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Physiology of Traumas in Boxing

Martin vs Gogarty

March 1996. Fight between Christy Martin and Diedre Gogarty on the under card on the Tyson-Bruno fight
is considered as a birth of women’s professional boxing.
The audience and millions watching on pay-per-view were captivated by the blood and end-to-end action in the six round female bout
(being disgusted with the boring and less than entertaining Tyson fight).
The women stole the show and lent instant credibility to women’s boxing.
Being one of the leaders in this sport, Martin however, is not a stickler of women’s boxing development on a large scale.
Photo from Orlando Sentinel

Русская версия

Boxing is a fist fight between two persons wearing special gloves by special rules.

Knockdown. Photo by Jan Plitko
A knocked down (out) athlete can experience a sudden traumatic loss of consciousness caused by a physical blow. Single powerful blows to the head (particularly the jawline and temple) can produce a cerebral concussion and cause a sudden, dramatic knockout. Body blows, particularly the liver punch, can cause progressive, debilitating pain that can also result in a knockout (knockdown). A knocked down athlete suffers exhaustion, pain, disorientation, or unconsciousness.

Chest punch
Christy Martin (left) lands a chest punch
during the fight against Kathy Collins
at Madison Square Garden in New York.
12 May 2001
Getty Images

Boxing bouts are held on the ring 6 x 6 m bordered by ropes. The boxer is considered as a winner who gained more scores for successful attacks, won by a knockout (when an opponent temporarily loses consciousness – partly or totally), as well as if an opponent is unable to continue fighting, disqualified or gives in.

Only punches by a certain part of a glove to certain body parts are allowed in boxing (front parts of torso and head). Blows by internal part of a hand, by elbow, by legs or by head are prohibited. Holds, trips, hooks and throws are prohibited. Blows below the belt, to back of the head, to back (spine or kidneys) are prohibited as well. Besides, any blows against knocked down opponent are prohibited.

Boxing is one of few sports, in which inflicting physical damage to an opponent by blows is the ultimate goal. The main object of boxing punches is a head, actually brain. Brain damage causes losing orientation and consciousness which is the common way to gain “upright” victory by knockout. The upright victory (“technical knockout”) may be also achieved by inflicting different traumas to an opponent, for instance nose bleeding or eye swelling. Besides brain and other vitally important organs located in the head, other organs might be damaged during a boxing bout: liver, diaphragm, female breast, etc. Hands and arms as well as knees legs and feet also might be damaged.

Despite relatively low level of traumatism in boxing in compare to some other sports, it doesn’t include long term consequences of brain injuries. For instance, according to “Archives of Neurology”, about 20 percent of professional boxers develop chronic traumatic brain injury. Brain damages, especially regular ones must leave a trace. Suffice it to say that one of the ever dangerous boxers – Mohammed Ali suffers the Parkinson syndrome, even though he delivered more punches than got.

Many doctors and medical scientists consider boxing to be too dangerous for women because of high vulnerability of mammary glands, women’s breasts and other female organs. Another reason against women’s boxing is that women’s bones and ligaments are more delicate and exposed.

Head and face traumas


Typical cut areas are shown at the pic 1. Some of them are required to stop the bout. Cuts in the area A are not critical, whereas cuts in the areas B -  F require to stop, Cuts in the area D causes terminating the bout.
Nose bleeding

Uncontrolled nose bleeding is the reason for terminating the bout. Damage of external ear

Injuries of external ear are common for boxers. Formation of haematoma might cause more serious traumas. Blood and earwax might collect between perichondrium and cartilage. That might cause disfiguring of auricle, permanent thickening of external ear and fibrosis.
Jaw fractures

In fact, fractures of lower jaw happen often in boxing, particularly at the condyle, mental protuberance and symphysis (pic. 2). Usually, the Barton bandage and ice are used as a first aid. In many cases, a surgical operation is necessary.

Brain traumas

Brain damages caused by a blow or blow series are localized in the depth of the brain as well as in the cerebral cortex. Brain damage mechanisms
A kinematics of punches has been studied. Blow power depends on the fist speed and a boxer’s body mass. The following factors should be considered when punch strength is measured:

1) Punch taker’s parameters - mass of head and brain, body mass, hand and glove size.
2) Speed of the punch delivery, angle of the punch, the number of punches in series.

Based on the study of the five physical characteristics of the human brain, such as incompressibility and low rigidity module, the conclusion has been made that the essential principle of brain traumas is shifting forces.

The most dangerous blows are rotating ones. Due to incompressibility of the brain, no empty space may form in the cranium as a result of a blow. The only possibility is that the brain might shift alone the internal surface of the skull if rotating acceleration is applied. Since the soft brain membrane is tightly attached to the surface, the movement takes place only between the hard membrane and arachnoids of brain which causes stretching of cortical veins, which is turn causes subdural and subarachnoid hemorrhage.

Two types of blows should be considered in this matter – central and skew ones. The central blow directs to the focal point of the brain causing a simple displacing acceleration. The skew blows cause to combination of shifting and rotating. Uppercut to the lower jaw causes rotating but since the brain remains at place, veins might be broken.

So, doctors unanimously agree that the rotating acceleration causes the most serious brain damage. Head rotation as a result of a punch might cause a pass-out. The blows causing head rotation might provoke even a sudden death. A blow to the carotid sinus might cause a sudden death as well. A blow to eye might cause cardiac arrest due to Aschner's reflex.

Acute head trauma

Knockout is a spectacular finis of a boxing bout. 8.7 % (547 bouts) in USA amateur boxing championships (1964, 1987) ended with knockouts or punches to head. Actually, a knockout should be considered as a synonym of the "concussion of the brain", which represents a typical acute neurological trauma.

Subdural and epidural hemorrhage

Guterman and Smith (1087) state that subdural hemorrhage causes up to 75% of brain damage cases and high probability of fatal outcomes. Subdural hemorrhage is the result of vein break. Epidural hemorrhage happens more rarely in boxing. The symptoms may appear immediately or in a few days, even in a few weeks or months. The most of fatal outcomes occurs during a few days after the gotten blow.

Cerebral-vascular and embolic syndromes

Thrombosis of carotid may be a result of boxing practicing or a result of direct blow to neck or stretch of carotid after a skew punch causing head rotating (for instance, a sliding uppercut). This syndrome may cause acute hemiplegy.

Recurring blows to the chest area may cause heart arrhythmia which in turn may cause formation of parietal thrombus and embolic stroke (cerebral arterial embolism).

Boxer encephalopathy

Guterman and Smith (1987) state that second rate boxers usually suffer encephalopathy, especially those who are used mostly for sparring. They may have a few knockouts a day and experience amnesic conditions. Robert (1069) notes that damage heaviness directly depends on the number of bouts the boxer participates in.

Ross and others (1987) contend that boxers have a wide specter of neurological problems – from minor sub clinical forms (which might be determined only by neuropsychological studies) to shock conditions. On their opinion, neurological consequences of the boxing activity directly correlate with the number of given bouts, especially for professional boxers.

Neurological consequences do not precisely reflect damage levels. It doesn’t allow forecasting a sudden death. However, there are some typical indications of dementia. Ross and others (1983) point to the following ones:

1) deceleration of motor activity;
2) clumsiness;
3) dysarthria;
4) ataxy;
5) tremor;
6) rigidity;
7) spasticity;
8) amnesia;
9) bradyphrenia;
10) personality change.

According to Ross’ estimates, one ore more such symptoms are observed for 17-55% of professional boxers. Robert (1969) found such symptoms for 37 out of 224 former pro boxers which goes to 12%.

Amnesia syndromes

Boxers happen to have transient conditions characterized by consciousness confusion, deceleration of the motor function which might be a cause of progressive encephalopathy. Guterman and Smith (1087) note that very often a boxing bout keep going even if one of a boxer is in the amnesic condition.

Head ache syndromes

Headaches (even in form of migraine) are often caused by either above mentioned syndrome or by other reasons. Elai (1962) found that 86% of all boxers having had knockouts suffer frequent headaches. Just 4% of boxers having not experienced knockouts suffering headaches.

Neck syndromes

Damage of the neck part of the spine as a result of a boxing punch, was studied In Rehabilitation center in Texas in 1981. There are components of such damage:

1. Compression of barbate processes / neural arcs.
2. Extension of the intervertebral space (at the front.)
3. Back dislocation /shift.
4. Fracture of barbate processes / neural arcs
5. Subluxation of I—II jugular/cervical vertebras.

Eye damage in boxing

Curvill (1992) introduces the terms related to head/eye traumas: “damage peculiarly in the place of blow” and “damage of a counter blow type”. The eye is incompressible, that’s why it may undergo damage directly in the place of the blow or in rear areas (damage by a counter blow).

According to National electronic system of trauma analysis in 1881, the percentage of eye traumas in boxing was 2% of all traumas.

Eye angle deformation by contusion is the typical eye trauma in boxing. Fracture of ciliary body due to direct damage by a blow causes invagination of eye angles. Glaucoma is developed for about 10% of such patients.

The invagination occurs in combination with hyphema. About 90% of hyphema cases are related to fracture of ciliary body. Retina detachment happens due to counter blow damages. Blindless might be permanent or temporary depending on damage level.

Lens subluxation is another serious eye trauma in boxing. It might cause glaucoma or cataract as well as well as eye-socket fracture. Hruby (1999) detected 5 cases of retina detachment, 4 of them led to blindness.

Traumas threatening one eye blindness (damage of peripheral retina, spot, lens or angle) come to 58% cases of boxing eye traumas. Traumas which might lead to both eye blindness come to 28%. Actually, peripheral retina damages were observed for ? of all examined boxers

The typical boxing trauma - angle deformation – was indicated for 20% examined boxers, in Palmer’s research (1976) this figure was 16%.

Orthopedic traumas in boxing

According to Insurance Society of New Zealand, in 2006 58 acute orthopedic traumas were fixed in boxing. They are broken into the following groups:

Hand / wrist – 19
Shoulder (including collar-bone / shoulder-blade) – 7
Ankle-bone – 5
Finger / thumb – 5
Knee – 5
Other parts - 17

Hand traumas in boxing

Noble (1987) states that boxing gloves actually have never been really improved. Examining 100 hand boxing traumas, he considered three hand/wrist zones, each of which might be equally traumatize (pic. 4).

The zone A includes: thumb, III middle metacarpal bone, os multangulum majus and os naviculare. Damages might caused by the fact that the thumb is separated in the most gloves from the rest of the fingers and it’s impossible to clench. The zone A accounts for 39% of all hand traumas.

The zone B includes II—V metacarpal bones. The zone B accounts for 35% of all hand traumas, mostly sprains of metacarpal-wrist joints. The mechanism of the trauma is related to the inability of fist clenching (Pic. 5).

The zone C includes distal parts of II—V metacarpal bones and phalanges. It accounts for 26% of hand traumas in boxing. Fractures of metacarpal bones and phalanx bones are the most common injuries. Also typical traumas are fractures of IV—V metacarpal bone necks. The pic 4 represents hand traumas studied by Noble.

As far as the athletic career is concerned, the most critical traumas are fractures and dislocations of wrist.

The trauma called “knuckle” might also cause termination of the athletic career. Unfortunately, doctors often let boxers get steroids and allow them to go into the ring but this leads to progressive damage.

Posner and Ambrose (1989) noted that the boxer’s “knuckle” is a synonymous of the rupture of dorsal capsule of the wrist-phalanx joint. They considered 6 such traumas, 5 of which were gotten due to clenched fist punches. In each case, boxers experienced period of sensation of pain which ended in a few days. However, after each sparring the pain and succulence came back. Surgery is the most effective way to treat such traumas.

Traumas of lower extremities in boxing

A boxer may get the following traumas of lower extremities:

1. Damage of the back muscle of revolving cuff and rhomboid muscles as a result of delivering a boxing hook.
2. Rupture of medial collateral ligaments of the II degree as a result of valgus knee load during a strong punch from an opponent.
3. Tendonitis.

Women’s breast traumas in boxing

Punch to chest Due to heightened sensibility of mammary glands and high speed of cell division in the breast flesh, any breast trauma is dangerous because it stimulates active cell division. Consequences of blows to breasts are unpredictable. From this prospective, punches to breasts unavoidable in boxing (especially hooks) substantially increase a probability of posterior canceration (even in the presence of breast protectors).

A direct blow to the breast may cause a contusion (bleeding within the muscle or breast) and nipple problems.

Women boxers at the professional level may be at greater risk for serious or fatal injuries than men. In recent years, numerous prestigious medical organizations, including the American Medical Association, the American Academy of Neurology and the American Academy of Pediatrics, have called for the abolishment of boxing.

Punch to face
Is a punch in a boxing glove more traumatizing than a punch by a knuckle fist?

Some medical specialists consider a blow to head delivered in a boxing glow is more dangerous to brain (not to bones or face soft tissues) than a punch by a bare fist. Although this subject is not enough researched, many doctors recommend using boxing gloves of maximum weight (16 oz) in order to prevent injuries, dissections and ruptures causing serious infectious diseases.

Punch to liver delivered by Regina Halmich. Animation
Traumas in boxing

Punches to head delivered by Regina Halmich. Animation
Traumas in boxing

Main source:
Online magazine Sport Medicine (in Russian)

Other sources:
Women Boxing
Science and Life (in Russian)

Traumas in boxing

Pic 1. General localization of cuts

Fight stoppage in case of face cuts.

A - Not dangerous, not cause fight stoppage
B – May cause supraorbital nerve function disturbance
C – May affect infraorbital nerve of nasal-lachrymal duct
D – May cause damage of tarsal lamina
E – Lacerations in the lip areas may cause subsequent ruptures
F – Nose fracture

Traumas in boxing

Pic 2. Localization and frequency of fractures of the lower jaw in boxing
1 — coronoid process (2%)
2 — condylar process (35 %);
3 — ramus (4 %);
4 — angle (20 %);
5 — dental process (4 %);
6 — body (20 %);
7 — symphysis (14 %).

Pic 3. Head damage mechanism in boxing

Traumas in boxing
Angular acceleration causing rotatory motion of the brain resulting in subdural haematoma as a result of vein rupture and diffusive trauma of long neurons which occurs due to damage of long fibers of alba, corpus callosum and brain stem.

Traumas in boxing

Linear acceleration resulting traumas of parasagittal cortex areas, ischemic traumas of cerebellum and long brain neurons.

Traumas in boxing

Damage of carotid artery and compression of carotid sinus cause general brain ischemia.

Traumas in boxing

Deceleration of head motion during falling down on the floor or ropes causes damages in form of counter blow in the orbital surface of anterior lobe and tips of temporal lobes.

Traumas in boxing

Pic 4. Three hand zones undergoing traumas

Distribution of damages in the zone A

Rupture of elbow collateral ligaments in the thumb phalanx joint - 23%
Damage of wrist-metacarpal thumb joint (traumatic synovitis, dislocation, Bennett fracture) – 10%
Various fractures – 2%
foundation of metacarpal bone – 15
foundation of proximal phalanx – 1%
body of metacarpal bone – 2%
Fractures of naviculare bone - 29%

Distribution of damages in the zone B

Inflammation of wrist-metacarpal joint – 12%
Subluxation of foundation of metacarpal bones – 12%
Dislocation of foundation of II and III metacarpal bones – 1%
Fracture/dislocation of II, III and IV metacarpal bones – 1%
Damages of wrist joints with diffusive succulence and painful feelings (negative roentgenogram) – 6%
Fracture of foundation of metacarpal bone – 35%

Distribution of damages in the zone C

Synovitis – 12%
Fracture of neck of metacarpal bone – 8%
Fracture of metacarpal bone body – 3%
Fracture of proximal phalanx – 3%

Traumas in boxing

Pic 5. Roentgenogram of a hand in a boxing glove

When clenching the fist in the boxing glove, the tip of III metacarpal bone protrudes and the joint undergoes the common boxing trauma called "knuckle".

Traumas in boxing

Pic 6. Fight in boxing helmets protecting helix, jaw and nose

Women's Boxing Knockouts. Videoclips from Youtube

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