we were leaving a bar and some guy was messing with a girl. I fractured my hand due to an altercation. The first time it broke, it was fixed with pins, but the second time it had to be fixed with a plate. Now I wrap my hands all the time and spar with 18-20 oz gloves to protect my hands as much as possible.”

FINGER DISLOCATIONS AND FRACTURES

Besides fractures, finger dislocations can occur. With the use of fingerless MMA gloves, the incidence of dislocations is higher than in boxing. Dislocations can be either simple or complex. Simple dislocations often can be reduced and immediate range of motion performed. Complex dislocations, however, may involve rupture of ligaments or fractures, neither of which can be confirmed without proper x-rays and examination. While the instinct of a fighter may be to just pull on a dislocation and not seek medical treatment, it is very easy for a finger injury to lead to pain and stiffness if not treated properly. Ken Shamrock has suffered several ligament injuries on his thumb, which have led to chronic instability of his thumb joints. Ken recalls one of his injuries. “I was in the middle of training and blocked a kick with my hand. The kick caught my thumb and pushed it backwards towards my wrist. I taped it and finished training. However, it ended up swelling a lot and becoming stiff. In hindsight, I wish I had seen a doctor!” If you look at Ken’s first hand x-ray, you can see a fleck of bone at the base of his thumb metacarpal that was pulled away by his ligament — this is often referred to as a “skier’s thumb” or “gamekeeper’s thumb” depending on whether it’s acute (skier’s) or chronic. In the second x-ray looking at his hand from the side, you can see the joint above the other injury is not completely lined up, because of his non-reduced partial dislocation.

X-rays of Ken Shamrock’s hand showing an avulsion of a piece of bone at the base of the thumb MCP joint (left image) and a partial dislocation of the thumb IP (interphalangeal) joint (right image).

PHOTO COURTESY OF KEN SHAMROCK

Front and oblique view of a fifth (small finger) metacarpal neck fracture, also known as a “boxer’s fracture.”

PHOTO COURTESY OF THE AUTHOR

Gilbert Melendez has developed a small technique change to try to avoid getting your fingers caught and bent into awkward positions. “A lot of the time in MMA, your hands are loose while grappling and your fingers can get caught. You can’t keep your hands tight like in boxing, so it’s easy to get a knuckle caught. My advice is to always tape your hands and always be aware of your position. Keep your hands in a fist or tense in a flexed position. Stay loose for flow but keep them ready to tense up at any time. This goes for all of your body. When you throw a punch, you start loose then tense up. Your kicks start light and then snap at the end. The same idea holds for your hands. Keep them loose for flow, but be ready to tighten them up quickly.”

TENDON INJURIES

Other hand injuries a fighter may encounter are ligament and tendon ruptures. Ligaments are strong ropes of tissue that connect two bones together. Tendons are the ends of muscles that attach to bones to move them. The tendons on the top of the hand that allow the fingers to extend are called extensor tendons and the tendons on the bottom of the hand that flex the fingers are called flexor tendons. Sometimes due to a sudden pull or twist, tendons or ligaments can rupture. While some of these ruptures can be treated with strict immobilization using a splint, many others will need surgery. If you rupture a tendon, you should seek medical treatment within a week.

Intra-operative and post-operative views of Pete Spratt’s finger after pinning the IP joint.

PHOTO COURTESY OF PETE SPRATT

If the extensor tendon ruptures from its insertion at the tip of the finger, it is called a “mallet finger,” since the tip of the finger bends, and it looks like a mallet. If the flexor tendon is ruptured off the tip of the finger, it’s called a “jersey finger,” since it is often caused when a player is grabbing another player’s jersey and the jersey is suddenly pulled away. In both cases, a doctor will need to examine the fighter and get x-rays to determine whether a splint or surgery is the proper treatment. A third common hand injury in MMA is called a “boxer’s knuckle.” In this injury, the hood that holds the extensor tendon over the MCP knuckle ruptures and allows the tendon to move to the side of the knuckle, especially when a fist is made. This can lead to the extensor tendon not working as it should and preventing the fighter from fully extending the finger. This is often treated with a splint, but sometimes surgery is necessary to repair the extensor tendon hood.

MMA veteran Pete Spratt explains his injury, “The biggest injury I have sustained in 13 years of fighting has to be the ruptured thumb tendon. I remember feeling a pain in my thumb in the first round and when I came back to my corner in between rounds, I looked down at my thumb and it was pretty swollen!” Pete went on to have surgery to reattach one of the thumb extensor tendons and insert a pin to keep the thumb in place while the tendon healed.

GIVING YOUR HANDS TIME TO HEAL

Renzo Gracie learned the hard way that not letting a hand injury heal only prolongs your downtime. “I hurt my hand fighting Oleg Taktarov in 1996. Back then it was bareknuckle. I didn’t realize his head was so hard! It took six months for me to recover because I never rested it. I didn’t stop training and was constantly looking to fight. Looking back, I would have stopped and let it heal. You can work around it. Run, do elliptical, do the bicycle. In the end I probably delayed my fighting by not properly resting it to heal it.”

UFC Middleweight Champion Chris Weidman also felt the pain of a significant hand injury and wasn’t able to let it heal until after his fight. Hands often get hurt, and fighters often do not pull out of fights for various reasons. If that’s the case, make sure to give your hand the time it needs to heal after the fight. At UFC 175, Weidman successfully defended his UFC Middleweight Championship in five rounds against the always dangerous Lyoto Machida. But three weeks before the fight, Weidman suffered a thumb injury and was worried he would need to pull out of the match. His trainer Ray Longo remembers the story, “Weidman hurt his hand three weeks before the Machida fight. He got x-rays and an MRI. They showed a sprained ligament. The doctor told him it was injured, but wouldn’t get worse. However, he couldn’t use it. He couldn’t throw a left hand. So we had to change up his game plan and Chris did more kicking. It was a high stakes fight, so I have to know my fighter. He wasn’t going to pull out so we needed to find a new strategy. After the fight, it never got better. Even grazing the thumb would kill him. We ended up seeing a second doctor and getting more images. This time the doctor saw a hairline fracture, and he ended up needing a cast. After the fight, we were able to work around it and not cause any more stress on the thumb until it finally healed.”

According to Mark DellaGrotte the importance of proper hand wrapping cannot be overstated. “How we wrap fighters’ hands can make or break careers. There are very few coaches who wrap hands. I do it because Stitch taught me. If it weren’t for guys like him who know what they are doing, more careers would be ended. He actually calls me Grasshopper because of my interest in learning from him. Not only is it important to wrap the hands for fight night, but it’s also important during training camp. Guys don’t pay attention to this during training camp, and they suffer smaller injuries that predispose them to injury on fight night.”

Legendary MMA and Brazilian Jiu-Jitsu expert Mario Sperry has some hand injury advice too, “Most of the time, hand injuries happen because a fighter is used to training by shadowboxing and is too relaxed with his open hands. This becomes especially true when they are tired. During the fight, you fight how you train, and the combination of small gloves, the extra force of a fight, and punching with open hands can be devastating.”

And if you do hurt your hands, Mario has some more thoughts: “Always use ice right away and see a doctor. Whenever someone is recovering from a hand injury, I give them the advice that a famous Brazilian volleyball player gave to me: contrast. Hot and cold. Get two buckets. One with warm water and the other one with ice water. Stick your hand inside one then the other and alternate for a few minutes.”

Former UFC champion Sean Sherk also recognizes the importance of hand wrapping and ice. “For the first six or seven years of my career, I never wrapped my hands. I was throwing a thousand punches a day on heavy bags, Muay Thai mitts, and ground and pound bags. My hands started hurting all the time. I was trying to be a tough guy. I don’t know what I was thinking. I definitely should have been wrapping my hands.”

Stitch, however, reminds everyone that while wraps are important, they don’t make you invincible. “One thing I always tell people, because I have a very good wrap, is that a good wrap doesn’t guarantee you won’t break your hand. It minimizes the possibility of you breaking your hand, but a lot of these guys, especially in MMA, where they’re throwing a lot of hooks and land on top of the head — there’s no support factor when the knuckles make contact with the head. It’s pretty easy to break your hand that way.”

Coach Mike Winkeljohn echoes this statement. “Hand wraps are very important. Especially wrapping the thumbs to make the hand one unit makes a gigantic difference. But be careful with overhand punches. Overhands with the first knuckle are good if you can knock a guy out, but if you are too long with your punch and hit his head, you can really get hurt.” Former professional fighter Andy Foster has seen fighters neglect hand wrapping and the resulting injuries. “I broke my right hand once. The trick to avoiding this is to make sure the wrapping used for sparring is consistent. In haste, sometimes we shortcut the wrapping process to get into the ring. This leads to hand injuries. Haste makes waste … and injuries.”

For non-competition, Mark Dellagrotte prefers Mexican-style hand wraps, which use a more flexible material to allow for better circulation. Longer lengths are usually better than shorter lengths so you don’t run out of material. Once you take it out of the package, unroll it and then roll it back up in the reverse direction starting with the end that was originally on the outside.

Start by placing the thumb in the thumb loop, and then begin wrapping over the back of the hand, away from the thumb. Wrap around the wrist three to five times depending on the size of the hand.

Start on the thumb side. Bring the wrap over the thumb to the space between the index finger and the thumb, wrapping around the thumb, then across the lower back of the hand (where the hand meets the wrist) to the small finger side. Wrap under the wrist to the thumb side. Do this two to five times.

Once you are back around to the thumb side, cross diagonally over the back of the hand to reach the outside of the little finger. This is the first step of wrapping the fingers together as a whole.

Wrap around the base of the fingers with the fingers spread wide three to five times. Then return to the wrist and wrap around to the thumb side to prepare for wrapping each finger individually.

From the thumb side cross diagonally over the top of the hand and wrap the small finger by passing along the outside, wrapping around it, moving in between the small finger and ring finger, and then returning to the thumb side. Open the hand when you pass between the fingers, then close the hand into a fist when you come across the knuckles, heading back towards the wrist. Pass the wrap under the wrist to reach the small finger side.

From the small finger side, wrap the index finger by passing over the top of the wrist to the thumb side of the finger, wrapping underneath the index finger through the space between the index finger and the thumb, and returning to the wrist through the index and middle fingers. With each finger wrap, you return to the same side you started wrapping the finger from, then pass under the wrist to prepare for the next finger to be wrapped.

Wrap the ring finger by passing between the ring and small fingers, wrapping around the ring finger to come out between ring and middle, then return to the thumb and wrap around the wrist. Then wrap the middle finger by passing between index and middle fingers, wrapping around the middle finger to come back out between middle and ring. It is important to make sure there is no bunching of the material.

After the middle finger has been wrapped, wrap around the wrist one more time to bring the wrap back to the knuckles.

Wrap around the knuckles another two to five times.

Finally, finish up by wrapping around the wrist. Open and close the hand to make sure material does not bunch up or cut off circulation. Examine all sides of the hand.

Make sure no material has bunched up anywhere and that your hand has a flexible range of motion and proper blood circulation.

PHOTOS COURTESY OF RICHARD FOX