The Pathophysiology of Boxing Injuries Volume 1 of 1 Michael Paul Loosemore A thesis submitted for the degree of Doctor of Philosophy University of Bath Department of Health November 2015 COPYRIGHT Attention is drawn to the fact that copyright of this thesis rests with the author. A copy of this thesis has been supplied on condition that anyone who consults it is understood to recognise that its copyright rests with the author and that they must not copy it or use material from it except as permitted by law or with the consent of the author. This thesis may be made available for consultation within the University Library and may be photocopied or lent to other libraries for the purposes of consultation with effect from……………….(date) Signed on behalf of the Faculty/School of Health 1 2 Who killed Davey Moore Why an’ what’s the reason for? Bob Dylan 1964 3 Abstract This thesis explores the prevalence, nature and pathogenesis of injuries in boxing. Following an introductory chapter and literature review (Chapters 1 and 2 respectively); Chapter 3 examines injuries in the GB boxing squad from 2005 to 2009. There were a total of 66 boxers on the squad during this period 61% were injured, a total of 297 injuries were recorded. The injury rate in competition was at least 460 times higher than in training, and most injuries were new rather than recurrent (246 v 51). The incidence of concussion is comparatively low compared to other studies in amateur boxing (5 in 5 years). Hand and wrist injuries were the most frequent (23.2%). Chapter 4 describes the nature of hand and wrist injuries in more detail. ‘Boxers’ knuckle’, skiers thumb, Bennett’s fracture and carpometacarpal instability were the most frequent hand and wrist injuries and also took the longest time to recover compared to all other hand and wrist injuries that occurred. These injuries occur significantly more frequently in competition than in training (347 injuries per 1,000 hours in competition less than 0.5 per 1000 hours in training). Chapter 5 describes efforts to identify and validate a means to measure the pressure at each knuckle, given that ‘boxers’ knuckle’ was found to be such a debilitating injury. This does differentiate between the proportion of knuckle impact forces (PKIF) displayed during punching and no punching but displays very poor test-re-test reliability. This method might allow the impact of changes in the hand wraps or the gloves to be measured. Chapters 6 and 7 deal with head injury in boxing. Head guards were removed from amateur boxers in 2013. The effect of this removal on boxers’ health was investigated by reviewing the number of bouts stopped due to blows to the head both with and without head guards (Chapter 6). To improve the quality of this analysis, an examination of video from championships with and without head guards (Chapter 7) was carried out. A significant decrease in observable signs of concussion (p<0.05) and a significant increase in cuts (p<0.001) was observed when the head guards were removed. This work will have implications for the protection of boxers’ hands and the use of head guards in other contact sports. 4 Acknowledgements The completion of this thesis and the research contained within it would not have been possible without the support and expertise of many people. I owe a great debt to Professor Greg Whyte who acted as a mentor and who helped greatly with my academic writing and general encouragement during this process. I would also like to thank Professor Hugh Montgomery for his help and constructive criticism. I would like to acknowledge the support of the following people: Chris Beasley who has been a constant source of support and encouragement. Dr Joe Lightfoot who has supported this research throughout amongst many other things he helped wrapping and unwrapping boxers hands and cut out thousands of pieces of pressure film and sticking them together (almost always the right way round) and Dr Jay Meswania, who very patiently advised on the scanning of the pressure film. Rob Gibson who was the chief video analyst and all the other analysts who spent thousands of hours viewing boxing footage. Professor Jeremy Lewis for his advice on structuring this thesis. I would like to thank the English Institute of Sport and AIBA for their support and willingness to release data for use in this thesis. Further I would like to thank the coaches and support team at GB boxing who allowed me to use valuable potential training time for various experiments, and of course the boxers who without any animosity had their hands wrapped and unwrapped, a process that takes about 20 minutes, up to 24 times each. Finally I would like to thank my wife Donna for her continuous support. 5 Supporting Material Peer reviewed publications: Loosemore M, Knowles C, Whyte G. Amateur boxing and risk of chronic traumatic brain injury: systematic review of observational studies. British Journal of Sport and Exercise Medicine Nov 2008, Vol 42: 564-567 Exercise Medicine highlights from the BMJ Loosemore M, Ansdell M, Business BS, Charalambous CP, Harrison J, Hayton M.Traumatic Extensor Hood Rupture. Hand (N.Y).2009 Jun;4(2): 177-179 Bianco M, Loosemore M, Daniele G, Palmieri V, Faina M, Zeppilli Amateur boxing in the last 59 years. Impact of rules changes on the type of verdicts recorded and implications on boxers' health. P.Br J Sports Med. 2013 Jan 12. [Epub ahead of print] PMID:23314931 Nazarian, R. S. Page, G. A. Hoy, M. J. Hayton and M. Loosemore May 2013 J Hand Surg Eur Vol N Combined joint fusion for index and middle carpometacarpal instability in elite boxers. Journal of Hand Surgery (European Volume) http://jhs.sagepub.com/content/early/2013/04/23/1753193413487469 The online version of this article can be found at: DOI: 10.1177/1753193413487469 published online 6 Loosemore M, Lightfoot J, Palmer-Green D, Gatt I, Bilzon J, Beardsley C. Br J Sports Med. 2015 Sep;49(17):1100-7. doi: 10.1136/bjsports-2015-094755. Epub 2015 Jul 17 Boxing injury epidemiology in the Great Britain team: a 5-year surveillance study of medically diagnosed injury incidence and outcome. Published Abstracts: Loosemore, M., Knowles, C.H., Wilson, M. and Whyte, G. Amateur boxing and risk of chronic brain injury: A systematic review. Medicine & Science in Sports & Exercise. 39(5):S320, May 2007. doi: 10.1249/01.mss.0000274246.73292.1a Papers Accepted for Publication: M.Loosemore, C. Butler, J. Bailes. Use of Boxing Head Guards in Amateur Boxing – A Cross-Sectional Observational Study. Accepted in the Clinical Journal of Sports Medicine. Papers in Review: Loosemore, M. Lightfoot, J. Gatt, I. J. Hayton, M. Beardsley, C. Hand and wrist injuries in elite boxing: A longitudinal prospective study (2005- 2012) of the Great Britain amateur boxing team. Under review by the journal Hand. 6 Articles in the Popular Press: Head guards and concussion http://www.telegraph.co.uk/sport/rugbyunion/news/11150094/Headguards-in- rugby-would-add-to-the-concussion-problem-not-solve-it-says-doctor.html http://www.dailymail.co.uk/sport/othersports/article-2700538/Male-boxers-not- wear-head-guards-Commonwealth-Games-time-32-years.html Presentations Given: 6th September 2015 Boxing Injuries, is it all in the Head? Aspetar Doha 27th August 2015 Presentation to IOC, Lausanne, Switzerland. 6th July 2015 Talk to MSc Students at ISEH. Boxing Injuries 15th May 2015 Sport Resolutions, concussion Conference. Concussion in Boxing. 22nd January 2015. RSM. Sports Orthopaedic Conference. Hand injuries’ in Boxing 29th October 2014. Talk to plastic surgery unit Swansea re Boxing injuries. 22nd September 2014. Chaired panel discussion on Concussion at RSM. 25th June 2014 Government round table meeting on Concussion in Schools. 18th February 2014 Lecture to MSc students UCL, Boxing Injuries. 9th January 2014 Sports Injuries and sports Orthopaedics. State of the Art. Hand Injuries in Boxing. 28th November 2013 ‘A Fighting Front: Medical Considerations of Boxing and MMA in the Military’ Army and Navy Club. London 12th February 2013 MSc Lecture, Boxing Injuries, Prevention and Management. 22nd February 2011 MSc Lecture, Boxing Injuries, Prevention and Management. 7 Table of Contents ABSTRACT ................................................................................................................................ 4 ACKNOWLEDGEMENTS ......................................................................................................... 5 SUPPORTING MATERIAL ...................................................................................................... 6 TABLE OF CONTENTS............................................................................................................. 8 LIST OF FIGURES .................................................................................................................. 13 LIST OF TABLES .................................................................................................................... 15 ABBREVIATIONS .................................................................................................................. 17 1.0 INTRODUCTION ............................................................................................................. 18 2.0 LITERATURE REVIEW .................................................................................................. 21 2.1 An Historical Overview of the Sport of Boxing ..................................................................................... 21 2.1.1 Pre-History ..................................................................................................................................