The K.O. The eternal contrast of the victor and defeat. An effect that goes beyond the count of ten.

Boxing as contact sport has the scoop: damage and avoid being damaged, also known as the "Sweet Science" is a sport that if something has historically lacked is precisely science. The ultimate goal of a boxer during a fight is deal it rival a Knock Out, is nothing more than a concussion ... An article published in 2015 by The Physician and Sports Medicine presents a serious and outstanding analysis as to brain damage to boxers as the cumulative impact of blows to the head and protocols that exist for treating, monitoring and return to activity in the best possible conditions, and suggest measures to prevent brain injuries. I intend to make a very brief summary and analysis of this article for the general public lover of this beautiful sport, for my medical colleagues, and most importantly, our brave and admired fighters who leaves everything and expose all in the ring. In the huge spectrum of a boxer winning a bag of millions of dollars to one that seeks ways to survive, the only sine qua non that prevails is that of two human beings slapping each other on the hard solitude of a ring to the admirably expectant fans and morbid look.

 

I firmly believe that we are about this sport should and can contribute much more than a shout at fighters.

There is a devastating numbers: 20 to 50% of former boxers have symptoms of permanent chronic brain damage, there is a wide range of long-term brain disorders, to name a few: pugilistic dementia, posttraumatic parkinsonism, chronic dementia syndrome post contusion and encephalopathy chronic traumatic, mainly. In an average race thousands of blows to the head, the type and severity of damage depends on the angle of impact, strength, head movement, relaxation and fatigue of cervical muscles are received when the fights are very advanced and boxer tired, this causes greater rotational and translational acceleration with each stroke. Given these factors is understandable need and responsibility to take preventive measures prior to the fighting and after them, and make the decision to suggest or prescribe retirement from the sport.

This article entitled "Determining brain fitness to fight: Has the time eat?" Quotes the Declaration and Consensus Concussion in Sport, Consensus statement on concussion in sport, held in 2012 in Switzerland and should be part of the daily practice of all Doctors related to sports where the risk of concussion is imminent. This work marks clearly how to handle the gradual return of an athlete, regardless of the discipline that practice, which has suffered a concussion, adhering to these recommendations can have an adequate and safe return to physical activity and sport with a wide range of safety for our patients, and above all, preventing injury or brain damage, or in the worst case scenario damage limitation.

In professional boxing after suffering a KO or TKO, the fighter must keep a full suspension of sporting activity rest within 30-180 days, this variability is depending on the medical or athletic commission where this is the fight, as well as the country or organization to which it belongs boxing the boxer.

So far everything seems to be very clear, but there is a real situation and problems, which becomes a true risk factor in boxing: the different rules and regulations of the commissions of boxing and wrestling in Mexico, many of which medical review is limited to a pre-combat, usually performed on the day of weighing where monitoring of vital signs, pupillary reflexes, review of the oral cavity, chest and hands is performed general medical examination. There is no standardized medical examination nationally for fights professional boxing in Mexico, much less a full neurological assessment linking a ban to fight preventively, further battery imaging studies of examination (CT or Magnetic resonance Imaging), showing the current state of the brain and that can guide or suggest chronic damage, and in some cases, show structural changes that make risky practice a contact sport. If there is a committee that has a comprehensive and correct protocol medical review that is limited to the commission, if a boxer is not allowed to fight as a result of a thorough neurological examination, the fighter can compete in any other state without complying strictly all necessary health standards and will take the ring. This scenario is similar in the United States, where are the best purses and represent "the big leagues of world boxing". There is a great difference between the athletics commissions in the regulation of "boxing, entities such as California, Texas, Nevada, New York and Washington do not share the test battery or the rigor of them to give professional boxing license.

The article to which I refer recommends three major actions intended to increase safety and prevention of chronic brain injury: 1) standardized neurological evaluation by a neurologist or neurosurgeon must be done, supported by brain imaging studies and the use of assessments that measure boxer cognitive function, this as early as possible within the sports career boxers can conduct studies in the future and compare changes as a result of cumulative injury or TKO, KO. 2) Neuroimaging studies as protector of the health and safety of the athlete. There are images that indicate the existence of pre-practice boxing (congenital malformations) lesions with this information can prevent many adverse events. In following boxers if these scans are performed frequently and routinely changes may become apparent brain tissue caused by the accumulation of impacts received and provides evidence of brain injury already established in the fighter. 3) Identify high-risk boxers; able to identify boxers with high number of fights per year, played rounds and losses by KO, I would add to this identification of boxers high risk to those winners fighters who have a record with few, including undefeated or defeats lost fights without suffering KO but they have been subjected to continuous punishment because of his boxing style or technical deficiencies on defense. This identification of the fighters could be done with proper and effective coordination of boxing commissions nationwide to take timely and actual record of reach boxer. It should not surprise the reader that there are boxers who have many more fights disputed that declaring its official record, if these fights are losses will be much better than not reflected in the official record that, in the end, is a tool to promote a boxer.

Realistically the above mentioned will not be performed by any of the boxing commissions of our country, the promoters will not perform these actions from these written handlers, in the best case, invest their time and money on the boxers that represent better future or present and, finally, boxers are subject to the above.

Where do enter the medical task in all this ?. The doctor ring, that mythical character known to all, is a professional who spends his time giving this service mainly from weighing until the end of the boxing function, are admirable knowledge that these doctors have in identifying the many and varied injuries and medical conditions that casts a boxing card. But historically its role is limited to those bittersweet and bloody moments of glory and defeat. These professionals belong to the medical commissions of boxing and wrestling and usually do not accompany the fighters in the transit time between the end of the fight and the beginning of the next period that can range from days to months.

For all above takes relevance  the role of Sports Medicine Doctor within the work team of amateur and professional boxer permanently to monitor and control the activities necessary to observe the progress and health of athletes, and to identify quickly deteriorate and limit the damage. These actions are made all the way between fights, day by day, with monitoring and training camps to the last innermost sacred place and this may be next to his fighter: the corner.

The sports medicine doctor must plan together with the team visits neurological reviews as an element of pre-competitive activities that routinely be performed, remember: resting electrocardiogram, echocardiography, ergometry test , physical therapy and medical injuries that occur, medical supervision of sports training, the legendary and problematic weight control, among many others.

I can not stop imagine myself the ideal of seeing a Mexican boxer, (already a great show), with a true master of boxing as main and only pair, closely supported by a trainer and sports medicine, What could get ?, a longer safe boxing career, probably with fewer injuries and at the end of this, a former physical fighter and mentally full and lucid that you can enjoy and remember the glories of the past, enjoying their defeats, suffering the undeniable negative effects of fame and victory, but with all the mental and cognitive capacity to do so. 

Everyone has the right to be healthy and whole as Julio Cesar Chavez successful interventions in mexican television or Ricardo "El Finito Lopez" flaunting a lot of gray matter in their speeches.

Sincerely I invite boxers to consider this message and take a more active role in their own care medium and long term.

Miguel Angel Nazul Aké Montiel
Sports Medicine Ph.

Ref

:

1. T. Seifert et al. Determining brain fitness to fight: Has the time come? Phys Sportsmed, 2015; Early Online:1–8

2. McCrory P, Meeuwisse W, Aubrey M, Cantu R, Dvorak J,Echemendia RJ, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held inZurich, November 2012. Br J Sports Med 2013;47:250–8

OREJAS DE COLIFLOR EN EL DEPORTE.

(Modificado de la publicación original: Oreja de coliflor en el Boxeo, revista Box World).

 El otohematoma, otoseratoma o pseudoquiste auricular  es una lesión muy común que se produce en diversos deportes,  es debido a golpes, fricciones,  contactos  intensos y continuos en el pabellón auricular (oreja), esta lesión tan característica en los deportes de contacto  es la mejor conocida como “oreja de coliflor”. 

En el boxeo las orejas de coliflor fueron muy frecuentes en épocas antiguas, en los deportes de contacto suelen ser una especie de trofeo, orgullo o tarjeta de presentación del deportista. En el boxeo esta lesión puede producirse por contactos directos sobre la oreja, tallones, abrasiones y hasta mordidas. Es una lesión que puede prevenirse si se usa la adecuada protección y atención inmediata y correcta cuando se produce, en el caso del boxeo una adecuada prevención es usando protección de cabeza y cara durante las sesiones de sparring. En la actualidad las orejas de coliflor son más frecuentes en deportes como el Rugby, Luchas Asociadas y MMA principalmente. Para los dos primeros existen protecciones específicas que evitan la lesión sin embargo no han resultado del todo efectivas y también genera una “desventaja” ya que los atletas perciben que del casco u orejeras pueden ser sujetados con mayor facilidad. En el caso del rugby, durante el scrum, el ruck, y en menor medida en el maul es donde se produce la lesión por fricción; en luchas asociadas la fricción ocurre en muchas y diversas fases del combate y durante los entrenamientos.

Lo que sucede en la oreja de coliflor es que un impacto de gran magnitud, o la repetición de los mismos, un tallón, fricción o abrasión producirá la separación de los tejidos internos de la oreja  de su piel externa (cartílago y pericondrio) esto generará un sangrado abundante interno en la oreja pero no un corte, por lo tanto sangre y fluido se acumulan lo que deforma el sitio de la lesión y por consiguiente la oreja, una vez que se produce el daño, se inicia la formación de cartílago nuevo deficiente entre 7 y 10 días después; la separación entre el pericondrio y el cartílago puede ocasionar necrosis y, por ende, pérdida de la base cartilaginosa, que da forma al pabellón de la oreja.

El fluido inicial es sólo sangre, pero a medida que la sangre se acumula, y no se drena la oreja, ésta comienza a calcificarse, con el paso de los días se absorberá parte de la sangre pero quedarán ahí otros componentes, entre ellos cristales de calcio. Al final en algunas zonas existirán pequeños depósitos de calcio y en otras la ruptura del cartílago, la zona deformada se tornará endurecida, como resultado se genera una oreja de coliflor. Todo esto ocurrirá si la lesión se presenta y no se acude al médico.

Cuando se produce la lesión a corto plazo, horas o minutos, existe un incremento en el volumen de la oreja, cambios de coloración, (se torna enrojecida), hay aumento de la temperatura y dolor, si se acude de forma inmediata al médico, este realizará un drenaje de la oreja y  podrá prevenirse en gran medida la deformación, esto debe realizarse en un lugar estéril y se valorará el uso de antibióticos y cuidados generales. Con esto se logra que los tejidos que se desprendieron de forma interna, el cartílago y la piel, cicatricen y sanen de una mejor forma en lugar de mantener la acumulación de sangre y fluidos que ocasionarán todo lo anteriormente mencionado.  Posteriormente la oreja debe ser mantenida con compresión para mejorar aún más el tratamiento. 

También existen diferentes medidas de prevención secundaria o de manejo crónico mediante compresión avanzada en las orejas lesionadas para tratar de disminuir la deformidad existente y que ya no son susceptibles de drenar.

Dr. Miguel Angel Nazul Aké Montiel.

Especialista en Medicina del Deporte y la Actividad Física.

CORTES EN EL BOXEO

Publicado originalmente en la Revista Box World.

Como hemos mencionado en ocasiones anteriores el boxeo es un deporte de contacto por excelencia, hemos repasado ya algunas de las lesiones que se producen en este deporte, en este número hablaremos de los cortes, y su eventual sutura, que se presentan en los boxeadores como consecuencia de un golpe directo independientemente de cómo se produzca.

Publicación original Box World diciembre 2016.

Es muy importante evaluar el tipo de corte, localización, longitud, profundidad (abrasión, epidérmica, en dermis o subdermis), el sitio donde está localizado el corte y si es un corte seco, no sangrante o con sangrado escaso, o un corte con sangrado activo.

Los cortes más delicados son los que se encuentran en las zonas más importante de la cara, órbita de los ojos, párpados, conductos lacrimales, nariz, labios, boca, y los huesos naso etmoidales (nariz y zona posterior de esta)  esta zona forma una especie de campana invertida en la cara, esta región es de sumo cuidado, deberá considerarse no continuar en la reyerta si los cortes son en esta zona, no sólo son estructuras delicadas per se, si no que de continuar con el impacto los daños a los nervios, huesos y músculos pueden tener serias repercusiones en la salud y en la carrera deportiva del boxeador(ra).

Manual del médico de ring AIBA, 2016.

Cabe mencionar que el “cutman” asignado al peleador debe tener estas consideraciones para prevenir el empeoramiento de los cortes de su púgil, recordemos que sólo cuenta con vaselina, gasas, apósitos o hisopos para contener y manejar los cortes de los boxeadores. Dicho sea de paso la vaselina sólo debería usarse para prevenir los cortes, hidratando la piel y haciendo más difícil la fricción del golpe que produzca el corte, cuando ya existe un corte no debe aplicarse vaselina sobre la herida pues entorpece el proceso de coagulación, lo único apropiado es comprimir la herida y usar la adrenalina (en concentración 1:1000).  La adrenalina está permitida usar para contener las hemorragias de los cortes vía tópica, las especificaciones y concentraciones de la misma dependen del organismo que sancione la pelea.

Suturas.

Una vez concluido el combate los cortes deberán valorarse para realizar la sutura más apropiada de acuerdo a su localización, configuración, extensión y profundidad, el médico que realizará la sutura deberá contar con vasta experiencia en este tipo de lesiones sobre todo si se trata de cortes en las zonas mencionadas con posibilidad de riesgo futuro,  como una herida en planos profundos: hueso, tejido conectivo o en estructuras donde se requiere una compleja reparación como en párpados y labios. Siempre deberá realizarse la sutura en un lugar limpio (clínica, consultorio, hospital), con adecuada luz, material estéril y los hilos adecuados. Si no existe la capacidad, equipo, instalaciones o experiencia apropiada para este tipo de cortes deberá llevarse al atleta a un centro médico y solicitar atención  especializada para realizar la sutura, reparación apropiada y funcional. En caso de cortes fuera de la zona de riesgo, lineales y secas deberá realizarse el afronte de los tejidos con puntos independientes, no continuos y profundos, realizar una sutura continua puede correr el riesgo de infectar la herida, teniendo en consideración que ese corte ya está sumamente contaminado por los continuos impactos y manipulación en la esquina. La sutura del corte deberá hacerse lo más pronto posible, evitando el transcurso de horas para realizarlo, pues esto entorpecerá el proceso de cicatrización y recuperación del mismo. Las suturas en promedio se dejan durante una semana o diez días y esto dependerá de la naturaleza de la herida, al retirar los puntos de sutura se pueden recomendar sustancias dérmicas que estimulen una adecuada cicatrización, (vitamina E o biomoduladores tópicos). El tiempo para retomar actividades de sparring y contacto deberá ser recomendado en cada caso por el médico tratante.

Hay que tomar en cuenta que hay boxeadores (as) más propensos a cortes por la naturaleza de su piel y la configuración de los huesos de la cara. En el caso de torneos de boxeo amateur, el corte deberá afrontarse sin suturas, con tiras especiales o pegamentos dérmicos para presentarse a su siguiente combate, durante la revisión médica matutina será el servicio médico del evento quién autorizará al deportista presentarse o no a su combate, cabe mencionar que en estos casos el corte mismo no es un problema si el sangrado remitió y los tejidos se afrontaron, sino el proceso inflamatorio que presente la zona del corte.

Miguel Angel Nazul Aké Montiel.

Médico Especialista en Medicina del Deporte y la Actividad Física.

MUSCULOESKELETAL ULTRASOUND IN SPORTS MEDICINE.

Musculoskeletal ultrasound in Sports Medicine, has become a diagnostic and therapeutic tool useful complement in our specialty. Years ago specialties such as cardiology, gynecology and obstetrics, anesthesiology, etc., have made an appropriate and critical use in their daily practice. Today there are already many sports medicine doctors encouraged by this great tool increases the diagnostic and therapeutic options in daily consultation, offering patients quality service and medical innovation, it is noteworthy that the use of these technologies does not replace the medical history and physical examination, the doctor must conduct the study in mind a clear clinical diagnosis, which seek to corroborate with the sonographicexamination, is not intended as a radiological cabinet, this diagnostic method is operator dependent, it means, the physician performing the studies should be
thoroughly trained in highly specialized sites and understand that is a curve of gradual and progressive learning.

There are many conditions that have a timely and very useful approach using musculoskeletal ultrasound, muscle injuries, tendon, ligament,bursitis, etc., before these conditions are not diagnosed properly, or worse, are not diagnosed; therefore proper treatment was not performed,resulting in recurrence or worsening of symptoms and injury.

Ultrasound provides real-time images of a region of study, which also allows therapeutic approaches
guided by ultrasound image with great precision: drainage bursae, hematomas, infiltration of substances, applying different techniques prolotherapy, etc.

The medical profession is constantly changing, it is the health professional that must adapt and adjust to these new techniques, learn and seek to master.
Our patients appreciate it.

Miguel Angel Nazul Aké Montiel.
MD Sports Medicine.