CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care Youth Participation and Injury Risk in Martial Arts Rebecca A. Demorest, MD, FAAP, Chris Koutures, MD, FAAP, COUNCIL ON SPORTS MEDICINE AND FITNESS The martial arts can provide children and adolescents with vigorous levels abstract of physical exercise that can improve overall physical fi tness. The various types of martial arts encompass noncontact basic forms and techniques that may have a lower relative risk of injury. Contact-based sparring with competitive training and bouts have a higher risk of injury. This clinical report describes important techniques and movement patterns in several types of martial arts and reviews frequently reported injuries encountered in each discipline, with focused discussions of higher risk activities. Some This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have of these higher risk activities include blows to the head and choking or fi led confl ict of interest statements with the American Academy of Pediatrics. Any confl icts have been resolved through a process submission movements that may cause concussions or signifi cant head approved by the Board of Directors. The American Academy of injuries. The roles of rule changes, documented benefi ts of protective Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. equipment, and changes in training recommendations in attempts to reduce Clinical reports from the American Academy of Pediatrics benefi t from injury are critically assessed. This information is intended to help pediatric expertise and resources of liaisons and internal (AAP) and external health care providers counsel patients and families in encouraging safe reviewers. However, clinical reports from the American Academy of Pediatrics may not refl ect the views of the liaisons or the organizations participation in martial arts. or government agencies that they represent. The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. INTRODUCTION All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffi rmed, The term martial arts is derived from the “arts of Mars” (Roman god revised, or retired at or before that time. of war) 1 and presently encompasses formal combat traditions that DOI: 10.1542/peds.2016-3022 can be practiced for self-defense, competition, physical fitness, motor PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). development, and emotional growth. More than 6.5 million children Copyright © 2016 by the American Academy of Pediatrics participate in some form of martial arts in the United States. 2 Martial FINANCIAL DISCLOSURE: Dr Koutures is a consultant to Neural arts can be effective tools for building muscle strength and balance and Analytics for their clinical trials. Dr Koutures also receives royalties enhancing flexibility in children and adolescents, 3, 4 as well as positive from SLACK Publications. Dr Demorest indicated she has no fi nancial interventions and activities in which to help build cognitive function, relationships relevant to this article to disclose. self-esteem, self-respect, and self-awareness.5 – 7 FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they Various types of martial art disciplines can be categorized as striking have no potential confl icts of interest to disclose. (using blocks, kicks, punches, knees, and elbows to defend oneself while on one’s feet 8), grappling (taking an opponent to the ground to achieve a dominant position or use a submission hold to end a fight), weapon- To cite: Demorest RA, Koutures C, AAP THE COUNCIL ON based, or low-impact/meditative style with overriding philosophies that SPORTS MEDICINE AND FITNESS. Youth Participation and Injury Risk in Martial Arts. Pediatrics. 2016;138(6):e20163022 are oriented toward combat, health, or spirituality. Mixed martial arts Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 138 , number 6 , December 2016 :e 20163022 FROM THE AMERICAN ACADEMY OF PEDIATRICS (MMA) involves the combination of • variations in injury definitions Risk stratification in studies of different types of martial arts in a (eg, cessation of match, observed martial arts does not show consistent competitive venue. injury, reported injury, time loss results. Results are inconsistent as injury); to whether age (younger versus The practice of a particular martial older) and level (beginner versus • differences in study methods art or MMA involves both training professional/advanced) place an (competition injuries [more and possibly competitive activities. individual at increased or decreased commonly studied] versus training All martial artists execute forms, risk for injury. 11, 14 – 20 A 2005 study injuries [less commonly studied]); which are individualized repetitive spanning 5 martial arts disciplines practice of movements, striking/ • accounting mostly for acute but not (Shotokan karate, Aikido, taekwondo, blocking techniques, and potential chronic injury; kung fu, and tai chi) found that use of weapons without any contact people 18 years or older were 4 • lack of consistency across studies with objects or other performers. Not times more likely to sustain an injury in use of protective equipment; and all martial arts practitioners progress compared with those younger than to combat practice or competition. • lack of detailed, accurate, complete, 18 years and that competitors with For those martial arts disciplines or any reporting (recall bias, at least 3 years of experience were that involve combat elements, a retrospective self-reporting, 2 times more likely to sustain injury common training practice involves postmatch video recall). 9, 10 compared with less experienced competitors. 14 Participants younger sparring. Sparring is defined as Most studies to date of martial arts than 18 years doubled their risk of actual combat or fighting between comprise data largely from the injury with every 2 additional hours 2 individuals that uses particular adult population; however, when of training per week after the first 3 techniques of blocking, kicking, pediatric data were available, they hours, and those training for more striking, and takedowns (throws were evaluated and are noted in this from the standing position 8), as than 3 hours per week had an overall report. 14, 15 taught by each style of martial arts increased injury risk. One study and overseen by instructors. Sparring In a cumulative epidemiologic study of children and adults participating may begin at any age, as directed by of pediatric martial arts, overall in martial arts found that those the martial arts instructor, and often reported injury rates varied from younger than 10 years had an overall after learning basic movements/ 41 to 133 injuries per 1000 athletic lower injury rate per 1000 athletic forms. Martial arts students are exposures. 11 In a 2006 study, an exposures compared with all other often categorized according to age estimated 128 400 children aged ≤17 age groups; however, when adjusting and belt color, with advanced belt years (mean age, 12.1 years; 73% for exposure time, the 10- to 14-year- designations earned after proper male) were treated in US emergency old age group had a higher injury risk execution of forms often combined departments for martial arts–related per minute exposed compared with 18 with sparring. injuries from 1990 to 2003, with the open division. To what degree most injuries attributable to karate skill and age may help or harm Some martial arts styles require (79.5%).2 Generally, martial arts athletes continues to be researched. participants to use soft gear intended injuries are not life-threatening Sex stratification in studies for head and body protection. Martial (abrasions, contusion, sprains, also yields inconsistent arts competitions are formal and and strains); however, fractures, results. 2, 10, 11, 14, 15, 17, 21 Without ritualized time-measured events neck injuries, dental injuries, and significant participation of female with referees often awarding points concussions do occur. 2, 11 Overall subjects in many of these studies, and supervising conduct of the fracture rates of 10% and higher more research is needed. performers. of all documented martial arts injuries have been described in Injuries specific to different martial multiple articles.2, 11 – 13 Most reported art forms are detailed in the following EPIDEMIOLOGY OF PEDIATRIC AND pediatric martial arts injuries sections. Not all disciplines are ADOLESCENT MARTIAL ARTS INJURIES are acute. 11 Free sparring during covered, because not all disciplines Pediatric and adolescent martial tournaments seems to cause many have been studied in detail, especially 14 arts injuries and injury risk are very overall injuries in martial arts. The with children and adolescents. Of difficult to quantify, stratify, and nature of the martial art (kicking, note, despite kicks to the head and extrapolate because of: sparring, grappling, and takedowns) takedowns naturally increasing dictates the injury risk and rate. the risk of head injury, concussion • lack of pediatric and adolescent Very few catastrophic injuries are rates are not well accounted for study