Fistic Medicine: Roxy’s Case

Roxanne Modafferi (left) and Hitomi Akano | Taro Irei/Sherdog.com

It was the chills that let Roxanne Modafferi know she had a problem. Most fighters have abdominal cramping and loose, irregular stools in the first few hours after their post weigh-in meal, but the chills were something new for her.

Two hours later, she was on her knees, racked by chilling convulsions, crawling from her bed to the bathroom for the third time in 40 minutes. The abdominal cramping was getting worse. She felt nauseous, and there was a woman with a penchant for punishing submissions waiting to hurt her.

Athletes who re-feed following weight cutting commonly experience something known as “dumping syndrome.” The abrupt introduction of carbohydrate-rich food into the intestinal lumen creates an osmotic gradient that draws water across the mucosal membrane, leading to loose, irregular stools. Fighters experience loose stool, bloating and abdominal cramping. Usually these symptoms are short-lived: a fighter who carefully re-hydrates with electrolytes and is cautious in transitioning from a low carbohydrate/low sodium/ low fat diet to a more normal diet should be asymptomatic within 12 hours of weigh-ins.

But for Modafferi, her GI symptoms were steadily getting worse, not better. This was not a re-feeding issue; this was illness.

For unknown reasons, elite athletes are at somewhat higher risk for infection. The relationship between athletic exertion and infectious risk is “J” shaped: while moderate exercise reduces the risk of infection, very heavy exertion paradoxically pushes athletes’ immune systems past the point of optimization. To combat the risk of infection, many top athletes practice a form of reverse quarantine prior to competition. Closed training camps reduce a competitor’s pool of first- and second-degree “communicable contacts” from theoretical thousands to just a handful. The reason many Olympic athletes skip the opening ceremonies is that the health risk posed by being in close contact with thousands of new potential viral exposures a few days before competition is simply too great. When forced out of protective isolation by the demands of sponsors and promoters, athletes often wear surgical masks, tap elbows in lieu of shaking hands and do whatever they can to avoid being sabotaged by a last-minute illness.

Modafferi walks to the ring on Dec. 30.Modafferi stated that for the entire week prior to her Sengoku “Soul of Fight” bout against Hitomi “Girlfight Monster” Akano on Dec. 30 she had been irritated by nagging viral upper respiratory infection symptoms -- nasal congestion, scratchy throat, etc. She made sure to get plenty of sleep, lightened her training load and was careful not to endanger herself further with aggressive weight cutting techniques. Quite rightly, she was not overly concerned. A beautiful 1997 study by Wesiner et al looked at the effect of a common rhinovirus infection on athletic performance. Surprisingly, the study showed that in athletes who had been deliberately infected with the common cold there was no decrease in performance. Even though infected subjects felt worse than uninfected controls, objective measures of performance showed no decrease in performance at two-, five- and eight-minute intervals.

What has been shown to impair athletes, and what Modafferi suddenly found herself in steadily growing peril of developing, is dehydration. As loose stools progressed to frank diarrhea, her total body volume of water dropped.

Even low levels of dehydration have profound physiologic consequences. A fluid deficit of as little as two percent Total Body Weight (TBW) -- approximately one liter for Modafferi -- results in increased perceived effort and has been shown to reduce performance by as much as 20 percent. Cardiovascular performance, strength, reaction time, judgment, concentration and decision making are all affected. For fighters, dehydration increases the risk of brain injury.

Severe diarrhea, in Modafferi’s case probably caused by some form of food bacterial poisoning, can rob the body of as much as eight milliliters/kilogram/hour of fluid. A night of severe diarrhea can leave a fighter seriously depleted; perhaps a four- to five-percent TBW fluid deficit. The most direct treatment for this degree of severe dehydration is oral re-hydration with electrolyte solutions. The most notorious killer in the world -- infectious diarrhea -- can be effectively combatted with a treatment as simple as a few grams of Sodium, Potassium and glucose in clean water. Unfortunately for Modafferi, oral rehydration was made impossible by vomiting, and, even after the vomiting eased, nausea that impeded her ability to take in fluids.

When the miserable night ended, Modafferi saw her doctor and was immediately sent to the hospital. Doctors diagnosed her with severe dehydration and started anti-diarrheals and IV therapy with normal saline -- fluid with the same salt composition as blood plasma. Because of time restraints, she received 800 milliliters before being rushed to the arena. That’s too little fluid.

The diarrhea persisted. She developed fevers. As her immune system fought the infection, cytokines and prostaglandins poured into her system, releasing debilitating waves of whole body trembling and bone chilling cold.

Promoters and Modafferi’s coach encouraged her -- and she is not a fighter prone to bowing to adversity -- but the mind cannot drive the body beyond its physical limits. In pre-fight warm-ups, she was lightheaded and unstable on her feet. Dizziness, weakness, persistent vomiting and constant shaking left her huddled in the locker room. Any competent ringside physician would have recognized a compromised fighter unable to properly defend herself. It would have been a violation of the most basic ethics of medicine to let her fight.

In her blog, Modafferi described the misery of walking to the ring knowing she would not be able to perform for the fans cheering her name. A moment after her entrance into the ring, the physician on duty followed her, arms waving over his head, and the fight was over before it began. There were tears in the fighter’s eyes. There probably still are.

“I really, really hope I get the chance to fight Hitomi Akano someday,” she wrote, “and I am super, super disappointed my body failed me this time.”

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Fistic Medicine: Reader Questions, Feedback

My thanks for your e-mails and questions, as they have made this column more fun and satisfying than I had hoped or expected it could be.

Flexion bridge maneuvers and flexion curls. Any exercise that involves bending the neck forward against resistance. Heavy weights should not be used. This is a good, simple Web site: http://www.exrx.net/Lists/ExList/NeckWt.html.

In terms of basic science, there has been no watershed development, but evidence of the dangers of CTE is mounting. The autopsy results of NFL player Chris Henry are concerning: Chronic Traumatic Encephalopathy present in a 28-year-old wide receiver. UFC heavyweight and former NFL lineman Matt Mitrione says, “I guarantee you I have brain damage.” He would know. An Ivy League footballer commits suicide and shows extensive brain damage at autopsy. Eventually, the evidence will be impossible to ignore.

No one knows but presumably much lower than a professional fighter. Risk of CTE is a function by the number and severity of brain injuries. We assume the timing of repetitive injuries, the parts of the brain affected and an athlete’s genetics play a big role, as well, but no one knows how to quantify these risks for a population or individual. I wouldn’t give up a sport I loved, but I would keep my eyes open. And my chin down.

An October 2009 article in “Dental Traumatology” suggests so. It was a small study, but it came out of a well-reputed university. I’m not entirely sure the proposed mechanism is legitimate, but that is the beauty of science: hypotheses can be supported or debunked in time.

I do. The articles on Staph Aureus, Women’s MMA, Mouthguards and Cauliflower Ear were prompted by readers’ questions. A few others were “prompted” by my editor.

Either because I haven’t gotten to it yet, or, just as likely, because I’m wholly ignorant. I make a point of basing my articles on published research and established science. If I can’t find research to answer a question, I’m hesitant to add just another opinion to the blogosphere.

I have some thoughts on the matter, and there’s a tremendous amount of information about liver injuries in the medical literature. However, to date, I haven’t found articles that address liver trauma from hand-to-hand combat trauma, pain associated with liver trauma or how a liver blow debilitates an opponent so effectively. When I find it, I’ll publish it. In the meantime, I think you’ll appreciate this:

You may be right, possibly on all counts, but I doubt you have the evidence to prove it. The German sport system compiled detailed data on every aspect of athletes’ performance but virtually none regarding their health. We know there are risks to steroid use, but we don’t know -- quantitatively -- what those risks are. If we know there are rocks beneath the surface of the lake, how much more do we need to know before choosing to jump in? A lot of the people jumping are kids.

Stepping into a closed cage with a man willing and able to badly hurt you should evoke a robust sympathetic response. More difficult is controlling it: mental discipline, yoga, visualization, training and experience.

There are canaboid receptors in the brain. During times of stress, the brain releases chemicals that stimulate a sense of calm and well-being, which is vital for an animal whose intelligence is arguably its best hope for survival. Marijuana -- specifically delta-9-tetrahydrocannabinol -- exogenously stimulates these same receptors.

Can they fight professional MMA? Yes, clearly. Can they do so safely? This is not a safe sport for anyone who participates in it. As long as promoters match fighters of roughly equal ability, my read of the literature does not suggest women are in greater danger. Can they fight at an “acceptable” level? De gustibus non est disputandum.

As far as you’re concerned, don’t shave immediately before training; shower immediately after; don’t share personal equipment; wear a rash guard; avoid opponents with visible red patches of skin or large red pimples; and avoid opponents with long nails and coarse 5 o’clock shadow that will open microscopic skin wounds. As far as your gym is concerned, clean the mats and gear religiously, and promote a culture of caution that encourages self-policing.

Forrest Griffin is adamant that there is a difference between fighters (like him) and mixed martial artists (like a whole lot of us). Hess is a fighter.

I’m not their doctor. I’m not their friend or family member. I have an opinion, but it’s a fundamentally ignorant opinion -- it doesn’t belong in print.

So do a whole lot of commenters on the Sherdog.com Facebook page. This seems like a great opportunity for Sherdog to set up a dating Web site. Contact Jordan Breen if interested.

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Fistic Medicine: Cauliflower Ear

One figure in particular stands out among the beautiful sculptures of the Ny Carlsberg Glyptotek museum’s Greek antiquities wing. Amidst the marble beasts, eternally pouting graceful maidens and delicate youths, a hard faced man stares balefully at visitors. A hostile, unpretty face, he could be a soldier, a slave, a god. But by his deformed ears, we know him for what he truly is: a fighter.

No physical deformity is so inextricably bound to a specific athletic endeavor as cauliflower ear and combat sports. True, other forms of ear injury can lead to the deformity -- 19th Century opium addicts were recognizable by damaged ears born of uncounted hours lying insensate on hard wooden opium den palates -- but none as surely as the high-intensity repeated trauma of grappling. For years, the physiology and treatment of cauliflower ear was a matter of debate, and athletes had no choice but to bear their scars. Advances in surgery and a landmark 1975 study from Sweden changed all that.

In the Swedish study, investigators took two cohorts of young rabbits. In the first, they injected blood beneath the skin of the ears. In the second, they injected the same amount of blood beneath the perichodrium -- the thin layer of connective tissue that covers the cartilage of the ear. It is this cartilage that gives the pinna of the ear its distinctive curved and ridged shape. In the first group, the blood was readily absorbed; there were no complications. In the second group, where the perichondrium had been disturbed, the blood persisted, and the ears developed deformities. The study showed that not all auricular hematomas cause cauliflower ear, only those in which the perichodrium has been disrupted. Unfortunately, the shearing forces seen in grappling are very likely to cause those perichondrial injuries.

The Swedish study also elucidated what is happening at the microscopic level in the formation of cauliflower ear. When the perichodrium is torn away from the cartilage of the pinna, chondroblasts on the perichondrium are exposed to blood. In the presence of blood, chondroblasts build cartilage; in the ear, they build flexible elastic cartilage. Rapidly, new cartilage forms on top of the existing ear cartilage. When the hematoma is eventually absorbed, the taut perichodrium contracts, creating the irregular buckled appearance of cauliflower ear. The timeline for this progression is rapid: chondroblast activation occurs within hours, extensive chondroblast invasion of the hematoma occurs within days and solid cartilage is in place in less than a month.

The best approach to cauliflower ear is prevention -- the distinctive head gear of modern wrestling has proven remarkably effective at preventing ear trauma. Unfortunately, grapplers in MMA frequently forgo ear protection because it inhibits escaping chokes.

When injury does occur, treatment begins immediately. As soon as a fighter notices pain or swelling in his ear, he should ice the ear to prevent further injury; cauliflower ear pathophysiology is not strictly an inflammatory response, but similar principles apply. Firm non-traumatic pressure to the injured ear will reduce the amount of bleeding into the hematoma. The next step involves evacuation of the hematoma. While not all auricular hematomas are subperichondrial -- and thus cauliflower ear generative -- it is impossible to readily tell which are and which are not; a prudent fighter treats every auricular hematoma.

The gold standard of care for treating an auricular hematoma is surgical incision and drainage. This can be done within seven days of injury by an emergency room physician trained in the procedure or at a later point by an Otolaryngologist (ENT). After local anesthesia, an incision is made along the edge of the hematoma, following the natural contours of the ear, and the clot within is suctioned out. The skin flap is then replaced, and the ear is packed tightly with bolsters held in place using sutures sewn through the ear. Recent published research has suggested that bolstering may not be necessary: the primary risk is recurrent bleeding and the need for a repeat procedure.

An alternative technique employs needle aspiration to drain the hematoma. Long used by self-treating grapplers, this approach is gaining increasingly legitimacy in medicine. An 18- or 20-Gauge needle is used to evacuate the clot. This technique is much simpler -- simple enough that there are YouTube videos of various athletes performing the procedure on themselves with the aid of a bathroom mirror. This technique is associated with more frequent re-accumulation of fluid and incomplete evacuation of the hematoma.

When these early steps to prevent cauliflower ear formation fail or when they are never undertaken by the injured athlete, the only remaining option is cosmetic surgery. Surgery offers benefits beyond mere aesthetics: cauliflower ear can be painful and, in extreme cases, affect hearing. The auricuoplasty procedure can be done relatively cheaply, perhaps for $3,000. Even so, when balanced against the cost of protective headgear -- no more than $50 for the top-of-the-line guards -- the argument for prevention rather than treatment is difficult to refute.

There appears to be some genetic predisposition to cauliflower ears, some unfortunate combination of ear shape and perichondrial friability. But by far the greatest risk factor for cauliflower ear is the fighter’s attitude. In the subculture of grapplers -- much like German dueling scars or African ritualistic scarification -- the deformed ears may be valued for what they putatively represent: hours on the mat, endurance of pain, disinterest in the mores and aesthetics of mainstream culture. In such a culture, beauty and pathology are in the eye of the beholder.

Matt Pitt is a physician with degrees in biophysics and medicine. He is board-certified in emergency medicine and has post-graduate training in head injuries and multi-system trauma. To ask a question that could be answered in a future article, e-mail him at mpitt@sherdog.com.

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