Stefan Struve’s Jaw Xray after UFC on Fuel 8

In a sport where the aim is to cause disabling injury to an extent that the opponent cannot continue, various injuries are common. In mixed martial arts, with a large percentage of strikes aimed at the head and face it is a surprise that there are not more serious facial injuries. In fact facial injuries occur in only 10.1% of MMA matches according to Ngai et al. (2008) who examined 1270 fights over a period of 5 years and published his findings in the British Journal of Sports Medicine.

In the last month UFC heavyweight Stefan Struve and former UFC heavyweight champion Andrei Arlovski, now fighting for World Series of Fighting, have both suffered serious jaw fractures caused by their opponent’s strikes. The aim here is to discuss the jaw as an area of potential injury and advise strategies prevent such injuries.

The jaw consiststs of the jaw bone (the chin) and its connections either side to the skull; also known as the temporomandibular joints (TMJ). These are the joints where the jaw bone (mandible) and the larger part of the skull (temporal bone) meet. It is a prominent protrusion from the front of the face and as such is generally an area to aim for when striking in combat sports. It has a complex anatomy including cartilage and a small disc, which allows it to slide and rotate and when dysfunctional can lock, dislocate or result in malaligment of your bite. Pain can refer into the neck, across the face or even cause headaches.

The TMJ is most stable in a closed packed position (when the jaw and mouth are tightly clenched). This stability is produced by strong bite which utilises muscles including the masseter, temporalis and pterygoid muscles. When contracted together the masseter muscles are one of the strongest in the human body according to the force it can apply.

Mouth guards, or gum shields, provide many benefits including shock absorption to lessen impact through the jaw. It is commonly thought that the main aim of gum shields is to prevent damage caused by the teeth of the lower jaw impacting the relatively softer teeth above. Whilst mouth guards do prevent some dental damage, the main aim is in fact to dissipate force from a strike landing on the jaw through the TMJ and into the cranium.

As mentioned, the preservation of stability in the jaw is by maintained by a closed bite. Biting into a mouth guard allows a greater dissipation of force and prevents excessive motion of the lower jaw. This is considered important for prevention of concussion through the reticular hypothesis.

Sudden movement of the jaw with subsequent rotation of the head and neck, is thought to cause depolarisation of cervical nerve fibres sending an excitatory wave across the ascending reticular activating system (ARAS)- a key area of brain stem neurones which are involved with inhibition of brain activity. This can cause disruption of synaptic activity enough to result in loss of consciousness. Therefore, the combination of isometric masseter contraction and isometric cervical spine musculature stabilisers (e.g. scalenes, trapezius, levator scapulae, sternocleidomastoid), are essential to counteract the force transferred from a strike. A mouth guard can work as a shock absorber to further prevent this effect.

Top Tips:

- Do some of your strength and conditioning with the mouth guard in place. The guard won’t work if you are poking it out because it’s stopping you breathing.
- No gaps! Fit is everything! The greater the guard fits the contours of all of your teeth, the better. This means custom- made is far better than Boil & Bite
- Always have a spare. There is no excuse for sparring or competing without a mouth guard securely in place.
- Isometrically strengthen your neck muscles into extension, side flexion and rotation
- Develop your bite strength- use an old mouth piece to provide resistance to strengthen your masseter muscles or statically hold the jaw as you apply pressure on either side

As always, Stay Healthy & Keep Fighting!

Chris Tack is the lead physiotherapist and owner of All Powers Rehabilitation &
Conditioning in London, England.

You can follow Chris on Twitter @AllPowersPhysio

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UFC Fighter Dan “The Outlaw” Hardy

Last week, UFC Fighter Dan “The Outlaw” Hardy announced he was out of the UFC on Fox 7 card against Matt “The Immortal” Brown. While most fighters announce they are out of a card due to an injury, Dan’s story was a little different. Pre-fight tests showed Dan has a syndrome called Wolf-Parkinson-White, which is an abnormality in the conduction system of the heart.

The heart’s job is to pump blood to the lungs to get oxygen, receive that blood back, pump it to the rest of the body, and then re-collect it to start the process again. The heart has four chambers, each of which is responsible for one of the four tasks mentioned. The heartbeat that you can hear with a stethoscope is actually the sound of valves between each of these chambers closing after the blood has flowed to its next destination. The coordination of each of these chambers requires a finely tuned electrical conduction system.

Electrical conduction system of the heart

The heart muscle cells are triggered to contract by a wave of electricity that starts at the top of the heart (the Sinus or SA node) and spreads across the top two chambers (the left and right atrium) causing them to squeeze blood towards the bottom of the heart. The electrical signal then triggers another node (the AV node) above the bottom two larger chambers (the left and right ventricles). From the AV node, a bundle of electrical fibers travel to the two large ventricle chambers which causes them to contract, squeezing the blood to the lungs and the rest of the body (right goes to lungs, left goes to the rest of the body).

In people with Wolf-Parkinson-White syndrome, there is an extra pathway that bypasses the AV node and goes straight from the left and right atrium to the left and right ventricles. This alters the coordination of the heart and can cause the ventricles to squeeze before they have had a chance to fill completely with blood. As a result, less blood gets pumped out of the heart for each heartbeat. Many people are without symptoms, but on occasion someone may show signs of dizziness, fainting, or heart palpitations. In really bad cases, the whole heart loses its coordination and sudden death can occur.

The diagnosis is usually made by an electrical heart monitor called an EKG. We have also seen the spikey pattern on a heart monitor in the movies before it flatlines and someone dies. That spiking pattern represent s very specific electrical discharges from different parts of the heart. The EKG is also sometimes called an ECG. This is just because EKG is based on the German word electrokardiogram, and the English version is electrocardiogram with a “c”.

When the EKG pattern is disrupted, it means something is wrong with the heart’s electrical activity. In the case of Wolf Parkinson White syndrome, the abnormality is called a “delta” wave because it looks the Greek letter delta.  Patients with this condition must be careful what heart drugs they take, because they can make the electrical abnormalities even worse.

If a fighter or other athlete is diagnosed with Wolf-Parkinson-White syndrome, they should see a heart specialist (cardiologist). He or she should not fight until a cardiologist says it’s OK to fight. The cardiologist may order something called a stress test which is a way of seeing how your heart functions during exercise, since as it beats faster, the coordination may get out of control. This test can be done on a treadmill with an EKG, or a medication can be given to speed up the heart.

If a cardiologist thinks that the abnormality is kept under control, then no medication or intervention is necessary. However, if the stress test shows that the heart becomes even more out of control with exercise, he may order medication.  The most definitive treatment is a procedure known as radiofrequency ablation, in which specialized instruments are used to “burn away” the abnormal heart pathway. This helps restore the coordination of the heart.

Dan Hardy appears to have undergone these tests, but the California State Athletic Committee is playing it safe and keeping Hardy off the UFC on Fox 7 card and out of action for now. After all, bone and tendon injuries heal, but a heart that stops beating may not come back! Dan has shown us he can be as tenacious as a wolf; now we know he has a “wolf” heart to go with it.

Jonathan Gelber, M.D. is licensed to practice medicine in the State of California

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This week, John will discuss the dangers of losing water weight and altering electrolyte balances for weight cutting before an MMA bout.

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The views of FightMedicine contributors are not necessarily the same as those of the website or other contributors.

Keep it simple stupid!

There are far too many things in life that are complicated. Relationships, Politics, Religion, Sudoku and even fitness. Exercise should be fun; challenging yet rewarding. No matter what level
of fitness you are trying to reach or maintain, you should be looking forward to  your next workout. It needs to be fun and easy to understand. Marketing  campaigns have made fitness riddled with buzz words and filled with complex concepts that create the illusion that this new fitness program you are about to try is the latest and greatest thing to hit the market.

The truth is that it’s a lot of the same stuff that you have already seen and done just packaged in a different way with some new terminology. Bottom line: You should be able to fully understand what your program is and does for you. This should be so easy to understand that you could explain it to a toddler. In one sentence explain what the program does and why it’s effective for you. If you struggle to understand what and why you are doing the training you are doing, then you need to have someone explain it to you.

As you have probably seen on those late night informercials, there are always new and effective ways to get in shape. The common denominator between all of these “new” fitness programs and what experts in the fitness industry have been doing for years is that they all require commitment and hard work in order for them to be effective and give you results. I have heard several people tell me about this ”great new fitness program” that is changing the fitness industry, P90X.

The P90X program requires you to work out for 90 minutes, everyday. If you run for 90 minutes, go to Zumba classes that are 90 minutes long or swim for 90 minutes everyday you will see results just as fast, if not more than the P90X program. 90 minutes of any physical activity will get you in shape fast. Don’t be fooled in to believing that a fancy new DVD series with drill sergeant for an instructor is anything more than 90 minutes of calisthenics. It’s just commitment and hard work. Understand that I am not putting down the P90X programming, it’s a solid routine of body weight
exercises, but that’s all it is. You are the machine, the secret ingredient, the magic pill that makes all of these workout programs work.

When it comes to health and fitness, just stick to the basics. Try not to get wrapped up in trying all the “secret” training and dieting tips. There is no secret diet or secret training system that magically makes you loose weight and look like a hollywood celebrity on the red carpet overnight. There are basic fitness principles that you can use as a simple guideline to use when making a decision for choosing your next fitness program.

Two simple concepts  will help keep you healthy and fit:
1. Healthy Eating Habits

2. Regular Exercise

Three basic principles for fitness.
1. Strength
2. Stamina
3. Endurance

Does the new program that your about to try involve or incorporate any one or all three of
the principles above? If not, ask questions, have the instructors explain to you why the three basic fitness principles are not focal points for their program and ask yourself if this program lines up with what your goals are? At the end of the day, are you going to enjoy it or dread it? Your fitness program should be fun and exciting, if it doesn’t challenge you or keep you motivated it’s merely going to set you up to fail. Set yourself up for success by setting a goal and a plan to reach that goal, without a plan of action your goals are just wishes.

Matt “The Law” Lindland is a UFC (Ultimate Fighting Championship) and Mixed Martial Arts veteran fighter, trainer, and coach. He is also a co-founder of Team Quest.

Be sure to check out Matt Lindland’s blog at http://coachmattlindland.com/ and Team Quest at http://teamquestmma.net/

The views of FightMedicine contributors are not necessarily the same as those of the website or other contributors.

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Fallon Fox, MMA’s first openly transgender fihgter.
Photo via glaad.org

Males competing in MMA is the accepted standard. Females have begun to gain widespread acceptance in MMA. Now, what happens when an openly transgender (male–>female) fighter wants to compete at the professional level? 37-year-old Fallon Fox was born a male, but underwent gender reassignment therapy and hormonal treatment beginning in 2006 to become a female. As such, she has applied to fight as a professional female MMA fighter.

The main questions that seem to arise is not whether transgendered fighters should fight, more specifically will the male–>female transgendered fighter have an advantage over female fighters that were born as females. While the Fight Doctor is not an endocrinologist, I will attempt to analyze this issue on a medical and scientific basis.

The key question is whether Fox, being born a male, has a distinct physical advantage over her genetically female opponents. A cornerstone of muscle physiology is that a muscle strength, or the force it can generate, is directly proportional to its cross sectional area. In other words, bigger muscles can generate stronger forces. Therefore, if Fox had bigger muscles, than theoretically she would be able to generate more force than her opponents. This concept, however, simplifies the biologic make-up of a gender-specific muscle. It’s not just a question of muscle size, but also composition.

A simple equation in physics in Force = Mass x Acceleration. More specifically, the lean muscle mass a person has theoretically can determine how much force and damage they can inflict on their opponent. Genetic males tend to have higher amounts of lean muscle mass, less fat, and more dense bones than their genetic female counterparts. So, if Fox was born a male, then she should be bringing those tools with her into the fight. However, a major part of gender re-assignment surgery is not just the physical act of the surgery itself, but also subsequent hormonal therapy. The effects of this hormonal therapy helps the transgendered male–>female person look more female. In the process, lean muscle mass decreases; total body and muscle fat increases, and bone density decreases. This has been studied in male–>female transgender individuals compared to male controls. After treatment, all of these things the transgender females have less lean muscle mass, more fat, and thinner bones than their male controls. This, however, has not been studied against female controls. The reason being is that medical doctors are performing these studies, not to compare the transgender patients to females, but to study if the hormonal therapy can lead to diseases such as osteoporosis, or thin bones.

Before the 2004 Olympic Games, the International Olympic Committee ruled that transgendered athletes may compete as their re-assigned gender provided they have undergone hormonal therapy for more than 2 years, or the surgery occurred before puberty. The Transgender Athlete Policy has also been adopted by the World Tennis Association, LGPA/PGA and U.S. Track and Field.

The effects of hormonal therapy over time, in this case testosterone deprivation and estrogen supplementation, are not completely understood. However, what is clear is that transgender individuals that underwent surgery after puberty will retain some male features, such as increased height. Male–>Female transgender patients tend to retain more muscle mass than female–>male transgender patients gain, suggesting that some gender-specific attributes remain. Whether effects such as height will prove beneficial in MMA like they do in other sports such as basketball remains to be seen.  Another question is  if the fighter is completely transgendered. Taking estrogens without castration will leak out testosterone that can maintain muscle mass. Furthermore, how much estrogen is being taken? If it’s not enough, then muscle strength can be closer to male levels

Ironically, with all the recent talk of Testosterone Replacement Therapy, this certainly falls into the opposite category! This is obviously a controversial issue with no clear answers. What is clear, however, is Ms. Fallon’s desire to compete. No scientific or medical analysis will question her dedication to the sport of MMA.

Jonathan Gelber, M.D. is licensed to practice medicine in the State of California

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FightMedicine.NET: How did you get into MMA and become one of MMA’s top trainers?

Greg Nelson: I started training and mixing different martial arts far before ‘No Holds Barred’ and MMA was known in the US. As a 9th and 10th grader in 1979-80 I was wrestling, boxing and kickboxing…and we were sparring with the goal of winning through striking, takedown and ground and pound (we did not have submission skills yet). In 1993, after graduating high school I started training in the Jun Fan Martial Arts (the art and science of Bruce Lee). That same year I started wrestling at the University of Minnesota. Shortly after, in 1984, I started training Thai Boxing. I was combining all of them, and as new arts, techniques and training methods were being introduced I started to combine them as well. In 1989, while living in California and training with Erik Paulson, Erik introduced me to Rickson Gracie and I did my first private  class in Gracie Jiu Jitsu. Now the submissions were being introduced to the striking and wrestling. We now had the basic building blocks of our program; Muay Thai, Wrestling, and Brazilian Jiu Jitsu and . Later in 1989 we started to train with Sensei Yuri Nakamura with Shoot Wrestling, one of the first real competitive Mixed Martial Arts competitions. Having a wrestling base, compounded by Boxing, Muay Thai and Jun Fan Kickboxing, then progressively adding Gracie Jiu Jitsu (from the source) and Shoot Wrestling (a compilation of Japanese Jui Jitsu, Catch As Catch Can Wrestling, Russian Sambo, and Muay Thai) created the perfect formula of arts that became to this day our equation for success.

A competitive wrestler through college, it was not good enough to simply train, I had to test what we were doing. In 1993, I fought Thai Boxing in Chicago and Canada, then the 1st Amateur Shoot Wrestling fights in LA in 1995. After earning my Blue Belt in Brazilian Jiu Jitsu I competed in the Pan Ams in 1999, 2000 and 2001. Competing in every area of the Mixed Martial Arts, individually and collectively in Shooto, gave me a first hand understanding of training and fighting. Ever since I started wrestling I have had a true passion for the Competitive Combat Arts. I started my school in 1992 for the sole purpose of following that passion. Even before any competitive outlets were presented to us, we were training and preparing simply to be better fighters.

What is your philosophy when it comes to MMA training?

My philosophy is simple. Be dedicated to the disciplined and hard working individual, and to the Integrity of the Combative Martial Arts (MMA, Muay Thai, Brazilian Jiu Jitsu, Submission Grappling, Judo, Wrestling…). If a fighter has discipline, works hard and has the passion to maintain the integrity of the martial arts he can be great. However, very few fighters really possess the qualities necessary to develop into good fighters, let alone great fighters. Therefore, as far as professional fighters are concerned I only train those that are serious, that really want to be the best they can be. Even then, only a few will live up to their real potential.

What mistakes do you see a lot of fighters or trainers make that should be avoided or corrected?

I feel the biggest mistake fighters and trainers make is not spending the time to master the basics of each area of Mixed Martial Arts. Collegiate wrestlers make strong fighters because they have truly mastered the clinch, takedown and top control. High level BJJ Black Belt competitors have done well because they have mastered submission grappling. Now the most successful fighters have been disciplined enough to spend the time to master the skills they need to succeed. Generally, they already have one of the key areas already mastered. I have been fortunate to have had great wrestlers to work with, who are willing to work with the great BJJ/Submission Grapplers and Strikers we have developed. Many fighters do not have the discipline, patience, persistence or passion to develop the total game. Likewise, many trainers don’t demand those same qualities from their fighters, they don’t demand them of themselves.

What are some of the common training or fighting injuries that can be easily avoided or treated?

Injuries to the knees and shoulders. They are the same injuries that many wrestlers have and most likely for the same reason: over training. In MMA a competitor has to develop and maintain high level striking, wrestling and ground work, in addition a fighter has to be in great condition. Therefore, they do their fight specific training and then conditioning, or worse yet, fatigue themselves doing their supplemental conditioning and then try to push themselves in wrestling, live grappling or sparring and get injured. If a fighter is over trained his muscles are not as strong, yet they keep pushing and then, not wanting to give up or lose, end up getting injured. It is not just about simply training hard, it is about training right. Fighters have to listen to their bodies and trainers have to listen to their fighters. If a fighter has all the ingredients to be a champion, he probably will also not want to appear weak, and always want to push hard. It is up to the trainer to design program that will allow the fighter to progressively develop their conditioning and skill level so that they peak on competition day. Then they need to rest, recover and reevaluate their performance. The fighter can then spend extra time to develop speed, strength, explosiveness, stamina, power. Also, the fighter can now spend extra time technically expanding their game.

What are some of the injuries you and your bigger fighters have had to deal with and how were they treated?

One major injury that could have been a key reason for a loss was with Sean Sherk and his fight with Kenny Florian. Sean had a great training camp leading up to that fight. We were coming up with new and creative drills to improve his guard passing and top control, while at the same time continuing to ever improve his lightening fast shot. 10 days before the fight Sean shot in for a double on one of our bigger fighters (Mistake #1: working with a bigger fighter with a great sprawl). Sean shot and his teammate sprawled and dropped his weight perfectly on Sean’s shoulder. In a split second, Sean went from 100% healthy to having a torn labrum and a Grade II separation. He continued to train, but could not use that arm with any real strength. Considering he was fighting for the 155 lbs Lightweight UFC Title, not fighting  was not an option. We hid the injury up until the pre-fight medical check at the weigh-ins. Despite having limited motion and decreased strength, Sean dominated the fight, beating Kenny Florian by Unanimous Decision to win the UFC Lightweight Title Belt.

How did you work with the doctor during that process?

Sean met with a doctor and told him he wanted to fight, so what could he do to decrease the pain and give him a better range of motion. The doctor gave him a cortisone injection to relieve the inflammation, giving him increased range of motion and decrease the pain. The doctor at the UFC asked Sean in front of Kenny which shoulder did he get an injection in. Sean immediately said, “it was my knee”, the doctor says, “No, this said you had a cortisone injection in your shoulder.” Up until that point we had kept the shoulder injury away from everyone. Prior to the doctor saying that in front of Kenny, and who knows who else heard, Sean was a 3 to 1 favorite to win. Within an hour after the medical exam, the odds in Las Vegas went to even. Regardless, Sean ran through Kenny’s guard and dominated the fight.

What can the medical community do to help fighters get treatment and get back into fighting shape?

It is very important that fighters go to a good sports doctor. Many regular orthopedic doctors work with the everyday people that wince at even the slightest pain. A driven athlete is willing to rehab and build their body, doing whatever it takes. I personally went to a ‘regular’ Orthopedic Surgeon with an MRI on my knee. I had a full bucket tear with my meniscus and was going to have 98% of it taken out. The Orthopedic doctor told me that I should get a new job. I got my MRI and went to an athletic Orthopedic Doctor that Brock Lesnar had used. He said, “OK, we will get you in, clean that up and get you on the mat drilling in a couple of weeks” What a difference, and I was back on the mat teaching class and drilling in two weeks. That was my fourth (4th) knee surgery and my knees feel great. I can do more now than I could for years. You have to find the right doctor that understands your sport and the high level athlete in general.

What do fighters and trainers need to focus on when rehabbing from an injury?

I believe in active recovery. Even when rehabbing an injury you can drill and continue to develop technique. Personally, I have had four knee scopes. My first knee injury while wrestling the U of MN in 1986 I partially tore my anterior cruciate ligament and my medial collateral ligament, had a scope and then went into rehab. I was in the wrestling room as soon as I could work safely on the bike, slowly increasing my range of motion, until I could start to pummel and work upper body. And then I started to work Greco Roman, kept my knee out of the action, working the upper body. When I could, I started to shoot and work leg attacks. I was shadow boxing, then started to add knees and finally worked the kicks in. Soon enough I was doing Thai Pads, sparring and training full out. The other 3 surgeries I had scopes to repair cartilage tears. The last one, as stated above, it was important to have a top level sports orthopedic surgeon. I can honestly say that I am living proof of active recover. I even trained while going through Chemo and used Brazilian Jiu Jitsu to build my legs ups, when I had to relearn how to walk. As soon as I could begin kicking and punching, I did.

What is a safe plan for a training camp?

A training Camp should be 8-10 weeks max. If a fighter is training daily, he should be at about 60% of his optimum fight shape. The training camp is going to be a very directed training camp that is shaped by the opponent that we are preparing to meet. A game plan is devised: where the fighter wants fight, do they want to keep it standing or pressed up against the cage. Are we fighting a better striker and want to get the fight on the ground or against the cage. Are we better on the ground and we are fighting a very good counter wrestler or strong wrestler. There are many factors that come into play. Where are we weak, need to improve or stifle our opponents attacks. I am a big believer in training as many fight specific training methods as possible during fight camp. I have recently seen many fighters stress outside conditioning (throwing tires, doing weight training circuits, sprints, etc…) and they come in tired for the actual fight training. If a fighter cannot hit the mitts or Thai Pads like they should, as close to fight pace as possible, or they are fatiguing too fast in live grappling or sparring, they are most likely spending too much of their energy with supplemental training. I cut the outside training quite a bit and focus on hard increasingly fight paced Thai Pads and Focus Mitts with varied responses, including shooting for takedowns and defending them. On the ground the goal, and where many of the injuries occur, is to mimic the fight, yet keep the fighter from getting cut and/or injured. Due to the nature of the sport, the fighter will have tweaks, and muscle pain and strains, but you have to push the limit of your fighter. In a higher end pro fighters career, he will always have time to heal after the fight, therefore you can push them beyond what they are comfortable with, while at the same developing specific and necessary technique and skills that will be directly used in a fight. When you consider all of the conditioning (strength, speed, stamina, reactio/reflex…) methods there are in Boxing, Muay Thai, Brazilian Jiu Jitsu/Grappling, Judo, Wrestling and MMA it is easy to come up with very intense conditioning session during or after the primary training session.

How do you avoid overtraining?

The most important way to avoid overtraining is to create a training schedule, what you are going to do, when and why you are doing it. many fighters feel they have to do more and more, keep pushing and not know why they are doing it. You should have your training sessions broke apart and set up throughout the week. For example, Monday: Wake up and run before eating to increase your metabolism and build over all stamina. Eat (know what you are eating and why), rest and mentally prepare for first training session. Monday morning training focuses on Takedowns and Grappling (Warm Up and stretch-15 minutes , Strike to Takedown-5 minute round, Strike to Takedown to Submission-5 minute round, 6 x 5 minute Live MMA Grappling Rounds, starting with Striking to Takedown and once your partner hits the ground it is Live, strikes are controlled, but are placed with enough force to register their potency. At the same time you are battling for position and submission.

Having solid and technically sound training partners that are in shape is absolutely necessary. A tired and sloppy training partner will do unorthodox and unexpected reactions, that will often put him and his training partner in jeopardy of injury. After the 35 minutes of hard goes, Round 7 will be a Striking-Takedown-Submission Round to build technically sound movements during a fatigued state. After a short water break a short, sprint style conditioning session can follow.

In the afternoon fighters can do a Strength and Conditioning Circuit. The Circuit should be 20-30 minutes, but very intense and push the fighters, building what is most needed (Muscular Endurance, Power & Speed, Agility, Speed…or all of the above). Again, making sure the fighter is hydrated, has eaten the proper fuel to allow them to push past their perceived limits, and then what to eat after the session to rebuild. Again the fighter should now rest and recover. At this point, having done two hard sessions it is important to have a serious drilling session where the fighter focuses 100% on the submission and striking skills he wants to build. This has to be part of a fighters training, if not they will not be complete and will have holes in their skill level. This type of day should happen 3 X a week.

On two days a week the fighter should focus on sparring, leg and arm conditioning. Again, starting the day with a run, the fighter needs to establish that as a habit. Once the fighter eats and recovers, he then is ready for his sparring session. The fighter should jump rope 10-15 minutes, followed by shadow boxing for 10-15 minutes. Once the body is warmed up, the fighter is partnered up with a solid well skilled partner. They then throw combination back and forth with control, but solid, this prepares the body and eyes for the sparring to come. We do a variety of striking drills to warm up the fighter, physically and mentally. We will do combo for combo, shadow boxing with your partner, All offense to All defense, and more.

After the fighters are wholly ready we will initiate sparring. Our rounds start with Timing Sparring (live but controlled attempting to build timing over speed), they gradually build up to full sparring. On the outside the coach and others should monitor the action, making sure no one is getting hit too much, getting fatigued and losing focus, or any two fighters are allowing their emotions to rule their reason. Again, it is important that the fighter being fully prepared for a hard fight, but the coach and other trainers should closely monitor the fighters.

Lastly, there should be a day off for full recovery. It is necessary that the fighter have a game plan, that increases in intensity as his conditioning grows. They should always be monitored and the coach should be aware of all of the supplemental conditioning that is being done. The fighters must be hydrated, fueled with a proper diet and get the necessary sleep. It is important that the fighter is as disciplined with his recovery and rest as he is with training.

What are your views on weight-cutting and how to avoid going to extremes?

Weight cutting is part of the sport. As a wrestler I have cut weight for years, and in an era where everything was done wrong. Now, the fighter has many alternatives for diet, and weight cutting. In fact, weight cutting has become a science and those that choose to learn how their body works and the different ways the most successful are cutting weight will be able to safely and successfully cut weight. All of my fighters cut weight, some more than others, and none of them cut exactly the same. One thing is constant, the best weight cutters have a disciplined diet and they stick to it. With a clean diet and maintaining proper hydration throughout the camp, and familiarity with cutting weight, a fighter can easily cut 10-20 pounds and be healthy.

Consistency is key

Sharks drown when they stop swimming. Inactivity
kills. Keep moving, be the shark that is always swimming, always on the move. Be
the shark…be consistent.

Another year is upon us and by now you’re sick and tired of all the campaigns for health and wellness. The ad campaigns  like “It’s the best time to start working towards a new you!”, are on repeat  24/7. The truth is that there is no better time than the present to get started regardless of the date. It’s about consistency, getting fit is not an impulse because of the season.

Set goals.

Photo via FitQuest

Start small and work your way up to bigger goals. Every small victory is another notch in the belt that will help you eventually reach your ultimate goal. That goal might be to get faster, get stronger, lose weight, lower cholesterol or just look good in a swimsuit for the upcoming vacation on the beach. Whatever the goal, consistency with training will help get you there.

Measure your success.

Photo via FitQuest

Would you go shopping for groceries on an empty stomach without a list? Sure, maybe if you are a frat boy, but those of us who have a little life experience know that going in to something unprepared and without a game plan is foolish. You need to see the fruits of your labor by keeping track of your results and measure the success by keeping times, PR’s, weight loss/gain etc. This will keep you motivated. Consistency is key.

Push yourself past your limits and know when you plateau. Anyone that has experienced the “get fit quick” bug, where they spend  2-4 weeks killing themselves trying to get in shape will know what this means. Athletes will know what this feels like when they are peaking too soon or coming into another season without enough rest. Pushing yourself past the normal comfort zone is hard but important for advancing towards reaching your fitness goal. It’s when you stop pushing yourself or you don’t change the workout up enough that you begin to see a stagnant plateau. The weight stops dropping & weight gain (if trying to lose) or decrease in strength seem to be among the first side effects. Avoid this by consistently changing your workout up and varying reps & sets frequently.

So…if sharks don’t ever stop swimming because they know they’ll drown…do the fish that they stalk as prey ever stop swimming too? Keep moving. Inactivity kills. Be the fish that is consistently being chased by the shark who never rests…be consistent.

Be sure to check out Matt Lindland’s blog at http://coachmattlindland.com/ and Team Quest at http://teamquestmma.net/

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FightMedicine.NET:  Can you tell us what injury you suffered at UFC on Fuel TV 5?

Duane “Bang” Ludwig: I suffered a torn ACL and tore both menisci in my knee. (For the ACL sugery) I’ll be using my own patella graft. This is my first knee surgery. With the meniscus repair, no weight bearing is allowed, but I start physical therapy for range of motion. My ACL surgery is scheduled for December 19^th.

The top image shows a tear in Duane’s meniscus next to the metal probe. The bottom image shows what a more normal part of the meniscus should look like.

What would you say was the biggest injury you have sustained during training and how did you deal with it?

A completely broken jaw while sparring.

What was your doctor’s role in treating your injury?

I underwent surgery with a plates and a few screws.

Do you feel any lingering effects?

My jaw is a little misaligned

What would you say is the most common, but not mentioned training injury?

The tear in Duane’s meniscus is being pulled together and repaired with sutures

Shin bruises

How can they be prevented or treated?

Double up on the shin pads

Do you have any advice on preventing injuries in MMA or training?

Take care of one another. It’s all about building skills so you can perform in the cage. It’s not about being the toughest guy in the gym.

What are the major differences in injuries in Muy Thai vs MMA?

The legs get a bit more beat up in Muay Thai.

What advice to you have for upcoming fighters in terms of trying to keep their career as long as possible?

Be smart and allow time to recover and repair the body.

Is there anything that a fighter is experiencing during the fights that the people at home can’t appreciate?

Haha. A lot.

What helps get you back on your feet and ready to fight quicker?

 Heart

The above image shows Duane’s ACL ruptured from its attachment on the femur. The reddish round structure in the middle is the part of the ACL that has pulled off the femur.

FightMedicine.NET:  What would you say was the biggest injury you have sustained during training or fighting and how did you deal with it?

Frank Shamrock: By far, it was when I broke my right arm and displaced my ulna bone. To fix it, they put a titanium plate with 6 screws and took about 3 months to recover before I could wrestle again. It was major surgery. Then I had the plate taken out about a year later because I wanted to fight and I didn’t want my bones to grow around the plate or for my arms to break anywhere else because of the plate. The bone had fortified by itself. Now that plate is a necklace that I wear – makes a nice piece of jewelry.

What was your doctor’s role in treating your injury? 

I’ve had a great many doctors. Most of them were chiropractors or sports physiotherapists. Towards the last stage of my career (last 5 years), I brought my own doctor with me to each event so my doctor could consult with whoever was there. I liked to travel with my own doctor.

How did you rehab from your injury and do you feel any lingering effects?

I did extensive rehab with all of my injuries. The major injuries I had were with my arm, broke my right leg, tore my ACL in my left knee, and I had surgery to repair a tear in my right shoulder. Yes, I do feel lingering effects from some of them. I never had surgery on my left knee and although it felt strong after rehab, I still feel tightness. Hiking helps to loosen up my knee and that’s good because I enjoy hiking.

Even after surgery, my right arm feels crunchy — I think I may have also damaged a tendon because I hear quite a bit of a popping noise, but it’s not painful. When the bone in my right arm broke, I don’t think there was any way to fix it perfectly.

Have you ever had any surgeries related to your fighting career? If so, can you comment on them?

 The SLAP tear surgery on my right shoulder was related to my fighting career, and that’s it. I’m not a man of surgery. (SLAP = a tearing of the labrum, or cartilage ring, around the shoulder socket that helps deepen the socket. It stands for Superior Labrum torn from Anterior to Posterior).

I hurt it during a boxing sparring session with a very fast featherweight boxer. I got frustrated from chasing him and threw my biggest punch just as he moved out of the way. I tore the tendon out of my shoulder. That happened two weeks before I fought Elvis Sinosic in my first MMA match in K-1, in front of 80,000 people at the Tokyo Dome.

How did your ACL injury occur?

The ACL injury happened two weeks before the Phil Baroni fight in 2007. It happened during a sparring session with judo champion, Rameau Thierry Sokoudjou (Soko), as he attempted a judo leg trip where my body hit the mat and my foot stayed planted. I have that on video too. Now it feels most unstable with activities like basketball, tennis, skiing – anything with fast lateral motion where I need to stop quickly or twist my knee.

What would you say are the most common, but not mentioned training injuries?

Probably the most common but not mentioned training injuries are those involving the neck and feet. Neck and feet injuries never get enough attention. Injuries like twisted ankles and broken toes happen all the time. And for older guys, the hips get banged up frequently too.

What do you see as the doctor’s role in helping an MMA fighter and how can the medical community improve their role in MMA?

The role of the doctor is similar to a coach in that the fighter doesn’t really understand the limits to his body, so the doctor should teach him in ways that will help him to understand. The hardest thing to realize is that by age 40, you’ll amass all these injuries. We think we’re invincible when we’re young and we must understand all the risks involved. The doctor’s role is critical to educate, support, and help an athlete understand his physical limitations.

Do you have any advice on preventing injuries in MMA or training?

 My advice would be that you don’t have to beat each other up to have a good time. Most of the injuries (95%) happen during training.

How has the training for fights evolved over the course of your career and do you see this as increasing or decreasing the rate of fighter injuries? Has the treatment for injuries evolved with it?

 Yes, the training has evolved and so have the injuries. The sport mainly consists of wrestling and striking, and with that we see more hip, knee, and shoulder injuries. The training has evolved to make athletes bigger and stronger so they can inflict more damage to their opponent. Sports medicine has progressed at same time and that is because, luckily, a lot of doctors are helping our professionals in martial arts.

Do you think MMA athletes are driven to overtrain and thus injure themselves in training or come into fights less than 100%?

Yes, I think there is a culture of overtraining because of the very fact that people must be ready to fight at all times; that is how the industry is structured. Unless you are one of the top 15 five-star athletes, you must be ready to step in and compete at any time if you want to make serious advancements in your career.

Do you think MMA as a whole is a safer place to fight than it was when it first started?

 Yes, I do. With added regulations and the advancement of the sport, I definitely think so.

You have mentioned before that you think rounds prolong fights and make it a “points” game. Do you think eliminating rounds would have an effect on fighter safety or injury rates?

I think it would lessen the injury rates, especially head trauma and strikes just because when you eliminate the rounds, it eliminates that rest and recover period. It would become a battle of attrition and a fatigue-based sprint, so the athlete would get tired faster and therefore have less energy to damage each other.

There has been some talk about fighters suffering traumatic brain injuries that can lead to depression. Gary Goodridge has come out as saying he suffers from chronic traumatic encephalopathy (CTE). Others have pointed to Junior Seau’s suicide as an example. Do you think there is any validity to this or are people using it too broadly when perhaps something else may be to blame for fighter behavior?

 I believe 100% that damaging the human brain is the worst thing in the world for you. Damaging the areas that control speech, emotion and memory is really bad, and we’re seeing the after-effects of those who have been injured in their careers. So with that said, if you plan to stay in a game where you risk damage to your head, you need a style or plan. Take precautions to protect your brain and body. And you must get out of that career before you get hurt, or you are taking a bad gamble. Weigh your options and decide for yourself if the risk is worth it and remember that your brain controls the body — if you destroy the brain, the body will follow.

Every now and then the idea of bare-knuckle matches returning is thrown around. Do you think this is a safe avenue for the sport to pursue? Obviously you have your background with Pancrase as a framework to draw upon.

 I think that any type of combative sport can be safe if regulated with safety measures in place. It is what it is. Whether it’s boxing or kickboxing, it’s like my coach, Maurice Smith used to say, “A fight is a fight is a fight.” It doesn’t matter whether it’s bare-knuckle or anything else, it’s going to be dangerous and you’ve got to figure out a way to win. Fighting is sport as entertainment — sometimes they’ll fight with hair, no hair; shoes, no shoes; etc. No matter what, the bottom line is that it’s still a fight. I fought with bare knuckles for years and it’s all the same stuff.

What is your most memorable experience in the ring or octagon?

 My most memorable experience was beating Olympian Kevin Jackson in 16 seconds and becoming the first UFC middleweight champion. That’s when I went into the books of the Guinness World Records for Fastest UFC Title Fight Victory by Submission in 16 seconds at UFC Japan in Yokohama, Japan. I will never forget winning the title that quickly or how Kevin Jackson, the Olympic Gold Medalist in 1993 for wrestling, walked out the cage without shaking my hand.

FightMedicine.Net: What would you say was the biggest injury you have sustained during training or fighting and how did you deal with it?

Pete Spratt: The biggest injury I have sustained in fighting has to be the recent ruptured thumb

Fluoroscopic images (xrays) of Pete’s thumb after surgery

tendon from my last fight in Brazil. I remember feeling a pain in my thumb in the 1st round and when I came back to my corner in between rounds, I looked down at my thumb and it was swollen pretty huge!

What was your doctor’s role, if any, in treating your injury?

My doctor’s role was to diagnose the extent of the injury and repair it if necessary!

How did you rehab from your injury and do you feel any lingering effects?

I did my rehab with Airrosti Rehab Centers with Dr. Brian Ellsperman. My rehab comprised of soft tissue manipulation, range of motion (ROM) stretching and ice treatment. I do suffer from a lack of ROM and some nerve damage in the tip of my thumb.

Have you ever had any surgeries related to your fighting career? If so, what were the injuries/surgeries done?

The only fight related surgery I have had was this latest injury where I had to have my tendon reattached. This is the only one in a 13 year career!

What would you say is/are the most common, but not mentioned training injury or injuries?

I don’t think there are many common injuries that are not mentioned in this game. Typically a fight cancellation is due to a knee injury in most cases. Some common issues for myself have been hand and wrist injuries.

What do you see as the doctor’s role in helping an MMA fighter and how can the medical community improve their role in MMA?

A doctor’s role in my opinion is to first understand the type of patient they have. Typically doctors like to diagnose a recovery process to the average person not a professional Mixed Martial Artist. Then their role is to diagnose and treat the patient accordingly to ensure a healthy, speedy return to the fighting arena.

Do you have any advice on preventing injuries in MMA or training?

Make sure you train smart and protect yourself with protective gear and supports where needed. Sometimes when I am teaching and training my fighters they ask me, “Do I need a mouthpiece?” I always say, “If you feel like you have to ask then you should probably put it in!” Most injuries occur when you think about protecting yourself and you don’t. Many times I have said, “Man I should have wrapped my hands!” when I banged up a wrist or my hand when I thought about it and chose not to do it.

How has the training for fights evolved over the course of your career and do you see this as increasing or decreasing the rate of fighter injuries? Has the treatment for injuries evolved with it?

As I have gotten older, I have started to pay more attention to what my body is telling me. Sometimes you need to just stop and treat yourself and not make the injury worse. That’s what I have learned. I am not afraid to take a day off when my body is telling me to shut it down. I learned that when I do this my body responds faster to treatment. You just have to be smart about what you are doing to yourself. I think training methods have evolved and treatment as well.

Do you think MMA athletes are driven to overtrain and thus injure themselves in training or come into fights less than 100%?

I totally think that is the case with MMA athletes. I have been a victim of that myself earlier in my career. I train 3-4 weeks for a fight. Any longer than that I tend to regress in training, I start to get banged up here and there and have all these little injuries. 3-4 weeks puts me right at my peak! A lot of times MMA athletes do this because it is a need to pay bills and this supplemental income (if they have a day job) will be the only way to make ends meet.

Do you think MMA as a whole is a safer place to fight than it was when you first started?

Yeah I think MMA as a whole is safer! I haven’t seen many MMA athletes with extensive brain trauma, slurred speech or slower reaction to normal stimuli after a long MMA career. Boxing on the other hand is a different story. Most boxers have this trauma after a long career due to repeated blows to the head. In MMA if you get dropped and pounded on they will stop the fight. In boxing they will step in, give you an 8 count and send you back out to get pounded in the head some more.

How has fighter safety changed during that time?

Fighter safety has changed a bit with the referees because they are more apt to stop a fight too early than waiting too late. I have seen many stoppages that the referee probably could have given the fighter a chance to come back. But the rules are very clear, if you are not intelligently defending and turtling up, the fight will be stopped.

Is there any difference between the promotions you have worked with in terms of fighter safety?

I can’t say there is any difference. Most all the promotions try to follow the UFC format with everything they do. I know different provinces in Canada require some more extensive pre-fight testing and exams but for the most part fighter safety is most important will all promotions!

How about differences in substance testing?

If you’re clean, you’re clean. Substance testing shouldn’t be an issue with any fighter. I was never concerned!

What can be done to improve fighter safety?

I think there needs to be change in the way the gloves are made to reduce hand and thumb injuries. I have broken my hand 5 times and my thumbs are always sore after a fight with thumbless gloves!

What can the medical community do to help fighters or MMA as a whole?

I think what you are doing now will be a great help, education and continuing education of fighter related injuries and treatments. Knowledge is key!

What is your most memorable experience in the ring or octagon?

My most memorable experience has to be my fight with the promotion Instinct MMA on December 2, 2011. My grandmother adopted and raised me from a baby. She had been having some health issues. I was schedule to leave for Montreal on a Tuesday and got a call late Saturday night that she had taken a turn for the worse. So I drove 6 hours from San Antonio,TX to my hometown of Sherman, TX to be there for her. I arrived at the hospital around 6am Sunday morning.

I waited at the hospital to speak with the doctor and get the results of her test and to make sure she was out of the woods. By around 3:30 the doc said all her test came back normal and that she would be fine. My family told me, “We know you have to fight this week so you go ahead and go and we’ll keep you posted on her.” I didn’t want to leave because if something happened I wanted to be there but I did leave for my fight.

So I am in Quebec City on my way to the weigh-ins and I get a call from my biological mom telling me that she has taken a turn for the worse and they wanted my permission to put her on a morphine drip to make sure she wasn’t suffering or in pain. I immediately started to cry and gave my permission for the drip and then started to beat myself for leaving her side.

The weigh-in starts and I am just a mess. I keep checking my phone and I got a call from my cousin about 15 minutes later saying “Grandma is gone!”. I couldn’t believe it. I called my mom and asked her if it was true and she said, “Yes baby, she’s gone!” I lost it but had to compose myself to weigh in!

They tried to interview me about the fight and all I could say was “My grandma just passed away.” Through tears I managed to say, “It’s going to be a great fight!”

The next night I won by TKO in the second round!

FightMedicine.Net would like to thank Pete for taking the time to talk with us and share such a moving story. Pete brings up a lot of good issues, including knowing when to train and when to take it easy, as well as wearing proper protective equipment.

When Pete injured his thumb, he ruptured an extensor tendon. Stay tuned to FightMedicine.net for an upcoming article on extensor tendon injuries. Feel free to leave a question or comment!

Jonathan Gelber, M.D. is licensed to practice medicine in the State of California

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FightMedicine.NET:  Shannon Knapp sought you out to work with Invicta.  In your experience, is there any difference with female fighters?  Is there something different that you have to deal with or is it just “a cut is a cut is a cut”?

Stitch:   A cut is a cut is a cut.  And it’s funny because these girls, they can fight and it’s going to be a very successful program that Shannon put together.  But I laugh at them because they get all bruised up and banged up and all that and if you’re a guy and you had those same bruises and cuts on your face and you’re going through the airport and you’re getting on the plane, people would ask you and you tell them you’re a fighter.  And, for the most part, those are trophies, right?  But if you’re a female and you’re all banged up and you’re wearing sunglasses or you’re swollen or your eye’s swollen, first thing they’re gonna think is it was spousal abuse.  So that’s the only difference.  But no, these girls, they’re no different than guys.  They come to fight and they do a good job.

When the ringside physician stops the fight, do you feel that you’ve lost a battle?  Does that affect you at all?  Do you feel like you could have kept the guy out there?  Or is it just” it is what it is” and you did what you can?

Well, it used to bother me at a point. But knowing what I know, there will be times where I would recommend stoppage when a guy’s taking a pretty damn good beating. But in the same token, and in all fairness, it doesn’t happen as often as it used to.  These guys know what we’re capable of doing and they give us every opportunity.  And I remember there was a fight which Stefan Struve was – I can’t remember who he was fighting but his lip was all shredded, it looked like a shark took a bite out of his lips.  And the doctor was ready to stop the fight and I’m looking at Stefan, looking at his face and he’s saying, “No, no, no, I’m okay.”  So I convinced the doctor.  I said, “Look man, if you guys have a pretty good plastic surgeon, he’ll be fine.  Let him continue one more round.”

And the doctor did and he went one more round and knocked the guy out.   So yeah, a little shredded lip won’t hurt. It’s not that all that serious.

Because you know what you can and can’t do and what your limitations are, do you ever tell the ringside doc, “Hey, I can’t do any more with this, you got to call the fight.” 

Yeah, I haven’t been asking them for a while, but if it’s a real big old nasty, gnarly cut that let’s say it’s above the eyebrow or something that’s been bleeding into the eye, you can start getting into optical nerve damage and double vision and all that.  And if it’s getting real, real bad, then it might be time.  If you can work on it for that one minute and he goes out and right off the bat it’s gushing blood and it’s going into his eyes and he’s starting to wipe his eyes and all that, and you give it another shot and it’s just not working, then it might be time to go ahead and call that a night for the fighter so he can come back another next day.

Are the fights called more often due to blood dripping into the eye or due to the size of the cut or is it either or?

Either or.  And a lot of it really depends on who the doctors are and who’s working the cut.  But if you’ve got a big old nasty ass cut and it just doesn’t look good on you and it’s not gonna get better, then a doctor will stop the fight. If you get continuous blood over the eye and the guy’s wiping it and then he’s complaining that he can’t see – and as soon as a fighter says they can’t see, whether he’s poked in the eye or whether he’s got blood in his eyes, then the referee automatically stops the fight.

 Are there any locations for cuts that you think are worse?  That if that happens, it’s doomsday for the guy?

Nah, not really.  I’m known to keep my composure and I’ve seen a ton of cuts and there’s not one specific one outside of that big vein between our eyes, if you can control the blooding for half the round, then you’re okay.  But the rest of them, when you got a big old scalp wound or something like that, then yeah, there’s bigger wounds to work on and we’re pretty good at that.

When guys get broken finger bones or hand bones, are you dealing with that between rounds or is someone else dealing with that?

If you break a metacarpal or something like that, then guys start talking pain and that’s really kind of the corners decision to keep fighting and just do something with it.  What we’ll do is wrap their hands and try to protect them as much as possible.

And one thing I always tell people, because I have a very good wrap, but 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 their punches as big hooks and on top of the head, there’s no support factor when it comes to making contact with the knuckles and the hand is bent away from the palm, there’s just no support.  Pretty easy to break it that way.

In boxing, the punches are a little bit straighter and the gloves are a little bit bigger. And I know a lot of these guys in MMA are trying to stay away from those big old looping hooks. And with the boxing gloves for the most part are eight or ten ounces.  When a guy hurts his hand, it’s usually through the metacarpal. And a lot of that is attributed more to how they punched the guy on the top of the head than anything else.

 Who pays for the cutmen?  Is it the promotion or is the fighter’s camp?  Who’s paying for you guys to be there?

Well, both actually.  And we’re all freelancers.  So I don’t work for the UFC, I work with the UFC.  But the UFC on their shows, the Invicta shows, the promotion will pay us for doing our services.  I work in Russia Viali Klitschko.  He’s a boxer, but he’s the one that pays me.

Does insurance coverage factor into any of this?  A lot of fighters don’t have insurance, and with your experience in and out of the ring, does that affect a lot of things?

Every fighter that gets hurt during an event is automatically insured.  And so in that aspect, that’s not a problem.  But let’s say a fighter gets hurt in a gym preparing for a fight. The UFC is a little bit different because the UFC has actually insurance for all their fighters, whether they get hurt in the gym or whether they get hurt during the fight.  But in the smaller shows, the fighters are insured only during the fight.

But in boxing for many years, we were always trying to campaign to have some kind of kitty or some kind of program where if a fighter that was licensed by whatever state or whatever organization got hurt during training, that there would be a fund that would at least cover some of the expenses. He would be able to go to the hospital or a doctor and there’d be a kitty that would be able to compensate and will pay the doctor or the hospital for the services that were provided for them.

 Do you think there should be something like a fighter’s union, somebody that can organize these things?

That’s been a program that they’ve been trying to work in boxing for years. Jimmy Hoffa Jr. about ten years ago in Boston tried to bring the teamsters in and they tried to create a union for the fighters, but it’s really difficult because fighters and trainers, we’re all independent contractors.  And it’s really kind of tough to organize something that will be able to satisfy somebody that’s an independent contractor.  So none of that has ever happened.  It’d be nice if there were some kind of a program where fighters are protected in and out of the ring, but unfortunately, there’s not.

Do you think there’s anything in general that can be done to make MMA safer?  Do you think there’s issues that need to be addressed?

I  think whenever you’re in any kind of combat you’re gonna have some kind of injuries that go with the type of sport that you’re in.  In football you get the concussions and you’ll even get a broken hand. I know I did a show with Junior Seau before he passed called Sports Jobs with Junior Seau and I showed him how to be a cutman.  And one of the things I showed him how to do was wrap bandage.  And he showed me his hands and just about every finger was broken from doing what he did as a linebacker.  And so those are the causalities of war I guess you call them. I think whenever you’re making some kind of contact with fists or elbows or knees or hands and all that, you’re gonna receive some kind of damage.  And as long as we can contain that damage to its minimum, I think we’re doing a pretty damn good job.

Do you have any crazy stories going up through the ranks or even in the UFC as a cutman that just stick out in your mind?

I have tons of stories from guys and we’re talking about the importance of a cutman.  When B.J. Penn fought Joe Stevenson, I think we were in England, I was working B.J. Penn’s corner and Joe Stevenson ended up with a big old gash between his eyes.  He’s bleeding like a pig and we stopped the fight.  And in the dressing room, his trainer is telling me now after the fight in the dressing room Joe was saying, “Where was Stitch?  Where’s Stitch?”  And those guys kind of look up to what we do.  I think, especially of all the cutmen, they have a lot of confidence in me and that was just a nice little gesture. It was nice that he made that kind of comment.

 You’re obviously known as one of the best in the business, how does one guy get to have you in his corner rather than the other fighter?

Well, it’s just the luck of the draw.  When it comes to wrapping hands, and keep in mind now it started off with Leon Tabbs in UFC 1 by himself.  When I came onboard in UFC 32 when Dana and Lorenzo and Frank first bought it, there was only two of us.  And the thing that we offered the fighters is the opportunity – they could either have their own corner wrap their hand or we could wrap their hands.

And it got to the point where everybody wanted us to wrap their hands.  Then we brought in the third man, which was Don House, and even that got so busy that we brought in a fourth cutman.  And now we use five cutmen in each night. When the fighters get through the weigh-in, Burt Watson, our coordinator will ask, “Who wants their hands wrapped by the UFC cutmen?”  There’s 12 fights, there’s 24 fighters.  We’re gonna end up wrapping anywhere from 20 – 22 guys.  And the majority of those guys want me to wrap them.

So now it’s to the point where Watson will assign guys to which fighter.  And a lot of the time I’ll get the populars automatically, I’ll do eight or nine guys because it’s tough for me to say no to a guy because I know that if I give them that little ounce of confidence, then I know it’s gonna mean a lot to them.  And I go out of my way and bust my ass a little bit more and work a little bit harder just to get two or three other guys in there.  But there’s many times where I’ll wrap both guys that are fighting each other.  And come fight time to be in neutral, if you’ve noticed I’m always in the red corner.  And I’ll let the UFC determine who goes in the red and who goes in the red and who goes in the blue.  And we’re as neutral as possible and we want to keep it that way.

Is there anything that you would say to the medical community that can help MMA or help the fighters?  Is there an issue that you think could be better addressed?

Well, that’s a very good question.  When I look at the sports, I look at both boxing and MMA.  Boxing still is so far behind.  Even now, it’s so far behind from MMA that nobody has really come forward and tried to educate the fighters and trainers and all that.

If the docs could come forward and maybe explain to these guys during the weigh-ins or something like that about how these injuries are caused or here’s what you could do to prevent it or here’s what you could do if you do get hurt, and just give them a bird’s-eye view of their profession and what’s the best way to treat an injury after it happens.  I think that’s very important.

Also, maybe let us know if there’s any new techniques, because for the most part we’re doing the same ideas that boxing was doing in the ‘30s and the ‘40s.  And the techniques are all pretty much the same.  I’ve polished them up a little bit, but they’re all the basic techniques.  And sometimes old is good.  And those seem to work.

Let the medical community come forward and give their two cents.  And anybody that’s doing articles like you, your website and I think that’s great. I chose to do an interview with you because education is the one thing that I want to bring to the table. And I’m good at what I do. But, I only got a high school diploma. I’m just good at what I do in that first minute.  But what happens before and after is not my life.

So, Rehab of injuries is a big thing for fighters to deal with?

Absolutely, because so many guys get hurt in the gym.  And years ago I produced a documentary called Boxers Nightmare and it deals with all this stuff that fighters go through behind the scenes.  And one of the scenes I sent out a bunch of survey sheets and got a bunch of responses.  I knew what the answers were just because of experience, but the point is every fighter gets injured in the gym.  And the majority of the fighters, when they go into a fight, they go into a fight already injured.

Also, a lot of fighters don’t know that if they take simple things like the ibuprofen, the anti-inflammatories, that if they take those before a fight and then they get cut, it makes our job a lot harder.

 And you’ll notice now as you watch these fights on TV so many guys are just doing the wrong thing.  But I was looking at the fights on HBO last night and just one that guy that’s working the corner – it makes me feel good because he’s doing everything that we do.  And really, everything that I put together at the UFC that the other cutmen are doing is using the clean towel to wipe the face and he’s putting the Vaseline on the back of his hand so he could grab it like an artist and apply it to the face.  And little things like that, a lot of guys weren’t doing before.  And now I see that really I have made a difference in cutmen working and cutmen using the same techniques that we use.

Because you are working under a 60 second time limit, is economy of  movement important?

Oh yeah.  And even in setting up my bucket, everything is always in its own little location at all times.  I know where the end-swells are, left side of the bucket.  I know where the Vaseline is at.  I know where’s the epine is at.  I know where the towel is at.  Everything goes in the same location.  And I’ve had guys that work for us in UFC say, “Hey, Stitch, let me use your bucket.”  And I said, “No.  You got to get your own”. I let a guy use it one time. He had no formula. And the next thing I know, he just grabs the stuff and puts it back wherever. When you’re dealing with a cut that could happen right away, as a lot of times they do, you got to know without even looking, just reach in there and grab what you need.

 And one of the things I always tell cutmen that are learning to be trainers, when they ask me what to do, I say, “Always prepare and expect the worst case scenario.  And always have a swab ready and keep it sterile”. Some guys, you’ll see in boxing, a guy gets cut and he has his bottle of epine and he’s already in the ring.  And he’s putting the swab into the epine, already getting it wet.  So that should have been done a long time ago. You just wasted six, seven seconds.  And those are techniques that we improved and they work.

 A lot of times when I see guys, they’re just going at it toe to toe and the guy’s taking a beating, I’ll have my stuff, I’ll put my Vaseline on my hand and I’ll have my swab ready and I’ll have my towel ready.  I’m ready to jump into the ring and I’m looking at him and at that point he’s not cut, but there’s that possibility that before the bell rings he will get cut.  And it’s happened, three or four times before, and at that point, boom, I’m in there.  So you got to always prepare for the worst scenario.  If the guy’s not cut, then just get back to square one.

Better to be safe than sorry?

Exactly.  That’s the difference between what makes a good cutman and a bad cutman.  When a guy gets cut, first thing I do is I start counting the seconds when the bell rings to see how long it takes the cutmen to get into the ring.  And some guys, it takes them 10 seconds, 12 seconds.  We do it under five, so that’s a good thing.  A lot of it depends on how quick they open the gate.  But we’re right there.  As soon as the gate opens, we’re the first ones in.

FightMedicine.NET would like to thank Stitch for talking to us. There is no doubt he is a legend at what he does. You can purchase his video “Giving the Fighter One More Round” at cutman4hire.com or titleboxing.com. His autobiography is also available at Amazon.com or you can it through Kindle.

Keep an eye out for Stitch in the red corner this weekend at UFC 153: Silva vs. Bonner in Rio de Janeiro, Brazil.

Follow @FightMedicine

Get updates on future interviews and articles by Liking facebook.com/FightMedicine

FightMedicine.Net would also like to thank Sandra for her transcription services. She can be reached at sh.transcriptions@gmail.com

FightMedicine.NET:      You recently published an autobiography. Could you give us a summary of your path: how you got into MMA, how you became a cutman in boxing and then eventually to the UFC?

Stitch:      Well, it started off with me joining the Air Force and getting stationed in a place called Thailand in 1974.  And I didn’t even know what the hell that was.  I knew the Vietnam War, but they sent me to Thailand.

So I think like three days after I got to Thailand I went to see my first Muay Thai and I got hooked up on it and I started training in taekwondo. They had taekwondo on the base for the G.I.’s. Eventually, Master Toddy, who is pretty world-renowned right now, took over. But then he left and placed some Thai instructors in charge. We stayed with the taekwondo system, but incorporated a lot of the Muay Thai style into that.

So for a whole year I did that and got back to the States and I got into boxing so I could improve my hands and polish up.  And from there I opened up my own school of street boxing.  And I was pretty good at training and had a lot of good fighters and traveled the world.  But that’s where I learned to be a cutman and I was good at what I did.  And I was working with kickboxing and boxing and I figure I’d move to Vegas and challenge the world of boxing and try to hang with the big boys.

So 17 years ago I made the move to Vegas and actually, at that point it was only boxing.  And then Dana White, I’d known Dana for years.  We were all trying to make a buck as trainers in the gyms and getting the old ladies  pissed off at us.  I hadn’t seen Dana in about a year and I was working the K1 at the Bellagio and Dana was in the audience.  He asked for my card and called me the next day, said, “Look, man, we bought the UFC.  You want to come onboard?”  And that totally changed my whole life.

 So you and Dana White were trainers at a gym together?

We were at different gyms.  We’re all trainers and we’re blue-collar guys trying to make a buck.  And trainers in this industry, you really don’t make a living.  So we were all trying and yeah, exactly, I’d run into Dana all the time.  And I used to sell boxing equipment from Mexico, the brand M&M.  And I used to sell Dana equipment for his guys and other guys.  And Dana never forgot what I did.  My main thing was being a cutman.  I was a trainer, and a good trainer in boxing, but my whole goal was to be a cutman.  And he remembered that, and the first thing he did is give me a call.

 How did you start doing what you do?  Were you an apprentice or did you just figure out along the way how to do it?

Unfortunately, there was no apprenticeships as I was coming up. The old boxing cutmen, even now, the old boxing cutmen will not divulge any of their “secrets.”  Juan Guarilito, when I asked him what he was doing  and how he did it, he literally said, “I’m taking this to my grave.”  And I said, “Well, that boy right there changed my whole life because I’m never  going to be like this guy.”

So I looked and I studied guys wrapping hands and guys doing what they did.  And unfortunately, at that time that was the only way we could really learn to be a cutman.  And a lot of guys still do that, and that’s why a lot of guys still make a lot of mistakes.  But I read books, and I had – and still do have – a pretty good relationship with a lot of the ringside doctors.  And I ask them a lot of questions and I eliminated a lot of the stuff that a lot of these guys did.  Now, knowing what I know now, there are wrong techniques and I kind of got it better now. It’s been pretty successful and this is the one that I teach other guys with.  When guys ask me a question about what it takes to be a cutman or what it takes to wrap hands, and I think back about that time that I got blown off, so I don’t mind passing information on.

 What are some of those mistakes that you made along the way that you think you could teach other people so they don’t have to make the same mistakes?

Number one, the first thing I always tell guys is those swabs that we use that you apply the epinephrine on the cut with, you’ll see these cutmen, they put them in their mouths and they put them in their ears.  And first thing I tell them is not to do this. Keep them sanitized and keep them actually cleaned.  Also wear gloves.  A lot of these guys don’t even wear gloves.  Even though they check all the fighters for HIV and Hepatitis and all that, it’s just if you’re going to work with an open wound, at least pretend that you’re clean.   And even with the end-swells, a lot of the guys work to move the clot. And I was told as I was coming up is that you get that clot and you try to move it to the side.  But talking with the ringside doctors now that know the business, what you’re doing is just moving that blood into tissues that otherwise has not damaged.  And it eventually comes right back. It’s the direct pressure with the cold compress that closes up most blood vessels and that’s really the basic principle.

Like I saw last night, I saw a fight on HBO and the guy put the swab in the guy’s nose and tried to clean it out and puts it right back into his mouth.  They’ve got all of that in his mouth and that’s pretty disgusting.

How well do you work with the ringside physicians and how well do they work with you?  Do you feed off each other a little bit, teach each other some stuff?

Oh, absolutely.  I make it point about 30 minutes before a fight to go to ringside and introduce myself to the new doctors I don’t know.  And I let them know, I say, “Look, man, here’s what we do and we’re very good at what we do.  We understand that your decision is the final decision, but give us the opportunity to work on the cuts”. And these guys, especially with the UFC, they know what we do as cutmen and they’re very good at letting us do our stuff.  But the bottom line is they do have the final decision on whether a fight can continue or whether it can’t continue.  And doctors have been very good with us in giving us the opportunity to work on a cut and give that fighter the opportunity to win a fight.

 Do you have any advice to people that want to become a cutman? What makes a good cutman, what they can do to move up through the ranks or even what they should do to prepare to become a good cutman?

Oh yeah, absolutely.  I get calls or emails and Facebook.  Everybody’s got somebody who wants to be a cutman. They see what we do in the UFC and in all fairness I got the best job in the world, but it wasn’t an easy road to get here. I get paramedics, I get EMTs, I get nurses. I get your layman person that wants to be a cutman and the first thing I tell them is, “Look, man, you’ve got to spend hours and days and weeks and months and years in the gym learning to be a fighter and learning what these fighters go through.  And as you’re going through that process, you’re learning how to wrap hands and you’re learning the nature of swelling and working on cuts and you learn as you go.  There’s not a remedy or a solution where you push a button and go straight to the top and be a cutman.”

And that’s a lot of misconceptions that a lot of guys have.  It’s just not that easy.  One doctor said, “You know, Stitch, I’m very good at what I do, but I wouldn’t be very good at what you do.”  And I think that was a very fair analogy because for the most part we’ve got 50, 55 seconds maximum to do what we need to do.

Besides just trying to stop the bleeding or working on cuts, what are you guys doing in the ring between rounds that we can’t appreciate watching from home?

Well, I think one of the things that we’re doing while we’re working on the cuts is we’re also cleaning the guy’s body up.  And these guys have blood from their front to their back, on their shoulders and arms, and the legs sometimes.  And as we’re applying direct pressure and the epine (epinephrine) on the cut with one hand we’re also wiping them down with the other one.  And I always say, “It doesn’t look good on TV when the guy goes back with blood all over his body.”  On the same token I always say, “I know your mother or your father or your wife or your brother or anybody wouldn’t want to see all this blood on you.”  So that’s kind of the big stuff. You’re doing everything at once and there’s even a confidence builder where we throw in a little word of encouragement that they’re okay and go out there and give it your best shot. We do those. And those are things that the average fan never really gets to see.

How do you keep the guys calm during that?  You just talk to them?  You reassure them?  How do you make it so you can do your job?

 Another thing about what would be a good cutman is having a lot of confidence in yourself and keeping your composure.  And when you go on there and you – you don’t make it seem like it’s something real big like, “Damn, that’s a big cut.”  You can do that after the fight, but during the fight you get to work on them and you make that eye contact and you let him know that he’s okay and that I’ll be taking care of you.

Do you find that you ever get in the way of the guy’s corner or his trainers?  Or you guys work pretty well together so that they can talk to him and get their game plan done while you do your work?

Yeah.  That’s a good question.  That’s a great key element.  There’s been times where the guy is cut on the left side of the eyebrow and the trainer’s on the right side, I’ll have them switch sides with me.  I’ll say, “Let’s go ahead and we’ll switch,” and we’ll switch.  And especially at the UFC level when these fighters are the top of the line and everybody’s at the elite level, there are guys that go in there that weren’t there to work and we always try to take the primary position.

What have you picked up in general as far as what a corner can do to get a guy back out there?  Whether it’s mentally, physically, what seems to be the best thing to get a guy back to the best shape possible between rounds?

Well, I think the part of trainer is to give him the proper advice.  And just like in boxing, if the trainer’s – and there’s been some trainers I’ve had to tell, “Just slow down there, relax a little bit.”  And if you give the fighter two or three good instructions and keep calm and give them some water and tell them to take a brief breath, it’s in that one minute he has to regroup. Especially if he got his bell rung and he’s walking in already hurt.

So on the side of the trainers, he has to keep his composure and give a few instructions, not a whole essay on what you got to do.  Can’t give him 45 minutes of instruction in 45 seconds.  You go in there and you get them to calm down, give them some water and tell him what he’s doing right, tell him what he’s doing wrong.

And the same thing with the cutman.  And our job, our primary job, is not to speak.  We just go in there and do the maintenance on the guy.  And at the end when the trainer’s finished giving his instructions, I always try to give a guy some encouragement.  “You’re looking handsome,” or, “You’re looking great, go out there and bust his head,” and little things like that.

 What equipment do you use?  Is there a standard equipment amongst all cutmen or do you have specific tools that use that you think everybody should use?

Well, you have your basic stuff. You have your Vaseline and you have your ice pack.  And a lot of these guys use these rubberized ice packs, which, to me, I think are terrible because the cold just doesn’t penetrate.  We use sandwich bags which works great for us because you’re, for the most part, applying cold direct pressure with that.

And now we have face towels that we use, that we keep wet.  And that’s what we use to wipe down the cut and clean it.  And you’ve got the swabs and the adrenaline chloride, the 1:1000.  And now the United States let us use Avitene and Thrombin, but those are medications from the past and we really don’t even need them.  And if you do the right job with epinephrine, then that’s really all you need.  The end-swells, the basic end-swells that they have are kind of a flat stainless steel apparatus that you would apply on the cut, right?  Or on the swelling.  But as I used to look at this, I said, “Wait a minute, it doesn’t make sense,” because the cheekbones and the eyebrows and all those are pretty much contoured, right?

So I created one that is curved on one side and flat on the other side so when you’re applying pressure on the cheek or on the eyebrow, then it contours with that, with the foundation of those areas.  And if you got swelling on the temple, then you could use the flat side.  So instead of having just one tool to work with, now you have two.

To get things like epinephrine, the adrenaline chloride, do you need a prescription or do you get that from the ringside physicians?  How does that work?

Yeah, those are all by prescription, unfortunately.  And that’s what makes it very difficult for a lot of the guys now that are up and coming.  People ask me, “What do I do to get one?”  And I say, “Good luck.”  But they’re by prescription.  But now I’m endorsing a new product called Qwick-AID that is hemostatic gauze that doesn’t require a prescription.  It’s 100% natural and it stops bleeding 45 to 50 seconds.  And now Nevada has already improved it and I’m working on other states approving it because now the layman cutman or the layman trainer or even somebody at home that gets cut, all you have to do is just very simple.  Just put that gauze on the wound and give it 45 to 50 seconds and it does a good job of stopping cut.

What’s in that?  What’s the active ingredient?  Is it epinephrine?

No, no, no.  It’s all 100% natural.  It’s made out of a seaweed and coral based.  But the matrix that is created with the gauze draws the blood into the matrix and then just with that natural hemostatic compound that the seaweed and the coral creates, it clots the blood up and it looks great, man.

What are some of the biggest injuries that you’ve seen and what did you do to treat them?   

Well, they’re all pretty much the same.  A gash is a gash.  And head wounds are pretty solid and cuts around the eyebrows are pretty constant.  But it’s the same application.  I clean up the cut and put the epi on it and direct pressure and then just – we always mix a little bit of epinephrine with Vaseline and just kind of coat it after that and hope that it controls the bleeding.  The thing with the doctor stopping the fight is, the key element is, if fighter is ever at a disadvantage and if we can’t control the bleeding and the bleeding gets into the eye. If that doesn’t happen, then I think we did a pretty good job.

 Some fighters seem to bleed easier or more than others.  How you noticed a difference in what constitutes a fighter’s ability to withstand being cut or bleed a lot?

Well, that’s one of the things that I always ask the guys: what kind of medications they’re on, and are they taking any anti-inflammatories. Because they all get banged up, and a lot of these guys do take anti-inflammatories, Advil or anything like that.  Some might even take aspirin. I know that makes my job a little bit harder.  But whenever they pop a vein or something, that big vein that we all have between our eyes, when they pop that one, I know that I’ve got my job cut out.  But it’s more of what he’s taking before the fight.

 Have you noticed whether certain moves cause more damage than others in terms of getting guys cut?

They come from everything.  And I was doing the Ultimate Fighter reality show two weeks ago, and these guys are fighting, and I don’t see a whole lot of punches being thrown around.  And the next thing I know the guy comes out with two cuts.  And I’m asking the guy how he got cut. And he says, “I don’t know.”  So everything depends on contact and angles and everything, but you get them from elbows and knees and fists.  And I know the time B.J. Penn kicked, who was it, Diego Sanchez in the forehead, as soon as that foot recoiled back, you could see the blood already pouring.  So yeah, cuts come from everywhere.

Are there any tricks that guys can do to help prevent cuts?  Obviously Vaseline is one thing most people talk about.  Do you have any tricks of the trade that you can give guys to prevent getting cut?

No.  And if you know of any, let me know.  I think that would be the information that guys would need to know.  I remember in boxing, Julio Cesar Chavez would get a thumb-full of vaseline and just get some on his face.  The old boxing guys would use brine, I guess, is what it’s called. And they would supply that and pickle juice.  These are the old-school types of things.  But I don’t really how that stuff work.  And I always taught or explained that the more pliable that the tissue is, the skin, then the least likely you are to get cut, as opposed to having dry skin.  They said it was theory of the dry branch and the branch that is still green.  The green branch is gonna bend and fold.  And when it’s dry, it’s gonna be break.

Have you noticed any differences between promotions as far as how you guys are able to do what you do?  Is there a big difference between a smaller show versus something like UFC?

Well, we do the Invicta shows right now and Shannon Knapp was smart enough to give me a call and see if she could hire us to help her run her show.  So I got Don House and we went in and we built two shows with them.  And basically we put them on the same format as the UFC.  And people have to give Dana a lot of credit, and a lot of people don’t really realize that when Dana first hired me to come onboard to be a cutman with Leon Tabbs – now Leon Tabbs is the original cutman from UFC 1 and he was the only cutman.  So when I came onboard, there was two of us, but that was really one of Dana’s first ingenious moves is that you have professional cutmen, at least out of the Octagon.

So I’ve done the Invicta fights. And they brought us onboard to basically do the same thing.  I really haven’t been in any other organizations.  I’m always booked on the weekends.  I either go get the fights or see how these guys operate.  When I do see them on TV it’s funny because I see these guys copying what we do and follow the same thing.  So I’ve got to think due to what we do on TV, these guys pick up on it and try to follow what we do.

Do you ever see something on TV and just know a guy is doing wrong and you just wished you could tell him how to do it right?

                                    Well, more in boxing.  I see it all the time with boxing, and the guys that are transplanted as top-of-the-line cutmen, knowing now what I know, these guys make so many mistakes.  And if they were to get what we call a UFC cut where it’s a big one or either multiple cuts, I don’t think these guys would be able to handle it.  In fact, I know ‘cause some guys have screwed up when they get a big old cut or they get a couple cuts.  Keep in mind in boxing they’re not used to working on cuts all the time.  And like I say, we at the UFC, you’re only gonna get better by doing it.  And we do a ton of them in the UFC.  So we’ve seen just about every cut.

And with some of these guys in boxing, I kind of cringe.  Even my kids, they grew up in the game and they know the game as well as I do and my daughter, she’ll text me or my son will text me, even my wife.  We’re watching TV, I said, “How gross that this guy is doing that and actually putting a swab into his nose and back into the mouth and using the end-swell and just try to rip the guy’s skin off?”  Yeah, so I’ve seen a lot of mistakes, no doubt.  And in all fairness, it’s not that these guys aren’t trying, it’s just that nobody has taught them

 Do you think that there should be a standardized school or a standardization of practice for cutmen so everybody’s trained at the same basic level?

It’d be nice.  It would be nice to get everybody on the same page.  That’s why people ask me, “Do you do seminars?”  And I have and I’d like to do even more, but because of time restraints or I’m always traveling and this and that, it becomes quite difficult.  And unfortunately, like in boxing or even MMA, the only that’s required to be a cutman, to be a trainer is to apply for a license to whatever state you’re gonna be working at.  And there’s no qualification that a commission will ask you what are your qualifications for being a cutman, what are your qualifications for being the chief second of a trainer or of a fighter or what are your qualifications of wrapping a hand.

And I’ve talked to a lot of commissions and they’ve, especially when it comes to wrapping – I know there’s so many guys that just don’t know how to wrap hands.  And once again, I can’t fault them because nobody’s ever sat there and taught them.  But I did a video called “Giving the Fighter One More Round” and it deals with wrapping hands, etc.

I used to go co-host a radio show, a boxing show called The 13^th Round.  And when it came to working on cuts and the medications and all that, because I know I’m not a doctor and I’m not qualified to tell you how to use a medication that is by prescription, so I had Dr. Davidson and Dr. Watson which are the top two doctors here in Nevada that came onboard.  And they explained it. Dr. Davidson is now the head doctor for the UFC.  So I brought in some heavy hitters and they explained that in laymen’s terms what these medications do and what’s the proper way to apply them.

A big thank-you to Stitch for talking to us and helping spread education to make MMA safer! Stay tuned for Part 2 of our interview.

Jonathan Gelber, M.D. is licensed to practice medicine in the State of California

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FightMedicine.Net would also like to thank Sandra for her transcription services. She can be reached at sh.transcriptions@gmail.com

Dr. Goodman and VADA were recently in the news when both BJ Penn and Rory MacDonald both agreed to be tested openly by the organization prior to their UFC 152 bout. Unfortunately, Rory suffered a cut during training and the fight was postponed to UFC on Fox 5.

Dr. Goodman and VADA recently were encouraged when female MMA fighters Rosi Sexton and Sheila Gaff volunteered to be tested before their Cage Warriors 49 contest on Oct. 27.

In addition, Georges St. Pierre has also suggested VADA as the organization for which he would be willing to submit to testing before his UFC 154 title unification bout against Carlos Condit.

FightMedicine.net:  Could you tell us a little bit of how you first got involved in VADA and what the main mission of VADA is.

Dr. Margaret Goodman:  Well, I was a ring physician and head of the Medical Advisory Board for a number of years with the Nevada Commission.  Even when I came on they were already doing extensive drug testing.  It didn’t really so much include performance-enhancing drugs (PEDs).  It was mainly detailed drug screens for stimulants, narcotics, and things of that nature.  But it became clear – you started to read that all these other sports athletes were getting caught and there was testing going on – that this was something that needed to be included (PED testing).

Dr. Flip Homansky, who used to be the Chief Physician with the Athletic Commission and Head of the Medical Advisory Board for many, many years, and he was a ring physician for over 20 years, then became a commissioner and really prodded the Commission to go ahead and add performance-enhancing drugs, mainly anabolic steroids.  And that was around, I think, 2001 if I’m not mistaken.

The problem is the way athletic commissions test most of it. This is how I ended up thinking that VADA would be a good idea. If you look online at the Association of Boxing Commissions, you can look at the regulations and the rules and requirements for licensure.  And if you look at it, you’ll see that there’s very few commissions that do any testing, drug testing, at all.  And even less conduct testing for performance-enhancing drugs, and that’s for a number of reasons.

Obviously, I always felt that when I was associated with the Association of Boxing Commissions that their commissions could push through whatever they really wanted, and to some degree that’s true. But there’s budgetary issues. A lot of commissions don’t feel they have the upper hand to require those kinds of tests, let alone more expensive test like MRI scans, expensive neurological tests, etc.  So a lot of commissions don’t do anything, and it’s only recently where probably more commissions than not do HIV and Hepatitis screens, so adding performance-enhancing drug testing is certainly down on the totem pole as far as getting that going.

So after I had left the Athletic Commission over the last several years, I was writing for The Ring magazine.  I had a column called The Fight Doctor.  And I started to look into this issue more and more and realized that not only in other athletic endeavors, but extensively in boxing and in MMA, performance-enhancing drugs were a strong issue, but nobody was really dealing with it to the extent that they needed to.  And the way testing goes on in most commissions is it’ll be right after a fight.  Even if they do include anabolic steroids, it might be at the weigh-in, or it might be before the fight.  What we used to do, because we had to collect so much urine for steroids in addition to just the regular drug screen, we used to have the athletes do the steroid screen before the fight and then do the other test after the fight just so we would have enough.

But the bottom line is, it’s really only during right around the fight, and obviously we’re missing the main time periods where athletes were abusing these substances – while they are in training, in preparation for a fight.  So ideally it would have been nice to do a traditional Olympic type program where 24/7, 365 days a year.  So I realized that there was a problem.  I realized it wasn’t being addressed.  It appeared that it wasn’t going to be addressed to the degree that it needed to, and one of my people said, “Well, if you really care about it, why don’t you just do it yourself?”  And lo and behold, that seems to be the right way to go, although I think I was extremely naive on how complicated it was, besides the aspect of the expense, that it’s just very complicated in setting up this type of program.

You mentioned it’s complicated. What kind of roadblocks have you met along the way inhibiting the widespread testing that you think needs to happen? 

Well, number one, I didn’t perceive that it was going to be as complicated in putting together the actual policies that are necessary; protocols for the testing.  In speaking with Dr. Don Catlin – he’s considered the father of anti-doping – he was the one that set up the first anti-doping lab that was at UCLA and he’s an M.D.  He also is a scientist in all of this and understands the process probably as much as anyone in the world.

And so I had interviewed him and talked with him a long time before I even came up with the idea of putting together VADA, and so when I was doing an article for The Ring, I talked to him again.  And he made it really clear what I had to go through to really put together this.  And if you look at our website and you look at our policies and protocols and forms, you’ll see how complex it is.  And it certainly is in keeping with what’s used by the U.S. Anti-Doping Agency (USADA).  And in talking and putting together the program, what you need to do this type of program is you really have to do it to the ultimate.  Otherwise your program has no credibility and it’s not of as much value as you would want it to be.  So you couldn’t do it halfway.  At first I was like, “Well, okay.  Well, we’ll just start.  Hopefully, we’ll have fighters that want to demonstrate that they are in favor of clean sport and will allow us to do the testing.”

I didn’t understand that in order for it to be done the right way, you had to have the right protocols and procedures.  And so Dr. Catlin hooked me up with our attorney, Ryan Connolly, who’s just a great guy.  He understands all of the legal aspects and at the ground floor when they started the UCLA lab as well.  He comes from an anti-doping background and worked with Dr. Catlin for a number of years at UCLA and is just very, very knowledgeable.  And so helped us set up the right protocols and procedures.  So that took actually months and months to come up with.

The other roadblock, and it wasn’t really so much a roadblock, but because we were a small entity just starting out, we had to work with the appropriate types of groups that actually do the collection.  In athletic commissions, and the way it still is, for example in Nevada, and I’m pretty sure it’s the same way in California, is the inspectors. They are actually the individuals that oversee the fights while the fighters are wrapping their hands or getting their hands wrapped and gloving up and watching the fighters in the dressing room and staying with the fighters at ringside, they’re the ones that often end up collecting the actual specimens.

So what we needed, because this was obviously just like doing a traditional anti-doping program where you have to actually go to the fighter or where the athlete is, we had to have doping collection officers.  And those officers have to be extensively trained and certified.  And there’s only a few companies in the world that have these individuals or train them and have them under contract.  So it was tough finding those groups that would work with a new agency.  So we had to prove our worth.  In other words, have the right policies in place.  And the same thing went for the labs.  We wanted to work with WADA (World Anti-Doping Agency) accredited labs of which there are only a few in the world.

So you really have to demonstrate that you have a legitimate program that is free of conflicts of interest, that’s done extensively as it can be, because the worst case scenario if you have positive results or abnormal results, you want to be able to back those up to the extent to which you need to.  So it took months and months.  It took about eight months to really get this program set up the way it needed to be.  And obviously it’s a learning process, but I think we’re in keeping with any anti-doping program as far as having the most stringent protocols and features in places.

Who covers the cost for those collectors and for all the other things that are entailed in the testing?  Do the fighters pay for it or is it through your organization?

 Well, it can be a done in a number of ways.  Practically, we’re a non-profit, so we survive on contributions and donations.  So it can be done that way.  And in some instances, for example, with BJ Penn and Rory MacDonald, that kind of instance, because we wanted to demonstrate what our program is all about and those athletes had volunteered to submit themselves to our testing, we’re covering the cost for it.VADA is based on donations.  However, athletes or promoters can pay to have their fighters tested, which can be either written off as a business expense or as a contribution.  The fighter themselves can pay for it.

Obviously, it’s a little bit different than the testing that’s now done in athletic commissions in that we include testing for human growth hormone (HGH), for erythropoietin (Epo).  We also do more extensive anabolic steroid testing that includes carbon isotope ratio testing.  So all of those things are more costly than you would have with an athletic commission typically.  But the main point, it wasn’t so much that we were trying to set up VADA as a testing program as much as it was supposed to be an educational program.  And so you’re looking into it, other media entities are looking into it, the fighters are looking into it.  It just opens up the discussion.  That was the whole point.  The bottom line was not to have fighters lining up around the block asking to be tested, that certainly wasn’t the point.  It was the educational aspect.

And there’s so much misinformation out there still.  You still hear the discussion of whether or not testosterone is an anabolic steroid, and that just shouldn’t be a part of the confusion out there.  This should be something that should be understood and known.

One thing I always said when I was a ring physician, and I always go back to this, I would talk to fighters at weigh-in and you try to, while you’re examining them, hear them talk and so you get an idea of where they are at during that point in time, so that when you’re working their fight, you know more about when there’s changes going on as far as neurological changes especially.  But I used to try to talk to them about substances and even simple things like why aspirin is dangerous to take before a fight.  And so you find that there was a lot of misinformation and lack of knowledge in simple things like that in understanding that it (aspirin) would make them bleed, or be harder to stop a cut.

So there were those kinds of entities.  And so that’s really the main point of what we’re really trying to do with VADA is be an educational resource for athletes to understand what’s safe for them to take, what’s not safe for them to take as well as what’s legal and what’s part of clean sport.  And it also was supposed to be a way for athletes to take control over their own career.

That was always something that always bothered me and continues to bother me a great deal in that they’re kind of at the behalf of either the networks or the promoters.  They themselves don’t have as much control over what they’re doing.  And this is a way for them to demonstrate that and also to maybe, I would like as time goes on, to be a resource for what you’re doing as far as educating athletes about safe ways to drop weight, safe ways to put on weight, safe dietary habits, fluid replacements, avoiding dehydration as well as substance abuse and also be a way for athletes that are abusing these substances to have someone to go to.

One thing that VADA has is we have a psychiatrist and a psychologist available that has a lot of experience in the fact that there’s almost (never) a day that doesn’t go by anymore where you’re seeing either an MMA fighter or boxer or somebody getting arrested, somebody having problems with drugs or psychiatric issues.  And there has to be someplace for these athletes to go and seek help.  And obviously, athletes in football or baseball have players’ unions.  They have somebody to contact.  But boxers and MMA athletes don’t have somebody specifically to contact.  So we want to be a resource for that as well.

 Do you think mental health is something that’s not really addressed, that it’s kind of an unspoken issue in combat sports? 

Oh, I think it’s a big problem.  Whether you want to chalk it off to – and this is something that I’d written about in The Ring before, you know, whether you want to chalk it off to head injury that are contributory to it, all you have to do is look at what’s going on in the NFL as far as the football players that are in litigation and the class action suits going on for injuries that they’ve sustained and for evidence of possibly chronic brain injury as a result of their sport.

You obviously see that in boxing, in MMA, but it’s also tandem with psychiatric issues: depression, violent outbursts, perhaps even bipolar disorder.  You see all these things going on and obviously in the general population there are problems. They get ignored, especially in athletes.  I’ve written about this too for The Ring. When it happens after someone loses the fight.  Nobody wants to talk about it.

I think too often after a bout people say, “Oh, the guy’s tired or who wouldn’t feel depressed,” but these things get pushed under the rug.  The athletes have to pretend like it doesn’t exist.  And then you combine that with athletes that have been using performance-enhancing agents, and then you’ve got depression, whether or not that’s related to the usage, whether it’s related to their career, whether it’s related to getting hit in the head, it is a big problem that gets ignored.  It should be treated sort of strongly as a broken hand, a tendon injury, a cut.  But it gets ignored and not talked about.

And when you see these athletes – I think there was a period of time where you had a few MMA athletes within a couple of years that had either been victims of silent acts that had resulted in their death or have taken their own life or substance abuse that have resulted in their death.  And it’s just so sad that it gets ignored.  But it certainly shouldn’t be.  And the more that you see these fighters fighting, the more injuries you see, the more problems that they’re having, they have to be recognized.

The UFC has this great insurance policy that they’ve started for athletes that have injuries.  I hope that it includes access to psychiatrists and psychologists for them.  I don’t know that if it does, but I would hope that it does.  But that would be a good question to find out.

Have you found that you’ve gotten some resistance by fighters or promoters or has VADA been received as a good idea?  Are they ambivalent?  What’s the feeling that you’ve gotten out there? 

I think there’s the element of ambivalence.  I think just when you start anything new, there’s a strong element of fear as far as nobody wants anything in existence that’s gonna stop fights from happening.  It’s the same thing I faced when we started requiring MRI and MRA scans. It’s like, “Well, wait a minute.  Yeah, nobody wants to see anybody get hurt, but you guys may start finding things that are going to impede or stop a fight from taking place.”  So it’s the same kind of thing.  And obviously, that is an issue and I certainly understand that.  But unfortunately, performance-enhancing drugs are a part of the sport, on both sports, boxing and MMA, and need to be addressed.

And everyone likes to say that they want to protect the health and safety of the athletes, but it’s not an easy thing to do.  So yeah, I wouldn’t say we’ve had resistance so much as, number one, obviously there’s expense involved and the time commitment.  You have athletes, especially a lot of the MMA guys, that have participated in the Olympic programs and are used to being tested throughout the year, so it’s not as much of an unknown to them.  But it is a commitment.  You have to make yourself available.  You have to let our organization know your whereabouts at all time so that if you are called upon to be tested, you have to be available.  So there’s that entity.

I think that there is a strong element of fighters out there that want their opponents to be clean, they want to demonstrate that they’re clean, and I think that this is a way for them to do it.  And so we have had a lot of positive feedback.  I think if there’s any group that’s given us the greatest positive feedback has been the fighters themselves.

That’s good to hear.

Yeah, which is really cool.  I think that’s what you’d want.

Definitely.  You mentioned there’s the you, WADA and the USADA, how do you guys differ?  What’s the niche that you’re filling that they (WADA and USADA) may not be?

Oh, obviously we’re just geared towards boxing and mixed martial arts.  That’s one entity.  With USADA, typically the athletes that they’re testing are doing 365 days a year. We’re predominantly geared towards beginning our program for an athlete eight weeks before they have a competition, although we do have athletes that are willing to, and we have boxers that are, doing it for an entire year, which was certainly difficult to coordinate.  As for as the exact other aspects, I would say that as far as you look at the protocols that we have and our policies, they’re probably very similar.

How well have you interacted with the state commissions?  What interaction have you had with Nevada or with the other big state commissions like California or New   Jersey?

We haven’t had to interact with New Jersey, but, for example, when the Penn-MacDonald fight was to take place in Toronto, I had a really good interaction with Ken Hayashi who heads the Ontario Commission and they were very positive about us forwarding the results to them.  The Association of Boxing Commission has been very, very positive and has welcomed us forwarding the results. And really, what we try to do is to be as transparent as possible and keep everyone in the loop, so to speak, so that whether it’s a boxer or MMA fighter, we let the record keeper that’s appointed by the Association of Boxing Commissions know that fighters are in our programs and forward the results to them.  We’re a new program and we haven’t had huge numbers of athletes that we’ve been testing, but we’ve certainly made our program available to athletic commissions.  I hope to be able to do that even more soon as far as offering educational tools on supplements, etc.  But no, I’ve had really good response so far.  Haven’t had any issues.

How about the MMA organizations like the UFC, what kind of interactions have you had with them and why do you think they don’t adopt these independent testing services regularly?

I don’t know why.  You would have to ask them.  So far we’ve had very little interactions because we’ve really just had the first two years. But we’ve been in contact with them and will continue to keep them informed as far as the test results.

I’ve had really good contact with Bellator with Bjorn Rebney who really is very excited about our program, very positive.  I think that the only issue with Bellator would be for them to not adopt something like this is the cost.  Obviously they’re a newer entity, they’re just getting started and advancing themselves more and more.  So I think it probably wouldn’t be fair to expect them to be able to cover a program like this, but they’ve been very, very positive as far as anxious to even have us include their athletes in the VADA program.

 That’s also good news. When Rory MacDonald pulled out of UFC 152, do you think that was a setback?  You guys already got your message out there, so was it really a setback?  What are your thoughts on him having to pull out?

Obviously, injuries happen.  I saw photos online of the cut; it was a really bad cut in a bad place.  Obviously you need extensive time off.  I think that probably fighting in December is probably the right thing, to give that enough time to heal because of the location.  Headgear can’t really protect  that type of injury that much.  So it’d be hard for him in terms of training.

One of my biggest pet peeves as a ring physician was that the time off for cuts to heal was often not long enough and fighters would get back in and training in the gym and have a fight scheduled way too soon.  And so not necessarily that cut would open up again, but an adjacent area would be predisposed to cutting and it just wasn’t really right.  So, I think that the time that they have, that they do reschedule it for December 8 is probably the right time for Rory.  And sometimes it can work positively or negatively.  I think it was enough before the scheduled fight that it probably will be a positive.  I think the hard part with fighters I’ve seen on multiple occasions is when their fight gets cancelled a few weeks before the fight, two weeks or a week before, something like that.  They spent all this time training and to go back and continue the training, especially if it doesn’t get postponed that much, they can be over-trained and then that can be an issue, but that’s probably not going be an issue here.

Everyone’s talking about testosterone replacement therapy now, or TRT. What are your thoughts on it?  Do you see it as a performance-enhancing drug?

Well, number one, it’s obviously a performance-enhancing drug.  I think that the sad thing is that it’s advertised on television and in the media, online, etc.  I think I was watching an Olympic event and the commercial was for Androgel.  And I think that’s just really, really sad because for athletes it makes it more difficult for them understand.  It’s like, “Wow, people are advertising.  Go get it.”  But the problem is is that a healthy athlete shouldn’t need it.  It’s definitely performance-enhancing.  It obviously has a whole host of side effects besides being cheating.

And it’s just something that’s just not – after all of the discussions that have taken place online and in newspapers and from a lot of the shows that cover MMA, it should be a known fact that whatever form it’s given in, whether it’s Androgel you get from a doctor, that it’s a performance-enhancing drug and is illegal and should not be necessary for essentially just about any fighter.  I think that for someone to get a TUE for it, it should be – I’m trying to think what would be the right way to put it.  I just think that it should almost never be necessary for a fighter needing a TUE for testosterone or an anabolic steroid.  I just think it’s just way overplayed at this point.

Some people point to the fact that there are some studies that show repeated head trauma can cause pituitary dysfunction and that may cause low testosterone.  There may be a loose connection with repeated weight loss also. Do you think these are all valid reasons or do you think these people are doing this to support their idea that they want to use it?

I just think that probably 99.99% percent of the reason why a fighter needs it is because they were using anabolic steroids before.  I think if somebody needs it because they damaged their pituitary that significantly that their hormones are inadequate, then they shouldn’t be fighting.  Then they obviously have had enough trauma in their head.  It demonstrates they shouldn’t be in a cage or a ring or anywhere near anything where they’d continue to take punishment to their head.  So I think the answer is right there.

 So basically you’re saying that, if you’ve taken so many steroids or you’ve taken so much punishment that you need this therapy, that’s pretty much a red flag that you shouldn’t really be competing anymore. 

Yeah, I think.  The point is that it takes a long time to come off of it, to get your level back to normal.  If somebody was using it as an anabolic steroid for performance enhancement, obviously coming off of it can take months and months till you get your hormone levels back to normal.  I’m not even sure exactly.  It can take a year before you normalize again and feel good again.

So my point being is that unfortunately, I’m not saying it would take a year to determine if somebody really needed it or not, I’m not an endocrinologist, I would certainly use an expert opinion to help me with this, but bottom line is that from what I’ve learned is that it takes an awfully long time off of this stuff to really get your levels back to normal.  So I would hope that the commissions that are granting Therapeutic Use Exemptions are taking enough time and looking at all the various hormones that are involved, just not the testosterone levels or T/E levels to determine whether or not somebody needs a TUE for testosterone or not.  I think that almost never is it indicated.

Do you think that there is enough endocrinologist (hormone doctor) representation out there?  Because it’s usually ringside physicians being involved and they’re usually the orthopedic guys or neurology guys or emergency docs, but I don’t think there’s a lot of endocrinologists really in this business.  Do you think we need to get more of them involved?

Well, that’s a good point because I was talking to someone from the Association of Boxing Commissions and I was saying that they really need to put together a committee of physicians including endocrinologists with experience in this to have a uniform standardized determination of when a TUE is indicated, if at all, for somebody that’s asking to use it.  I know that there are individual commissions, for example, New Jersey does a really good job in this.  But I think that it should be more uniform because this is a problem that it’s hard if one commission grants somebody a TUE, it’s hard for another commission to say that individual doesn’t deserve it.  And so there should be a standardized way, and, yes, I think it takes endocrinologists that are well-trained.

And according to Dr. Catlin, there are really only a few people in the world that really understand when a TUE is truly indicated for an athlete.  And that’s why so few are recommended through the World Anti-Doping Agency or probably USADA because there are too few individuals.

But because it has so many serious repercussions for the athletes themselves, I think that it behooves the Athletic Commission before they grant TUEs for testosterone to really seek out these individuals to form a committee.  But yeah, I agree with you, it really needs people with that type of expertise to make determinations, because otherwise these things are given and it starts this vicious cycle for this athlete for a substance that obviously can have great harm for them down the road.  It’s unfair to their opponent and probably, and more often than not, they shouldn’t have been given it in the first place.

 What do you see as the biggest medical issue in MMA now and what could we as the medical community do to better address it?

I think being involved on these boards for so long, there’s so many different things.  I don’t think there’s one.  I think most ring physicians would tell you, the biggest problem is lack of standardization in testing, pre-fight recommended testing, post-fight evaluations, examinations that need to be done.  Obviously, performance-enhancing drugs are a big problem, but I think the biggest problem from a medical standpoint in MMA and boxing itself is just lack of standardization.  And this has always been the issue as long as I have even known about the regulatory aspect of these sports.  And I think if you talk to any athletic commission around the country, they’ll tell you the same thing, that that’s the biggest problem out there.  There’s just no standardization.

You go to one venue in one state or wherever, if it’s a tribal nation where you’re competing, there’s just no standardization.  And so you may need a general physical, you may just need an HIV or Hep screen.  You may not even need that in one of these states and then in the other state you need MRI scans and ophthalmologic exams and blood work and EKGs and chest x-rays and urine exams, and it’s just not right.  And it just creates an atmosphere where promoters and even fighters can commission shop depending on what they want to undergo or not undergo or perhaps even want to keep medical issues hidden or not found out.

That’s always been the biggest problem and that’s why so many people continue to say there needs to be some kind of federal oversight.  The one thing that isn’t understood is that even though MMA fights take place in many state commissions, MMA is not under any kind of federal law like boxing is.  And that’s a big problem.  It’s not discussed.  It’s ignored.  I know that most commissions would like to see it under federal law, but it’s never pushed by anyone specifically.  And I think it’s toward the detriment of the sport and it’s definitely to the detriment of the fighters.

Who would be in charge of that? How would you be able to create a national standardization?

A lot of people talk about having a federal boxing commission or a national boxing commission. The problem is there’s so many political aspects to it for people that are against it, even athletic commissions that are against it because everyone likes to have their own piece of the pie and have everything state controlled with no one telling them what to do.

There’s certainly a large subset of athletic commissions that would like MMA and boxing under some kind of federal commission because it would help them, it would give them more power, more juice to standardize things.  But then there’s the whole subset of prominent athletic commissions that don’t want these things more federally regulated and things taken out of their hands.  They’d like to be able to make their own decisions and worry about any kind of federal oversight.

So you need politicians that are willing to stand up and ask for that, and unfortunately, there’s so many other things on their plates, it just never happens.  And there’s so many lobbyist type groups that help these politicians that it just never gets pushed through.  That’s got its own hour of discussion.

Dr. Goodman raised many important points, many of which can be addressed through education. It is the goal of this website to bring together fighters, fans, and medical professionals to spread real information about medical MMA issues.

FightMedicine.net would like to thank Dr. Goodman for taking the time to talk to our site. She is truly a pioneer in ringside medicine and has the fighter’s best interest in her heart. You can read more about VADA at vada-testing.org.

You can also read more about what Testosterone Replacement Therapy really is here.

Jonathan Gelber, M.D. is licensed to practice medicine in the State of California

Follow @FightMedicine

Get updates on future interviews and articles by Liking facebook.com/FightMedicine

FightMedicine.Net would also like to thank Sandra for her transcription services. She can be reached at sh.transcriptions@gmail.com

Erik spoke with FightMedicine.net about his injury, rehab, and insurance coverage.

FightMedicine.net:  What injury did you suffer?

Erik Koch: It’s a partial tear of the MCL. It’s exactly what Dan Henderson had.

How did you get your injury?

I was training back in my home town, Cedar Rapids. I was here for a family reunion. I decided to get a little extra training in. We had a really hot, sweaty practice and I was grappling on a wrestling mat. I was trying to pass someone’s guard and my toes got caught on the wrestling mat and my knee ended up going in an awkward way. I heard a pop and immediately after my leg stiffened up. The only ligament damage I had before was years ago in me elbow. My knee got really, really stiff. I couldn’t really straighten it or move it. Then the pain came about 20 minutes later. My knee started swelling up and by the next morning it was immoveable.

Did you see an orthopedic surgeon?

Yeah, I went to Iowa City and they did the MRI and checked the report. Luckily I don’t need surgery, just four weeks of rehab

Were you given a hinged knee brace to wear? (The hinges on the knee brace provide side-to-side support, which in this case, is needed when the MCL is injured)

When I first went to the Emergency Room, I was given a knee immobilizer (A long brace which keeps the knee locked out straight in full extension). They gave me crutches for a couple of weeks.

So the timeline is that you will be cleared to return to training in 4 weeks?

Yeah, 4 weeks of rehab and I should be good. Honestly, the pain isn’t terrible. It’s painful, but it’s more that it’s very uneasy. I can’t really pivot or turn. It feels like it’s about to slip out of place. It feels more weak than anything.

Do you have access to Physical Therapists and formal physical therapy?

I am actually going to do my physical therapy here in my hometown. I am also going to look into PRP (Platelet-Rich Plasma – a treatment where your own blood is spun in a machine until it separates into specific layers containing healing factors and is injected back into your injury. This will be a future fightmedicine.net article). I have heard it’s good for recovery and a lot of football players have had it done. I start my therapy on Thursday.

The PRP issue is a little controversial. The literature is divided. Some studies say it helps and other studies say there is no benefit. The biggest issue people have is that it costs a lot and may have no benefit. It’s often a question of whether your insurance will cover it.

It’s one of those things that it couldn’t hurt, I guess.

Does the UFC cover you under their insurance while you are on their roster (a relatively new development)?

In the fight game, people often don’t have insurance. Under the UFC, everything is covered. It’s included in my contract as accidental insurance. If I get hurt training, they cover it; the MRI; the rehab. If I do PRP, that’s covered. If they didn’t do this for me, I honestly don’t know if I would do it.

When was your fight scheduled for? How would this have affected your training camp?

The fight was scheduled for October 13^th. Since we are six weeks out, I would only have had 2 weeks. This would have been the biggest fight of my life. I am a big featherweight. Just cutting the weight to get down would have been a mess. I am the type of guy that is willing to take the fight regardless, but I have a group of people  behind me that try and look out for what’s best for me and want to see me at 100%, so it’s probably the smartest move. I also don’t want to damage anything further. It has probably been the worst week of my life thinking that I needed surgery. Just because I could feel the injury, I knew it wasn’t good. But when they told me that I didn’t need surgery, it was a load off my shoulders.

How does it work when you get an injury? Do you call up Dana White?

My management does all of that. I don’t talk to anyone directly. The only people I talk to are my coaches and my manager. They do their job and do what’s best for me.

You said that this was the fight of your life. You obviously don’t want to let it slip by. Has anyone told you that you could still get a title shot?

As of right now, I haven’t heard anything. Nobody has told me I am going to fight. It’s one of those things where I just want to fight. I have trained for Aldo for about 9 months and we ended up not scrapping. I am just going crazy! Training as hard as I am and not fighting in general is driving me nuts. I just want to get back in there.

Do you have a feeling between Frankie Edgar and Jose Also who will win?

I think Aldo will win. I think it’s a bad match-up for Frankie. I want to fight Aldo. I’ve trained for that guy so much it just feels like a waste if I don’t. I have done so much PR and stuff like that with him and we never got to fight. It’s one of those things I’ve wanted back in the WEC days, so I am pulling for him.

Have you noticed any differences between WEC and UFC as a fighter?

The only difference to me is the popularity. A lot of people knew the UFC but didn’t know about WEC. People are paying attention more and the fan base is getting bigger. The only big thing is the popularity that the UFC branding brings.

Do you think the merging is a good thing or do you worry that some of these weight classes will be lost in the shuffle?

I thought it was a great idea. WEC was only 3 weight classes so you might as well merge it with the UFC. For us fighters, its better. We make more money. We get our name out there. I think the lighter weights put on the more exciting fights, so I think the switch-over was a great idea.

Looking back on your injury, do you think there is anything you or other people can do to prevent these injuries from happening?

Until this year, I didn’t get hurt a whole lot. One thing may be overtraining – just not letting your body get enough rest. I am the type of guy that is a workhorse. I like to outwork my opponent and train more and know that I am training more. But that can be your downfall. You can work your body until its weak and then that when something slips. That’s when you hurt yourself. Honestly, I would just say smart training.

How do you find that fine line between not training enough and possible gassing during a fight versus not training enough?

Everybody is different. You just have to see how your body feels. If you are dead and can’t do anything and can’t push that extra mile, it might be better just to take that day off. That’s one of the things I’m guilty of. I always say I am going to take weekends off to recover for the next week, but I never do.

Erik has volunteered to keep fightmedicine.net and his fans updated with progress on his recovery as he goes through his rehab. We thank Erik and look forward to hearing more from him and wish him a speedy recovery!

For more from Fightmedicine.net on MCL Injuries, click here.

Jonathan Gelber, M.D. is licensed to practice medicine in the State of California

Follow @FightMedicine

Get updates on future interviews and articles by Liking facebook.com/FightMedicine

Keith Kizer, Executive Director of NSAC

In our continuing coverage of Testosterone Replacement Therapy (TRT) and its associated issues in MMA and combat sports, FightMedicine.Net interviewed Keith Kizer, Executive Director of the Nevada State Athletic Commission (NSAC). Since there is no federal oversight of athletic commissions, each state has their own. With a large majority of fights taking place in Las Vegas, most other commissions look to the NSAC to set the standard for other commissions. In the first part of our interview, Keith discusses how the NSAC tests for TRT and how a fighter is allowed a Therapuetic Use Exemption (TUE). He also discusses other organizations out there such as the World Anti-Doping Agency (WADA) which tests on an international level such as cycling and the Olympics. If you missed our primer on TRT basics, you can see it here.

FightMedicine.Net:  A lot of people have been talking to you about testosterone replacement therapy (TRT). What are your thoughts? Do you see TRT as a performance enhancing supplement or drug?

Keith Kizer:     Oh, it could be.  It certainly could be.  I don’t know anyone that could argue that it couldn’t be if it’s abused.  The general idea, of course, on all this is therapeutic use.  If a contestant, be it a fighter or be it another athlete, has a legitimate medical condition and there’s a way to treat that condition in such a way that it doesn’t put the fighter in undue risk or give the athlete an unfair advantage, they should have that right.  Just like you and I would, if we had similar condition or the same condition, that we have the right to get medical treatment.  And it does bother me a lot of people almost act like these fighters shouldn’t have basic rights to medical treatment or would have to choose.  And there might be some situations, there might be some medical conditions, where they do have to choose between fighting or getting treatment.

Or maybe it’s a situation that you don’t get a choice, you can’t fight anymore.  If you know you have this serious medical condition and there’s just no way to treat it in such a way to make it safe for you to keep competing then you need to retire.  And that’s happened with a lot of athletes, of course, over the years – not just fighters, but especially fighters, because it is such an inherently dangerous sport.

So with all that in mind, you want to have a situation where you have some therapeutic use exemptions, when applicable.  And as you probably know, it doesn’t mean that you get the drug of your choice or you can take as much of it as you want.  It’s very seriously regulated and monitored. I saw the interview with Bas Rutten on your website that you gave the other day and he said – and I don’t blame Bas for this, it’s not his fault he’s wrong because he’s got people out there saying this stuff; But he said “You need six times the normal amount,” or something, and it’s just not the truth by any means here.

These fighters who are entitled for TRT, for example, their testosterone levels need to be below normal.  It can’t just be low normal, you have to be below normal.  And then we look at things like cause and condition and treatment plan. And in the fighters who do get the exemption, we closely monitor them.

And sometimes even with the treatment, they’re still below normal or they’re on the lower half of normal.  So it’s not like I can get TRT and I get to shoot up to 1100 or even 800 (Total Testosterone Level).  And these fights, I know the last couple we’ve had, the fighters have been below 300. And we look at the total testosterone and the free testosterone. We look at the FSH, the LH, the hematocrit and the hemoglobin levels. These are the main six things that our personnel will look at.

So all that stuff comes into play in addition to other information they need to provide us.  So yeah, it’s heavily regulated.  You hear people say things like, “Oh, once you get a TRT TUE (Therapeutic Use Exemption), you can take as much as you want or you can get your levels to that of a 20-year-old; Or they can be like Bas commented, six times the amount or something, which is just not the case. We basically follow what WADA (World Anti-Doping Association) has set forth on these exemptions. And then add in some additional requirements on the athlete to prove their case. It’s a burden for them to make the case.

But modern medicine has grown by leaps and bounds in the last couple decades.  And it’s a great thing for all of us, not just athletes.  And it’s good that you have these treatments that you may not have had even ten years ago.

But if you’re involved with any type of regulated substance, you need to get clearance and you need to go through all the proper steps.  And in some situations, including with TRT, we’ve had some situations where fighters have not met those requirements and they’ve not been able to compete.

It seems that most people worry about, not that a fighter needs it medically, but fighters or doctors abusing the prescription of TRT.

We’ve had some people apply for TRTs that perhaps follow that category and they were not granted.  It’s a very high burden on us as well to do the homework and our doctor talks with the fighter’s doctor and reviews all the medicals. There’s a lot of medicals we get, and if there’s any issues, that’s definitely addressed, including up until the point of saying, “Sorry, you’re not competing.”

 Do you think more of the abuse is on the medical side or on the fighter and his camp’s side?

Well, I don’t know if that’s mutually exclusive.  I gave an interview awhile back and I was actually on the phone with a medical facility to get some information that had nothing to do with drugs, but they had an infomercial, or whatever you want to call it, on hold.  And it was like, “Check with your doctor.  See if you might have low testosterone.  There’s new treatment plans available to help you with that.”

So it’s obviously being pushed pretty hard, and not just for athletes, but for all type of men– especially in the 30 plus age bracket.  And there’s probably a lot of doctors out there taking advantage of this.  You got a 45-year-old recently divorced man who wants to get back on the dating scene, and he goes to his doctor and his doctor says, “Hey, look, I can make you look a little younger here and give you a little more energy here.”  And that’s abuse by the doctor, and hopefully the medical boards handle situations like that.

So I think it’s a situation where there’s probably a lot of non-athletes out there who either want to look better or they want to do better on their softball team on the weekends or something like that.  And it’s unfortunate.  I think it is a situation where doctors see a lot of dollar signs and some of them are going to act improperly. Other doctors, though, they have legitimate patients who have legitimate concerns with low testosterone and they’re going to be able to treat them and get them the help they need.  That, again, probably wasn’t available ten years ago.

But the flipside, though, is that the athlete is the ultimately responsible party here. And I’ve told other athletes who’ve been on this, “Look, you talk with your doctor. You’re entitled to this exemption, but you better play it conservative with your treatment plan.  I’m not going to tell you how much to take or how much not to take. That’s up to your doctor talking with our doctor on this“.  I think there’s always going to be a feeling in a lot of these athletes, “If I take this much, I’ll get to be healthier and good and it won’t give me any kind of advantage or anything, but it’ll give me the medical treatment I need, so why not take twice as much?  Why not take three times as much?”

I think that’s probably true with other drugs too; probably with pain medication.  Your doctor tells you, “Hey, look, I’m going to give you some pain medication for your injury. You should take no more than two a day.”  There’s people who take four a day, six a day, eight a day. Because why not?  Why not take four?  If two’s great, four is going to be doubly great.

I think it’s always important to recognize that situation.  Part of that is human nature, I guess.  It’s very important to let these athletes choose for themselves – but we monitor them.  We test them a lot before the fight. We test them at the fight night. We test them the morning after the fight.  And if they’re at a level that they shouldn’t be at with their approved treatment plan, they’re subject to discipline as if they had no therapeutic use exemption whatsoever.

Keith Kizer Ringside

When you do review TUEs, who’s on the board that reviews these exemptions?  Are there ringside doctors or endocrinologists (hormone specialists) on the committee?We have a consulting physician who does all of our medical information.  Timothy Trainor’s his name. So he does all that stuff, and he’s the consulting physician for the Commission. What he does is he’ll go out and review the information. He’ll talk to experts in the field if it’s something beyond his basic level of practice or knowledge.  And so he’ll have his consultants and specialists he’ll talk to, in this case endocrinologists or something along those lines, that helps him in these issues.

There’s also a broader policy type issue.  We have a medical advisory board or medical advisory panel, which we have doctors with various different specialties that come onboard and, again, if it’s something that doesn’t fall within one of their specialties, we’ll invite other experts in the field – specialists in the field – to come and testify before the panel.

You mentioned you follow the WADA (World Anti-Doping Association) rules. Dr. Margaret Goodman is promoting VADA (Voluntary Anti-Doping Association) as a voluntary alternative.  Is there a need that she’s trying to fill or do you think that it’s something that you guys are doing fine on your own? Or is it something that you guys could do together?  What are your thoughts on that?

 Well, my basic view on drug testing is the more the better.  So if fighters or promoters want to sign up for additional drug testing, supplemental drug testing is probably the best way to word it, in addition to the primary testing done by the Commission, I’m for all that.  Obviously, there’s a price issue there with athletes or the promoter whether they’re willing to spend it or not, but we basically test almost everybody.  Most fight cards we test every athlete.  Some, if they’re out of the way or somewhere, we might test only 70% of the athletes, or something along those lines.  I think in the Olympics they test about half, so we test a hell of a lot more than that and we’ll continue to do so.

But they have the supplemental testing, whether it’s done by USADA (United States Anti-doping Association, a branch of WADA) or VADA or somebody else, that’s something for the contracting parties to decide.  But I definitely would be in favor of any additional drug testing that the applicable parties want to do.  But I’m not endorsing anybody.  I know USADA and VADA have had their war of words with each other because they both want that dollar from the promoters.  And they both have their PR people masquerading as journalists in the press or in the blogs pushing for them.  I make it easy.  You want to do a fight here in Nevada?  You have to come through the Commission and we’re going to do any test we want to do.  If you don’t like it, you’re not fighting here.  It’s very easy.  There, they have to fight it out, a peer battle and put each other down and put other people down and try to get that buck, that ever important buck.  We don’t have to do that.  So I just want to make it clear that we’re not endorsing anybody.

You mentioned Bas talked about six times the testosterone limit.  He was probably talking about the T to E ratio. Where did that range come from?  Some commissions allow six to one, others allow four to one. Why is there a discrepancy in that? 

 I think that it is just a matter of what standard deviation you want to go.  I think four to one is two standard deviations and six to one is three standard deviations from the average.  As you know, not all doctors out there realize this.  One guy gave his interview not too long ago saying, “You can’t be two to one naturally.”  And, of course, you can.  You can be five and a half to one naturally.  I don’t think he ever publicly corrected that. And that’s unfortunate, but that’s who he is.

But you can be two to one naturally.  You can be three to one naturally.  You can be five to one naturally.  So the average is, of course, one to one.  I think that’s funny because I think one of the people who was complaining about the six to one that we have, and New York has, and the NCAA has, said, “We use four to one.”  And I think the reporter asked him, “Well, why don’t you go to two to one then?”  And he had no good answer for them.  And then it was a pair of question, “Well, why don’t you guys go three to one or two to one?”  “Well, uh, uh, uh…”  It was kind of strange, but I think a telling response.

And the six to one, of course, came from what?  That’s what WADA has used for most of its existence.  Most of the time they’ve been doing T/E ratios, they have used six to one. You don’t want to brand someone as a cheater.  You don’t want these false positives.  To me, a false positive is a lot worse than a false negative.  It’s the whole thing about sending an innocent man to jail or a guilty man going free.

And here in Nevada, these are public records.  We don’t have the luxury that some of these semiprivate or semipublic groups have of keeping these things private.  So you’ve got to be very, very concerned about that.  So it’s very important.  But yeah, it’s a good debate.  I’m by no means saying six to one is definitely the answer or four to one is definitely the answer; but there’s arguments for both.  It was only about five or six years ago that WADA went to four to one. I think this is only the second Olympics, actually, that they used the four to one ratio.

I know I talked with the California Commission.  They went from six to one to four to one about two years ago. When I checked with their recently departed executive officer a couple of months ago, I said, “How many guys did you get – that you test – that fell between four to one and six to one on their T/E ratio?”  And he said, “Keith, absolutely nobody.  Of the hundreds we tested, nobody.”

And I think other states I’ve only heard of one situation where the person was between four and six to one.  Again, that doesn’t mean that four to one is not the better ratio to have.  But there are definitely some pros and cons of both.  Obviously, you probably want to be as close to that one to one as you can be with the ability to make sure you’re not unfairly accusing somebody of a violation that they did not commit.

It seems most people now in the media are talking about TRT. Do you think steroids are less of a problem now or do you think it’s just being overshadowed by TRT?

 I don’t think it’s been overshadowed by TRT.  I don’t know.  I hope so.  I give a lot of credit to Congress on this.  I remember when I started out here, still, there were a lot of people, it was a small but vocal minority who would say, when people get caught, “The only real crime is that they didn’t cycle correctly.”  They didn’t really see it as cheating.  They didn’t see it like jumping on a subway during the Boston Marathon.  They were more so, “Oh boy, next time hopefully I’ll cycle better.”

And again, it wasn’t most people. Most people did say, “It’s cheating.”  But you didn’t hear much about that.  And then I came out and did what I needed to do to push this stuff, and I think we’ve had dozens and dozens of people we’ve caught.  And we started with a leniency and now it’s been ratcheted up to some pretty serious penalties for these fighters.  But your ultimate goal is always deterrence and education.  And I hope that came out.  But Congress, I think, when they had their hearings on baseball, I think more and more people started seeing this as, “Hey, this is straight up cheating.  This is nothing about, ‘Can you sneak by,’ or the old saying from pro wrestling, ‘Oh, if you’re not cheating, you’re not trying hard enough,’ ” which people laughed about it when it came to steroids.

I think in great part because of the Congressional hearings, a lot more people not only see this as cheating, but they see it as very serious cheating.  Especially in a sport like MMA and boxing and kickboxing, where you can seriously harm your opponent, I think that comes into play.

I can tell you we’re testing more people than we ever have.  I think when I took over for Marc (Marc Ratner, former NSAC executive and now VP for UFC) back in 2006 we probably were testing about 25% or so of the fighters.  I immediately jumped it up to over 50%, and now it’s close to 100%.  It’s very rare we don’t. Like if we have a fight in the middle of nowhere, which we occasionally do, we might have only testing of the winners. That’s still 50% of the people we’re testing – a lot more than any other commission. But for most fights, we’re testing 100% of the people on the cards.

And I think that’s very important to do that.  But it took time.  It takes a lot of different aspects to it and we’re able to finally get some help with some independent drug testing collectors who come out to the fights and collect the urine on fight nights for some of the fights, the earlier fights, which have a been big help.  Because our inspectors were doing it, of course, they had to also worry about hand wraps and gloving and being in the corner and checking on the fighters after the fight in the back to make sure no one’s having an episode 20 minutes after their fight ends – which unfortunately has happened at times.

So having independent specimen collectors has really helped.  That got us the pushed from the just above 50% to basically 100%, where we’re at now.  We have that luxury that other commissions may not have, so we definitely are appreciative of that.  But I think at the end of the day, you don’t know.  You’ll never know who’s using and who’s not.  It does bother me when people want to use blanket statements that 90% of the people are using, and it’s just so disrespectful to the athletes.  To the clean athletes, it’s too bad.

 But people are still getting caught, so obviously people are still using. We’re doing more testing than we ever did, and in some cases testing 100% of the athletes, and very few are failing for steroids.  We’re actually having more of an issue with diuretics than anything else.  But nothing makes me happier than when we test everything, the labs are done and everybody comes back clean.  It’s a good feeling to get, and I think the message is out there and I think the promoters are pushing it in-house on their athletes.  Obviously, the press is very hard on these guys when they fail.  In the past sometimes they’d make excuses for the guys, but not anymore.

So I think all in all, it’s a very important thing.  And I think the education aspect, including your site and other sites like yours where the athletes can learn the dangers and the consequences and feel comfortable knowing that hey, the odds are very good that my opponent’s fighting clean as well.  So I think that all goes in the whole thing about deterrence and education being the main aspects.

Do you think that there should be a national standard?  Some states don’t require mandatory testing.  Do you think it should be mandatory? 

 I only can tell you about the WADA model, which I think is the best model or I’d change it.  So I think it works based on our budget. But some commissions have less of a budget than we do.  So it’s hard to blame them if they’re not doing as much testing as we can.  Other states where they have the money and they’re not doing it, I think they are apt to criticism.  But I think most states that I know, that I deal with, see this as a very important issue and are doing what they can in that regard. And you see fighters getting caught in other states, and in fact, some very high profile fighters getting caught in other states and having to face the consequences for that.

So I think most of the commissions, if not all, would like to do more than they are, but because of different constraints, including budgetary constraints, they have issues there. And it’s easy for an outsider to say, “Oh, come on, money’s no excuse.  Don’t use the money excuse.”  What do you mean don’t use the money excuse?  You don’t have the money, you don’t have the money.

It’s funny, if you ask the people making the argument to test everyone why they don’t do it themselves, they won’t answer you because their answer is, they don’t have the resources to do that. I don’t know any drug testing group that tests every athlete in their jurisdiction every week.  You can’t.  You can’t.  And if you could, it wouldn’t be fair to the athletes to do that.  But you do what you can with your resources, and obviously, we do very a good job with ours.

We would like to thank Keith Kizer for taking the time to discuss these very important issues in mixed martial arts and combats sports. TRT is a very controversial issue and the first step in having it discussed in an open and productive manner is educating the fighters and fans. FightMedicine.Net will also be posting an upcoming interview with Dr. Margaret Goodman on the new Voluntary Anti-Doping Agency (VADA).

FightMedicine.Net would also like to thank Sandra for her transcription services. She can be reached at sh.transcriptions@gmail.com

Jonathan Gelber, M.D. is licensed to practice medicine in the State of California

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