My friend – a physiotherapist for the NHS – has sent me a brilliant podcast. It’s an interview with two physios – Chris Tack and Rob Tyer – about the unique challenges of treating martial arts and combat sports (MACS) practitioners for injuries.
Chris holds a second dan in Shōrin ryū Karate, while Rob is a second dan in WTF Taekwondo. Both men also have substantial experience across various other MACS – and specific clinical interest and expertise in treating MACS practitioners.
There’s a link to the full podcast below (90 mins) which is well worth listening to.
Here are seven of the most interesting points from the discussion. It was aimed at clinical professionals; but I think it’s interesting for us to hear these clinicians talking about us, and reflect on the insights they shared with their professional audience . .
1. Martial artists often fiercely resist taking a break from training to let an injury heal – more so than many other sportspeople
Like other sports, MACS can be addictive, due to the release of endorphins. In addition, Chris explains that many martial artists have invested years or decades into their training, which means they have more of themselves channelled into the sport.
Rob adds that many people train for self improvement; or meaningful personal reasons such as wanting to stand up to bullies, become more confident, heal from trauma, or overcome other challenging life circumstances.
For all these reasons, if MACS practitioners can’t train, they can lose their sense of self, and show higher levels of anxiety and depression, compared with people from other sports.
The first appointment is therefore critical. Rob explains that if a physio simply tells a martial artist not to train for an indefinite time, the patient is likely to ignore them and walk away. However (Chris adds) if you can manage expectations right from the start, and map out a clear path to recovery with them (e.g. in terms of speed and/or intensity of training, or building up certain other variables,) they’re more likely to engage.
When you’re treating a martial artist, you’re trying to manipulate their rehabilitation to return to some form of their martial art as soon as possible, which you may not be as focused on with other athletes, who are perhaps happier to have time away from their event.
So for example, a physio could say something like: I expect this to take X long, but I’m very much on your side and trying to get you back as soon as possible. In the meantime we can do X/Y/Z which is effectively an early return to training.
It’s helpful to be very specific about the things the martial artist can’t do for now, and give alternatives.
2. The martial arts can be a hotbed for pseudoscience
Chris explains that many traditional martial arts (TMAs) are rooted in Far Eastern cultures – which leads to some Western practitioners absorbing fanciful and exotic ideas about healing. Movies can be a rich source of such fantasy – for example the iconic scene in Karate Kid where Daniel is healed by Mr Miyagi’s “magic hands”.
Rob adds that combat sports practitioners are less likely to pursue overtly “mystical” or alternative remedies. However, they can drift into “therapist-hopping” – searching for the one special clinician and/or technique that will fix their complaint and get them back onto the mat or into the ring.
Chris explains that MACS practitioners are “real people who want to get back to their sport as soon as they can, by any means they can”. As such, they can be vulnerable to embracing treatments such as the Fascial Distortion Model, which doesn’t have a clinical evidence base, and may even be harmful to some patients
The martial artist may therefore have strong beliefs about what they need to heal, which can contradict the physio’s own scientific views and training.
Rob adds that for TMA practitioners, this can be complicated by the special role of the Sensei / Sifu / Master. Students can trust their teacher/coach as a kind of guru or parent figure – more so than many other sports – and be strongly influenced and guided by their belief system.
However, Rob advises therapists that even if they believe the student’s beliefs are clinically unsound – or even counterproductive or dangerous – it can be unhelpful and alienating to steam in and contradict them as a scientific “expert”. As with any client, it’s important for the therapist to make every effort to understand the patient’s own view of their training and injury, and what it means to them – and not dismiss their position without really understanding it.
3. Although all MACS differ, there are some core transferable components across them all
Jack asks Chris and Rob if physios should try to glean a basic knowledge of martial arts or combat sports to help them treat these patients – for example from YouTube. Rob explains that while a general awareness can be very helpful to engage the patient, understanding their specific art/style in any detail would be hard. This is because there’s so much variation between the arts – and (as we know) each one takes years or even decades to learn the nuances of.
Chris advises that the best way to approach this is to understand the core, transferable components of the martial arts, and ask the client questions about these. For example:
– Stance – how do you stand? How long is your stance? What’s the position of your centre of gravity relative to your feet?
– How do you use your limbs, and at what speed?
– What is your personal “go-to” technique?
– What technique were you doing when you got injured?
– What kind of agility and flexibility do you need? (For example, Taekwondo practitioners may need more agility, flexibility and range in their legs, than some other arts.)
– What kind of strength / conditioning work do you do? (For example, a boxer may be more interested in power, while other MACS practitioners may emphasise endurance.)
If you ask about these, your patient will be really interested to engage with you, and appreciate your awareness that there are differences between the arts / styles. You won’t need to know all the intricacies, because the patient will tell you. As long as you know the right way to ask these questions . . .
Rob adds that while it’s impossible to quickly gain a detailed understanding of any given martial art, it can be helpful for the physio to have some idea of how the art feels – how to move laterally; having someone take your balance, and so on. Because these are physical experiences that non-martial artists don’t often encounter in everyday life . . .
4. Martial artists have an unusual relationship to pain and injury
Chris explains that MACS practitioners have an unusual relationship with pain, and being uncomfortable. As part of our training, we become used to being hit, receiving joint locks and so on. Over time, we therefore become desensitised to some forms of pain and discomfort. This could lead to us to ignore injuries and let them worsen or compound over time.
(On the flip side however, our training can put us very much “in touch” with our bodies and how they feel. So the opposite could also be true, and we may become better than non-practitioners at noticing and attending to injuries.)
Rob explains that:
Hardly anyone who trains in MACS is 100% pain-free at any given time – you’ve always got minor injuries and niggles but you just get on with it. Because that’s a certain type of training you’ve entered into. Your tolerance is increased by repeated exposure – it’s a mindset.
He further explains that on the competitive side, some people will ignore pain because the opportunities (e.g. financial) outweigh the threat. Some professional or semi-professionals may need to take part in a fight to maintain their sponsorship. The physio therefore sometimes has to enter into an adult conversation with the client – How much are you prepared to put up with? And what can we do about it?
Combat sports practitioners are also different to other sportspeople in that the opponent is actually trying to hurt them. This means that they can have less control than other athletes over whether they’re injured or not.
Rob also points out that most MACS differ from some other sports, as they generally don’t have off seasons.
5. A period of injury can be an exciting learning opportunity for martial artists
One advantage of the MACS is that they incorporate so much variety. As the guys say: If you can’t run, you can’t run. But if you’re unable to punch properly for a while, you could choose to spend some time improving your groundwork. Or maintain your cardiovascular fitness by kicking instead of punching the bag. Or many other things . . .
Rob says: If you don’t understand boxing, you might think it’s one-dimensional – you punch left and then you punch right. But it isn’t. So it can be really exciting to explore all those different elements.
The guys then talk about empowering the patient and letting them lead, by asking them what they feel capable of and would like to do.
Rob explains that injury can be an opportunity to work on parts of your game you’re weaker at. So there’s a little bit more play, than say someone who needs to do the Great North Run in three weeks’ time – they’ve effectively just got to run.
Chris agrees: this is the fun bit! There are so many bits you can incorporate into the rehab. And if you can communicate this – let’s focus on head movement, or dropping your centre of gravity, because I know these are important to you – they’ll be excited, and see their rehab in a totally different way.
6. Martial artists can be vulnerable to dangers within their own clubs
Rob explains that to be a martial arts or combat sports instructor in many schools, all you need is a certain degree of black belt, and perhaps an instructor course, first aid certificate and safeguarding check. But teaching status isn’t generally regulated. And it can be unhelpful or even dangerous for people who are not fitness professionals to teach these arts to others. As Rob says:
Any fool can make you tired – it doesn’t mean they’re making you fit. So people who are novice, or completely unexposed to the martial arts can rock up to an unregulated environment – and hand over money to be trained dangerously.
For example, people who are unfit may end up pushing themselves too hard. Rob adds:
Unless you’re paying for 1:1 tuition, you’re often training alongside all ages and abilities – a blanket training regime regardless of needs. And that can be dangerous.
Chris advises that competitive MMA can be especially risky. Although at the same time, there’s often more fitness-related training and information made available to MMA students than those in the TMAs.
(At this point, Jack plugged Chris’s own comprehensive resource: Evidence-Based Guidelines for Strength and Conditioning in Mixed Martial Arts.)
Rob explained that the martial arts world is full of excellent clubs but also many “McDojos”; and students often won’t realise this. This leads to a related risk, especially associated with the TMAs – students wrongly believing that they can defend themselves and others in dangerous situations such as knife attacks.
Such students may even end up putting themselves into dangerous environments, thinking they can handle it.
Rob also highlights risks around the use of illegal substances in some clubs within the MMA / boxing communities, to aid recovery from injury, or enhance performance.
Finally, Chris notes that the MACS can attract some strange or unstable people. While these people do tend to be “whittled out” of the dojo by their peers and teachers, they present risks that we should all be aware of:
They can sometimes do more harm to you, than you can do to yourself.
7. Martial artists can be exposed to unsafe cultures of machismo or bravado
Good martial arts schools keep their students safe even while pushing their boundaries and exposing them to appropriate stressors. But some clubs fail to care for their students in this way, either intentionally or unintentionally, due to a culture of extreme bravado.
Rob and Chris explore the expression: black out before you tap out, which obviously runs counter to the basic common sense principle of tapping out for safety. They explain that this expression is sometimes misunderstood.
It was originally associated with some of the Gracies, and referred specifically to blood chokes (strangles). It’s used on the basis that there’s no scientific evidence showing long-term harm from being put unconscious in this way.
However, Rob warns that a lack of evidence doesn’t necessarily make these chokes “safe”. For one thing, medical science is moving forward all the time, and it’s possible that some form of harm could come to light in the future.
Also, even if the choke itself is harmless, there are risks from the torsional forces that go through the neck e.g. from a person’s arm wrapped around your neck. For example, training in some chokes has been linked to cervical artery dissections – a tear in one of the large blood vessels in your neck, which can lead to a stroke.
Also, Chris points out that there’s a risk students might extend this mantra to other techniques such as joint locks, which could be very dangerous. Rob explains that it’s best to “train smart”, and not glorify excessive bravado.
If you know your technique, and you know you’re in a bad spot there’s no shame in tapping out. Because then then you get to live another day and fight another day. If you tap early, you save that energy reserve to spend later in training. To spend minutes fighting a choke you just can’t get out of is very energy-demanding. Because there are certain things you just can’t get out of.
So the guys highlight various risks and other considerations for health professionals working with martial artists. But throughout the whole podcast, they never lose sight of their own passion and respect for this training – and the benefits it can bring.
Do you recognise yourself in any of the points above? Or do you think the guys have missed anything . . . ?
You can listen to the full podcast – Fighting Talk; Making Sensei of Martial Arts – at: http://chewshealth.co.uk/tpmpsession45/
Chris Tack is a highly specialised musculoskeletal physiotherapist working at Guys & St Thomas’ NHS Foundation Trust, London, United Kingdom. He is a lead clinician and owner of All Powers Physiotherapy, Rehabilitation & Conditioning, providing acute and chronic injury management for amateur & professional combat sports and mixed martial arts athletes.
Rob Tyer is a Musculoskeletal Physiotherapist, who provides high quality, evidence-based care for patients with neuromusculoskeletal, vestibular and chronic pain conditions. He has a particular specialism in combat sports injuries. Rob is also an administrator and interviewer for the Physio Matters Podcast.
The Physio Matters Podcast is produced by Chews Health, a physiotherapy-led, independent healthcare company with clinical specialism in rehabilitation. Chews Health (named after co-founder Jack Chew) also works to develop the knowledge and skills of other healthcare professionals through innovative educational platforms such as podcasts and evidence-based seminar series.
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