The Journal of Primary Prevention

https://doi.org/10.1007/s10935-018-0518-7(0123456789().,-volV)(0123456789().,-volV)

ORIGINAL PAPER

Brazilian Jiu Jitsu, Judo, and Mixed Martial Arts Injuries

Presenting to United States Emergency Departments,
2008–2015

Caroline Stephenson1,2 • Matthew E. Rossheim1

Ó Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract
Limited research has systematically examined injuries resulting from Brazilian Jiu
Jitsu (BJJ), Judo, and mixed martial arts (MMA), especially when compared to more
well-known or -established martial arts. These three combative sports differ sub-
stantially regarding their rules and techniques. BJJ emphasizes ground positioning
and submission, Judo rewards throwing an opponent on their back with submission
ending the match, and MMA emphasizes knocking out or forcing the submission of
one’s opponent. We examined injuries, among people of any age, experienced from
participation in BJJ, Judo, and MMA. We analyzed data from the United States
(U.S.) Consumer Product Safety Commission National Electronic Injury Surveil-
lance System to create estimates of injuries presenting to U.S. emergency depart-
ments (EDs). We compared injury profiles between sports, including estimated
numbers of injuries, their site, type, and mechanism. Participation in BJJ, Judo, and
MMA resulted in an estimated 39,181 injuries presenting to U.S. EDs from 2008
through 2015. Strains and sprains were the most common diagnoses for BJJ and
Judo participants, whereas abrasions/contusions were the most commonly diagnosed
MMA injury. Being struck resulted in the majority of injuries for all three sports.
The head was the most injured body region for BJJ and MMA, whereas the leg was
the most injured body region for Judo. Finally, the majority of BJJ and Judo injuries
occurred during noncompetitive grappling, whereas most MMA injuries occurred
during competition. Our study adds to the limited literature examining injuries from
BJJ, Judo, and MMA using data from a probability sample and is an initial step
towards understanding the national burden of injury from participation in these
sports. Given the quantity and severity of injuries sustained by participants, addi-
tional research is needed to assess the riskiness of participation and the effectiveness
of interventions, such as improved personal protective gear and mats, as a means to
prevent commonly occurring injuries.

Keywords Brazilian Jiu Jitsu (BJJ)
Judo
Mixed martial arts (MMA)

Extended author information available on the last page of the article

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Introduction

In combative sports, two opponents fight to subdue one another while following a
predetermined set of rules (Gauthier, 2009). However, the techniques permitted in
various unarmed, combative sports differ substantially. For example, in Judo,
submission is the ultimate goal, although the scoring system greatly rewards
throwing an opponent forcibly on their back (IJF, 2014). In comparison, the rules for
Brazilian Jiu Jitsu (BJJ) encourage a wider variety of takedowns, including
wrestling techniques (IBJJF, 2015). Further, the nature of BJJ and its scoring system
emphasizes securing superior positioning and forcing an opponent’s submission
with chokeholds and joint locks (IBJJF, 2015). Striking an opponent is not permitted
in Judo or BJJ, in which only grappling techniques are used (IBJJF, 2015; IJF,
2014). Mixed martial arts (MMA), however, incorporates multiple styles of martial
arts, based on both grappling (e.g., BJJ, wrestling, Judo) and striking (e.g., muay
thai, boxing, and karate; UFCÒ, 2017). Fighters’ ultimate goal in MMA is to
knockout their opponent or force them into submission.
Participants in different combative sports likely have varying injury profiles as a
result of the diverse techniques used (Pappas, 2007). Injuries from ‘‘martial arts’’ as
a whole and from more traditional sub-groups of martial arts (e.g., karate, boxing,
wrestling, and Taekwondo) have been more well documented (Birrer & Halbrook,
1988; Diesselhorst, Rayan, Pasque, & Peyton Holder, 2013; Hojjat et al., 2016;
Lystad, Pollard, & Graham, 2009; Pappas, 2007; Pieter, Fife, & O’Sullivan, 2012;
Potter, Snyder, & Smith, 2011; Yard, Collins, Dick, & Comstock, 2008; Yard,
Knox, Smith, & Comstock, 2007; Zazryn, Finch, & McCrory, 2003; M. Zetaruk,
Violan, Zurakowski, & Micheli, 2005; M. N. Zetaruk, Violan, Zurakowski, &
Micheli, 2000), whereas injury research from more recently established combative
sports (i.e., BJJ, Judo, and MMA) is available, but with notable limitations. For
example, most data on injuries from BJJ and Judo come from either case studies
(Davis, Hiller, Imbesi, & Chang, 2015; Galanis, Anastasiadis, Grigoropoulou,
Kirkos, & Kapetanos, 2014; Hashiguchi et al., 2015; Itagaki & Knight, 2004;
Kurosawa, Nakasita, Nakasita, Sasaki, & Takeda, 1996; Nambu & Noji, 2014;
Rosenberg & Beck, 2011; Shepard, Westrick, Owens, & Johnson, 2013),
convenience samples from tournaments (James & Pieter, 2003; Kim, Park, Lee,
& Kang, 2015; Kreiswirth, Myer, & Rauh, 2014; Scoggin III et al., 2014; Souza,
Monteiro, Del Vecchio, & Gonçalves, 2006), or studies examining a specific type of
injury (e.g., head and neck or knee injuries; de Sá Oliveira & Pereira, 2008;
Kamitani, Nimura, Nagahiro, Miyazaki, & Tomatsu, 2013; Koshida, Deguchi,
Miyashita, Iwai, & Urabe, 2008; Liao, Xie, & Gray, 2015; Reis, Dias, Newlands,
Meziat-Filho, & Macedo, 2015). As a result, there is limited generalizable
knowledge about the type of injuries resulting from competing or training in these
sports overall, and certainly less when compared to the more well-known and
established martial arts.
Previous research on Judo athletes (Judokas), though not collected from a
national probability sample, shows that common injuries include sprains, strains,
and contusions, and often affect the knee or shoulder (de Sá Oliveira & Pereira,

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2008; Kim et al., 2015; Pocecco et al., 2013; Souza et al., 2006). Similarly, limited
research suggests that knee, elbow, and other joint sprains are common for BJJ
practitioners (Kreiswirth et al., 2014; Scoggin III et al., 2014). Though there are
numerous MMA injury studies, most are case studies and/or focus on a particular
type of injury, such as head trauma or cervical injuries (Heath & Callahan, 2013;
Hutchison, Lawrence, Cusimano, & Schweizer, 2014; Kochhar, Back, Mann, &
Skinner, 2005; Sims & Spina, 2009; Slowey, Maw, & Furyk, 2012). Additional
studies aim to estimate the risk of injury from MMA participation, but mostly
concentrate on professional athletes and competitions, many relying on convenience
sampling; in these studies, lacerations are the most commonly reported injury, in
which the head and hand are most commonly injured (Bledsoe et al., 2006; Lystad,
2015; Lystad, Gregory, & Wilson, 2014; Ngai, Levy, & Hsu, 2008). These study
designs leave stakeholders with little generalizable information to guide preventive
measures against injury among general practitioners of these sports across the
United States (U.S.).
Compared to non-scholastic sports, injuries experienced in scholastic sports are
better monitored. There are multiple national databases for reporting sports injuries
at the high school and collegiate level (Datalys Center, 2016; NCCSIR, 2016; RIO,
2017). These databases have enhanced our understanding of the incidence of
scholastic sport injuries and helped identify risk factors for various injuries and have
provided key data on participation (Comstock, Collins, & Currie, 2014; Datalys
Center, 2016). However, few combative sports are offered as scholastic sport
options, and there is no specified reporting system for non-scholastic sports. Non-
scholastic martial arts are typically practiced at private training facilities estimated
by market research companies to vary between 8500 and 30,000 establishments
throughout the U.S., depending on whether they strictly count martial art studios or
also fitness centers that offer classes/training for these sports (Sports Club Advisors,
Inc., 2017). No study to date has systematically assessed injuries from participation
in BJJ, Judo, or MMA using a large, nationwide sample. To help guide coaches,
participants, researchers, and other stakeholders in the development of injury
prevention measures, more information is needed about the most commonly
occurring injuries sustained from participation in BJJ, Judo and MMA.
Our study aimed to address this gap by examining injuries from BJJ, Judo and
MMA resulting in emergency room visits using a national probability sample and
creating profiles based on site, type and mechanism of injury. The U.S. Consumer
Product Safety Commission’s (CPSC) National Electronic Injury Surveillance
System (NEISS) is designed to estimate the number of injuries reporting to U.S.
emergency departments (EDs; Birrer & Halbrook, 1988; Hojjat et al., 2016; Pappas,
2007; Potter et al., 2011; Yard et al., 2007) and our study is the first to utilize CPSC
NEISS data to examine injuries sustained from BJJ, Judo, and MMA.

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Methods

Data Source

Our study utilized NEISS data maintained by the U.S. CPSC. Since 1971, the CPSC
has collected data from a sample of U.S. EDs on injuries associated with consumer
products and activities (CPSC; Schroeder & Ault, 2001). Hospital EDs were
selected by the U.S. CPSC using probability based sampling, from a list of all
known U.S. hospitals with more than five beds and an ED. They sampled using five
strata, four related to the size of the hospital and one including children’s hospitals
(Schroeder & Ault, 2001). Since 1997, this sample has comprised approximately
100 of the more than 5000 hospitals in the U.S. CPSC. Based on this sampling
design, cases were assigned weights which enabled the generation of injury
estimates using SAS (version 9.4) syntax by the U.S. CPSC. The publicly available
database included information on the date of the ED visit, the body part(s) injured,
and resulting diagnoses. Additionally, a narrative was provided for each patient that
often included information on the specific events that led to their injury (CPSC).

Identification of Cases

We obtained and subsequently analyzed NEISS data for the years 2008 through
2015 from the U.S. CPSC NEISS website (CPSC, 2017). There were no exclusion
criteria based on demographic information. Although NEISS data included a
specific code for martial arts (3257), this code did not distinguish between the
multiple types of martial arts (e.g., BJJ, Judo, and MMA). We identified 6949 cases
with the martial arts code (3257) for the years 2008 through 2015. The narrative
information provided with each case often included a description of what specific
martial art was performed and the events leading to the injury. In order to
understand the general frequency that specific sport names are mentioned in
narratives, researchers examined all cases of product code 3257 for the year 2015
(n = 724). The greatest proportions of the sample had narratives that did not
mention a specific sport (31%) or mentioned karate (31%), followed by Taekwondo
(10%), boxing (10%), BJJ (7%), MMA (6%), Judo (3%), and others (2%). Using
Microsoft Excel, two independent coders searched the 6949 martial arts narratives
for mentions of BJJ, Judo, or MMA and identified 909 cases. Researchers searched
the dataset for numerous misspellings (e.g., jitus, jujitsu, jejutsu) and shortened
versions (e.g., jits, jiu, brazilian, brasilian, bjj) of each term, as well as vocabulary
that was often used in combination with the terms of interest (e.g., cage f, grap,
sparring). Researchers also removed spaces within each narrative and cases were
searched again to ensure that excess spaces did not inhibit cases identification. Our
search with these additional terms and after removing spaces was successful in
identifying 101 (10%) more total cases than were identified using the initial search
technique. The resulting dataset included 1010 cases extracted from the NEISS
database.

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Variables

Body Region Affected and Injury Diagnoses

NEISS data included numeric codes for both the body part injured and the specific
injury diagnosis. We recoded the variable ‘‘body part affected’’ into seven distinct
groups based on body region: (1) head (including face, mouth, eyeball, ear, and
neck); (2) shoulder; (3) arm/elbow; (4) hand/wrist/finger; (5) trunk (upper and
lower, including pubic region); (6) leg/knee; and (7) foot/ankle/toe. Throughout the
text, we refer to these seven body regions as (1) head, (2) shoulder, (3) arm, (4)
hand, (5) trunk, (6) leg, and (7) foot for ease of reading, modeled after similar
research utilizing CPSC NEISS data (Potter et al., 2011; Yard et al., 2007).
Similarly, we recoded injury diagnosis codes into the following distinct groups: (1)
internal head injury/concussion, (2) abrasion/contusion, (3) fracture, (4) strain/
sprain, (5) dislocation, (6) laceration, and (7) other. These variables describe the
types of injuries caused by participating in BJJ, Judo, and MMA, as well as have
been used to produce national estimates.

Level of Participation

Based on the narrative data, two independent coders assessed the extent to which
participation in the sport contributed to the injury. We created a codebook to rank
individuals’ level of participation in each sport at the time the injury was
experienced. The code ‘‘not from the sport’’ indicates that, although one of the three
sports was mentioned in the narrative, participation in the sport clearly did not cause
the injury; a narrative example includes, ‘‘at jujitsu studio playing dodgeball, fell
onto elbow.’’ We assigned the code of ‘‘ambiguous’’ when there was uncertainty
whether participation in the sport led to the injury; a narrative example of this was,
‘‘the patient tripped and fell onto corner of couch then went to Judo practice.’’ Our
subsequent analyses excluded cases coded as either ‘‘not from the sport’’ or
‘‘ambiguous.’’ Out of the 1010 identified injuries, 32 cases (3.2%) were coded as
‘‘not from the sport’’ or ‘‘ambiguous’’ and were excluded from the sample. Thus,
there were 978 BJJ (n = 304), Judo (n = 265) and MMA (n = 409) cases used in
subsequent analyses.
Additional participation codes included ‘‘at least practicing,’’ ‘‘grappling/
sparring,’’ and ‘‘competing.’’ We assigned the code ‘‘at least practicing’’ if the
person was injured while conducting training exercises or practice drills for the
sport, but either was not involved in grappling or sparring with another individual or
it was unclear whether they were grappling or sparring. Direct narrative quotes that
we marked as ‘‘at least practicing’’ were ‘‘patient sprained wrist while punching a
bag for MMA practice’’ and ‘‘training in jujitsu and had ankle pain after pulling foot
for an exercise and heard loud pop.’’ When patients were clearly grappling or
sparring with an opponent when the injury occurred but a formal competition was
not mentioned, researchers assigned the code ‘‘grappling/sparring,’’ referred to as
‘‘grappling’’ through this text. Direct narrative quotes that we gave the grappling
code were ‘‘thrown onto head during Judo class, closed head injury’’ and ‘‘punched

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in the chest 2 days ago while sparring at jutjitsu.’’ We assigned the code
‘‘competing’’ when a competition, tournament, or professional match/fight was
mentioned in the injury narrative for any of the three sports. Direct narrative quotes
that we marked as ‘‘competing’’ were ‘‘punched in the nose during mixed martial
arts match, nasal bone fracture’’ and ‘‘leg lock during jiu jitsu tournament; felt pop
in right knee.’’ Two researchers independently utilized a codebook to assign codes
to each injury instance. The code of ‘‘practicing/ambiguous’’ was a catchall
category for mentioned participation in one of the three sports without any
additional description of what the patient was doing before injury. As such, cases
designated as ‘‘practicing/ambiguous’’ were excluded from comparison in Table 2
and we only compared cases coded as ‘‘grappling’’ and ‘‘competing,’’ since those
narratives were explicitly clear regarding the participation level before the injury
occurred. There was sufficient information in the narrative for us to code for specific
participation level (either grappling/sparring or competing) in 83% of overall data,
including 83% of the BJJ cases (n = 254), 75% of the Judo cases (n = 200), and
87% of MMA cases (n = 358).
Researchers calculated Cohen’s kappa (j), a measure of inter-rater reliability,
from the participation codes between the two independent coders to assess the
internal consistency of coding practices. The Kappa value for participation coding
was 0.73, indicating substantial agreement between coders (McHugh, 2012).
Following the calculation of Cohen’s j, researchers reevaluated codes that resulted
in disagreement and a third, independent researcher assigned a final code.

Mechanism of Injury

Using the narrative data, two independent researchers coded the mechanism
associated with each injury using a developed codebook. Possible mechanisms
included: (1) striking opponent or object (striking), (2) struck by opponent (being
struck), (3) was thrown by opponent (thrown), (4) was throwing opponent
(throwing), (5) landing, (6) was fallen on (fallen), (7) hyperextended, (8) was
performing a takedown (takedown), (9) was in a submission hold (submission), (10)
was grappling but no specifics were given (grappling), and (11) unknown (n = 446).
There was sufficient information in the narrative to assign a code for specific
mechanism of injury (codes 1–9 above) in 54% of overall data, including 47% of the
BJJ cases (n = 143), 50% of the Judo cases (n = 134), and 62% of MMA cases
(n = 255). For the type of event leading to injury, we calculated a Cohen’s j of 0.85
indicating substantial agreement between coders (McHugh, 2012). A third
independent researcher used the codebook to assign a final code for the minority
of cases that were coded inconsistently.

Statistical Analyses

We used SAS (version 9.4) to calculate injury estimates and 95% confidence
intervals (CIs) for the number of ED visits resulting from participation in BJJ, Judo,
and MMA. We present all results weighted for national estimation using probability
based sample weights provided by the CPSC NEISS database.

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Results

Injury Profiles

Table 1 summarizes the injury profile for participants of each sport. From 2008
through 2015, U.S. EDs saw an estimated 12,538 injuries resulting from BJJ
participation, and the head (21%) and trunk (20%) were the most commonly injured
body regions. Judo participation resulted in an estimated 10,102 injuries nationally,
and the leg (21%) and the shoulder (20%) regions were injured most often. MMA
participation resulted in the greatest number of estimated injuries presenting to EDs
nationally (16,541), and the head (43%) and hand (16%) were the most commonly
injured body regions. Strains/sprains and fractures were the leading diagnoses for
both BJJ (4042 [95% CI 2451, 5633] and 2606 [95% CI 939, 4274], respectively)
and Judo (3602 [95% CI 2412, 4791] and 1850 [95% CI 655, 3045] respectively).
Among patients with MMA injuries, abrasions/contusions (3362 [95% CI 2022,
4703]) and fractures (2947 [95% CI 1663, 4230]) were the leading diagnoses.
Lastly, among the sub-sample with sufficient data to determine what events lead up
to the injury—47% for BJJ and 48% for Judo—a majority of individuals were
injured from being struck or landing (BJJ 65% and Judo 57%). Among the MMA
subsample with sufficient data to determine what events lead up to the injury (62%),
being struck or striking an opponent or object was the most common cause of injury
(43%).

Table 1 Descriptive statistics (n = 978)

Overall BJJ Judo MMA

Injuries (95% 39,181 (26,780, 12,538 (6584, 10,102 (6447, 16,541 (9487,
CI) 51,584) 18,492) 13,757) 23,595)
Median age 25 (3–61) 27 (4–59) 21 (3–61) 25 (9–50)
(Range)
Male 89% 90% 76% 96%
White 89% 88% 89% 89%
Injury diagnoses Strains/sprains: 27% Strains/sprains: 32% Strains/sprains: 36% Contusion/
Fractures: 19% Fractures: 21% Fractures: 18% abrasions:
20%
Fractures: 18%
Mechanisms of Being struck: 44% Being struck: 41% Being struck: 29% Being struck:
injurya Landing: 16% Landing: 24% Landing: 27% 53%
Striking: 18%
Body region Head: 30% Head: 21% Leg: 21% Head: 43%
Trunk: 15% Trunk: 20% Shoulder: 20% Hand: 16%
Level of 52% Grappling Grappling: 75% Grappling: 57% Competing:
participationb 54%
a
Sample size for mechanisms of injury is n = 532
b
Sample size for level of participation is n =812

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Sport Comparisons

Figure 1 displays the proportion of injuries to each body region and the most
common diagnosis for each injured body region, disaggregated by sport. Approx-
imately one in five BJJ injuries were arm or foot injuries, and roughly 40% of those
injuries were fractures. For Judo, a large proportion of shoulder (34%) and arm
(58%) injuries were fractures. Concussions were the most commonly occurring head
injuries for MMA (38%) and Judo (37%); lacerations were the most common head
injury for BJJ (25%). Arm injuries for both BJJ (38%) and Judo were most often
fractures (58%), but for MMA arm injuries were most often strains/sprains (70%).
Hand injuries for BJJ (41%) and Judo (38%) were most often strains/sprains,
however MMA hand injuries were most often fractures (47%). Abrasions/contu-
sions were the most common trunk injury for all three sports (BJJ: 30%, Judo: 45%,
MMA: 45%) and strains/sprains were the most common leg injury for BJJ (36%),
Judo (58%) and MMA (42%).
In Table 2, the leading diagnoses and injured body regions are stratified by sport
participation-level, either grappling or competing. The majority of BJJ (9390 [95%
CI 4961, 13,820]) and Judo (5771 [95% CI 4334, 7207]) injuries occurred during
non-competitive grappling, while the majority of MMA injuries (9086 [95% CI
4325, 13,848]) occurred during competitions. There were several notable differences
between the proportions of body parts injured. For BJJ, there was a greater
proportion of arm (31%) and shoulder (30%) injuries from competing than from
grappling (8 and 10%, respectively). For Judo, leg injuries accounted for 34% of
competing injuries compared to only 11% of injuries from grappling. For MMA, a
greater proportion of grappling injuries were to the head (55%), compared to
injuries from competing (37%).

Discussion

This study was the first to examine injury profiles from participation in BJJ, Judo,
and MMA using a large, national probability sample. Our study adds to the limited
literature regarding the types of injuries sustained from participating in these
combative sports. Prior research comparing striking and non-striking combat sports
indicated substantial differences between injury profiles of the two groups, and
attributed these observed differences to the different styles of fighting (Noh et al.,
2015). Our study found striking to be a leading cause of injury for both the striking
sport, MMA, and non-striking sports, BJJ and Judo. This finding may indicate that
the rules prohibiting striking in BJJ and Judo are not sufficient or require better
monitoring or enforcement. This finding is also in contrast to prior research that has
identified falling, throwing and jumping or joint locks to be the leading causes of
injury for BJJ and Judo practitioners (McPherson & Pickett, 2010; Pocecco et al.,
2013; Scoggin III et al., 2014). However, the methods vary between studies and, to
date, our study uses the largest probability sample of any yet examined to assess
injuries from these sports in the U.S.

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Fig. 1 Proportion of injuries to each body site and the most common diagnosis for each injured body
region, separated by sport

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Table 2 Leading Diagnoses and Body Regions Injured: Grappling Versus Competing (n =812)
Sport Leading diagnoses Leading body regions

Grappling Competing Grappling Competing

BJJ
#1 Strains/sprains (26%) Strains/sprains (39%) Head (24%) Arm (31%)
#2 Fractures (22%) Fractures (17%) Trunk (20%) Shoulder (30%)
#3 Other (17%) Other (14%) Leg (17%) Head (16%)
Judo
#1 Strains/sprains (28%) Strains/sprains (37%) Head (22%) Leg (34%)
#2 Abrasion/contusions (21%) Fractures (33%) Shoulder (21%) Head (29%)
#3 Fractures (18%) Abrasion/contusions (11%) Foot (18%) Shoulder (17%)
MMA
#1 Abrasion/contusions (27%) Abrasion/contusions (19%) Head (37%) Head (55%)
#2 Strains/sprains (20%) Fractures (18%) Trunk (23%) Hand (12%)
#3 Fractures (15%) Lacerations (14%) Hand (15%) Trunk (9%)

Numerous sports, including martial arts, utilize protective gear to prevent

commonly occurring and/or severe injuries. Professional MMA competitions
require mouth pieces, groin protectors, and gloves (UFCÒ, 2017) but for BJJ and
Judo participants, protective gear is often not required (IBJJF, 2015; IJF, 2014).
Further, protective gear requirements and other training practices may vary between
gyms and organizations, leaving amateur practitioners potentially vulnerable.
Knowledge of the injury profiles for BJJ, Judo and MMA may be helpful in
informing the future direction of protective gear requirements in these sports.

BJJ

The most frequently injured body parts for BJJ that we found were the head, neck
and trunk, which is inconsistent with prior research showing the knee and elbow
were injured most often (Kreiswirth et al., 2014; Scoggin III et al., 2014), but may
be explained by the wider variety of takedowns permitted and the dynamic use of
one’s core. However, the most injured body parts in BJJ competitions were the arm
and shoulder, which may be due to the use of joint locks, but remains ambiguous;
most narratives mentioned the patient feeling a ‘‘pop’’ before their injury and only
one narrative mentioned a ‘‘wrist bar’’ maneuver contributing to injury. Lastly, a
large proportion of competitors’ injuries to the head, neck, and trunk in BJJ were a
result of their opponent landing on them or accidently striking them. Our findings
indicate that numerous injuries could potentially be avoided by increased training in
proper falling techniques as is frequently taught in Judo (Pocecco et al., 2013), as
well as protective gear that better absorbs the impact of accidental strikes.

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Judo

Our findings as related to Judo have many similarities with previous research. For
example, similar to James and Pieter (2003), head injuries accounted for a
substantial portion of injuries in this sport (19%), suggesting that soft helmets and
mats may be an effective way to reduce internal head injuries/concussions among
participants and warrant further investigation. A systematic review on Judo injuries
noted an average injury risk of 11–12% for Judo athletes competing in each of the
2008 and 2012 Summer Olympic Games which provides some insight into the risk
of injury in this sport but is limited in its generalizability to general practitioners
(Pocecco et al., 2013). Pocecco et al. (2013) identified the extremities, specifically
the knee, shoulder and hand or finger, as the most injured body parts, but suggested
that different study designs influenced data trends for injury types and risk. Our
findings add support to those reports as well as various others (de Sá Oliveira &
Pereira, 2008; Souza et al., 2006) by identifying the shoulder and leg (including the
knee) as the most injured body part in Judo, which may be a result of the sport’s
emphasis on throwing maneuvers (IJF, 2014). Our study adds to the literature about
common injuries experienced by general practitioners of these sports, beyond solely
competition-related injuries. Researchers and stakeholders should consider exam-
ining the effect of using additional protective gear and/or improved mats to reduce
commonly occurring injuries.

MMA

Although MMA is the newest of these three combative sports in the U.S. (UFCÒ,
2017), it resulted in the largest number of total injuries presenting to the ED.
Consistent with previous research, a large proportion of MMA injuries were head
injuries (Buse, 2006; Heath & Callahan, 2013; Lystad et al., 2014). Our study also
found a large number of hand, wrist and finger injuries for MMA participants, which
appears to be from striking. Though sanctioned MMA matches often require the use
of protective gear, the high number of reported head and hand injuries indicates that
these equipment requirements may be insufficient to properly protect athletes or are
not used during sparring and practice.

Strengths and Limitations

Our study has several limitations. First, unlike NEISS studies of sports with
validated activity codes, there were no specific NEISS codes for BJJ, Judo, or
MMA. Accordingly, we only included cases if their narrative explicitly mentioned
one of the three sports. Regardless, the estimates presented here are very likely
underestimations, suggesting that the actual burden of injury is much greater than
what we estimated. Second, NEISS data only includes individuals reporting to U.S.
EDs; thus, less severe injuries are likely underrepresented in the sample. Third, data
on participation level and mechanism of injury were not available for all cases
(n =812 and n =532, respectively). Lastly, because the total number of BJJ, Judo
and MMA practitioners in the U.S. remains unknown, we could not calculate injury

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risks at this time. However, this is the first study to provide injury profiles from
these sports using data from a large U.S. probability sample.

Conclusions

It is important to identify the specific ways people are injured while participating in
combative sports, because certain techniques and maneuvers likely pose greater risk
of injury than others, and many could be prevented. For example, examining the
cause of arm and shoulder injuries in BJJ competitions may help identify dangerous
types of joint locks. If this were the case, the implementation of additional rules and
training policies could better protect athletes. Preventive interventions could
intervene at multiple levels, including the refinement and requirement of safety
equipment, changing social norms surrounding the use of safety equipment,
improved training on how to prevent injurious situations, enhanced rules on high
risk maneuvers, and the consistent enforcement of these rules when violated. Future
research should examine the effectiveness of interventions designed to prevent
commonly occurring combative sports injuries. Given the quantity of severe injuries
from these three sports, more research is needed to better understand the risk
associated with participation in BJJ, Judo, and MMA. More broadly, throughout the
U.S. there is inadequate monitoring of participation in non-scholastic sports as well
as resulting injuries, indicating a need for improved surveillance.

Acknowledgements The researchers would like to acknowledge Nafisa Afrin, Humera Uddin, and
Shaheer Ahmed for their assistance with coding variables.

Compliance With Ethical Standards

Conflict of Interest The authors declare that they have no conflict of interest.

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Affiliations

Caroline Stephenson1,2 • Matthew E. Rossheim1

& Matthew E. Rossheim

mrosshei@gmu.edu
1
Department of Global and Community Health, George Mason University, 4400 University
Ave., MS5B7, Fairfax, VA 22030, USA
2
Department of Environmental and Global Health, University of Florida, Gainesville, FL, USA

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