Phys Med Rehabil Clin N Am

17 (2006) 645–676

The Martial Arts

Charles M. Terry, MD, FAAPMRa,b,*
a
Saint Lawrence Rehabilitation Center, 2381 Lawrenceville Road,
Lawrenceville, NJ 08648, USA
b
MKA Karate, 4800 Drexelbrook Drive, Drexel Hill, PA 19026, USA

Over the past several decades, the martial arts have become an increas-
ingly popular recreational activity among Americans. When the martial
arts were first introduced in the United States, ‘‘old school practices,’’
such as performing knuckle push-ups on the pavement or running barefoot
through the snow, were actually accepted training methods. In many in-
stances, only the fittest students endured the rigors of these practices
and continued to train. Today, the martial arts have evolved into an activ-
ity that can benefit students of all ages, shapes, and sizes. Some schools
accept students as young as 3 years old [1]. There are also those who
have first begun training in their 70s and 80s [2]. More recently, physically
challenged individuals have discovered that they can actively participate in
the martial arts [3–5]. Each different style of martial arts has its own risks
and benefits. It is important for health care practitioners to understand the
demands of any given martial art so as to advise patients properly about
participation.
Obtaining a detailed history about the specific requirements and training
practices of a patient allows the medical practitioner to propose the most ap-
propriate training regimen and restrictions if necessary. For several disease
processes, training in the martial arts may be an excellent adjunct to other
therapeutic interventions [6–10]. The purpose of this article is to provide
an overview of the martial arts, including styles, training methods, risks,
and benefits so that health care providers can make educated well-informed
recommendations about training to their patients.

* Saint Lawrence Rehabilitation Center, 2381 Lawrenceville Road, Lawrenceville, NJ

08648.
E-mail address: [email protected]

1047-9651/06/$ - see front matter Ó 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.pmr.2006.05.001 pmr.theclinics.com
646 TERRY

Background
History
The art of fighting has been around for thousands of years. There are
even references to martial arts in ancient Greece and Egypt. The history
of modern martial arts is shrouded in secrecy. Many arts were developed
in times when weapons or outright practice of martial arts was banned.
Therefore, systems of self-defense were often passed on privately. The roots
of many of today’s arts may be traced back to China and India. As these
arts spread, they continued to develop. The term te was used as early as
1629 to describe an Okinawan martial art. This eventually evolved into to-
day’s karate.
The martial arts were introduced to America through several different av-
enues. Chinese immigrants brought Chinese martial arts to the United
States in the 1800s. After World War II, many United States soldiers trained
in Japanese and Okinawan arts, later bringing these arts home. The Korean
War may have led to the rise of Korean martial arts in America, which have
gained even more popularity since being added to the Olympics.

Styles
There are many styles of martial arts. Some commonalities may be found
in techniques and training methods. Each style and each school within a style
are likely to have unique requirements of students, however. Some of the
most popular systems originated in Japan, Okinawa, Korea, China, the
Philippines, Brazil, France, Israel, and America. Different regions and coun-
tries have given birth to a myriad of newer systems. The sharing of tech-
niques and concepts makes it impossible to detail fully the ever-evolving
systems available to those interested in the martial arts.
In general, styles may be broken down into several categories: striking-
based systems, grappling or throwing systems, weapons-based systems,
and health-based systems. Each style may cross over into elements of other
systems as well. Many of today’s schools are based on striking systems but
also include some grappling and weapons. A school may be competitive and
tournament centered or may predominantly focus on calisthenics for health
and exercise (eg, cardio-kickboxing). Some schools do not allow any contact
at all between students, whereas others range from light contact to the body
without weapons to full contact with weapons (Table 1).

Participant profile
The exact number of participants in the martial arts is unknown. In 1989,
Ritter [11] estimated that 2 million people in the United States participate in
 MARTIAL ARTS 647

Table 1
Some of the major systems of martial arts
Style Country of origin Main features
Aikido Japan Throws and redirection
Arnis (Kali, Escrima) Philippines Stick Fighting, developing ‘‘the Flow’’
Capoera Brazil Wide sweeping kicks and handstands
Goju-Ryu Okinawa Kicks, striking techniques
Hapkido Korea Kicks, flowing, constant motion
Jeet Kune Do America/China The approach of Bruce Lee
Judo Japan Throws, holds, and chokes
Jujutsu (Jiu Jitsu, Jujitsu) Japan Joint locks, throws, holds, chokes
Karate Okinawa Kicks, striking techniques, blocks
Kempo Okinawa Kicks, striking techniques, weapons
Kendo Japan Use of the practice sword
Kenjutsu Japan Cutting and thrusting with the sword
Kenpo China/America Kicks, striking techniques
Krav Maga Israel Military-based hand-to-hand combat
Kung-fu China Hard or soft style, weapons, animal forms
Ninjitsu Japan Commando warfare, weapons
Ryukyu Kempo Okinawa Pressure point strikes and grappling
Savate France Kicks, boxing
Shorin-Ryu Okinawa Kicks, striking techniques
Shotokan Japan Kicks, striking techniques
Sumo Japan Wrestling
T’ai Chi China Cultivates Chi
Tang Soo Do Korea Kicks, striking techniques
Tae Kwon Do Korea Kicks, striking techniques
Wu Shu China Official art of the Chinese mainland

the martial arts. In 1996, Birrer [12] estimated that there were 8 million par-
ticipants in the United States. According to a representative from the Mar-
tial Arts Industry Association (MAIA), there were approximately 6.9
million Americans aged 6 years or older participating in the martial arts
in 2004 (C. Ryan, personal communication, 2005).
The percentage of students who are younger than 18 years of age is also
subject to debate. Although it is possible that schools were predominantly
populated by adults in the past [13], many commercial schools are domi-
nated by children’s classes today. According to MAIA demographics
from December 2004, 46% of students were between the ages of 6 and 17
years. This does not account for students younger than 6 years of age. There
has been a recent trend toward more age-specific classes, starting as young
as the age of 3 years [1,14]; therefore, it is likely that an even greater number
of children are training than adults.
Most schools have coeducational classes. It is also evident that more girls
and women are participating in the martial arts today. In 1991, it was esti-
mated that the male-to-female ratio was 5 to 1 [13]. In 2004, it was estimated
that 37.5% of practitioners were female (MAIA).
648 TERRY

Training methods
Training methods can be divided into three categories: individual or non-
contact group practice, equipment use, and partner work. In many cases, an
injured student may be able to continue training with individual or noncon-
tact group practice. The use of some equipment may be contraindicated un-
der certain circumstances. Partner work, most specifically sparring, is the
activity most likely to result in injury [12].

Individual or noncontact group practice

Warm-up
Most classes begin with a warm-up period. This consists of stretching and
light aerobic exercises. A broad range of calisthenics may be incorporated
into the average martial arts class, including jumping jacks, jogging, push-
ups, abdominal exercises, and related activities. These are used for
conditioning.

Basics
The core aspects of the martial arts are broken down into basic tech-
niques. Basics include blocks, strikes, falls, and rolls. Basics may also in-
clude drills to enhance speed, timing, balance, coordination, and other
skills beneficial to the martial artist. Although any part of the body may
be used as a weapon, from the forehead to the gluteus maximus, most strik-
ing and blocking techniques can be broken down into upper extremity or
lower extremity techniques.
Various parts of the upper extremity can be used for blocking or striking.
The hand is usually held in a chop-hand position (chuto) or in a fist. Other
positions and variations on these positions may also be used. In the chop-
hand, the fingers are held together straightened or slightly flexed with the
thumb approximated against the second digit in a plane rotated at an angle
of 90
to the other fingers (Fig. 1). Some styles advocate a flexed position for
the first interphalangeal joint; however, this leaves a practitioner open to
a thumb lock or risks jamming the thumb when interacting with a partner.
The finger tips are used as the striking surface in a spear hand. The ulnar
side of the hand (hypothenar eminence) is used in a basic chop. The radial
side of the hand is used in a ridge hand strike. The heel of the palm may also
be used as a striking surface. Other parts of the upper extremity used for
techniques include the dorsal carpal bones, the forearm, and the elbow.
The basic karate punch involves twisting the fist from supination into pro-
nation and making contact with the knuckles of the second and third meta-
carpophalangeal joints. An incorrectly thrown punch may connect with the
fifth knuckle (metacarpophalangeal joint), leading to a fracture of the distal
metaphysis of the fifth metacarpal, or ‘‘boxer’s fracture’’ [15].
One of the most common targets of a basic punch is the solar plexus.
Many styles of martial arts perform a ‘‘full-twist’’ punch, where the fist is
 MARTIAL ARTS 649

Fig. 1. Basic karate chop-hand.

fully pronated on completion. Other styles favor a vertical punch. These var-
iations are safer for the opponent, because the fist does not fit into the solar
plexus well and decreases the risk of causing a xiphoid fracture. They are
also more likely to cross over several ribs when striking the chest. Therefore,
a vertical or full-twist punch decreases the chance of breaking a single rib by
spreading out the energy of the strike over several ribs. Some styles perform
a ‘‘three-quarters’’ punch, which holds the fist at an angle of 45
so that it
can fit better into the solar plexus or can be directed at one specific rib
(Fig. 2) [16]. It has also been postulated that the twisting of the radius

Fig. 2. Three-quarters punch.

650 TERRY

over the ulna with a full-twist punch provides less support for the striking
surface by allowing the interosseous membrane between the radius and
ulna to become slack [17].
The three basic blocks are upper, side, and low. Variations and combina-
tions of these blocks are common. Many styles teach students to block with
the radius or ulna alone. It has been proposed that blocking with both bones
in parallel provides a greater surface area to disperse the energy of an on-
coming attack and reduces or eliminates the risk of an ulnar ‘‘night-stick’’
fracture [18,19]. Blocking with the dorsal aspect of the forearm protects
the critical nerves and blood vessels that pass along the palmar aspect of
the wrist and forearm. This is also likely to reduce the risk of a debilitating
or life-threatening injury in an actual self-defense situation against an at-
tacker armed with a knife or broken bottle (Fig. 3).
Basic leg techniques include parries, sweeps, and strikes with the knee,
shin, or various parts of the foot. The front kick is typically performed
with the ball of the foot. It begins by raising the knee, then thrusting the
foot forward and upwards, and then retracting. It can also be performed
with the instep or heel (Fig. 4). The roundhouse kick is performed with
the hips turned sideways. The strike moves perpendicular to the opponent,
first pointing the knee at the intended target, then extending the foot con-
necting with the ball of the foot or the instep, and then retracting (Fig. 5).
The side kick is performed with the leg extended to the practitioner’s side
using the heel or ‘‘knife edge’’ (lateral side of the foot) as the striking surface
(Fig. 6). The back kick is performed with the leg extended behind the prac-
titioner using the heel as the striking surface (Fig. 7).

Falls
Breakfalls are common to the martial arts. The goal of practicing falls, or
breakfalls, is to reduce the chance of injury in the event of a fall during train-
ing or when in a fight. Although each style may teach a different method of
falling, the principles are quite similar. With any fall, the practitioner is
taught to keep the mouth closed, with the tongue in the mouth to prevent
biting the tongue.
When falling to the rear, the chin is tucked down so that the head does
not hit the ground on impact. The knees are bent, and the spine flexes
forward while the trunk descends. Typically, the gluteal region hits the
ground, followed by the lumbar and thoracic regions and then the shoulders
and elbows, and, finally, the hands slap the ground. It is recommended that
the arms make no more than a 90
angle with the trunk when falling to pre-
vent injury to the shoulders. The natural reflex many people have is to
extend the arms in the direction of a fall, allowing the hands and arms to
take the brunt of the impact. This commonly leads to sprains or fractures
of the upper extremities. Allowing the uncoiling trunk to disperse the energy
of a fall can lessen the impact on any one body region (Fig. 8). Falling to the
side is similar to rear falls, except the body falls sideways and only one side
 MARTIAL ARTS 651

Fig. 3. (A) Upper block. (B) Side block. (C) Low block.

of the trunk and one upper extremity are used to disperse the energy of the
fall (Fig. 9).
When falling forward, the face is turned to the side. Practitioners may be
taught to land on the palms with the elbows slightly bent, and the downward
motion of a push-up is performed to allow the muscles of the upper extrem-
ities and eccentric contraction of the triceps to disperse the energy of the fall.
652 TERRY

Fig. 4. Front kick.

Some styles teach students to land on the forearms, with a slapping motion
on impact (Fig. 10).

Rolls
Rolling techniques are often found in aikido and jujitsu. A roll can be
used as a means to escape from a joint lock or an attack. In the event of
loss of balance, rolls can serve as another method of falling without getting
injured. Rolls may be done to the front or to the rear. In a roll, the potential

Fig. 5. Roundhouse kick.

 MARTIAL ARTS 653

Fig. 6. Side kick.

energy of a practitioner in the standing position is converted to kinetic en-

ergy. Just before impact with the ground, parts of the body are positioned to
create a circle intended to deflect the force of impact. Kinetic energy is
spread out along an increased surface area of the body and translated
into rotational energy. The impact of landing is dispersed and greatly re-
duces the risk of injury. Students begin learning to roll from a seated or
kneeling position. They then progress to standing rolls and may eventually
progress to diving rolls (Fig. 11).

Kata
‘‘Kata,’’ or forms, are common to many styles of martial arts. As a basic
description, a kata is a series of moves put together in a pattern that is

Fig. 7. Back kick.

654 TERRY

Fig. 8. (A–C) Breakfall to the rear.

memorized. Typically, more difficult kata are required to progress to higher

levels of rank. Originally, kata were developed by masters to incorporate
combinations of their favorite self-defense techniques. These techniques
can be directed against pressure points to disable, knock out, or even kill
an opponent [20].
In today’s schools, kata are most often practiced as an individual exercise
or in a group done in synchronization. Kata may be used to develop
 MARTIAL ARTS 655

Fig. 9. Breakfall to the side.

balance, agility, strength, conditioning, and focus as well as proper angle

and direction of techniques. In group kata, practitioners use peripheral vi-
sion and sound in addition to constant practice to stay together. Even
breathing may be synchronized.

Equipment
Sparring gear
Most modern schools require students to wear specific equipment when
engaging in sparring. The efficacy of this gear is subject to debate [19].
The use of sparring gear is often required by companies that insure martial
arts schools, however. Therefore, a discussion of the most commonly used
gear is appropriate and necessary. Many standard head protectors, gloves,
and foot protectors are made of foam. This equipment is more for the pro-
tection of the one wearing the gear than for the opponent [21]. Gloves and
foot protectors are meant to protect the hands, feet, and digits. Headgear
comes in several forms. The most common type protects only the side,
top, and back of the head. The usefulness of any foam headgear to protect
against closed-head injury has been questioned [21]. This author has always
preferred (from a safety standpoint) the type of headgear that also protects
the face (Fig. 12). This is because contusions, lacerations, and abrasions
occur in general practice far more frequently than closed-head injuries or
concussions [12]. This full-face headgear also affords more protection to
the nose (Fig. 13). Students may complain about decreased peripheral vision
656 TERRY

Fig. 10. Breakfall to the front.

with such headgear, however. This may be why it has become increasingly
more difficult to find this more comprehensive full-face headgear. A newer
alternative is a clear face shield that attaches to the less protective type of
headgear. It is more expensive, and its acceptance among practitioners re-
mains to be seen.
Most schools and tournaments require the use of a mouth guard during
sparring. These come in many varieties. For the elite athlete, a custom
mouth guard may be fashioned by most dentists. Chest protectors are re-
quired in some settings. Specific protectors are available for the female
chest. Nevertheless, it has been said that a blow to these protectors hurts
just as much as without a protector [22]. This author has yet to find a chest
protector that is well accepted by female practitioners. Groin protectors are
available for male and female practitioners. Typically, only male practi-
tioners are required to wear groin protectors. Optional equipment includes
shin pads, forearm pads, knee pads, and elbow pads. Because of frequent
clashing of the shins during sparring, many students opt to wear at least
shin pads.

Floor mats
Floor mats come in different thicknesses and degrees of cushioning. The
amount of padding recommended varies with the techniques being prac-
ticed. Inadequate padding for certain techniques can lead to injury. Insuffi-
cient hygiene of mats could lead to the spread of superficial infections [23]. It
 MARTIAL ARTS 657

Fig. 11. (A–C) Forward roll.

should be noted, however, that several investigators have failed to isolate

fungal organisms from wrestling mats and that the distribution of typical le-
sions on wrestlers suggests that skin-to-skin contact is a more likely mech-
anism of transmission [24–26]. These studies have yet to be performed on
martial arts mats. It is likely that systems focusing on grappling may incur
a similar incidence as that found in wrestling.
658 TERRY

Fig. 12. Standard sparring equipment: comparison of standard headgear (right) versus full-face
headgear (left).

Heavy bags
Heavy bags may be suspended from above (with or without a tether be-
low) or may be free-standing (supported by a base filled with sand or water).
They are typically filled with sand, water, or padding. The outer cover is
usually nylon, leather, or canvas.

Targets
Targets come in a variety of shapes and sizes. The surface may be canvas,
nylon, leather, or simulated leather. They are typically filled with padding,
foam, or air. Targets allow students to work together to improve strength,
focus, accuracy, and timing. The target serves to dissipate the force of the
technique and minimizes the impact on the student holding the target. Nev-
ertheless, it must be noted that the holder may still be subjected to a signif-
icant amount force with each blow. Therefore, a student with an injury may
have to modify his or her method of holding a target or avoid this aspect of
training entirely. Similarly, a student practicing with an injured upper or
lower extremity should obviously avoid hitting targets with the affected
limb. Practice with targets is essential for students who wish to learn how
to break boards and cinder blocks.

Breaking
Breaking of boards or other objects is a highly visible and exciting yet
risky practice of the martial arts. It may be used to test the effectiveness
and accuracy of techniques. Breaking is sometimes required when students
 MARTIAL ARTS 659

Fig. 13. Vulnerability of the face with standard headgear.

are testing for higher rank. Breaking is most commonly used for demonstra-
tion purposes and may be included in tournaments as a separate division. It
should be noted that not all schools practice breaking. Even in schools that
do practice breaking, it typically plays a small role in overall training prac-
tices. Breaking has also been taught to nonmartial artists by motivational
speakers (eg, Anthony Robbins) as a means of developing confidence.
In an unpublished study, this author attempted to measure the force
needed to break 1-inch thick common pine boards. Because of the variabil-
ity in seemingly homogeneous wood, some boards took up to three times the
force needed to break a single board. For this reason, it is essential for stu-
dents to exercise caution when practicing breaking and only to advance the
number of boards broken in single increments. Moisture may also have an
impact on the pliability of objects to be broken. The practice of heating cin-
der blocks in an oven to dry out any moisture and thus decrease the force
needed for a breaking technique is well known among martial arts folklore
(as is the story of a martial artist who tried to heat wooden boards in his
oven and burned down his kitchen). Conversely, this author has seen first
hand the effects of attempting to break a cinder block that had been over-
exposed to the elements. A highly trained black belt with years of experience
attempted to use a punch to break cinder blocks of uncertain origin. In spite
of previous success, this instance led to a severe wrist fracture. It was later
determined that the cinder block had been used for several seasons as
a weight to keep a pool cover in place. It is therefore recommended that
only new wood or cinder blocks that have been kept in a controlled
660 TERRY

Fig. 14. Board-breaking technique.

environment be used as breaking materials. Children whose epiphyseal

plates have not yet fused as well as older students who may have osteopo-
rosis should practice breaking only with caution, if at all (Fig. 14).

Miscellaneous equipment
Martial artists use many types of equipment that are common to other
sports. These include jump ropes, weights, hand grips, and resistance bands.
Other types of equipment are more specific to the martial arts: push-up bars,
stretch racks, makiwara, and weapons (Fig. 15).

Weapons
Weapons may be taught as an individual exercise through basic tech-
niques and kata or as an interactive exercise with another student who is
armed or unarmed. The most common weapons in the martial arts include
the bo (long staff), jo (short staff), arnis or escrima (rattan sticks), nunchuku
(two hardwood sticks connected by a rope or chain), sai (pair of three-
pronged swords resembling tridents), kama (sickles), tonfa (similar to to-
day’s police baton), and sword (Fig. 16). Because any common object
may be used as a weapon, this list could go on indefinitely. Proper mainte-
nance of weapons is imperative to minimize risk to practitioners and spec-
tators. Any damaged weapons should be repaired or replaced
immediately. Although many schools require students to go barefoot during
training, simple footwear may significantly reduce the injuries that can occur
from a dropped weapon landing on the foot.

Partner work
Partner work is when students are most likely to sustain an injury while
training in the martial arts. This aspect of training may include sparring,
drills, self-defense techniques, pressure point manipulation, and grappling.
 MARTIAL ARTS 661

Fig. 15. (A) Push-up bars are used to keep proper wrist alignment and to allow for increased
range of motion. (B) Stretch racks are used to provide passive resistance for increasing flexibil-
ity. (C) Makiwara are slightly padded targets used for conditioning, strengthening bones, and
toughening the skin.

Most documented martial arts–related injuries occur during sparring

(particularly competitive or tournament sparring) [12]. Rules have been de-
veloped to minimize the risk of injury during sparring, and most modern
schools do not permit sparring without the use of protective equipment.
Standard sparring rules generally state that no contact is allowed to the
head, face, back, or below the belt. Light contact may be permitted to the
body. Certain techniques, such as takedowns and grappling maneuvers,
may be restricted to more experienced students.
Drills may involve trading techniques or combinations with a partner.
Basic techniques can be practiced with another student acting as an attacker
with different degrees of complexity. Other partner drills may be used to
develop timing, focus, accuracy, and control.
Self-defense is one of the most commonly cited reasons for people to
train in the martial arts [27,28]. In the interest of safety, the rules of spar-
ring often forbid the same techniques that may be the most useful in an
actual self-defense situation. For this reason, practical self-defense is often
practiced as a separate exercise. One or more students act as attackers,
whereas a practitioner practices controlled blocks and counterattacks.
Initially the attacks are singular, predetermined, and basic. Eventually,
662 TERRY

Fig. 16. Weapons (left to right): wooden kama, kama with metal blades, sai, nunchaku with
strings, sai, nunchaku with chains, and tonfa.

students may progress to fending off multiple armed attackers using ran-

dom attacks.
Pressure point techniques have become increasingly popular over the
past 20 years. Ryukyu Kempo is a classic Okinawan martial art that in-
corporates striking and grappling techniques using the same points and
theories involved in acupuncture [20]. With basic techniques, pressure
points are activated so that the training partner feels pain but is not in-
jured (Fig. 17). These techniques have been recommended for law en-
forcement, medical personnel, and business professionals [29]. Advanced
techniques involve using pressure points to render a training partner un-
conscious. Although the physiologic mechanism of action of these tech-
niques has yet to be elucidated, no hazardous complications were
demonstrated during a study that monitored electrocardiography
(EKG), electroencephalography (EEG), pulse oximetry and blood pres-
sure [30].
Grappling with a partner is common to jujitsu, aikido, and judo. With
the success of grapplers in ‘‘no holds barred’’ competition, many predom-
inantly karate-based schools of martial arts have introduced grappling
techniques. Grappling employs the use of joint locks and chokes. An ob-
vious potential risk of joint locks is fractures and dislocations. Practi-
tioners are taught to ‘‘tap-out’’ before becoming injured during the
application of a lock. Unwillingness to concede or poor sensitivity on
the part of the practitioner applying the lock can lead to injuries, how-
ever. With respect to chokes, there is a case report of a stroke in
a 29-year-old previously healthy man after participation in six neck-hold-
ing maneuvers in a martial arts class [31]. Another case report involved
a 40-year-old practitioner who had a stroke likely secondary to traumatic
plaque rupture during a choking maneuver in a martial arts class [32].
 MARTIAL ARTS 663

Fig. 17. (A) Self-defense technique using pressure points on the wrist and leg. (B–D) Self-
defense sequence using pressure points on the arms and face.

Therefore, the practice of prolonged or vigorous neck holds is discour-

aged even in seemingly healthy individuals. Preparticipation physicals
should include screening for carotid artery stenosis, particularly in pa-
tients who state that choking techniques are part of their repertoire, al-
though blunt trauma to the carotid artery is possible in many styles of
martial arts.
664 TERRY

Injuries
Epidemiology of injuries
There have been several attempts to qualify and quantify the injuries at-
tributed to training in various types of martial arts [12,22,33–35]. The true
risks and types of injuries to which any given participant is susceptible
may vary greatly with style, hours of training, and degree of competitive-
ness. Often, the incidence of injury is expressed as a number per 1000 hours
of practice or competition [19]. In a study of injuries during competitive
Muay Thai Kickboxing, there was an average of one injury for every 42
minutes of competition [36]. In contrast, practitioners of Tai Chi (which is
generally slower and noncontact) may practice for hours each week for
months and rarely complain of an injury [37]. In a recent survey of a ka-
rate-based system, there was an injury rate of 2.70 per 1000 hours of practice
[19]. More than one study has suggested that the practice of martial arts is
safer than many other commonly practiced sports, such as soccer, gymnas-
tics, and volleyball [12,38,39].

Types of injuries, prevention, and return to martial arts

training after an injury
Injuries may be divided into those that are related to martial arts training,
preexisting conditions, and unrelated injuries that may affect training in the
martial arts. In this author’s experience, far more students are injured in ac-
tivities outside of the dojo than while training in the martial arts. Often an
‘‘injury’’ is defined as an event that interrupts the continuation of training or
competing [37]. It is likely that this misses most minor injuries that do not
interfere with participation. Most injuries encountered in the martial arts
do not require complete cessation of training. A modified training program
may actually be therapeutic for rehabilitation from an injury.
Whether an injury has occurred during martial arts training or elsewhere,
the timing of safe return to training is important. When an injury has oc-
curred in the martial arts class, there may be psychologic issues as well. A
physician who is not familiar with the martial arts may be inclined to advise
an injured student to avoid any training until an injury is completely healed.
This may be akin to telling a postsurgical patient to avoid rehabilitation un-
til he or she is completely healed. Certainly, if a post-coronary artery bypass
graft (CABG) patient can be admitted to a rehabilitation unit less than
a week after surgery, a martial artist with a sprained finger can continue
to train. The acronym RICE (rest, ice, compression, elevation) in a rehabil-
itation setting is often changed to RRICE (relative rest, ice, compression,
elevation). If our goal is to restore function and focus on quality of life, tell-
ing a dedicated martial artist not to train may do more harm than good.
Because most injuries in the martial arts occur during partner activities,
this aspect of training can be avoided completely for a brief period if
 MARTIAL ARTS 665

necessary. Many training drills do not require contact with another student;
thus, an injured practitioner can significantly control and modify the train-
ing environment to reduce the risk of exacerbating an injury. The following
section primarily addresses injuries specific to martial arts training. When
pertinent, disorders unrelated to a martial arts injury are also discussed.

Skin or soft tissue injuries

Contusions and hematomas are so common in the martial arts that they
are frequently unreported [40]. They often require no treatment. RICE may
be used as needed, however. In the case of a large hematoma, aspiration
may speed recovery [35,41].
Tinea corporis gladiatorum is a common affliction among wrestlers [24–
26]. It is reasonable to expect this to be found also among grappling-based
martial arts systems. What may be a more general concern to martial artists
is tinea pedis. Most martial arts are practiced barefoot. It is recommended
that any martial artist with signs or symptoms of ‘‘athlete’s foot’’ be permit-
ted to wear martial arts shoes during training to prevent its transmission to
other practitioners.

Head and neck

The most common injuries to the head involve contusions and lacerations
[42]. If a concussion is evident, a student should refrain from training until
medical clearance has been received. Many contusions can be minimized by
the use of appropriate headgear during sparring. Facial lacerations can be
reduced by keeping nails trimmed, using protective gear during sparring,
and eliminating sharp edges on weapons. Injuries to the eyes, nose, or teeth
should also be referred for medical evaluation by the appropriate specialist.
A simple mouth guard should be mandatory for all sparring matches. The
proper headgear should provide protection for the nose as well as for the
skull, because the nose is the most exposed feature of the face, especially
with inadequate headgear. In students with recent eye injuries or with pre-
existing blindness in one eye, sports goggles or headgear with a face shield
should be worn during all partner activities. With students who have had
a closed-head injury while training in the martial arts or elsewhere, training
can continue under certain restrictions. It is prudent to avoid falling practice
or take-down techniques as well as sparring for a period of 1 year after
a closed-head injury.
Contusions, sprains, and strains are the most common neck injuries.
Sprains and strains can be treated with stretching modalities, anti-inflamma-
tories, and muscle relaxants if needed. Guidelines on training can be based
on symptomatology. Persistent symptoms or those accompanied by radicu-
lar signs warrant further evaluation before training may resume.
Carotid injuries may occur with choke holds as previously mentioned in
this article. Injury to the carotid may also occur from blunt trauma. As
666 TERRY

described in a case report by Blumenthal and Riggs [43], a 43-year-old cor-

rections officer developed right neck and posterior head pain after a karate
punch to the right side of the neck during self-defense training. One week
later, he developed acute left hemiparesis. A right hemispheric cerebral in-
farction was demonstrated by MRI. Carotid ultrasound demonstrated com-
plete occlusion of the right internal carotid artery without evidence of
atherosclerotic disease. Their conclusion was that a forceful blow to the
neck can potentially lead to carotid occlusion and cerebrovascular infarction.

Trunk
Unfortunately, the twisting and bending motions required with some
martial arts moves may lead to a lumbosacral sprain or strain. This can
be particularly challenging for practitioners with a history of prior back in-
juries. In the general adult population, 2% to 5% of people report low back
pain that occurs at least once per year, and the lifetime prevalence of low
back pain has been estimated to be 85% to 90% [44]. Therefore, at any
given time, there may be several students in a class with current or recent
low back pain. This author has had some success with the incorporation
of a Pilates-based warm-up routine for certain students and a modification
of training requirements to curtail take-down maneuvers, throws, and, in
some instances, sparring.
Posttraumatic renal vein thrombosis has been reported after blunt
trauma to the flank during karate practice [45]. A kidney contusion was de-
scribed in a case report after a jujitsu practitioner had taken some ‘‘bad
falls’’ [46]. Using proper falling technique should minimize this risk. Using
mats to cushion the fall can help with riskier falling techniques. These tech-
niques should be avoided in the case of known internal organ dysfunction,
such as congenital absence of a kidney, history of nephrectomy, or recent
mononucleosis in which the spleen may be enlarged or weakened. Abdom-
inal protectors are also available and should be worn during all contact ac-
tivities to protect the injured or remaining organ.
Having one’s ‘‘wind knocked out’’ is not uncommon among sparring ses-
sions. This is generally a self-limited phenomenon. Students should be mon-
itored for signs or symptoms of other internal injuries nonetheless. Deep
breathing techniques can help to restore normal breathing. Learning to ex-
hale while blocking and strict refereeing to maintain control of contestants
may reduce the incidence of this occurrence. Psychologically, once the
breathing has returned to normal, it is useful to have a student resume spar-
ring (with even closer monitoring of control) to prevent the student from de-
veloping a fear of sparring.
Receiving a kick to the groin is another experience that is not foreign to
many martial artists. For this reason, a groin protector should be manda-
tory for all sparring sessions. Male and female versions are available.
Even with a groin protector, a kick to the groin can be painful. It is
 MARTIAL ARTS 667

traditional for instructors to have the subject bounce up and down on his
bottom or to make him or her jump up and down. It has been said that
this is to help stretch muscles in spasm [22]. The efficacy of this practice
has yet to be subjected to scientific scrutiny. Severe or persistent pain or
the presence of hematuria may be a sign of a more significant injury, such
as urethral trauma or testicular torsion [33]. There is a case report of
a 27-year-old man who presented to an emergency department with right
groin pain after being kicked in the right anterosuperior thigh. Radiographs
revealed right acetabular fractures and an inferior pubic ramus fracture [47].
This patient was successfully treated with Buck’s traction, physical therapy,
and restricted weight bearing.

Upper extremities
Although the details of shoulder injuries in the martial arts are not spec-
ified in several comprehensive articles [12,48,49], they composed 5% of the
injuries in an 18-year study of trauma epidemiology in the martial arts [12].
Joint locks and grappling techniques that torque the shoulder could lead to
shoulder injuries. Throws, rolls, and falls practiced in some forms of martial
arts may also lead to shoulder injuries. In particular, an acromioclavicular
(AC) separation can occur from a fall onto the tip of the shoulder. This
can be confirmed by a weighted anteroposterior (AP) radiograph. Treat-
ment of minor AC injuries consists of wearing a sling, using ice, and taking
analgesics for the first few days. Gradual resumption of training may occur
over a period of weeks. Severe AC injuries may require surgical referral.
Repetitive striking motions are common among practitioners of arnis
(Filipino stick fighting) and can lead to lateral epicondylitis. Bilateral lateral
epicondylitis has also been reported in the practice of open-hand techniques
[50]. Modifying or eliminating the activities that cause symptoms is the most
important step in treatment [51]. In the case of arnis-related lateral epicon-
dylitis, changing to sticks that are more pliable, using a wider diameter stick,
or wrapping the sticks to widen the grip may be sufficient. Wearing a tennis
elbow strap may also be useful during practice. Changing the orientation of
the hand during strikes (more ulnar position instead of dorsal position) or
substituting open-hand techniques for stick work may be necessary for pe-
riods of relative rest. Ice, nonsteroidal anti-inflammatory drugs (NSAIDS),
anti-inflammatory creams, or corticosteroid injections may be useful if train-
ing modifications alone are insufficient.
Wrist injuries can occur with improper and excessively forceful punching
techniques against targets or punching bags. They can also occur with
breaking techniques, poor falling techniques, or wrist throws and joint
locks. Correct technique may prevent such injuries. In addition to ice and
anti-inflammatory medications, minor sprains can be treated with wrist
wraps or splinting during training to prevent exacerbation. More severe in-
juries may require casting. Students may still participate in training but
668 TERRY

should avoid partner work or activities using the affected limb. Tenderness
over the lunate may be a sign of avascular necrosis (Kienböck’s disease) and
warrants orthopedic referral.
Sprained fingers are one of the more common injuries incurred by martial
artists [12,19]. Proper hand protection during sparring and weapons practice
may help to reduce the incidence of finger injuries. A radiograph should be
obtained to rule out a fracture. Splinting or buddy taping is generally suffi-
cient treatment in the case of a sprain. It is not necessary to interrupt train-
ing in such cases. In fact, practitioners can be instructed to keep the injured
extremity tucked into the belt behind the back and to practice defending
with only the unaffected limb.
Many schools have a rule that no jewelry is to be worn during class. This
author used to make an exception for jewelry with religious significance or
wedding rings. Unfortunately, during a sparring match a student jammed
his ring finger while wearing his wedding ring. In spite of icing and elevation,
the finger continued to swell and led to the ring having to be cut off in the
emergency room. Wearing jewelry in class can be a danger to partners, the
practitioner, and the jewelry. It is therefore strongly advised that jewelry be
prohibited under any circumstances.‘‘Karate kid’’ finger has been described
in a case report about a 12-year-old martial artist who developed segmental
perineural and interfascicular fibrosis of the dorsal branch of the ulnar dig-
ital nerve as a result of striking hard objects (eg, filing cabinet) with a karate
chop [52]. The painful symptoms resolved after surgical intervention, and
a modification of practice habits prevented recurrence.

Lower extremities
Injuries to the lower extremities are among the most common injuries in
the martial arts. This is particularly true of predominantly kicking-based
styles, such as Tae Kwon Do [28,48,49,53]. Toe injuries, including jamming,
fractures, and dislocations, are not uncommon in martial arts training
[19,28]. Proper foot protection during sparring and weapons practice or
the use of martial arts shoes may help to reduce the incidence of toe injuries
[28]. A radiograph may be obtained to rule out a fracture, and a dislocation
must be reset. In most cases, however, rest and buddy taping are sufficient
treatment for toe injuries. When training is resumed, students should ini-
tially avoid kicks that use the toes or forefoot as a striking surface.
Calcaneal apophysitis (Sever disease) was described by Wirtz and col-
leagues [54] in three children as a result of board breaking. The clinical
symptoms are posterior heel pain and a limp. Radiographs are not diagnos-
tic. Treatment includes short-term modification of training and restriction of
board breaking. The use of shoes with a 0.25-inch heel lift or heel cushion
and Achilles tendon stretching can be helpful [55].
Ankle sprains related to the martial arts have been observed by this au-
thor and have been described by several other authors [13,22,28,33,34,56].
 MARTIAL ARTS 669

Methods of taping have been suggested to lessen the incidence of ankle

sprains among martial artists [33,34,56]. The efficacy of this practice has
yet to be studied. Some styles of martial arts advocate balancing on the
ball of one foot with the foot plantarflexed while kicking with the other
foot. Because of the structure of the ankle joint, this is the least stable posi-
tion [56]. It would seem that keeping the foot of the supporting leg flat, thus
maintaining a more stable ankle position, should decrease the likelihood of
pain and ankle sprain during kicking techniques.
The knee is susceptible to acute injuries from direct trauma or during
kicking and twisting motions [57]. These include fractures, dislocations, con-
tusions, and meniscus or ligament tears. Chronic conditions, such as arthri-
tis and patellar maltracking (Osgood-Schlatter’s disease), may also limit
a practitioner’s ability to train. It has been postulated that avoiding full ex-
tension of the knee during kicks as well as using a stance with the leg slightly
internally rotated rather than externally rotated may reduce the incidence of
knee injuries [19].
Hip disorders, including arthritis and bursitis, attributed to the martial
arts or other causes may have an impact on the style of martial arts a student
chooses. Relative rest during acute flare-ups may be indicated. For milder
stages of arthritis, a modified training regimen may be sufficient. Alterna-
tively, the gentle art of Tai Chi has been studied as an adjunct treatment
of patients with arthritis [9,58]. For those interested in more vigorous train-
ing, arnis [59] or Wei Kun Do [60] offers an excellent alternative that focuses
more on upper body techniques. With an open-minded instructor, almost
any style can be adapted to suit the needs of students with a chronic debility
that limits the ability to kick.

Benefits of training in the martial arts

There are many benefits to training in the martial arts. What often attracts
students to the martial arts is the attempt to enhance not only the physical
body but the mind and spirit as well. According to a study by Twemlow and
coworkers [27], the top four reasons that people cite for studying the martial
arts are self-defense, exercise, building self-confidence, and developing
self-discipline. The copious works of Webster-Doyle [61] emphasize the
philosophic side of the martial arts and nonviolent conflict resolution. He
presents specific material on dealing with bullies and enhancing self-esteem
through the martial arts [62]. Numerous studies have attempted to demon-
strate and quantify the physical and psychologic benefits of the martial arts.
In one study, it was found that the practice of kata can lower aggression
[63]. It has also been shown that practicing the martial arts can improve self-
reliance and optimism [64]. Several other studies have reported improve-
ments in psychologic health through training in the martial arts [65–68].
Twemlow and Sacco [69] have proposed a ‘‘clinical martial arts program’’
for violent adolescents. It seems that gangs satisfy several basic needs in
670 TERRY

some teenagers: affiliation with a group, power, physical security, activities,

role models, and sparring. All these needs can be found in a martial arts pro-
gram. It has been found that participation in a martial arts program that
stresses not only physical but psychologic, meditative, and philosophic as-
pects can lead to lessened aggression, lowered anxiety, and increased self-
esteem in delinquent adolescents [70]. Zivin and colleagues [71] studied
juveniles at high risk for violence and delinquency. After a 10-week martial
arts program, students showed significant improvement in behavior.
Physical fitness is a common reason for training in the martial arts. For
many children and young adults, the martial arts provide a primary source
of exercise. The martial arts are not only for the young, however. In a study
of middle-aged practitioners (aged 40–60 years), an improvement in various
measures of fitness has been attributed to training in the martial arts, includ-
ing greater aerobic capacity, balance, flexibility, muscle endurance, and
strength as well as lower body fat [72]. Even senior citizens have been shown
to benefit from training in the ‘‘hard’’ martial arts (Fig. 18) [2]. It has been
hypothesized that learning to fall properly in martial arts class may prevent
injury from falls incurred later in life [73].
Tai Chi is generally considered one of the softer martial arts. With certain
instructors, the self-defense applications of Tai Chi techniques may still be
found. Most practitioners of Tai Chi are seeking health benefits, however.
It is commonly used as a gentle form of calisthenics and meditation. Tai
Chi is cost-effective and generally boasts a good compliance rate. Therefore,

Fig. 18. At the age of 67 years, this practitioner has no problem implementing a self-defense
technique.
 MARTIAL ARTS 671

numerous studies have been initiated to evaluate the potential positive ef-
fects of Tai Chi. Thus far, Tai Chi has been recommended to treat every-
thing from balance to sleep disorders.

Disabled martial artists

There are few peer-reviewed publications about those who have a disabil-
ity and practice the martial arts. A review of the Internet reveals many or-
ganizations that teach martial arts to the disabled. It can be said that every
martial artist has his or her own strengths and weaknesses. The goal of a suc-
cessful martial arts instructor is to capitalize on students’ strengths and to
minimize the effects of any weaknesses. This may be accomplished by reme-
diating areas of relative weakness or altering techniques to ‘‘fit the system to
the martial artist.’’ In the past, there has been an almost religious adherence
to ‘‘tradition’’ in many systems of martial arts. Now, many schools and
styles are sharing information and techniques, with students benefiting
from this evolution.
Many of today’s schools no longer have a ‘‘sink or swim’’ attitude toward
new students. By adjusting the curriculum, schools can successfully integrate
students as young as 3 years of age into age-appropriate martial arts–based
classes [1]. On the other end of the spectrum, older adults can discover the
benefits of martial arts even into their 70s and older [2]. Another segment of
the population that has benefited from open-minded instructors is the dis-
abled. Much like a physiatrist, the instructor of martial arts students with
disabilities may problem solve and develop different approaches to reach
the same goals. It is also inspiring to see long-time martial artists who de-
velop disabilities and still continue to train and teach.

Fig. 19. Sensei Manual was honored at the Pittsburgh EUSAIMAA Hall of Fame.
672 TERRY

Fig. 20. (A–G) Self-defense sequence in which the defender uses the attacker to cosign ‘‘you are
a monster.’’ (Courtesy of T. Harman, Elliott City, MD.)
 MARTIAL ARTS 673

There are many instructors and organizations available for the disabled
who are interested in pursuing martial arts training [7,74–77]. Self-defense
training has been integrated into the rehabilitation of patients with spinal
cord injury, polio, spina bifida, cerebral palsy, stroke, head injury, back in-
juries, upper and lower extremity amputation, multiple sclerosis, and blind-
ness [3]. A system of wheelchair-based techniques has been developed by
Van de Sandt [78]. Martial arts classes for spinal cord–injured wheelchair-
based patients were initiated in 1975 at the Long Beach California Veterans
Affairs Medical Center [79]. In spite of the tetraparesis that developed from
chronic spinal arachnoiditis, the well-known martial artist Martin Manuel
has continued to teach and judge tournaments and heads a chain of martial
arts schools (Fig. 19) [80].
Matthew Hayat has developed a self-defense system that integrates the
vocabulary of American Sign Language with the concepts and pressure
point methods of Grandmaster George Dillman [81]. His system, Martial
Signing, allows those who are deaf and hard of hearing to incorporate the
physical, emotional, and spiritual elements of their existence into martial
arts techniques. This system has also served to introduce basic sign language
concepts to martial artists everywhere (Fig. 20).

Summary
Given the increasing popularity of the martial arts, it is likely that physi-
cians in all specialties encounter patients who participate. From pediatric pa-
tients, to geriatric patients, to those living with various disabilities, the martial
arts may offer physical, psychologic, and therapeutic benefits. An apprecia-
tion of the physical demands of the martial arts is crucial to understanding
the pathogenesis of injury as well as to planning treatment and prevention
strategies and to determining safe return to participation after injury.

Acknowledgments
The author thanks Jennifer Kral and Leonna Bryant of the Health
Sciences Library Capital Health System at Helene Fuld Hospital for their
assistance with research and acquiring reference articles. He also thanks
George Dillman, Matthew Hayat, Martin Manuel, and the members of Dill-
man Karate International and MKA Karate for their input into this article.
Most importantly, he acknowledges Tricia Terry for her technical assis-
tance, astute editing, and constant support.

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