A review of Muay Thai boxing and combat sports injuries

Andrew K K Ip 葉傑權，Raymond H F Chan 陳凱輝

HK Pract 2007;29:242-247

Summary

Muay Thai boxing is an ancient sport originated from Thailand. In early 1900s, the sport was codified into a weight class competition. It was introduced to Hong Kong in the 1960s. After the establishment of Hong Kong Muay Thai Association in 2002, regular fighting competitions were organized. From a review of world-wide literatures, the injury rate per 1000 athlete-exposure of boxing ranged from 108 to 228; karate ranged from 90 to 280; taekwondo was around 21; and wrestling was around 10. Repeated exposure to punches and blows to the head would cause long term consequence. Boxers might suffer from potentially lethal intracranial injury. There was no doubt about the risk of professional boxers. The authors' experience in Hong Kong found similar injury rate as other literatures. The head and neck regions were the most commonly injured. However, most injuries were simple lacerations with no long term neurological consequence. In order to uphold the safety of the boxers, it calls for a need to conduct regular and routine examinations and to establish a registry for all the boxers.

摘要

泰國拳擊源自古代泰國武士運動。早於1900年代，泰拳已按拳手體重分組進行比賽。在1960年代傳入香港。 自泰拳總會在2002年成立後，常規性賽事逐正式舉行。從世界各地文獻所見，泰拳比賽所引起的受傷比率為每1,000人， 有108至288人受傷；空手道為90至280人，台拳道是21人和摔交則是10人。 頭部受到反復拳擊，可引致長期後患。拳手更可能因顱內受創而致命。職業拳手所受到的風險，無可置疑。 作者的經驗和文獻的類似、頭和頸均為最常受傷部位。但在香港多數僅屬於簡單裂傷，而未引起長期的神經系統後患。 要把拳手的安全性提高，我們需要為他們登記，並定期作健康檢查。

The origin of Muay Thai boxing

It was stated in the World Muay Thai Council website that the history of Muay Thai boxing is the history of the Thai people. Most people agreed that Muay Thai began as a close combat battlefield fighting skill. It was more deadly than any weapon in the old days. In the golden age of Muay Thai, everyone was trained and practised this sport. It was a part of the school curriculum until the 1920's. At that time, teaching in school was stopped because of the high injury rate. However, people continued to learn Muay Thai boxing in training camps or gymnasiums. For centuries, every Thai people watched this sport, practised this sport and grew up with this sport.

Muay Thai boxing as a sport

In 1930, the rules of Muay Thai boxing were formalized. It became a weight-classed sport. There were five 3-minutes rounds in one contest. Boxers wore 6-10 oz boxing gloves. The rules allowed boxers to fight with their fists, kicks, elbows, and knees. Amateur boxers wore protective helmet and body armour. Professional boxers usually did not wear any. Thus, Muay Thai boxing became one of the most exciting and appealing sports, as well as a game. But it carried one of the highest injury rates. World Muay Thai Council was established in 1991 with over one hundred member countries. Under the directive of the Thai Government, World Muay Thai Council aimed to foster Thai culture and promote the art of Muay Thai boxing around the world. With the support from the Olympic Committee of Asia, in 2004, Muay Thai boxing was included in the first Asia Indoors Games and also became one of the full medal sports in the South-East Asian Games in Philippines.

Muay Thai boxing was introduced to Hong Kong in the 1960s by returning immigrants from Thailand. In the 1970s, with the advent of television and booming of entertainment media, more and more people got to know Muay Thai boxing and it became very popular amongst the youngsters. This sport was also recognized as one of the most exciting, spectacular and entertaining game. However, the then government imposed restriction that all boxers had to put on protective armour and helmet during the fight. From thence, Muay Thai boxing was no longer exciting and hence, lost its popularity.

In 2002, the Hong Kong Muay Thai Association was established and joined the World Muay Thai Council. After referencing the rules and regulations of Muay Thai boxing in other parts of the world, the restrictions were relaxed. Protective gears were no longer mandatory. However, all boxers now had to be examined and certified fit to fight. Moreover, a ring-side doctor with appropriate first-aid equipments had to be present during the fights. With the active promotion by the Association, Muay Thai boxing regained its attraction. Regular fights were held in the stadiums.

At present, the Hong Kong Muay Thai Association holds regularly fights. Apart from local boxers, professional boxers from Thailand, New Zealand, Mainland China, Russia and other parts of the world are invited to participate. Usually there are eight to twelve fights during one event. Due to the high level of contact in the sport, injuries amongst boxers seem inevitable.

Injury rates

Sports carry a risk of injuries. The following literature review is intended to find out the injury rate of sports in general and the injury of Muay Thai boxing and related contact combat sports.

In the phase 1 report on sports injuries in EU countries, Petridou E (2001) mentioned that sports activities had unwanted side-effects.¹ The report estimated that mortality rate from sports injuries was around two per million per year; the admission rate was five per thousand participants per year and the rate of injuries, which were severe enough to seek medical attention, was about sixty per thousand sports participants per year. These figures reflected that sports, in general, were safe.

There was only one article found from the literature search about the injury rate of Muay Thai kick boxing. Gartland S and his colleagues studied the type and number of injuries that occurred during the training and the practice of Muay Thai kick boxing.² They obtained data by one to one interviews with standard questionnaire on injuries at various gyms and competitions conducted in the United Kingdom and a Muay Thai gala at Holland. The most common injured region was the lower limbs. The second one was the head region among professional boxers, trunk region was the next common amongst beginners. The annual injury rates were 13.5/1000 (beginners), 2.43/1000 (amateurs), and 2.79/1000 (professionals).

Kickboxing is similar to Muay Thai Boxing, the use of kneeing, elbowing and punch kicking are permitted. Zazryn and company studied the rate and type of injuries occurring to registered professional kickboxers in Victoria Australia over a 16-years period.³ The injury rate was 109.7 injuries per 1000 fight participations. Most of the injuries were sustained in the head and neck region (52.5%), followed by lower extremities (39.8%). Over 64% were superficial bruising or lacerations. 17.2% of these injuries were intracranial injuries. The authors collected data from the Victorian Professional Boxing and Combat Sports Board. This study faced difficulties in data collection, especially when there were differences in regulations in different states of Australia.

Enzenauer et al studied the boxing-related injuries in the US Army from 1980 to 1985.⁴ He reported one death from serious head injury and one case of unilateral blindness resulted from ocular trauma. Head injuries accounted for 68% of total admissions. Upper limb trauma accounted for 17% of hospitalization. Injuries to trunk accounted for 7%. Lower limb injuries constituted 6%. In this study, the total number of boxers or fights was not mentioned and the relative risk was not known.

Porter and O'Brien conducted a prospective five-month survey of injuries which occurred during amateur boxing and training.⁵ Data were collected from the amateur boxing competitions of the six largest amateur boxing clubs between November 1992 and March 1993 in Dublin. The incidence of injuries in competition was 0.92 injuries per man-hour of play or 0.7 injuries per boxer per year. The total number of injuries was 64 in 281 completed or partially completed bouts. The incidence was 228 per 1000 fighting bouts. The annual incidence of injuries in training was 0.69 injuries per boxer. He concluded that the yearly risk of injury resulting from participation in amateur boxing was relatively low.

Ohhashi et al investigated the incidence of boxing accidents in Japan by conducting a nation wide survey of boxers.⁶ There were 627 voluntary respondents. They found that 14.2% of the boxers forced themselves to lose weight before competition. This study did not give the rate of injury nor the type of injury sustained by the boxers. However, the study noted 47% of boxers suffered from symptoms after knock out. Symptoms included headache, vertigo, nausea, vomiting, double vision, tilted vision, tinnitus, hearing disturbance, weakening of leg, shaky hands, and forgetfulness.

Tuominen R analyzed the injuries of six national karate competitions in Finland.⁷ He found that the overall probability of injuries was 0.28 per bout occurring in 16% of 647 competitors. Most were minor injuries. More than 95% occurred in the head, which were caused by direct punch. The author recommended to wear a protective guard for head and to modify the competition rules.

Critchley GR, Mannion S, and Meredith C studied the injury rate of British Shotokan Karate championship from 1996 to 1998.⁸ Contact was limited to only ight' and ouch'. Protective padding of hand, head and knee was prohibited. There were 160 injuries in 1770 bouts among 1273 competitors. The incidence rate was 90 per 1000 bout and 0.13 per competitors. 57% were head injuries and 37.5 % were limb injuries.

Zetarul et al did surveys of karate injuries at Shotokan karate clubs in USA and Canada.⁹ There were 114 surveys and the response rate was 74%. They did not find a difference in injury rate between both sexes. Fewer injuries were found among players younger than 18 years old. Multiple injuries increased with belt rank until brown belt. Training more than three hours per week was associated with increase in injuries.

Pieter W and Zemper ED did a prospective study on the injury rate among the 3341 boys and 917 girls in the national and international taekwondo tournaments.¹⁰ The head and neck injury rate was higher in boys which was 21.42 injuries/1000 athlete-exposure as compare to 16.91/1000 athlete-exposure in girls. Contusions were the most common occurring injuries and cerebral concussion ranked the second.

Lorish TR et al evaluated the injury pattern of 1742 participants aged six to 16, who took part in two wrestling tournaments.¹¹ The overall injury rate was 12.7%. 4.6% of the injuries required participants' withdrawal from competition. They also found that older and heavier wrestlers were at increased risk of injury.

Jarret GJ and his colleagues studied the data of the National Collegiate Athlete Association Injury Surveillance System on collegiate wrestling.¹² These data included 800000 athlete-exposure over 11 years. The injury rate was 9.6 per 1000 athlete-exposure. 6.3% of the injuries required surgery and 37.6% took a week or more off wrestling.

Pasque CB and Hewett TE did a prospective study on the injury patterns of a large population of high school wrestlers during one season.¹³ There were 219 injuries among 418 wrestlers. The overall injury incidence was 53 per 100 wrestlers per season. The injury rate was six per 1000 exposures. Most of the injuries occurred during practice (63%).

These literatures gave a general picture of different injury rates of combat sports. However, the injury rates were given in different parameters. Some were given in number of injuries per bout, some in number of injuries per hour-exposure, and some in number of injuries per 1000 athlete-exposure or bout. There were difficulties to interpret different injury rates. For comparison, these injury rates were summarized in the following table (Table 1).

From this table, one could see that the injury rate per 1000 athlete-exposure of boxing ranged from 108 to 228, karate ranged from 90 to 280, taekwondo was around 21, and wrestling was around 10.

Our experience in Hong Kong

The authors have been the Honorary Medical Consultants for the Hong Kong Muay Thai Association since 2002 and have acted as ringside physicians for over 200 local Muay Thai fights. We found a total of 42 injuries among 330 fight-participations, making the injury rate 12.7% or 127 per 1000 athlete-exposure. The most common injured body part was the head and face region (81%), and the most common injury was facial laceration (47.6%). There was only one case (1/330 = 0.3%) of serious intracranial injury which required hospital admission.

Proposals to protect boxers

In recognition of the potential harms of boxing, there were recommendations and advocates to lay down regulations to protect the boxers. The American Medical Association addressed the issue of the dangers of boxing.¹⁴ It was concluded that boxing was a dangerous sport and could result in death and long-term brain injury. The council made several recommendations including establishment of a ational Registry of Boxers' for all amateur and professional boxer: to review the criteria for physical examination of boxers, determine measures to prevent injury, develop criteria for discontinuation of bout for medical reasons, and recommend that boxing bout should be held in area with adequate neurosurgical support, mandate the use of safety equipment, compulsory rest period after each fight; and to upgrade, standardize, and strictly enforce medical evaluations for boxers.

Conclusion

Muay Thai Boxing is an ancient sport originated from the fighters of Thailand. In early 1900s, the sport was codified into a weight class competition. It was introduced to Hong Kong in 1960s. After establishment of Hong Kong Muay Thai Association in 2002, regular fights were organized. At present, the association adopted the regulations and rules of the World Muay Thai Council.

From review of world-wide literature, the injury rate per 1000 athlete-exposure of boxing ranged from 108 to 228, karate ranged from 90 to 280, taekwondo was around 21, and wrestling was around 10.

Many of these injuries were in the head and neck region. It was recognized that repeated exposure to punch and blow to the head would cause long term consequence. Boxers might suffer from severe intracranial injury which could be fatal. There was no doubt about the risk of professional boxers. However, some researchers argued that amateur boxing was relatively safe. The authors' experience in Hong Kong found similar injury rate as other literatures. The head and neck regions were also the most commonly injured. However, most of the injuries were simple lacerations with no long term neurological consequence. In order to uphold the safety of the boxers, it calls for a need to conduct regular and routine examinations and to establish a registry for all the boxers.

Key messages

1. Muay Thai Boxing was organized regularly in Hong Kong.
2. The injury rate of boxing including Muay Thai Boxing ranged from 108 to 228 per 1000 athlete-exposure.
3. The injury rate of boxing was similar to other full contact sports such as Karate.
4. Repeated punches or blows to the head could cause long term consequence.
5. Regular and routine examinations were required to uphold the safety of the boxers.