Medical Musings: To Tap or Not to Tap? That is the Question. Karim Zidan October 6, 2012 The Doctor's Corner The one unique aspect of MMA that differentiates it from any other combat sport is the capability of winning a fight by forcing your opponent to submit, or tap out. Many fights are won by submission. In fact, when MMA was first introduced to the United States, Royce Gracie defeated every single one of his opponents (11) in UFCs 1-4 by forcing them into submission. However, with a sport such as MMA, pride and bravado have their place, and all too often it’s seen when a fighter decides he or she is not going to tap to a submission attempt, even when the potential damage is more than just pain. Even in gyms, during sparring sessions – there are fighters who refuse to tap immediately, and ultimately get injured when they could have easily avoided it by tapping out. While there are differing opinions on the matter, based on many different factors, this article aims to discuss why tapping out, from a medical perspective, is the only reasonable answer when caught in a submission attempt. Submissions There is an endless number of submission moves in which a fighter is able to submit his opponent with, and more are being created or modified every day. There are literally hundreds of different submissions available, however, with the exception of the choke – they all have one thing in common – they target the “soft tissues” in the human body, which are the joints, muscles, tendons, and ligaments. Further, it should come as no surprise that the most successful submission attempts are focused on the weakest of these tissues – the joints. For the purposes of this article, we will limit our discussion to one example – the “armbar”. In an armbar, a fighter secures his opponents wrist with his hands, and immobilizes the opponent’s straightened arm between his knees. Then, using the body as a lever, the fighter aims to hyperextend the elbow joint of his opponent in an attempt to get him to submit. Let us take a closer look at the structure of the elbow to fully understand what happens in this submission attempt. The Elbow Anatomy The elbow joint is a complex structure formed by three bones, the humerus of the upper arm, and the ulna and radius of the lower arm. Ligaments, muscles, and tendons maintain the elbow’s stability and allow for movement of the joint. A normal elbow joint allows three types of movement: flexion (bending the arm), extension (straightening the arm), and circumduction (rotating the arm). Since an armbar is based on hyperextension, we will focus our attention to this movement. Extension is defined as increasing the angle between two adjacent bones via a joint. The prefix “hyper”- means “excessive” or “greater than normal”. The excessive extension of the elbow joint is resisted by the muscles, tendons, and ligaments that anchor the bones to the respective joint. The fighter caught in an armbar first feels pain and must decide whether or not to tap out. Last week at UFC 152’s main event, Vitor Belfort surprised the defending champion Jon Jones (and the rest of the MMA world for that matter) when he sunk in a deep armbar early in the first round of their fight. At that very moment, Jon Jones was in pain and had to make a conscious decision of whether to tap out and lose his championship belt, or fight through the pain in an attempt to escape the submission attempt, knowing that the damaging to his arm increases exponentially for every second he is caught in the armbar. Jones remained calm and composed, eventually escaping the submission attempt. While Jones went on to ironically submit Vitor Belfort in his own submission via an americana later on in the 4th round, it was obvious that Jone’s elbow had been damaged by the end of the fight – mentioning that his arm “felt numb”. Without access to an MRI of his elbow, I can only speculate on the actual extent of the damage done to Jone’s elbow joint. However, in the next section we will discuss the myriad of damage that potentially could have occurred. Photo taken from the J Neurol Neurosurg Psychiatry 1997;63:808-810 Collateral Damage In elbow trauma, a medical professional must examine the soft tissues involved, the bones of the upper and lower arm, the blood vessels, and the nerves. The most likely damage to Jon Jone’s elbow joint is the weakest link, which is again, the soft tissues surrounding the joint. There are numerous ligaments that could have been damaged, including the radial collateral ligament, the ulnar collateral ligament, or the annular ligament of the elbow. Additionally, there a several tendons that could have been damaged, such as the biceps and triceps tendons, as well as the extensor and flexor tendons of the muscles of the forearm. Other potential complications include the possibility of nerve damage; there are three major nerves that travel through the elbow joint: the median nerve, the radial nerve, and the ulnar nerve. An extreme hyperextension of the elbow causing dislocation, as was the case with Jones, could potentially have damaged these nerves. Furthermore, a large blood vessel, the brachial artery, travels down the middle of the elbow and bifurcates (splits) into the ulnar artery and radial artery just below the elbow – and damage to any of these vessels is also possible, although much more unlikely than that of soft tissue damage. While I can only speculate, I believe Jones most likely did not suffer any major nerve or vessel injury, but the damage was enough to cause inflammation and irritation of a nerve (or nerves) in the arm, leading to the transient numbness Jone’s mentioned. Jones might have also sustained a minor strain (injury to a muscle or tendon) or sprain (injury to a ligament) of the elbow. Jone’s physician will conduct a physical exam to assess the elbow joint, and order an MRI of the elbow to investigate the potential injuries, and either confirm or rule out the extent of damage done to the elbow. It is simple to understand, from a medical perspective, that the only reasonable answer is to tap out to a submission attempt when escape is unlikely. Immediate submission usually prevents damage to even the weakest structure in the target area, and most definitely will prevent damage of the collateral structures. In addition, immediate submission allows the fighter to get back to training much quicker, and most importantly, maintains the integrity of the anatomy involved – allowing the fighter a much longer, healthier career.