On Friday, April 6, 2012, I sat in a conference room all day with thirty highly educated professionals to talk about the medical issues relating to combat sports. That Friday might have been the single most informative and energizing day I have ever had as a martial arts participant, writer and fan, as the Combative Sports Medicine symposium gave me rare insights into the lesser known medical aspects of the fight business. These are the people behind the bright lights and in the background that are always present and change the courses of fights in the spirit of protecting these warriors from others and from themselves.

The opening remarks of the day were delivered by Aaron Davis, the New Jersey Athletic Control Board commissioner. He began with a story about his mother watching a boxing event with him on TV and hearing her express her dismay at the combat sport with the phrase, "This is not natural, baby."

After calming her down and pointing to the ringside medical professionals, the trainers and the boxers' own desire to be there and to compete in this manner, he realized that combat sports is indeed not natural in the sense of other sports. The athletes involved are on an elite level of fitness, the degrees of skill are otherworldly and the injuries sustained before, during and after a fight can be eye-opening (literally) to someone unused to the combat sports world. These challenges require alert, informed medical professionals to make decisive calls in the heat of the moment - and for the commission to protect these ringside doctors from possible backlash from the fans, fighters, promoters or media.

For the commission to so firmly support these doctors is a relatively unusual state in combat sports. John Nash, the Head Kick Legend writer, has noted extensively how the boxing matches of Pierce Egan's time (early 1800s) could often go beyond a hundred rounds and a fighter was considered "stopped" only if they did not get back to their feet within thirty seconds or were declared finished by their own seconds. In the modern era, the collective of promoters, fighters, state athletic boards and fans themselves decided to have multiple "Smokey, this is not 'Nam... there are rules..." moments and we now have things like time limits, round caps, medical professionals on stand-by and medical testing for most boxing, Muay Thai and MMA bouts.

Combat sports athletes are safer than ever, yet the web of rules, enforcement and knowledgeable people that allow such safety is not omniscient or ubiquitous. More can and is being done to ensure fighter safety and at the forefront of this are the doctors treating fighters before, after and during fights. Their efforts to educate each other, the fighters, the promotions and the fans show an admirable faith in the vitality of combat sports and the desire to keep these sports exciting, profitable and safe for as many as humanly possible.

Did you know it is possible for a fighter to breathe in his teeth?

Despite seeing the chompers of Randy Couture and Mike Ricci go flying away or disappear, I had never thought of that happening. Ringside medical professionals know about that possibility and check to make sure dozens of similarly unlikely things get ruled out, noticed or treated. Preventing infectious diseases from spreading, looking for facial fractures, monitoring eye movement, checking ears and eyes are all things that ringside physicians have to keep track of with the fighters in their charge.

In the interests of further boosting this collective move towards more regulated and safe forms of sports fighting, some of the best fight doctors in the nation combined to present a full day of talks that not only educated medical professionals, but was also aimed at and featured fighters, trainers, coaches and commission members. The New Jersey athletic commission made their presence felt in a big way, as Deputy Attorney General Nicholas Lembo gave a short talk and was around the entire day and Commissioner Davis spent most of the day there listening and talking to the participants.

The Combative Sports Medicine symposium is the result of collaboration between Dr. Sheryl Wulkan and the Sports Medicine branch of Atlantic Health, a medical facility and research center located in Morristown, New Jersey. Dr Wulkan is one of the preeminent ringside physicians nationwide, having worked hundreds of amateur, professional and high-profile MMA and Muay Thai bouts over the years and is a longtime Muay Thai boxer herself. Alongside Dr. Wulkan, the symposium featured quite a few other medical and sports professionals with extensive ringside experience to create a true treasure trove of combat sports medicine knowledge. The hosts of the symposium, Atlantic Sports Medicine, are the official providers of health care for the New York Jets and the New Jersey Devils and had five fellows in attendance who have extensive sports medicine experience.

Nate Diaz and Jim Miller staredown via Michael Nagle of Getty Images.

Adding to that imposing presence was Jim Miller, the soon to be main-eventer against Nate Diaz at UFC on Fox 3, his trainer, Mike Constantino, and Stephen Koepfer, a prominent NYC coach and grappler. That sleek conference room packed with tons of people far more educated than I was a daunting environment for me enter, yet these professionals answered my occasional questions in great length and with astounding amounts of candor and expertise. Of course, the symposium was directed at those who have greater technical understandings of the medical issues or the legal issues involved, yet the presenters were eager to answer any and all questions.

Jim Miller spoke of the warrior nature of fighters and how his brother Dan Miller had no idea that he was badly injured when he received a broken cheekbone (zygomatic arch) during a fight. Miller had one of the deepest philosophical moments of the day when he said "A fight is a short moment in time where you are showing what you are apable of while preventing the opponent from doing the same." The adrenaline, the competitive desire and the refusal to quit leads fighters to insist that they are fine, even when not actually fine, because the brain hasn't registered the pain or is ignoring it, as Dan showed. Jim said that he was truly lucky, as the worst things he suffered in a fight were cuts and none were bad enough to stop a fight, but that he understood why the ringside docs would be making this call or that call. He closed out by answering some questions from the audience about his own experiences with international fights and dealing with language barriers when dealing with the pre-fight and post-fight processes. In response to my question, Jim noted that pain really doesn't correlate with the most severe injuries - especially at the time of the fight - and used his brother's injuries as an example to refer to, while Constantino nodded in agreement. Miller also mentioned that he wishes people would give him more space at the end of the fight, to ratchet himself down from 100% to 0% over time, rather than immediately being crowded by six or seven people all yelling, poking and prodding. Being an elite MMA fighter really does take an unusual mindset and patience level and Miller was very upfront about his warrior nature that comes out in the cage and how it can clash with people used to regular rules and regular people.

Jim's trainer, Mike Constantino, was a bit more focused on the medicals process and made several statements in support of the regulations that New Jersey imposes upon fighters and fight organizations. One story about a smaller event where a hot light that was far too close to the mats and heated up the decals on the canvas - to the point of burning the feet of the fighters - brought home that fighter safety is not always about tracking the damage the fighters inflict upon each other. Constantino said that the referees and doctors being aware of the possibilities of injury due to one fighter's tendency for armbars or leglocks was crucial, as well as referring to several potential cases of greasing, that are controlled by the banning of lotion or lubricant from the possession of the fighters or cornermen. Rousimar Palhares came up in both topics - not as a cheater, but as an example of how not to protest or a fighter to watch for leglocks. Constantino noted that he would love for all fifteen professional fighters under his management to be going through a New Jersey-style "one stop shop" medicals check-up process and liked the standards for the amateur system as well.

Referee Herb Dean talks to Rousimar Palhares. Photo via Esther Lin of MMA Fighting.

The concept of spectator syndrome came up repeatedly throughout the day. Dr. Wulkan explained it in a short aside as being a fan instead of a doctor and noted how that could be dangerous for the maintenance of fighter safety. Dr. Dominic Coletta, a familiar face from many Atlantic City bouts over the last two decades, mentioned that he had a couple moments like this early in his career, but soon recomposed himself and has no problems now. Coletta said that even Ward-Gatti III presented no serious problems to retaining his professional demeanor at the time. In response to a question I asked, Coletta answered that working as a ringside physician had no direct effects on his day job as an emergency medicine doctor - stitching is not usually something he did at the event, and that he encountered more diverse situations at the day job. However, his love for the sport allowed Coletta to keep doing these events.

Coletta did express frustration with the powerlessness of ringside physicians in other states, citing the licensing controversy that nearly stopped Margarito-Cotto II from happening. Initially, a doctor for the NYSAC would not clear Margarito for a license due to eye injuries sustained in his last fight and the commission went over that doctor's head to find another specialist who would license Margarito. Coletta mentioned that it was important for the commissions to back up the decisions of the doctor, no matter how unpopular they may be, because the trust and good will of that relationship is essential to the doctor's confidence in making the right calls.

Coletta answered one question that'd been bugging me for a while: Why do fighters do their post-fight medicals right next to each other, separated only by a curtain or something? In his experience, most fighters are friends or respectful of each other. There are few, if any, problems backstage with almost all fighters. They shake hands, hang out with each other and the cornermen are unusually respectful themselves. Add onto that the limited control the doctor has on the medical set-ups, which are done by the promoter or the venue. However, Coletta did say that in cases where bad blood was clearly obvious before the fight, they would separate the fighters backstage to prevent anything flaring up.

Nick Diaz and B.J. Penn backstage via Lorenzo Fertita's Twitter.

Drs. Kenneth Remsen and Howard Taylor probably won the Visual Gross-Out contest due to their chosen topic of "Facial Lacerations/Maxillofacial Injuries and Ear-Nose-Throat Issues in Combat Sports Medicine." The pair have well over twenty years of combined experience ringside and their breakdown of what injuries are commonly seen was incredible. For instance, Taylor has never seen an inner ear injury in a fighter and cautioned the medical professionals that deepset eyes combined with large eyebrow ridges usually means to watch for deep eyebrow cuts and shallower eyes usually have eyelid cuts. A particular section was set aside to cauliflower ear and possible ear injuries, with the remark that Taylor had never seen an inner ear injury in his time as a ringside doctor.

At one point, Taylor said "Any fracture that can be identified should stop the fight." In retrospect, I should have asked how this statement can stand with the commonplace attitude that a broken nose is not that big of a deal, but at the time I believed he meant "Any fracture that is not a broken nose is a fight-stopper."

Dr. Remsen gave a mighty discourse upon maxillofacial trauma - orbital socket fractures, jaw breaks, larynx calcifications, dental injuries and skull fractures. An unusual statistic that I've never seen before showed that roughly 30% of jaw breaks occur in the middle of the jaw (chin area), 33% occur in the region between chin and hinge and less than 30% occur near the hinge. This is where the "breathing in teeth" X-ray came up and gave me the heebie-jeebies.

Lyoto Machida knocks out Randy Couture. Photo via Esther Lin of MMA Fighting.

Nick Lembo, the Deputy Attorney General who generally runs MMA officiating in New Jersey, gave a short speech on the legalities of licensing, medical tests required by New Jersey, going through the shadow officiating and referee programs developed to train new officials and judges and closed with a clearly heartfelt story. Lembo told us of a fighter he knew for eight years or so who took a bad knock-out and thought Nick was a stranger he'd never met before in the backstage area. Nick ended the story by saying "This is why we do what we do. This is why we don't cut any corners."

In between the descriptions of the legal stuff and the powerful story, Lembo pulled no shots at the commissions and jurisdictions who do not approach New Jersey in terms of regulations and trained officials, judges and medical personnel. Lembo emphasized that the doctors have access to a database of medical suspensions, although the commission checks all fighters for such. He reminded the doctors to find out what exactly their malpractice insurance covered and whether they were allowed to do ringside work and retain coverage. Both Commissioner Davis and Lembo expressed significant desire for uniformity of standards, although they were easier on the states that were part of the Association of Boxing Commissions and reserved most of their criticism for the dealings with MMA and Muay Thai.

Dr. Damion Martins, one of the symposium organizers, asked a very insightful question regarding the certification and skills demanded of ringside physicians. He said that the NFL and NBA have collective bargaining agreements that require that the doctor on duty at the games be a sports medicine physician and wondered if boxing or MMA had that similar requirement. Several people answered different components of this one, but the essential thrust was that there is no such requirement, although it seems that New Jersey is slowly moving that way. Some certifications are required of the ringside physicians in New Jersey and in other states, although others have no such requirements. Dr. Coletta noted that it is not in the cards for every single boxer to do a balance test, an MRI or a CAT scan like every NFL player does right now. The money for the undercard fighters in particular just isn't there for that right now and the sports of boxing and MMA have no powerful unions like the NFL or NBA.

I had to skip a good chunk of Dr. Robert Smick's presentation on Infectious Diseases in Combat Sports as I was doing an interview with Commissioner Davis. However, the beginning and end were terrific in their clear, concise presentation of the possible and probable diseases for fight doctors to look out for. In perhaps my least professional-sounding moment, I asked Dr. Smick if there was anything virus or bacterium-related to the development of Parkinsons and other neurological diseases and he turned the question into a mini-discussion of head trauma and the research into that alongside the possibly unknown other causes of neurological diseases. He also noted that perhaps one third of wrestlers have herpes gladitorum.

Stephen Koepfer was unusually intent during this section, due to running his own gym and being a referee for grappling tournaments, and asked several questions about cleaning mats and ways to remind people of the virtues of cleanliness. It turns out photos and information in the locker room of the potential consequences of uncleanliness can have some good effects.

Matt Hamill fights Keith Jardine with a staph infection visible on his back.

Dr. Michael Kelly had the most interactive presentation of the symposium during his talk on Orthopedic Concerns, which means the potential and likely injuries to the muscles, tendons, ligaments and bones of fighters. Koepfer and one of his students were demo dummies for certain movements, demonstrating how this injury or that injury would occur. It turns out that grappling injuries often occur in pairs on either side of hinged joints, as the antagonistic workings of a joint lend themselves well to such injuries. Kelly combined the descriptions of the various injuries with photographs of recent fights in which such injuries did occur or could have occured. Ronda Rousey and Ben Saunders were stars during this section with their joint-based attacks. Frank Mir and Antonio Rodrigo Nogueira had their own moment in the sun too. Urgh.

Kelly spent quite some time on informing us all what hand and leg injuries boxers or strikers typically endure. It turns out that a boxer's fracture is actually a misnomer - most boxers break the third (middle) metacarpal and not the fifth. The training of the strikers means that the middle of the hand lands first in most conventional strikes. He did mention the different angles of MMA and the likelihood of the thumb catching on the head, due to its being uncovered by the glove. Noticing a Boxer's knuckle is serious business for a doctor to check out, as the bulge in the knuckle means that little ligaments are being torn off the tendon that allows the flexing of the hand. The tears mean that the tendon moves around and exposes the knuckle underneath, which can be painful and damaging to the fighter. Surgery is usually needed to fix this injury.

Jose Aldo whips a leg kick into Mark Hominick. Photo via Esther Lin of MMA Fighting.

Powerful and repeated leg kicks can lead to myositis ossificans, which is when bone grows in the muscle of the thigh - which is extremely painful and dangerous to the fighter. Naturally, this section was paired with a GIF of Jose Aldo wreaking havoc on the legs of Urijah Faber. Kelly noted that the gloves and hand wraps are taken off a fighter backstage first, because of the compression of the hands they create. Once the fighter's hands have time to loosen up and relax, he then asks about the pain or odd feelings in them. All kinds of little questions about the routines doctors go through were answered by Kelly.

Next up was Sharon Wentworth, DPT, MSPT, ATC, and trainer to several ranges of athletes from high school kids to Olympic athletes to professional MMA fighters. Her youth in Iowa gave her a knowledge of wrestling and being an athlete. After her career as a professional volleyball player came to an end, she went full time into physical therapy and athletic training. After a few sessions with Kurt Pellegrino a few years ago, she ended up getting linked into the New Jersey MMA scene and even working up at Tri-Star with a few athletes up there like Miguel Torres. Dr. Wentworth had some very interesting things to say about common injuries, recovery regimens and even how specifically to train for MMA in ways that differ from other sports. Some of the best stuff was about how the imbalances of the usual training regimen of an MMA fighter leads to hunching forwards, with very tight pecs and weakened stability in the thorax and knees. Wentworth gave a brief overview of how certain injuries affect the training camp, whether they affect certain areas and how the doctors can help the athletes make the decision to call the fight off or to treat the injury in time.

From Left to Right: Dr. Sheryl Wulkan, Unsung Tech Guy On His Phone,

Nick Lembo and Dr. Michael Kelly answering questions. Photo taken by me.

The last spot in the symposium went to Dr. Wulkan, who spoke of several unique medical issues present in high level MMA and of the decisions of referees and officials regarding stoppages by strikes or submissions. It turns out that only having one kidney is not a big deal. Carlos Newton and one other UFC fighter have that condition and they turned out fine. Foreign medicals are to be handled with some suspicion and the preference for having tests done in the United States or Canada was strongly emphasized.

Therapeutic use exemptions were discussed and Nick Lembo chimed in to say that very, very few TUEs have ever been granted in New Jersey due to the stringent requirements for such exemptions. I brought up the Overeem testing case and also that of Johnnie Morton case (where Morton tested at something like 78:1). When Dr. Wulkan was told of Morton's ratio, she paused for a long moment and then calmly said "Those levels seem to be consistent with absurd amounts of illegal drug abuse." Transgender fighters were briefly discussed, although this was mostly a legal issue combining with the medical side only to make sure that the hormones of fighters were within acceptable ranges. It turns out that fighters with sickle cell anemia or diabetes are of particular risk for exercise-induced problems or even death. Having them fight early on or not at all are some of the options available to ringside physicians who notice problems.

Kyle Maynard, the limbless fighter who made himself a brief shooting star in the MMA world, was discussed as an example of a fighter essentially being unable to defend himself and forcing the opposing fighter to essentially not play MMA anymore. Prosthetic limbs were discussed and it was generally agreed upon that in boxing, a fighter with a prosthetic leg might get licensed. In MMA, such a fighter receiving an NJ would be unlikely and that leg kicks with such a leg would be a doozy.

Wulkan noted that she is in the beginning stages of creating a program to follow people with symptoms of Chronic Traumatic Encephalopathy (CTE) more closely and for longer periods of times. She also mentioned how she handles suspicions of dehydration-related blood pressure symptoms persisting past the weigh-in period by giving the fighters another chance to rehydrate, come back and redo the blood pressure test. If still unsure about the results, she has them jump rope or do some form of exercise for fifteen or so minutes and then calls it one way or another based on the observations. This example shows how flexible and willing these doctors are to see the fighters actually fight, while keeping in mind fighter safety.

To end the symposium, Wulkan played several clips chosen and compiled by Nick Lembo and Anthony Lynn, a NJSAC drug testing inspector and coordinating official. Igor Vovchanchyn, Joe Warren, Pat Curran, Brian Rogers, Vitor Vianna, Gilbert Yvel, Gary Goodridge, Renzo Gracie and a few others were the MMA stars featured in the hybrid boxing/MMA clip list. Hashim Rahman and Arturo Gatti were some of the recent boxing stars shown. Almost all featured stoppages that were either right on or far, far too late. Some clips featured almost comically horrifying post-stoppage handling of an unconscious or dazed fighter by corners, doctors and officials. Others really displayed exemplary work by officials and doctors working in tandem. One clip featured a boxer being knocked out and falling through the ropes onto a table and then onto the floor - and triggering a riot. In that riot, you can see the doctors fighting through the crowd to get to the fighter and the officials turning to protect the doctors and judges from harm.

Fedor Emelianenko after the stoppage in the Antonio Silva fight.

Unfortunately, the pay for ringside physicians, EMTs and officials is generally miserable. These men and women are doing their jobs for the love of the sport and for the preservation of the fighters that entertain and inspire us fellow fight fans and participants. It is only this century that the stronger regulations governing combat sports has been imposed and already we have reached the point where the elite get a nearly-comprehensive battery of medical tests to certify their health and prowess. The future holds better things for our warrior athletes and more technical knowledge for our physicians to keep them healthy and well long after their fight careers are over.

The entire day was a brief insight into specific slices of the fight business given by world-class professionals to future medical professionals, trainers, commission officials and the solitary media member in attendance. The food was solid, the spiffy seats were comfortable and the knowledge taken in was staggering. It is not possible for a single day to allow the fullest discussion of of medical issues that doctors, EMTs, trainers or the athletes themselves would encounter in the lead-up to the fights, during the fights themselves and in the post-fight process. However, this was a damn good start.

Epilogue:

In speaking to Stefanie Pilip, the coordinator for Atlantic Health's Continuing Medical Education program and the coordinator for the Sports Medicine Fellowship Program, I learned that this symposium was relatively easy to put together due to her experience with other CME programs and the astoundingly tight community of fight doctors and officials with strong connections to the Fellowship Program. The next step is for the sports medicine physicians at the seminar to shadow Dr. Wulkan through at least six MMA events, further bolstering New Jersey's strong shadowing program for all officials and judges. The next part of the Combat Sports program will take place on April 27 and focus on Neurology and Neuroradiology. Pilip and Wulkan are looking into presenting similar symposiums in other states and in having another conference next year.