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Phys Med Rehabil Clin N Am 17 (2006) 645–676

The Martial Arts
Charles M. Terry, MD, FAAPMRa,b,*
Saint Lawrence Rehabilitation Center, 2381 Lawrenceville Road, Lawrenceville, NJ 08648, USA b MKA Karate, 4800 Drexelbrook Drive, Drexel Hill, PA 19026, USA
a

Over the past several decades, the martial arts have become an increasingly popular recreational activity among Americans. When the martial arts were first introduced in the United States, ‘‘old school practices,’’ such as performing knuckle push-ups on the pavement or running barefoot through the snow, were actually accepted training methods. In many instances, only the fittest students endured the rigors of these practices and continued to train. Today, the martial arts have evolved into an activity that can benefit students of all ages, shapes, and sizes. Some schools accept students as young as 3 years old [1]. There are also those who have first begun training in their 70s and 80s [2]. More recently, physically challenged individuals have discovered that they can actively participate in the martial arts [3–5]. Each different style of martial arts has its own risks and benefits. It is important for health care practitioners to understand the demands of any given martial art so as to advise patients properly about participation. Obtaining a detailed history about the specific requirements and training practices of a patient allows the medical practitioner to propose the most appropriate training regimen and restrictions if necessary. For several disease processes, training in the martial arts may be an excellent adjunct to other therapeutic interventions [6–10]. The purpose of this article is to provide an overview of the martial arts, including styles, training methods, risks, and benefits so that health care providers can make educated well-informed recommendations about training to their patients.

* Saint Lawrence Rehabilitation Center, 2381 Lawrenceville Road, Lawrenceville, NJ 08648. E-mail address: [email protected] 1047-9651/06/$ - see front matter Ó 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.pmr.2006.05.001 pmr.theclinics.com

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Background History The art of fighting has been around for thousands of years. There are even references to martial arts in ancient Greece and Egypt. The history of modern martial arts is shrouded in secrecy. Many arts were developed in times when weapons or outright practice of martial arts was banned. Therefore, systems of self-defense were often passed on privately. The roots of many of today’s arts may be traced back to China and India. As these arts spread, they continued to develop. The term te was used as early as 1629 to describe an Okinawan martial art. This eventually evolved into today’s karate. The martial arts were introduced to America through several different avenues. Chinese immigrants brought Chinese martial arts to the United States in the 1800s. After World War II, many United States soldiers trained in Japanese and Okinawan arts, later bringing these arts home. The Korean War may have led to the rise of Korean martial arts in America, which have gained even more popularity since being added to the Olympics.

Styles There are many styles of martial arts. Some commonalities may be found in techniques and training methods. Each style and each school within a style are likely to have unique requirements of students, however. Some of the most popular systems originated in Japan, Okinawa, Korea, China, the Philippines, Brazil, France, Israel, and America. Different regions and countries have given birth to a myriad of newer systems. The sharing of techniques and concepts makes it impossible to detail fully the ever-evolving systems available to those interested in the martial arts. In general, styles may be broken down into several categories: strikingbased systems, grappling or throwing systems, weapons-based systems, and health-based systems. Each style may cross over into elements of other systems as well. Many of today’s schools are based on striking systems but also include some grappling and weapons. A school may be competitive and tournament centered or may predominantly focus on calisthenics for health and exercise (eg, cardio-kickboxing). Some schools do not allow any contact at all between students, whereas others range from light contact to the body without weapons to full contact with weapons (Table 1).

Participant profile The exact number of participants in the martial arts is unknown. In 1989, Ritter [11] estimated that 2 million people in the United States participate in

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Table 1 Some of the major systems of martial arts Style Aikido Arnis (Kali, Escrima) Capoera Goju-Ryu Hapkido Jeet Kune Do Judo Jujutsu (Jiu Jitsu, Jujitsu) Karate Kempo Kendo Kenjutsu Kenpo Krav Maga Kung-fu Ninjitsu Ryukyu Kempo Savate Shorin-Ryu Shotokan Sumo T’ai Chi Tang Soo Do Tae Kwon Do Wu Shu Country of origin Japan Philippines Brazil Okinawa Korea America/China Japan Japan Okinawa Okinawa Japan Japan China/America Israel China Japan Okinawa France Okinawa Japan Japan China Korea Korea China Main features Throws and redirection Stick Fighting, developing ‘‘the Flow’’ Wide sweeping kicks and handstands Kicks, striking techniques Kicks, flowing, constant motion The approach of Bruce Lee Throws, holds, and chokes Joint locks, throws, holds, chokes Kicks, striking techniques, blocks Kicks, striking techniques, weapons Use of the practice sword Cutting and thrusting with the sword Kicks, striking techniques Military-based hand-to-hand combat Hard or soft style, weapons, animal forms Commando warfare, weapons Pressure point strikes and grappling Kicks, boxing Kicks, striking techniques Kicks, striking techniques Wrestling Cultivates Chi Kicks, striking techniques Kicks, striking techniques Official art of the Chinese mainland

the martial arts. In 1996, Birrer [12] estimated that there were 8 million participants in the United States. According to a representative from the Martial Arts Industry Association (MAIA), there were approximately 6.9 million Americans aged 6 years or older participating in the martial arts in 2004 (C. Ryan, personal communication, 2005). The percentage of students who are younger than 18 years of age is also subject to debate. Although it is possible that schools were predominantly populated by adults in the past [13], many commercial schools are dominated by children’s classes today. According to MAIA demographics from December 2004, 46% of students were between the ages of 6 and 17 years. This does not account for students younger than 6 years of age. There has been a recent trend toward more age-specific classes, starting as young as the age of 3 years [1,14]; therefore, it is likely that an even greater number of children are training than adults. Most schools have coeducational classes. It is also evident that more girls and women are participating in the martial arts today. In 1991, it was estimated that the male-to-female ratio was 5 to 1 [13]. In 2004, it was estimated that 37.5% of practitioners were female (MAIA).

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Training methods Training methods can be divided into three categories: individual or noncontact group practice, equipment use, and partner work. In many cases, an injured student may be able to continue training with individual or noncontact group practice. The use of some equipment may be contraindicated under certain circumstances. Partner work, most specifically sparring, is the activity most likely to result in injury [12]. Individual or noncontact group practice Warm-up Most classes begin with a warm-up period. This consists of stretching and light aerobic exercises. A broad range of calisthenics may be incorporated into the average martial arts class, including jumping jacks, jogging, pushups, abdominal exercises, and related activities. These are used for conditioning. Basics The core aspects of the martial arts are broken down into basic techniques. Basics include blocks, strikes, falls, and rolls. Basics may also include drills to enhance speed, timing, balance, coordination, and other skills beneficial to the martial artist. Although any part of the body may be used as a weapon, from the forehead to the gluteus maximus, most striking and blocking techniques can be broken down into upper extremity or lower extremity techniques. Various parts of the upper extremity can be used for blocking or striking. The hand is usually held in a chop-hand position (chuto) or in a fist. Other positions and variations on these positions may also be used. In the chophand, the fingers are held together straightened or slightly flexed with the thumb approximated against the second digit in a plane rotated at an angle of 90 to the other fingers (Fig. 1). Some styles advocate a flexed position for the first interphalangeal joint; however, this leaves a practitioner open to a thumb lock or risks jamming the thumb when interacting with a partner. The finger tips are used as the striking surface in a spear hand. The ulnar side of the hand (hypothenar eminence) is used in a basic chop. The radial side of the hand is used in a ridge hand strike. The heel of the palm may also be used as a striking surface. Other parts of the upper extremity used for techniques include the dorsal carpal bones, the forearm, and the elbow. The basic karate punch involves twisting the fist from supination into pronation and making contact with the knuckles of the second and third metacarpophalangeal joints. An incorrectly thrown punch may connect with the fifth knuckle (metacarpophalangeal joint), leading to a fracture of the distal metaphysis of the fifth metacarpal, or ‘‘boxer’s fracture’’ [15]. One of the most common targets of a basic punch is the solar plexus. Many styles of martial arts perform a ‘‘full-twist’’ punch, where the fist is

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Fig. 1. Basic karate chop-hand.

fully pronated on completion. Other styles favor a vertical punch. These variations are safer for the opponent, because the fist does not fit into the solar plexus well and decreases the risk of causing a xiphoid fracture. They are also more likely to cross over several ribs when striking the chest. Therefore, a vertical or full-twist punch decreases the chance of breaking a single rib by spreading out the energy of the strike over several ribs. Some styles perform a ‘‘three-quarters’’ punch, which holds the fist at an angle of 45 so that it can fit better into the solar plexus or can be directed at one specific rib (Fig. 2) [16]. It has also been postulated that the twisting of the radius

Fig. 2. Three-quarters punch.

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over the ulna with a full-twist punch provides less support for the striking surface by allowing the interosseous membrane between the radius and ulna to become slack [17]. The three basic blocks are upper, side, and low. Variations and combinations of these blocks are common. Many styles teach students to block with the radius or ulna alone. It has been proposed that blocking with both bones in parallel provides a greater surface area to disperse the energy of an oncoming attack and reduces or eliminates the risk of an ulnar ‘‘night-stick’’ fracture [18,19]. Blocking with the dorsal aspect of the forearm protects the critical nerves and blood vessels that pass along the palmar aspect of the wrist and forearm. This is also likely to reduce the risk of a debilitating or life-threatening injury in an actual self-defense situation against an attacker armed with a knife or broken bottle (Fig. 3). Basic leg techniques include parries, sweeps, and strikes with the knee, shin, or various parts of the foot. The front kick is typically performed with the ball of the foot. It begins by raising the knee, then thrusting the foot forward and upwards, and then retracting. It can also be performed with the instep or heel (Fig. 4). The roundhouse kick is performed with the hips turned sideways. The strike moves perpendicular to the opponent, first pointing the knee at the intended target, then extending the foot connecting with the ball of the foot or the instep, and then retracting (Fig. 5). The side kick is performed with the leg extended to the practitioner’s side using the heel or ‘‘knife edge’’ (lateral side of the foot) as the striking surface (Fig. 6). The back kick is performed with the leg extended behind the practitioner using the heel as the striking surface (Fig. 7). Falls Breakfalls are common to the martial arts. The goal of practicing falls, or breakfalls, is to reduce the chance of injury in the event of a fall during training or when in a fight. Although each style may teach a different method of falling, the principles are quite similar. With any fall, the practitioner is taught to keep the mouth closed, with the tongue in the mouth to prevent biting the tongue. When falling to the rear, the chin is tucked down so that the head does not hit the ground on impact. The knees are bent, and the spine flexes forward while the trunk descends. Typically, the gluteal region hits the ground, followed by the lumbar and thoracic regions and then the shoulders and elbows, and, finally, the hands slap the ground. It is recommended that the arms make no more than a 90 angle with the trunk when falling to prevent injury to the shoulders. The natural reflex many people have is to extend the arms in the direction of a fall, allowing the hands and arms to take the brunt of the impact. This commonly leads to sprains or fractures of the upper extremities. Allowing the uncoiling trunk to disperse the energy of a fall can lessen the impact on any one body region (Fig. 8). Falling to the side is similar to rear falls, except the body falls sideways and only one side

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Fig. 3. (A) Upper block. (B) Side block. (C) Low block.

of the trunk and one upper extremity are used to disperse the energy of the fall (Fig. 9). When falling forward, the face is turned to the side. Practitioners may be taught to land on the palms with the elbows slightly bent, and the downward motion of a push-up is performed to allow the muscles of the upper extremities and eccentric contraction of the triceps to disperse the energy of the fall.

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Fig. 4. Front kick.

Some styles teach students to land on the forearms, with a slapping motion on impact (Fig. 10). Rolls Rolling techniques are often found in aikido and jujitsu. A roll can be used as a means to escape from a joint lock or an attack. In the event of loss of balance, rolls can serve as another method of falling without getting injured. Rolls may be done to the front or to the rear. In a roll, the potential

Fig. 5. Roundhouse kick.

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Fig. 6. Side kick.

energy of a practitioner in the standing position is converted to kinetic energy. Just before impact with the ground, parts of the body are positioned to create a circle intended to deflect the force of impact. Kinetic energy is spread out along an increased surface area of the body and translated into rotational energy. The impact of landing is dispersed and greatly reduces the risk of injury. Students begin learning to roll from a seated or kneeling position. They then progress to standing rolls and may eventually progress to diving rolls (Fig. 11). Kata ‘‘Kata,’’ or forms, are common to many styles of martial arts. As a basic description, a kata is a series of moves put together in a pattern that is

Fig. 7. Back kick.

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Fig. 8. (A–C) Breakfall to the rear.

memorized. Typically, more difficult kata are required to progress to higher levels of rank. Originally, kata were developed by masters to incorporate combinations of their favorite self-defense techniques. These techniques can be directed against pressure points to disable, knock out, or even kill an opponent [20]. In today’s schools, kata are most often practiced as an individual exercise or in a group done in synchronization. Kata may be used to develop

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Fig. 9. Breakfall to the side.

balance, agility, strength, conditioning, and focus as well as proper angle and direction of techniques. In group kata, practitioners use peripheral vision and sound in addition to constant practice to stay together. Even breathing may be synchronized. Equipment Sparring gear Most modern schools require students to wear specific equipment when engaging in sparring. The efficacy of this gear is subject to debate [19]. The use of sparring gear is often required by companies that insure martial arts schools, however. Therefore, a discussion of the most commonly used gear is appropriate and necessary. Many standard head protectors, gloves, and foot protectors are made of foam. This equipment is more for the protection of the one wearing the gear than for the opponent [21]. Gloves and foot protectors are meant to protect the hands, feet, and digits. Headgear comes in several forms. The most common type protects only the side, top, and back of the head. The usefulness of any foam headgear to protect against closed-head injury has been questioned [21]. This author has always preferred (from a safety standpoint) the type of headgear that also protects the face (Fig. 12). This is because contusions, lacerations, and abrasions occur in general practice far more frequently than closed-head injuries or concussions [12]. This full-face headgear also affords more protection to the nose (Fig. 13). Students may complain about decreased peripheral vision

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Fig. 10. Breakfall to the front.

with such headgear, however. This may be why it has become increasingly more difficult to find this more comprehensive full-face headgear. A newer alternative is a clear face shield that attaches to the less protective type of headgear. It is more expensive, and its acceptance among practitioners remains to be seen. Most schools and tournaments require the use of a mouth guard during sparring. These come in many varieties. For the elite athlete, a custom mouth guard may be fashioned by most dentists. Chest protectors are required in some settings. Specific protectors are available for the female chest. Nevertheless, it has been said that a blow to these protectors hurts just as much as without a protector [22]. This author has yet to find a chest protector that is well accepted by female practitioners. Groin protectors are available for male and female practitioners. Typically, only male practitioners are required to wear groin protectors. Optional equipment includes shin pads, forearm pads, knee pads, and elbow pads. Because of frequent clashing of the shins during sparring, many students opt to wear at least shin pads. Floor mats Floor mats come in different thicknesses and degrees of cushioning. The amount of padding recommended varies with the techniques being practiced. Inadequate padding for certain techniques can lead to injury. Insufficient hygiene of mats could lead to the spread of superficial infections [23]. It

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Fig. 11. (A–C) Forward roll.

should be noted, however, that several investigators have failed to isolate fungal organisms from wrestling mats and that the distribution of typical lesions on wrestlers suggests that skin-to-skin contact is a more likely mechanism of transmission [24–26]. These studies have yet to be performed on martial arts mats. It is likely that systems focusing on grappling may incur a similar incidence as that found in wrestling.

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Fig. 12. Standard sparring equipment: comparison of standard headgear (right) versus full-face headgear (left).

Heavy bags Heavy bags may be suspended from above (with or without a tether below) or may be free-standing (supported by a base filled with sand or water). They are typically filled with sand, water, or padding. The outer cover is usually nylon, leather, or canvas. Targets Targets come in a variety of shapes and sizes. The surface may be canvas, nylon, leather, or simulated leather. They are typically filled with padding, foam, or air. Targets allow students to work together to improve strength, focus, accuracy, and timing. The target serves to dissipate the force of the technique and minimizes the impact on the student holding the target. Nevertheless, it must be noted that the holder may still be subjected to a significant amount force with each blow. Therefore, a student with an injury may have to modify his or her method of holding a target or avoid this aspect of training entirely. Similarly, a student practicing with an injured upper or lower extremity should obviously avoid hitting targets with the affected limb. Practice with targets is essential for students who wish to learn how to break boards and cinder blocks. Breaking Breaking of boards or other objects is a highly visible and exciting yet risky practice of the martial arts. It may be used to test the effectiveness and accuracy of techniques. Breaking is sometimes required when students

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Fig. 13. Vulnerability of the face with standard headgear.

are testing for higher rank. Breaking is most commonly used for demonstration purposes and may be included in tournaments as a separate division. It should be noted that not all schools practice breaking. Even in schools that do practice breaking, it typically plays a small role in overall training practices. Breaking has also been taught to nonmartial artists by motivational speakers (eg, Anthony Robbins) as a means of developing confidence. In an unpublished study, this author attempted to measure the force needed to break 1-inch thick common pine boards. Because of the variability in seemingly homogeneous wood, some boards took up to three times the force needed to break a single board. For this reason, it is essential for students to exercise caution when practicing breaking and only to advance the number of boards broken in single increments. Moisture may also have an impact on the pliability of objects to be broken. The practice of heating cinder blocks in an oven to dry out any moisture and thus decrease the force needed for a breaking technique is well known among martial arts folklore (as is the story of a martial artist who tried to heat wooden boards in his oven and burned down his kitchen). Conversely, this author has seen first hand the effects of attempting to break a cinder block that had been overexposed to the elements. A highly trained black belt with years of experience attempted to use a punch to break cinder blocks of uncertain origin. In spite of previous success, this instance led to a severe wrist fracture. It was later determined that the cinder block had been used for several seasons as a weight to keep a pool cover in place. It is therefore recommended that only new wood or cinder blocks that have been kept in a controlled

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Fig. 14. Board-breaking technique.

environment be used as breaking materials. Children whose epiphyseal plates have not yet fused as well as older students who may have osteoporosis should practice breaking only with caution, if at all (Fig. 14). Miscellaneous equipment Martial artists use many types of equipment that are common to other sports. These include jump ropes, weights, hand grips, and resistance bands. Other types of equipment are more specific to the martial arts: push-up bars, stretch racks, makiwara, and weapons (Fig. 15). Weapons Weapons may be taught as an individual exercise through basic techniques and kata or as an interactive exercise with another student who is armed or unarmed. The most common weapons in the martial arts include the bo (long staff), jo (short staff), arnis or escrima (rattan sticks), nunchuku (two hardwood sticks connected by a rope or chain), sai (pair of threepronged swords resembling tridents), kama (sickles), tonfa (similar to today’s police baton), and sword (Fig. 16). Because any common object may be used as a weapon, this list could go on indefinitely. Proper maintenance of weapons is imperative to minimize risk to practitioners and spectators. Any damaged weapons should be repaired or replaced immediately. Although many schools require students to go barefoot during training, simple footwear may significantly reduce the injuries that can occur from a dropped weapon landing on the foot. Partner work Partner work is when students are most likely to sustain an injury while training in the martial arts. This aspect of training may include sparring, drills, self-defense techniques, pressure point manipulation, and grappling.

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Fig. 15. (A) Push-up bars are used to keep proper wrist alignment and to allow for increased range of motion. (B) Stretch racks are used to provide passive resistance for increasing flexibility. (C) Makiwara are slightly padded targets used for conditioning, strengthening bones, and toughening the skin.

Most documented martial arts–related injuries occur during sparring (particularly competitive or tournament sparring) [12]. Rules have been developed to minimize the risk of injury during sparring, and most modern schools do not permit sparring without the use of protective equipment. Standard sparring rules generally state that no contact is allowed to the head, face, back, or below the belt. Light contact may be permitted to the body. Certain techniques, such as takedowns and grappling maneuvers, may be restricted to more experienced students. Drills may involve trading techniques or combinations with a partner. Basic techniques can be practiced with another student acting as an attacker with different degrees of complexity. Other partner drills may be used to develop timing, focus, accuracy, and control. Self-defense is one of the most commonly cited reasons for people to train in the martial arts [27,28]. In the interest of safety, the rules of sparring often forbid the same techniques that may be the most useful in an actual self-defense situation. For this reason, practical self-defense is often practiced as a separate exercise. One or more students act as attackers, whereas a practitioner practices controlled blocks and counterattacks. Initially the attacks are singular, predetermined, and basic. Eventually,

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Fig. 16. Weapons (left to right): wooden kama, kama with metal blades, sai, nunchaku with strings, sai, nunchaku with chains, and tonfa.

students may progress to fending off multiple armed attackers using random attacks. Pressure point techniques have become increasingly popular over the past 20 years. Ryukyu Kempo is a classic Okinawan martial art that incorporates striking and grappling techniques using the same points and theories involved in acupuncture [20]. With basic techniques, pressure points are activated so that the training partner feels pain but is not injured (Fig. 17). These techniques have been recommended for law enforcement, medical personnel, and business professionals [29]. Advanced techniques involve using pressure points to render a training partner unconscious. Although the physiologic mechanism of action of these techniques has yet to be elucidated, no hazardous complications were demonstrated during a study that monitored electrocardiography (EKG), electroencephalography (EEG), pulse oximetry and blood pressure [30]. Grappling with a partner is common to jujitsu, aikido, and judo. With the success of grapplers in ‘‘no holds barred’’ competition, many predominantly karate-based schools of martial arts have introduced grappling techniques. Grappling employs the use of joint locks and chokes. An obvious potential risk of joint locks is fractures and dislocations. Practitioners are taught to ‘‘tap-out’’ before becoming injured during the application of a lock. Unwillingness to concede or poor sensitivity on the part of the practitioner applying the lock can lead to injuries, however. With respect to chokes, there is a case report of a stroke in a 29-year-old previously healthy man after participation in six neck-holding maneuvers in a martial arts class [31]. Another case report involved a 40-year-old practitioner who had a stroke likely secondary to traumatic plaque rupture during a choking maneuver in a martial arts class [32].

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Fig. 17. (A) Self-defense technique using pressure points on the wrist and leg. (B–D) Selfdefense sequence using pressure points on the arms and face.

Therefore, the practice of prolonged or vigorous neck holds is discouraged even in seemingly healthy individuals. Preparticipation physicals should include screening for carotid artery stenosis, particularly in patients who state that choking techniques are part of their repertoire, although blunt trauma to the carotid artery is possible in many styles of martial arts.

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Injuries Epidemiology of injuries There have been several attempts to qualify and quantify the injuries attributed to training in various types of martial arts [12,22,33–35]. The true risks and types of injuries to which any given participant is susceptible may vary greatly with style, hours of training, and degree of competitiveness. Often, the incidence of injury is expressed as a number per 1000 hours of practice or competition [19]. In a study of injuries during competitive Muay Thai Kickboxing, there was an average of one injury for every 42 minutes of competition [36]. In contrast, practitioners of Tai Chi (which is generally slower and noncontact) may practice for hours each week for months and rarely complain of an injury [37]. In a recent survey of a karate-based system, there was an injury rate of 2.70 per 1000 hours of practice [19]. More than one study has suggested that the practice of martial arts is safer than many other commonly practiced sports, such as soccer, gymnastics, and volleyball [12,38,39]. Types of injuries, prevention, and return to martial arts training after an injury Injuries may be divided into those that are related to martial arts training, preexisting conditions, and unrelated injuries that may affect training in the martial arts. In this author’s experience, far more students are injured in activities outside of the dojo than while training in the martial arts. Often an ‘‘injury’’ is defined as an event that interrupts the continuation of training or competing [37]. It is likely that this misses most minor injuries that do not interfere with participation. Most injuries encountered in the martial arts do not require complete cessation of training. A modified training program may actually be therapeutic for rehabilitation from an injury. Whether an injury has occurred during martial arts training or elsewhere, the timing of safe return to training is important. When an injury has occurred in the martial arts class, there may be psychologic issues as well. A physician who is not familiar with the martial arts may be inclined to advise an injured student to avoid any training until an injury is completely healed. This may be akin to telling a postsurgical patient to avoid rehabilitation until he or she is completely healed. Certainly, if a post-coronary artery bypass graft (CABG) patient can be admitted to a rehabilitation unit less than a week after surgery, a martial artist with a sprained finger can continue to train. The acronym RICE (rest, ice, compression, elevation) in a rehabilitation setting is often changed to RRICE (relative rest, ice, compression, elevation). If our goal is to restore function and focus on quality of life, telling a dedicated martial artist not to train may do more harm than good. Because most injuries in the martial arts occur during partner activities, this aspect of training can be avoided completely for a brief period if

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necessary. Many training drills do not require contact with another student; thus, an injured practitioner can significantly control and modify the training environment to reduce the risk of exacerbating an injury. The following section primarily addresses injuries specific to martial arts training. When pertinent, disorders unrelated to a martial arts injury are also discussed. Skin or soft tissue injuries Contusions and hematomas are so common in the martial arts that they are frequently unreported [40]. They often require no treatment. RICE may be used as needed, however. In the case of a large hematoma, aspiration may speed recovery [35,41]. Tinea corporis gladiatorum is a common affliction among wrestlers [24– 26]. It is reasonable to expect this to be found also among grappling-based martial arts systems. What may be a more general concern to martial artists is tinea pedis. Most martial arts are practiced barefoot. It is recommended that any martial artist with signs or symptoms of ‘‘athlete’s foot’’ be permitted to wear martial arts shoes during training to prevent its transmission to other practitioners. Head and neck The most common injuries to the head involve contusions and lacerations [42]. If a concussion is evident, a student should refrain from training until medical clearance has been received. Many contusions can be minimized by the use of appropriate headgear during sparring. Facial lacerations can be reduced by keeping nails trimmed, using protective gear during sparring, and eliminating sharp edges on weapons. Injuries to the eyes, nose, or teeth should also be referred for medical evaluation by the appropriate specialist. A simple mouth guard should be mandatory for all sparring matches. The proper headgear should provide protection for the nose as well as for the skull, because the nose is the most exposed feature of the face, especially with inadequate headgear. In students with recent eye injuries or with preexisting blindness in one eye, sports goggles or headgear with a face shield should be worn during all partner activities. With students who have had a closed-head injury while training in the martial arts or elsewhere, training can continue under certain restrictions. It is prudent to avoid falling practice or take-down techniques as well as sparring for a period of 1 year after a closed-head injury. Contusions, sprains, and strains are the most common neck injuries. Sprains and strains can be treated with stretching modalities, anti-inflammatories, and muscle relaxants if needed. Guidelines on training can be based on symptomatology. Persistent symptoms or those accompanied by radicular signs warrant further evaluation before training may resume. Carotid injuries may occur with choke holds as previously mentioned in this article. Injury to the carotid may also occur from blunt trauma. As

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described in a case report by Blumenthal and Riggs [43], a 43-year-old corrections officer developed right neck and posterior head pain after a karate punch to the right side of the neck during self-defense training. One week later, he developed acute left hemiparesis. A right hemispheric cerebral infarction was demonstrated by MRI. Carotid ultrasound demonstrated complete occlusion of the right internal carotid artery without evidence of atherosclerotic disease. Their conclusion was that a forceful blow to the neck can potentially lead to carotid occlusion and cerebrovascular infarction. Trunk Unfortunately, the twisting and bending motions required with some martial arts moves may lead to a lumbosacral sprain or strain. This can be particularly challenging for practitioners with a history of prior back injuries. In the general adult population, 2% to 5% of people report low back pain that occurs at least once per year, and the lifetime prevalence of low back pain has been estimated to be 85% to 90% [44]. Therefore, at any given time, there may be several students in a class with current or recent low back pain. This author has had some success with the incorporation of a Pilates-based warm-up routine for certain students and a modification of training requirements to curtail take-down maneuvers, throws, and, in some instances, sparring. Posttraumatic renal vein thrombosis has been reported after blunt trauma to the flank during karate practice [45]. A kidney contusion was described in a case report after a jujitsu practitioner had taken some ‘‘bad falls’’ [46]. Using proper falling technique should minimize this risk. Using mats to cushion the fall can help with riskier falling techniques. These techniques should be avoided in the case of known internal organ dysfunction, such as congenital absence of a kidney, history of nephrectomy, or recent mononucleosis in which the spleen may be enlarged or weakened. Abdominal protectors are also available and should be worn during all contact activities to protect the injured or remaining organ. Having one’s ‘‘wind knocked out’’ is not uncommon among sparring sessions. This is generally a self-limited phenomenon. Students should be monitored for signs or symptoms of other internal injuries nonetheless. Deep breathing techniques can help to restore normal breathing. Learning to exhale while blocking and strict refereeing to maintain control of contestants may reduce the incidence of this occurrence. Psychologically, once the breathing has returned to normal, it is useful to have a student resume sparring (with even closer monitoring of control) to prevent the student from developing a fear of sparring. Receiving a kick to the groin is another experience that is not foreign to many martial artists. For this reason, a groin protector should be mandatory for all sparring sessions. Male and female versions are available. Even with a groin protector, a kick to the groin can be painful. It is

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traditional for instructors to have the subject bounce up and down on his bottom or to make him or her jump up and down. It has been said that this is to help stretch muscles in spasm [22]. The efficacy of this practice has yet to be subjected to scientific scrutiny. Severe or persistent pain or the presence of hematuria may be a sign of a more significant injury, such as urethral trauma or testicular torsion [33]. There is a case report of a 27-year-old man who presented to an emergency department with right groin pain after being kicked in the right anterosuperior thigh. Radiographs revealed right acetabular fractures and an inferior pubic ramus fracture [47]. This patient was successfully treated with Buck’s traction, physical therapy, and restricted weight bearing. Upper extremities Although the details of shoulder injuries in the martial arts are not specified in several comprehensive articles [12,48,49], they composed 5% of the injuries in an 18-year study of trauma epidemiology in the martial arts [12]. Joint locks and grappling techniques that torque the shoulder could lead to shoulder injuries. Throws, rolls, and falls practiced in some forms of martial arts may also lead to shoulder injuries. In particular, an acromioclavicular (AC) separation can occur from a fall onto the tip of the shoulder. This can be confirmed by a weighted anteroposterior (AP) radiograph. Treatment of minor AC injuries consists of wearing a sling, using ice, and taking analgesics for the first few days. Gradual resumption of training may occur over a period of weeks. Severe AC injuries may require surgical referral. Repetitive striking motions are common among practitioners of arnis (Filipino stick fighting) and can lead to lateral epicondylitis. Bilateral lateral epicondylitis has also been reported in the practice of open-hand techniques [50]. Modifying or eliminating the activities that cause symptoms is the most important step in treatment [51]. In the case of arnis-related lateral epicondylitis, changing to sticks that are more pliable, using a wider diameter stick, or wrapping the sticks to widen the grip may be sufficient. Wearing a tennis elbow strap may also be useful during practice. Changing the orientation of the hand during strikes (more ulnar position instead of dorsal position) or substituting open-hand techniques for stick work may be necessary for periods of relative rest. Ice, nonsteroidal anti-inflammatory drugs (NSAIDS), anti-inflammatory creams, or corticosteroid injections may be useful if training modifications alone are insufficient. Wrist injuries can occur with improper and excessively forceful punching techniques against targets or punching bags. They can also occur with breaking techniques, poor falling techniques, or wrist throws and joint locks. Correct technique may prevent such injuries. In addition to ice and anti-inflammatory medications, minor sprains can be treated with wrist wraps or splinting during training to prevent exacerbation. More severe injuries may require casting. Students may still participate in training but

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should avoid partner work or activities using the affected limb. Tenderness over the lunate may be a sign of avascular necrosis (Kienbo ¨ ck’s disease) and warrants orthopedic referral. Sprained fingers are one of the more common injuries incurred by martial artists [12,19]. Proper hand protection during sparring and weapons practice may help to reduce the incidence of finger injuries. A radiograph should be obtained to rule out a fracture. Splinting or buddy taping is generally sufficient treatment in the case of a sprain. It is not necessary to interrupt training in such cases. In fact, practitioners can be instructed to keep the injured extremity tucked into the belt behind the back and to practice defending with only the unaffected limb. Many schools have a rule that no jewelry is to be worn during class. This author used to make an exception for jewelry with religious significance or wedding rings. Unfortunately, during a sparring match a student jammed his ring finger while wearing his wedding ring. In spite of icing and elevation, the finger continued to swell and led to the ring having to be cut off in the emergency room. Wearing jewelry in class can be a danger to partners, the practitioner, and the jewelry. It is therefore strongly advised that jewelry be prohibited under any circumstances.‘‘Karate kid’’ finger has been described in a case report about a 12-year-old martial artist who developed segmental perineural and interfascicular fibrosis of the dorsal branch of the ulnar digital nerve as a result of striking hard objects (eg, filing cabinet) with a karate chop [52]. The painful symptoms resolved after surgical intervention, and a modification of practice habits prevented recurrence. Lower extremities Injuries to the lower extremities are among the most common injuries in the martial arts. This is particularly true of predominantly kicking-based styles, such as Tae Kwon Do [28,48,49,53]. Toe injuries, including jamming, fractures, and dislocations, are not uncommon in martial arts training [19,28]. Proper foot protection during sparring and weapons practice or the use of martial arts shoes may help to reduce the incidence of toe injuries [28]. A radiograph may be obtained to rule out a fracture, and a dislocation must be reset. In most cases, however, rest and buddy taping are sufficient treatment for toe injuries. When training is resumed, students should initially avoid kicks that use the toes or forefoot as a striking surface. Calcaneal apophysitis (Sever disease) was described by Wirtz and colleagues [54] in three children as a result of board breaking. The clinical symptoms are posterior heel pain and a limp. Radiographs are not diagnostic. Treatment includes short-term modification of training and restriction of board breaking. The use of shoes with a 0.25-inch heel lift or heel cushion and Achilles tendon stretching can be helpful [55]. Ankle sprains related to the martial arts have been observed by this author and have been described by several other authors [13,22,28,33,34,56].

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Methods of taping have been suggested to lessen the incidence of ankle sprains among martial artists [33,34,56]. The efficacy of this practice has yet to be studied. Some styles of martial arts advocate balancing on the ball of one foot with the foot plantarflexed while kicking with the other foot. Because of the structure of the ankle joint, this is the least stable position [56]. It would seem that keeping the foot of the supporting leg flat, thus maintaining a more stable ankle position, should decrease the likelihood of pain and ankle sprain during kicking techniques. The knee is susceptible to acute injuries from direct trauma or during kicking and twisting motions [57]. These include fractures, dislocations, contusions, and meniscus or ligament tears. Chronic conditions, such as arthritis and patellar maltracking (Osgood-Schlatter’s disease), may also limit a practitioner’s ability to train. It has been postulated that avoiding full extension of the knee during kicks as well as using a stance with the leg slightly internally rotated rather than externally rotated may reduce the incidence of knee injuries [19]. Hip disorders, including arthritis and bursitis, attributed to the martial arts or other causes may have an impact on the style of martial arts a student chooses. Relative rest during acute flare-ups may be indicated. For milder stages of arthritis, a modified training regimen may be sufficient. Alternatively, the gentle art of Tai Chi has been studied as an adjunct treatment of patients with arthritis [9,58]. For those interested in more vigorous training, arnis [59] or Wei Kun Do [60] offers an excellent alternative that focuses more on upper body techniques. With an open-minded instructor, almost any style can be adapted to suit the needs of students with a chronic debility that limits the ability to kick. Benefits of training in the martial arts There are many benefits to training in the martial arts. What often attracts students to the martial arts is the attempt to enhance not only the physical body but the mind and spirit as well. According to a study by Twemlow and coworkers [27], the top four reasons that people cite for studying the martial arts are self-defense, exercise, building self-confidence, and developing self-discipline. The copious works of Webster-Doyle [61] emphasize the philosophic side of the martial arts and nonviolent conflict resolution. He presents specific material on dealing with bullies and enhancing self-esteem through the martial arts [62]. Numerous studies have attempted to demonstrate and quantify the physical and psychologic benefits of the martial arts. In one study, it was found that the practice of kata can lower aggression [63]. It has also been shown that practicing the martial arts can improve selfreliance and optimism [64]. Several other studies have reported improvements in psychologic health through training in the martial arts [65–68]. Twemlow and Sacco [69] have proposed a ‘‘clinical martial arts program’’ for violent adolescents. It seems that gangs satisfy several basic needs in

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some teenagers: affiliation with a group, power, physical security, activities, role models, and sparring. All these needs can be found in a martial arts program. It has been found that participation in a martial arts program that stresses not only physical but psychologic, meditative, and philosophic aspects can lead to lessened aggression, lowered anxiety, and increased selfesteem in delinquent adolescents [70]. Zivin and colleagues [71] studied juveniles at high risk for violence and delinquency. After a 10-week martial arts program, students showed significant improvement in behavior. Physical fitness is a common reason for training in the martial arts. For many children and young adults, the martial arts provide a primary source of exercise. The martial arts are not only for the young, however. In a study of middle-aged practitioners (aged 40–60 years), an improvement in various measures of fitness has been attributed to training in the martial arts, including greater aerobic capacity, balance, flexibility, muscle endurance, and strength as well as lower body fat [72]. Even senior citizens have been shown to benefit from training in the ‘‘hard’’ martial arts (Fig. 18) [2]. It has been hypothesized that learning to fall properly in martial arts class may prevent injury from falls incurred later in life [73]. Tai Chi is generally considered one of the softer martial arts. With certain instructors, the self-defense applications of Tai Chi techniques may still be found. Most practitioners of Tai Chi are seeking health benefits, however. It is commonly used as a gentle form of calisthenics and meditation. Tai Chi is cost-effective and generally boasts a good compliance rate. Therefore,

Fig. 18. At the age of 67 years, this practitioner has no problem implementing a self-defense technique.

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numerous studies have been initiated to evaluate the potential positive effects of Tai Chi. Thus far, Tai Chi has been recommended to treat everything from balance to sleep disorders.

Disabled martial artists There are few peer-reviewed publications about those who have a disability and practice the martial arts. A review of the Internet reveals many organizations that teach martial arts to the disabled. It can be said that every martial artist has his or her own strengths and weaknesses. The goal of a successful martial arts instructor is to capitalize on students’ strengths and to minimize the effects of any weaknesses. This may be accomplished by remediating areas of relative weakness or altering techniques to ‘‘fit the system to the martial artist.’’ In the past, there has been an almost religious adherence to ‘‘tradition’’ in many systems of martial arts. Now, many schools and styles are sharing information and techniques, with students benefiting from this evolution. Many of today’s schools no longer have a ‘‘sink or swim’’ attitude toward new students. By adjusting the curriculum, schools can successfully integrate students as young as 3 years of age into age-appropriate martial arts–based classes [1]. On the other end of the spectrum, older adults can discover the benefits of martial arts even into their 70s and older [2]. Another segment of the population that has benefited from open-minded instructors is the disabled. Much like a physiatrist, the instructor of martial arts students with disabilities may problem solve and develop different approaches to reach the same goals. It is also inspiring to see long-time martial artists who develop disabilities and still continue to train and teach.

Fig. 19. Sensei Manual was honored at the Pittsburgh EUSAIMAA Hall of Fame.

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Fig. 20. (A–G) Self-defense sequence in which the defender uses the attacker to cosign ‘‘you are a monster.’’ (Courtesy of T. Harman, Elliott City, MD.)

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There are many instructors and organizations available for the disabled who are interested in pursuing martial arts training [7,74–77]. Self-defense training has been integrated into the rehabilitation of patients with spinal cord injury, polio, spina bifida, cerebral palsy, stroke, head injury, back injuries, upper and lower extremity amputation, multiple sclerosis, and blindness [3]. A system of wheelchair-based techniques has been developed by Van de Sandt [78]. Martial arts classes for spinal cord–injured wheelchairbased patients were initiated in 1975 at the Long Beach California Veterans Affairs Medical Center [79]. In spite of the tetraparesis that developed from chronic spinal arachnoiditis, the well-known martial artist Martin Manuel has continued to teach and judge tournaments and heads a chain of martial arts schools (Fig. 19) [80]. Matthew Hayat has developed a self-defense system that integrates the vocabulary of American Sign Language with the concepts and pressure point methods of Grandmaster George Dillman [81]. His system, Martial Signing, allows those who are deaf and hard of hearing to incorporate the physical, emotional, and spiritual elements of their existence into martial arts techniques. This system has also served to introduce basic sign language concepts to martial artists everywhere (Fig. 20). Summary Given the increasing popularity of the martial arts, it is likely that physicians in all specialties encounter patients who participate. From pediatric patients, to geriatric patients, to those living with various disabilities, the martial arts may offer physical, psychologic, and therapeutic benefits. An appreciation of the physical demands of the martial arts is crucial to understanding the pathogenesis of injury as well as to planning treatment and prevention strategies and to determining safe return to participation after injury. Acknowledgments The author thanks Jennifer Kral and Leonna Bryant of the Health Sciences Library Capital Health System at Helene Fuld Hospital for their assistance with research and acquiring reference articles. He also thanks George Dillman, Matthew Hayat, Martin Manuel, and the members of Dillman Karate International and MKA Karate for their input into this article. Most importantly, he acknowledges Tricia Terry for her technical assistance, astute editing, and constant support. References
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