Medical Aspects Of Amateur Boxing The Medical Commission of The Amateur Boxing Association Of England Limited 5th Edition 2006 2 I. Introduction This booklet is a summary of the rules, recommendations and advice relating to the medical aspects of amateur boxing in England. It is an attempt to present relevant information in a single cover to aid club and ABAE officials and medical officers in the care of their boxers and the promotion of the sport. It includes an introduction to the sport of boxing for the benefit of doctors newly involved with the sport. We hope it will help them to appreciate its ethos. Similarly, the section on general medical matters is directed towards coaches and other officials of ABAE, to give them some advice on the treatment of specific injuries, general hygiene, diet and so on, and to inform them of the various medical facilities so that they may make better use of them. It is a guide and it is not comprehensive. A. GENERAL PRINCIPLES Boxing is a contact sport in which points are scored by landing blows with force on the opponent. Inevitably there is a risk of injury to those who box. The objective of the medical scheme and those who operate it is to minimise that risk of injury. The care and welfare of the boxers is the most important aspect of amateur boxing. Many officials have a responsibility for the care of the boxer. These include the coach, the competition secretary (who arranges the bouts), the referee, the tournament medical officer and his assistant, the official-in-charge, the recorders and the medical officers of the clubs, associations and the ABAE. The ultimate responsibility rests with the executive council, where the rules are made and attitudes in the sport are determined. The highest standard of medical care can only be attained if all those concerned carry out their duties with the greatest sense of responsibility and in a spirit of co-operation. B. CONFIDENTIALITY It must be remembered by all those concerned with the training, care and administration of a boxer’s career that medical information is confidential and must never be divulged to any person, within or outside the sport, who does not have proper reason to be informed of it. A boxer gives information about himself on this understanding, and is entitled to expect that such personal information will be handled with due care and respect. The General Medical Council holds confidentiality to be a central pillar of medical practice and regards any breach of it to be a very serious offence. Breach of confidentiality is an abuse of privilege conferred by custom. A patient grants a doctor privileged access to confidences. Good medical practice depends upon the maintenance of trust between doctors and patients. A doctor must exercise great care and discretion in order not to damage this relationship. The medical officers of the ABAE and its associations and divisions rely on other officials paying this same regard to the confidentiality of the medical information that they hold, so that proper medical care may be provided for boxers. If it is desired to pass on such confidential information to a third party, the boxer or other person to whom the information relates, should be asked to give their consent for this to occur. It could be argued that this should be done even when two officials are in legitimate discussion about the case (e.g. local and central records officers), but in such cases it can be assumed that consent is given when voluntarily submitting to ABAE rules and regulations, such as when joining an affiliated club. This principle, however, should not extend beyond the correct transfer of personal medical information indicated in this booklet. Breach of confidentiality is serious and undermines the effectiveness of any medical care, whether part of amateur boxing or not. This has been a fundamental pre-requisite in the establishment of the secure database and website for collation and transmission of ABAE records, both medical and sporting. 2 3 All officials holding documents or computer records containing medical information have a duty to ensure that they are securely held and are not made available to any person who does not have legitimate access to them. If any official is in doubt about his position regarding the confidentiality of information he holds, advice may be sought from the medical officers of his association, from the medical commission, or from the legal adviser to the ABAE. All computer-held information must be held in accordance with the Data Protection Act of 1998 and any subsequent amendments thereto. The controller of such records must be registered with the information commissioner and medical information must be held within sections of such computers protected by security codes. Medical records will be destroyed after a boxer has retired from boxing in accordance with the then current government guidelines regarding data retrieval for medical records. Non-individual identifiable medical information may be kept in perpetuity for research and statistical analysis. 3 4 II. An introduction to the sport of amateur boxing Amateur boxing is a unique sport in which the ability to land legal blows with force on the target area of the opponent is balanced against the skill in avoiding them. It caters for those with a particular combination of physique, physical skills and psychological make-up. It attracts persons who wish to learn this form of self-defence and who desire to test themselves in this most arduous form of individual combat. In addition, an essential part of the sport is the open exhibition of skill and fortitude in front of a crowd. Females may now participate in amateur boxing and so all references to “He/his or boy” with regard to boxers (or officials) should also be accepted as referring to females as well. Boxing demands a high standard of physical fitness. The few minutes spent in a ring are a climax to many hours of hard physical training. It provides a healthy and enjoyable form of training for life and an excellent opportunity to develop discipline and self control. This is carried out in a friendly yet competitive atmosphere, in which mutual and self respect is acquired, together with a sense of social responsibility. After joining a club, a boxer trains in the gym for a time – usually many months – until ready for that first contest. During this period the basic skills and discipline of the sport are learnt and physical fitness is developed. Those who persevere progress to competitive bouts, where their own skill, ability and inner resolve are put to the test. A competitive bout consists of three or four rounds, each of which may last from 1½ minutes in schoolboy contests to 2 minutes at senior level. During this time the boxer must demonstrate to the judges an ability to deliver blows to the front of the opponent’s head and trunk above the belt (the target area). To score points, these blows must be delivered with the knuckle part of the gloved hand and must land “with force”. Generally a computer-operated scoring system is now used by ringside judges in amateur boxing. They have a small machine with a red and blue button which is pressed when either the red or blue boxer scores a correct blow on the opponent. When three or more judges press the button within one second of each other, a scoring blow is registered. The final score is the total number of points scored by each boxer when averaged out by the central computer. The winner is the one with the highest score but if equal then the computer then finds the winner by calculating back on all points awarded by every judge (‘countback’). Three judges (or five, if computer scoring is used) score each bout independently, sitting immediately outside the ring. Each sits on a different side, and thus has a different angle of view from the others. They watch for blows carefully to assess which are legal and count towards the score. If a true computer scoring machine is not available then hand-held AIBA calculator scoring machines are often used and the individual judges give their own score for each round. These are then added at the end of the bout to give the final result. Traditional, non-computer scoring is rarely used now, but in this system each round is scored separately, the winner being given 20 points. If 2, 3 or 4 legal blows more than his opponent have been landed, the latter is awarded 19 points; if the difference is 5, 6 or 7 blows the score is 20-18 for that round, and so on. If the bout is very one sided, the referee should stop the contest early on, ruling the opponent outclassed. The majority of bouts are decided on points – the boxer who gains the highest aggregate score being the winner. With this system, if points are equal at the end of three rounds, then the bout is awarded to the boxer who has done most of the leading off or who has shown the better style, or, if equal in that respect, who has shown the better defence. Each judge must nominate a winner. 4 5 A boxer is considered ‘down’ if any part of the body other than the feet touches the floor, or the boxer is hanging helplessly on the ropes. In this situation, the referee will start to count. If the boxer is not recovered and ready to box again in 10 seconds, this is a ‘knockout’ and the bout is awarded to the other contestant. The referee will halt the boxing and start a count if he considers that one boxer has received a particularly hard blow. However quickly the boxer recovers, the minimum count is eight seconds. If a boxer receives three such counts in one round, or four such counts in the entire contest, then the bout is stopped in favour of the opponent (this varies in junior and female bouts). Contests may also be decided by disqualification, by one boxer consistently fouling the other, by voluntary retirement, or if one boxer sustains an injury which in the referee’s opinion renders that person unfit to continue. At some contests adjudicators are present. These are senior ex-referees who sit at the ringside and monitor the performance of the judges and referees. This is essential for the maintenance of standards in refereeing, and thus for the safety of the sport. Other officials present at a tournament include the timekeeper, who regulates the number and duration of rounds and the interval between them, and the official-in-charge who has the ultimate responsibility for all aspects of the tournament and has powers commensurate with this. The referee remains inside the ring throughout the bout and is in sole charge of the contest once it is underway. He moves with the boxers and is in the best position to see that they are protected from unnecessary injury and that the rules are adhered to. He can order contestants to box, to stop, or to break. He can caution a boxer who infringes the rules, warn if these infringements are serious or repetitive, and institute a count if there is a knock-down or if he considers the nature of a blow indicates a short recovery period is required. Contestants are matched by the competition secretary, usually an experienced official of the host club, who has to match the pair who will face each other in the ring. He tries to select two boxers who are to all intents and purposes equally matched. Age, weight and experience are the factors to be considered. All boxers between the minimum age of 11 years and 17 years are divided in categories of 12 months, and, other than for exceptional open class boxers, a 17 year old may not box an opponent aged 19 years or over. Weights are classified into bands of about 3 kilograms (2kg in schoolboys) and only a certain amount of weight may be conceded. Senior boxers are classed as novice, intermediate or open, but for a youth, the competition secretary must take account of the number of contests, the standard of any opponent, and especially the calibre of the individual boxer. Matching is a most important task as real skill can only be shown when boxers are evenly matched. Good matchmaking is an important factor for maintaining safety in the sport. 5 6 IIl. General Medical Matters A. MEDICAL SERVICES 1. The General Practitioner Continuing medical care of every person in this country is provided by the general practitioner (GP – the family doctor). The GP should always be the first person to be contacted in cases of illness or non-urgent injury. The GP holds the medical records of the patient, is familiar with the patient, the family and social circumstances and will undertake the diagnosis and treatment of the majority of medical problems. In this, simple investigations (such as X-rays and blood tests) may be arranged in the local hospital and the GP can also call upon the health visitor, district nurse, chiropodist and a range of social services for assistance. 2. The Accident and Emergency Department The other facility to which patients have direct access is the hospital accident & emergency department. Its function is described in its title, and must not be abused. It has close links with X-ray and physiotherapy departments and is equipped to carry out minor surgery such as suturing lacerations and incising small abscesses. It is able to deal with a whole range of accidents from a simple cut to a major road traffic accident as well as the initial diagnosis and treatment of serious and sudden medical illness or collapse. The A&E department is not an alternative to the GP for routine care. It has been established to deal with accidents and emergencies and not long-standing conditions or minor medical problems. At the earliest opportunity, the patient will be referred back to the GP or, in more serious cases, to the care of a hospital specialist. 3. The Hospital Specialist Patients do not have direct access to hospital specialists but can only be referred to them by the GP or the A&E department. They may do this for a number of reasons – the diagnosis of difficult cases, for advice on treatment, for specialist treatment or rehabilitation, or for special nursing care. Unless the patient is admitted to hospital under a specialist, the GP retains control of the situation and is in frequent contact with the specialist to whom the patient the patient has been referred. 4. ‘Boxing Doctors’ Doctors who give their time to examine boxers, to officiate at boxing tournaments, to undertake the role of club doctor, or who take part in the administration of the sport, do so outside the provision of the National Health Service. Appointment as a medical officer to the ABAE or one of its associations is honorary, though travelling expenses are refunded. Payment to doctors acting in other capacities is by mutual agreement between the doctor and club or organisation. There is a standard BMA scale of charges for carrying out a full medical examination and for a doctor’s presence throughout a long evening tournament. A charge of £150 is not excessive (BMA sessional rates are far in excess of this). However, it is hoped that a doctor who offers his/her services to amateur boxing will recognise that many boxers are not well-off and that many clubs have small revenue, and so he/she may moderate their charges accordingly. This also applies to boxers’ medical examinations and clubs should have arrangements with their own doctors to ensure adequate recompense for the time and expenses incurred. £10-25 per medical is not unreasonable when BMA rates for one medical may be in excess 6 7 of £90. Clubs should ensure that their doctors are respected and well looked after and should co-operate in order to minimise any disruption to the doctor’s normal schedule. 5. First Aiders First aiders do not necessarily have medical training, but have a current first aid certificate issued by a reputable approved organisation. They are normally members of St. John’s Ambulance Brigade or The British Red Cross Society. These are both voluntary organisations and their personnel give their time freely. They perform a great deal of valuable work, both in the community and internationally, which is all funded by gifts from the general public. If clubs make use of their services at tournaments, then a donation to their organisation is appropriate. The first aiders themselves are competent to deal with an accident or medical emergency within their training qualification and also to decide whether or not further medical care is necessary. There are many more highly qualified personnel working for these organisations. They have advanced skills that can be used in more serious situations. The appropriately qualified first aiders for the event would be decided by their organisations and the event medical officer. The ABAE has a scheme for officials and coaches to undertake first aid training in order to administer care with their doctor using ABAE approved medical bags. B. FIRST AID ADVICE This can only be a brief introduction to some of the problems that might arise in the gym or at a tournament. Injuries are as likely to result from normal activities as from boxing and to officials and onlookers as to boxers. In using first aid techniques there is no substitute for practical experience. All officials, but particularly coaches, referees and officials-in- charge, are very strongly recommended to undertake formal training in first aid and to maintain a valid first aid certificate. Everyone assisting an injured person should be aware of the risk of infection from body fluids and therefore disposable gloves should always be worn when giving any first aid care. This is imperative when dealing with a bleeding wound. 1. Bruising and Swelling a) Swelling is usually caused by bleeding under the skin; the closer to the surface it is, the sooner it will appear as bruising. Both should be treated as soon as possible with ice packs and firm pressure. If the injury is to a limb, this should be elevated. Ice packs can be repeated frequently over the first 48 hours, during which time any form of heat or massage should be avoided as this will increase the bleeding. After this period, alternating applications of ice packs and hot compresses can be applied, a minute or so for each over a period of half an hour, repeated every few hours. b) Swellings which are tender to touch should be treated with care because a more serious injury to muscle, ligament, bone or joint may be present beneath. If in doubt, medical opinion should be obtained. 2. Sprains and Strains a) A sprain usually occurs at a joint when the ligaments and tissues around the joint are wrenched or torn. Some sprains are minor but others can cause extensive damage to the tissues and are difficult to distinguish from fractures. When in doubt, treat as a fracture. A strain occurs when a muscle or group of muscles is overstretched and possibly torn by a sudden movement. b) Initial treatment for sprains and strains is the same as for bruising and swelling; rest, ice, compression and elevation for the first couple of days. After this period, gentle mobilisation may be started and gradually increased with time. It is important not to 7 8 progress too quickly, otherwise further injury will occur. A good maxim is that if pain or swelling increases as mobilisation proceeds, then progress is too fast. Many sprains and strains require some splintage or support in the early stages, and supervision during healing. If they appear at all serious, then medical advice should be sought. 3. Fractures and Dislocations a) These injuries are serious and demand medical attention, but fortunately are rarely caused by boxing. They are more likely to occur as a result of general activities rather than those specifically associated with boxing. In boxing, the hands and jaws are most frequently involved. A very heavy blow might fracture a rib. Pain is severe and localised to the injury. Swelling and bruising are usually marked, and the bone is very tender to touch at the site of injury. Any use of the injured part is very painful. Signs which leave no doubt about such an injury are: an abnormal shape, an open wound in which the bone can be seen, and a coarse grating sound if the limb is moved. If there is a complete absence of movement below the injury, numbness of the skin or gross swelling, then there is also injury to nerves and/or blood vessels and emergency medical care is required. b) The injured person must be given nothing by mouth (not even a sip of water) in case an anaesthetic and operation may be needed. An injured limb should be supported in the position in which it lies. The casualty should be transported to hospital as soon as possible, unless the injury is such that he/she cannot be moved. In this case, be reassuring and call an ambulance. 4. Lacerations a) The only thing that should be applied directly to a cut is sterile gauze and the gauze should be held firmly in place until the bleeding has ceased. Adrenaline must not be used as it is readily absorbed and is a dangerous stimulant to the heart. The cut must not be rubbed with a wet sponge or towel. This will increase the bleeding, damage the wound edges, deepen the cut and probably infect it. This all leads to prolonged healing and a weak scar subsequently. b) Small, clean and superficial lacerations may be treated as above, and the wound edges may be brought together using micropore, steristrip or butterfly sutures. More serious wounds (and in any case of doubt) require the attention of a medical practitioner for suturing or the use of specialist medical glues, such as dermabond. 5. Bleeding a) Disposable gloves must be worn when dealing with any wound, especially if bleeding. b) Bleeding will usually stop with adequate direct pressure on the wound and elevation of the limb (if`applicable). If the wound contains a foreign body, then a ring pad should be made to exert pressure around the wound and not directly upon it. If the bleeding point is inaccessible, bleeding may be reduced by exerting pressure upon the major artery of the limb (deep in the groin crease for the leg, and on the inner side of the upper arm – feel for the pounding of the pulse). This pressure needs to be maintained until proper medical care is available. A Tourniquet should not be used. c) To arrest bleeding from the nose, squeeze the soft part firmly between thumb and finger for at least 10 minutes whilst sitting with the head leaning forwards. During a bout, a boxer suffering from persistent bleeding from the nose must be brought by the referee to the ringside MO, who will decide whether to terminate the bout. If bleeding is from inside the ear cover the orifice with a clean dry dressing and seek medical help. Do not plug the nostrils or external ear – you are more likely to cause further 8 9 damage than control the bleeding. To stop bleeding from the tongue or lip, squeeze the edges of the wound together using a dry sterile gauze swab. d) Blood loss of more than a pint is potentially dangerous and leads to shock which is a serious medical condition. This can be recognised by pale, cold and sweaty skin, a fast pulse which may be weak and thready (the normal pulse rate is 60-80 beats per minute), confusion, thirst and anxiety. It is unlikely to arise from a skin laceration, but is a potential complication from a severe scalp laceration or nose-bleed, or internal bleeding from lungs, liver or spleen (if damaged from a fractured rib, for instance). If shock is suspected, there must be no delay in transferring the patient to hospital by the quickest means available. e) Rarely, a blow to the back or the loin may bruise a kidney with the result that blood gets into the urine. When passed, the urine is ’smoky’ or may even appear actually bloody. If this occurs the boxer should be taken to hospital. He may need to be observed until his urine becomes clear. 6. Low Blows Blows to the testicles are illegal and uncommon in boxing. These organs are exquisitely tender and the slightest of blows will impede the concentration and movement of the boxer. If more severe, consideration should be given to retiring the boxer from the bout. Some ease in the discomfort will be gained by supporting the testicles and flexing the knees while the boxer lies on his back. After the bout, if the pain increases in severity, and especially if this is associated with swelling of the testicles, medical advice should be sought without delay since urgent scanning and surgery may be required. 5. Eye Injuries a) Eye injuries may occur in boxing and may be serious. They are usually caused by the thumb of a glove hitting the eye. Ophthalmology is a specialist subject, so if in doubt about any painful or red eye, always seek specialist medical advice. b) In the absence of any symptoms or other abnormal appearance, a subconjunctival haemorrhage (a bright red patch on the white of an eye) is inconsequential and will resolve in 1-2 weeks. c) Corneal abrasions (grazing of the transparent front surface of the eye) may be caused by the glove brushing across the open eye, or dragging of long hair into it. The eye feels gritty and irritable, the sclera (white of the eye) looks red and inflamed and vision may be blurred because of excessive watering. There may be a degree of photophobia (literally ‘fear of light’) but if pain is not severe then these usually heal without specialist treatment. The following conditions are serious and need urgent hospital referral: (i) Bleeding may occur within the eye itself. If this occurs immediately behind the cornea, then a thin layer of blood may settle. Serious bleeding into the back of the eye can only be suspected by its severe effect on vision, which may be almost completely lost in the affected eye. (ii) The retina (the light-sensitive lining within the eye) may become torn, and then peel away from the wall of the eye. This is painless. The initial tear may cause a period of bright flashing lights, and the subsequent separation is typically likened to a dark curtain progressing across the field of vision. 9 10 (iii) Other injuries can occur. They cause visible damage to the eye and/or seriously affect vision. If any eye injury is suspected, and especially if there is any pain or disturbance of vision in the eye, then a medical opinion must be sought urgently. 8. Unconsciousness and Concussion a) Strictly, there is no single state of unconsciousness but a graduated change in responsiveness. This passes from the normal alert state through a dull wakefulness to a state in which there is no spontaneous movement and no response to any stimulus. If a boxer is rendered unconscious, it is important to assess initially and then frequently monitor the level of responsiveness (level of consciousness). This is done by grading the clarity of speech and the stimulus that is required to make the injured person open their eyes and move the limbs according to the following scales: (i) Eyes open - spontaneously - in response to speech - in response to pain - remain closed. (ii) Movement - in response to spoken command - in response to pain - remains still (iii) Speech - normal - confused - inappropriate words - incomprehensible sounds - no attempt at speech (A painful stimulus can be applied by pinching the skin of the earlobe or back of the hand.) b) In boxing, unconsciousness rarely lasts more than a few seconds, and recovery is very rapid. If full alertness is not recovered immediately, steps must be taken, without delay, to maintain the boxer’s airway. This may be obstructed by the gum shield, the tongue falling into the back of the throat, or vomiting. The referee is the closest person to provide care in the ring and will, ideally, be trained in the techniques of immediate first aid care. The gum shield must be removed from the mouth immediately and an index finger swept around the mouth to put the tongue forwards. If necessary, the tongue should be held forwards with a piece of clean gauze. The doctor or resuscitation team personnel should be summoned into the ring and the boxer should be rolled onto their left side with great care, supporting the head and neck, to get into the recovery position so that the airway is kept open. If recovery is at all delayed, the doctor or resuscitation team personnel take over and an ambulance should be called. The boxer must not be moved from the recovery position until the doctor or resuscitation team personnel have decided on the appropriate further care. That may include stretchering out of the ring and immediate transfer to hospital by ambulance. Fully qualified paramedics, as well as the doctor, must be in attendance at all major championships, internationals and major tournaments. They have to be fully equipped for full airway resuscitation and have an ambulance on stand-by at the venue. Local hospitals and the nearest neuro-surgical unit must be warned prior to the tournament and the OIC should have direct line telephone numbers available so that immediate contact can be made if required. c) The risk of a cervical spine (neck) injury is small, unless the boxer falls outside the ring, but the grave potential of this injury must be borne in mind. If suspected, then the head, neck and trunk should not be moved at all. If it is absolutely necessary to move the boxer in whom a spinal injury is suspected, then special techniques, 10