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[Physio Discussed] Clinical challenges in combat sports with Dr Heather Linden and Dr Ian Gatt

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In this episode, we discuss some of the potential challenges and perks of working in elite sport. We explore: 

  • Most common injuries seen in combat sports
  • Key differences in elite sport vs private practice
  • Importance of interdisciplinary/multidisciplinary management
  • Use of objective measures in elite sport
  • Injury risk prior to competition
  • Supplementation in elite sport

Dr Ian Gatt is Head of Performance Services & Lead Physiotherapist for GB Boxing. He has over 20 years of clinical experience, having supported athletes on their path to success through several Olympic games. He forms part of Team Anthony Joshua (Boxing Olympic and Professional Double World Champion), delivering injury reduction and management strategies within a multidisciplinary team. Ian is an Upper Limb Injury specialist with the prestigious English Institute of Sport (EIS), and has recently completed a PhD in Wrist Biomechanics at Sheffield Hallam University. 

Dr. Heather Linden serves as the Senior Director of Physical Therapy at the UFC Performance Institute (UFCPI). She oversees the sports medicine departments at both UFCPI locations in Las Vegas, NV, and Shanghai, China. In 2022, Heather received the prestigious “Trainer of the Year” honor at the World MMA Awards. Prior to her role with the UFC, she was part of the Sports Medicine Division at the United States Olympic & Paralympic Committee and also led an outpatient orthopedic clinic in Los Angeles.

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Our host is @James_Armstrong_Physio from Physio Network

SPEAKER_01:

Welcome to Physio Discussed, the podcast that dives deep into the world of physiotherapy and performance. In today's episode, we're exploring the ins and outs of working with combat athletes. From injury management to the unique mindset of elite fighters, we'll uncover what it really takes to support some of the toughest athletes in the world. Joining us are two world-class experts, Dr. Heather Linden, Senior Director of Physical Therapy at the UFC Performance Institute, overseeing sports medicine for elite MMA fighters across Las Vegas and Shanghai and across the world. Former Trainer of the Year at World MMA Awards, Heather brings a wealth of experience in the UFC, the US Olympics and Paralympic Committee and outpatients orthopedics. Dr. Ian Gatt also joins us, Head of Performance at UK Sport Institute We'll be discussing everything from what makes working with combat athletes so unique, some of the common injuries and challenges in fighting sports, the mindset and physiological and psychological aspects of rehab in fighters, and how physiotherapy plays a crucial role in the crucial role in keeping athletes in peak condition. Get ready for an inside look at the high stakes world of combat sports rehabilitation. This is one you will not want to miss. I'm James Armstrong and this is Physio Discussed. Ian, Heather, welcome to the Physio Discussed podcast. It's brilliant to have you both on. We've not that long ago had both of you on the individual short form physics BAME podcast. I'm really excited to get into more detail about combat sports. I thought to start with, I'd love just an introduction of your current roles at the moment for the listeners so they can see where you're at and what you're doing. It's really fascinating stuff. Heather, do you want to kick us off what your role is currently in the wonderful world of the USC?

SPEAKER_00:

My name is Dr. Heather Linden. During their training camps, outside of their training camps, but also leading up to an event. My staff of 13 sports medicine clinicians travels around the world, covers 44 events a year. And anytime an athlete is coming to a performance institute, has an event they're about to do, they have access to myself and my team 24-7.

SPEAKER_01:

brilliant and Ian over to you your current role in boxing

SPEAKER_02:

yes I mean within boxing I'm the head of performance and still lead physio I've been lead physio now for the last 15 years but in the last say around 8 years taking on the role of actually coordinating, facilitating, supporting the wider support team, meaning that it's not just the doctors and the physios, but also the sports scientists, ranging from physiologists, performance lifestylers, strength and conditioning, psychologists, nutritionists, and so on. So for me, that's fantastic because I think for the last 17 years, for sure, I've been embedded in multidisciplinary teams, being boxing and even some other teams, which gives me a really nice understanding of how to provide holistic approach for athletes, whether they're injured, sometimes even when they're not injured, how to manage an athlete to make sure that they're performing at the right levels and ensuring they're not getting injured. In fact, whilst we're recording now, we're getting ready this week to do boat screening, which is an MTT approach, but also we'll be sitting down with every athlete to do reviews of the last year and actually look at their performances and move things forward. So it's shifting the two hats on that people sometimes will not see because thinking that it's just from a physio point of view but I'm also I work with the wider UK Sports Institute which means beyond the shores of boxing I support various practitioners various athletes particularly in the last year when we're leading into the Olympics and now after helping them the new cycle particularly around the upper limb where I think over the last decade and more, probably established myself as supporting people wide and far. I'd say even in the realms of the National Health Service also, where we've managed to help and support people using a lot of the examples from sport and cross the boundaries into the general public. So that for me is probably one of the great successes that we've managed to do of transcending what sometimes people think are separate entities.

SPEAKER_01:

Absolutely. Yeah. And the more someone works in the NHS, the more we can gain from elite sports and the learnings that go on, the better and how that, as you say, can transcend across. It's fantastic. Brilliant. So both working obviously in combat sports with high level athletes at the top of their game. And one of the questions that I think you probably get an awful lot and we certainly see a lot of is these injuries. And I remember talking to Heather quite recently on the podcast about this perception of what we might think are going to be lots of injuries in the middle of bouts and fights. And actually we potentially see them outside in training more. Heather, can we come to you first of all and talk about some of those injuries and the most common things that you see in and around And I particularly mean around the octagon.

SPEAKER_00:

I mean, definitely with our athlete population in combat sports, injuries are definitely something we see quite frequently. And I think it's managing those injuries and understanding the mindset of this athlete population. But depending on kind of what the background of each of our athletes are depends on the injuries we typically see. An athlete of ours that's really striking focused, that's one of their biggest game plans that you see them execute. accelerate and really do well in, we will see a lot of those shoulder injuries, right? Because they are doing a lot of overhead. They're doing a lot of upper body movements. And with that, we see everything from labrums to rotator cuff injuries to impingement. It's pretty similar, I would say, from a boxing standpoint. Being my background was also Olympic sports with Team USA and boxing, got to see a lot of that carryover with our strikers and very similar injuries of that upper body. The biggest difference with us now is we also have lower body injuries a lot more that I didn't quite see as much with my boxing population. We'll get a lot of fractures. We'll get a lot of knee injuries, especially with the submissions and things like that, especially ligaments. I think you and I talked a little bit last time about, I would say we have about 10 athletes in the top 10 right now without any ACL injuries. Usually when I say that, people are astounded that we haven't fixed them, that they still don't have ACLs. But with the demands of our sport and the lower extremity submissions and the lower extremity kicking, we do get a lot of ligament injuries in the lower body as well as fractures.

SPEAKER_01:

Brilliant. And I suppose with that in mind, we probably may well go on to this in terms of rehab. You mentioned there you've got a lot of athletes in the top kind of level who are deficient of an ACL. That must mean that the rehab that they've had has to be absolutely spot on to enable them to return to that level of sport.

SPEAKER_00:

Yeah, it really becomes a lifestyle, I would say, for the athlete population. And I think that's something that we've seen a big transition with MMA. It's not just a eight-week fight camp and the fight that occurs. It's a lifestyle change of adding those prehab exercises. Similar to what we were just talking about is the overall athlete making that an interdisciplinary approach and making sure that those knee deficiencies are constantly doing a warm-up that's going to really help them out and give them the stability they need when they get into training.

SPEAKER_01:

Brilliant. Ian, listening to that, taking into your world, what are some of the key things that you see regularly in terms of injuries in the ring and outside of the ring?

SPEAKER_02:

Everything except for ACLs. Pretty much that. I think boxing, as Hallowood agrees, is very much from a sport, an upper limb dominant sport injury, like your hand, wrist, elbows and shoulders become your bread and butter. Obviously, you can add weight traumatic necks. You can add concussions, obviously, to the mix and bruises and fractures, facially, thoracic. That goes with the whole area of impact. But, you know, at an Olympic level, particularly these days, I think if you compare to how they used to train 10, 15 years ago, you know, when they do their conditioning, their running, They train like runners. They do so much different and various things. And also because they're trying to maintain their weight and they're trying to be at peak performance. I think back in the days, they just used to go for a jog, like you see the old Rocky movies. Now they'll be sprinting. They'll be doing fartlek runs. They'll be doing so many different types of intervals that We actually see lots of lower limb injuries, like overuse, stress reactions, stress fractures. I don't think we see as many, luckily, hips and knees as much as we see from the knee downwards. But you get the occasional hip, you get the occasional knee. I think from the knee downwards, you have to be as good as you were working in football. Your ankles, you know, a couple of Lisfrancs. We were never surprised when we were talking about those things. But definitely, I agree, you know, anything to do with the shoulder, the labrales, there's so much translation going on. And for me, it's not when they're hitting, it's when they're missing. And then when they're getting into grappling, whether they're standing or on the floor, as Heather will have them more, you're still going to get all that stress going forward. So, I think if you're working in combat sports, you need to be proficient in a bit of everything. You can't just say, oh, I know this area and I'm comfortable. You have to be very uncomfortable in knowing a bit of everything, really.

SPEAKER_00:

And it's funny, I think we take that for granted being in combat sports and how easy it is to do an assessment from head to toe. I know recently we have had a lot of outreach from other sporting organizations, football, soccer, and stuff that just don't see those unique injuries as much as you would in combat sports.

SPEAKER_02:

One of the sports that always reach out to me to do CPDs for them are your rugby players, tennis, cricket, and even football, particularly goalkeepers and defenders who have higher risk, particularly your goalkeepers. So I think what's interesting for me is that because they don't have those as their bread and butter, when they have those injuries, sometimes they lose more training availability, mainly because of how to manage them. And I think that's probably been my campaign over the years is help people understand these injuries better, but linking them to function better rather than spending months and months trying to learn the anatomy. I go, no, don't worry about that. You can transcend that. Anatomy is important, but let me do that and I'll try and simplify it for you.

SPEAKER_01:

So a question for the both of you in terms of injuries. When you're looking at this level of athlete, some of the things that you might do differently to something that myself and the NHS might do in terms of getting those athletes back in the ring, back in the octagon where they're making their money, where their livelihood is. What do you think some of the key differences that you might do in your arena as opposed to out in your everyday populations?

SPEAKER_00:

Yeah, I definitely think for us, we aren't taking that time off that you would do in a general population. We have learned how adaptable, how resilient the body is in these injuries that normally maybe in the general population, they might say rest, do this, where I kind of agree with Ian, it's getting that function back as soon as possible. These guys, this is their bread and butter. especially for our population that are independent contractors. They're not making any money if they're not out there. I mean, you just saw this past weekend, some of the injuries that have come out from the athletes that were fighting. We typically fight through a lot of injuries. You would be shocked at how many injuries the body, you know, if you can return that function, you can get that strength back. It's pretty amazing what the human body can do. And I think that's something that both Ian and I get to see. And we get to move forward a little bit faster than I would say the general population.

SPEAKER_01:

Definitely. Ian, is that something you see as well? Is that something similar in your field?

SPEAKER_02:

There are similarities, though, that we need to consider. So I think whenever I'm speaking to colleagues in general, they always think that sports, we have to think differently. I think we need to remember that everybody has performance requirements. Everybody has to return to something. that requires a level of performance. An old lady going to reach for her coffee mug in the morning is a performance requirement. The only difference is potentially the relative forces going to her might be different, but the relative force when you compare it to somebody else might be quite similar actually for what she can withstand. So I tell people it's the performance you need to do and it's the time scales. The only difference when you're working in sports is Because you're working, especially like myself and also Heather, you're working in a full-time environment with athletes that needs to be there now. They get injured, within an hour they need to be training. That training available is so important. You have to make decisions so quickly and the communication, the conversations with the wider team and everything has to be so fine-tuned. You wouldn't get that as much in the general population where athletes In one day, you could be speaking to so many stakeholders and repeatedly over the next few weeks and repeatedly going on. And because obviously you're measured on the training availability, you don't have the luxury so many times of the rest, as Heather was saying. Everybody says, oh, injuries get better with natural history. The natural history in sports is a bit skewed because the coach won somebody yesterday. You have to play the battle of, physiology, natural history, their functional abilities, which you have to become really good at understanding and measuring, in my opinion, knowing the pathology so that you're not missing something bad as a red flag. But then hopefully you've got athletes who are motivated. You hope so, because not all the athletes are motivated. And because they're young and healthy, they don't have all the underlying issues, you hope again, that your general population might have at an older age. So, you know, you're smoking, you're your diabetes, medical conditions, and so on and so forth. But it doesn't mean they don't have lots of psychosocial elements because a lot of them still have the financial constraints sometimes. It depends how much they're earning. They might have problems at home. They may have somebody who's dying in their family and it affects them. So when somebody says, oh, dealing with athletes is easier than the general population, I say, well, it depends on the context. It depends where you are. If you're working in the general population in a terminally ill environment, I get it. That must be really heartbreaking and difficult. But you can't say that sports is easy in comparison to what? That's where we need to be careful because we deal with a lot of issues today. psychosocial not just bio on a regular basis hence why in my team i've got psychologists and performance lifestyle advisors and we talk on a regular basis about athletes potentially have issues going on generally in their life

SPEAKER_01:

you're not in there heather you see the same sort of thing

SPEAKER_00:

A hundred percent. I mean, there's so many factors. And honestly, I think for us in the States, because of insurance driven medical care, we see that they will not treat them the same, you know, and you're like, get them moving, get them up. And why do we do rehab two to three days a week when it comes to the general population? Well, that is because that's only what insurance will cover. So everything is very much healthcare is guided through insurance driven decision making, which is absolutely not. I mean, we see in our sport population that we rehab people daily, we can get them back a lot faster, you see their function return a lot faster. And I would challenge our clinicians in the US to go outside of the norm of what insurance will cover. And you know, prescribe the prescription of rehab that's actually needed for the person in front of you, just like Ian said, whether it's an old lady trying to regain balance and be able to function in her own home, or whether it's a top elite athlete. I think that's something that's so important. And I think the psychosocial factors are huge. I mean, we're looking right now into concussion studies with the psychosocial factors and how poor socioeconomic could lead to maybe a higher risk of concussions and things like that. Things that people don't even think or correlate to injury management or or life in general.

SPEAKER_01:

Absolutely, definitely. And then it's really nice to segue through there into the additional considerations that we have around this population group. What are some of the other things that you have to take into account that might be different?

SPEAKER_00:

So I think definitely the mental and emotional resilience of this population, striking a balance between recovery and then also maintaining fight readiness, right? So like our athletes might have to take a short notice fight or our athletes have to be ready all the time. So we see a lot of those normal return to play phases having to be blended, having to have a really good interdisciplinary management on those cases to make sure that an injury can't heal at its best optimal level if nutritionally that athlete's really depleted and not really having the appropriate nutrients for the body to heal. We see sleep a huge factor in healing and recovery. So pulling in our sports psychologists, pulling in our sports scientists to look at what kind of wearables, what can we track, what can we objectively measure to give this athlete that optimal healing phase. Also, when we have an injury, those strength and conditioning is so important and tied into us so closely because we still have three extremities that can be working. We still have a cardiovascular system. We have still have so much we can work on where previously I think rehabs and injuries were always looked at just medically. But if you don't take all these factors into play, you are not going to get that athlete or that general population person back. If you have someone elderly that doesn't have good nutrition, that could impede healing. So I think, you know, understanding in this athlete approach, very an interdisciplinary model, looking at load management, looking at the resilience, both mentally and emotionally in this population are factors that I think are so critical for the sports medicine providers in combat sport. I mean, I know with us, you know, whether an athlete can afford paying for their family is critical. If an athlete has visa issues, I love when we get into a fight or even any sport where someone's like, oh, this guy is giving his opinion of why this person isn't performing. But if you take a step back and truly understand and get into the mindset of these athletes, there are so many factors on the backside of it that people don't even consider. We had an athlete even this week that had some injuries going into it, was struggling to get his family even over here so that he could see his family and be close with them. He needed this fight financially. I in there, how do you expect someone to be 100% every time they step into that octagon or even in life?

SPEAKER_01:

Absolutely. Ian, anything more on those additional considerations that you find that you have to take into account that might be slightly different or even the same?

SPEAKER_02:

Yeah, there's a couple of things. The first thing, obviously, the MTD approach, the multidisciplinary approach that Heather mentioned, I think it's important to establish it even before they get injured. I know sometimes In various sports, you're trying to fight about trying to get the basics right. You see it also plastered everywhere on social media, and it's not easy. Getting somebody to sleep well, to eat well, to recover well, you know, when they're not training, not to overtrain. People will think that athletes do that naturally. It's not easy because a lot of education. One of the difficulties we have, if you think, because I actually operate in two worlds. One is the professional boxing world and one is the Olympic world. And the Olympic world are classed as amateurs. Now, particularly in the UK, it's quite tough because there is such a big pro world, professional world, that athletes will see this Olympic route as a journey to become professional. Whereas athletes, before you spend more time on the program, before turning professional, now they're spending less time. And we know one of the biggest risks of injury is skill, level of experience, maturity. Maturity means also how you manage yourself, but also musculoskeletal maturity. So, you know, I've been now with boxing. This will be my fifth Olympic cycle, starting as we head towards LA hopefully we come towards header in the next few years but the difficulty I'm seeing is that probably the average age on the program when I say age years spent on the program and probably even generally their age is much younger now than it was a few years back and so for us you're fighting that battle of you need to get them ready to compete every year you need to get them ready to be complete level in four years time in Los Angeles but also you You need to not push them too hard. And it's such a tough battle that I feel that I have to be in the middle between the support staff and the coaches and the director of how to work it out. Plus, the other thing that we need to also mention is that the mentality of today is different from the mentality of a few years back. Although we talk about combat athletes and we talk about sports in general, I feel young people They are different than how we were when we were young. That's a big difference in how much they commit to the sport versus what they commit in other activities. And you've got social media and the presence and everything. So I think there are a lot of factors there that make it tough to manage athletes these days because you're fighting against lots of things on a day-to-day basis, even just to establish the basics.

SPEAKER_01:

Absolutely. I suppose what leads nicely into this one is obviously, as you both mentioned there, there's lots of considerations. It's sort of a multifactorial approach that's needed. You both also mentioned the MDT, and I think it would be really remiss of us not to talk about that and how important that is. Ian, coming back to you, so your MDT, particularly within your boxing role, what does that MDT look like? And can you give us a bit of an example of how that's so important?

SPEAKER_02:

So the nice thing, it's varied both in gender and in age group. So we've got young practitioners in the 20s to all the practitioners in their 40s, 50s, especially the ones that have stuck around like myself forever. I'm like Morgan Freeman, never leaving the prison. That's how it feels sometimes. But I think what's nice is, first of all, we all collectively are in the same building at any given time, or at least we're on various WhatsApp groups. make meetings every week so that we've got hybrid ways of approaching and what we tend to do is ensure that we don't miss a trick we're all the time discussing athletes from various areas it could be an injury part of thing it could be a behavioral thing that they're not attending you know even from a rehab point of view you're not doing your rehab that's a behavioral thing we need to pull that up and actually work it but also you know even though i've got a big team i've got probably about 17 practitioners on various disciplines. We also need to think of the wider MDT that sits outside of the sport. Your consultant, we've got chiropodists, we've got podiatrists, people that you will use dependent when you need them, but you can actually reach out further. And as I said, because I also operate for the UK Sports Institute, the nice thing is they have certain experts, for example, even like clinical psychologists, where you've got an athlete who needs a referral for clinical psychology, which means we're talking now, it's beyond the sports. There are issues going on with this person. They need support. a very deep level that there is that available because, you know, it sounds like a buzzword, mental health, but there are mental health issues in the sport. It's a tough sport, competitive, weight management. Sometimes, you know, as Heather was alluding before, it could be a socioeconomic area. Some people come from maybe more impoverished environments. So when you put everything together in the mix, it sometimes can be hard, you know, and you know, you've got four years to go to the Olympics and sometimes it's tough. You might have somebody who you're challenging but at times it doesn't feel like you want to be there so I think there's so many things which I see around athletes that it's not as easy just to think you know just turn up do your job as an athlete and go home and if you get an injury we look after you it's so complex and their characters are so unique also so that's what probably creates the opportunity for us to ensure that collectively behind the scenes we don't work as a silo we work collectively together And the information is shared in a good way, in a positive manner, in the right forums, in the right environments.

SPEAKER_01:

Absolutely. That communication is really key. You can have all of the right individuals in your team, but if you're not talking, it's not going to work so well. And Heather, your MDT, what does it look like? And can you talk us through the importance of it in your world?

SPEAKER_00:

Yeah. I mean, I couldn't agree with everything that Ian is saying so much. And I think one thing to touch base that he has said is having that individualized approach to that multidisciplinary team, right? Because the athlete in front of us are so unique, like Ian has said over and over, from them as a human to an athlete, to what their lifestyle is and stuff. So we really look and try to touch on that individualized approach. By having the support, we have sports medicine clinicians, we have dieticians like Ian has talked about that have to work from the weight cut side, and also on a healthy athlete of making sure we're rehabbing them and giving them the appropriate nutrient for their day-to-day diet. We have our strength and conditioning coaches. We have our sports psychologists. We have a clinical psychologist. We have 73 support teams. clinicians that are all based through performance globally around the world. I mean, the most unique thing for our population is we have about 750 athletes that are all across the world. It's not one area where we have to connect. We have to develop relationships with clinicians in all of the disciplines of performance globally around the world to support this athlete population, which is a very hard thing to do. That is why kind of we've opened the three facilities. But I think I think the biggest thing with this population is looking at them as an individual and really deciding what's best for that individual. I know our team does weekly meetings. Every Monday morning, our team does rounds. So all of those performance specialists are under one roof. And just like Ian said, maybe I'm taking the lead on the medical side, but maybe there's an athlete that is really healthy and everything is going perfect, but they're having weight cut issues or, you know, things like that for the nutrition. And we bring all these conversations. It's pretty funny because the athletes like you guys talk about us. And I was like, we should be talking about you. The more minds, the better. I mean, we, because we have 73 performance clinic people all over the world, we have different ways people have been taught, which is so cool to have my Australian physios with a mindset of something, maybe their education taught them with physios from Spain, physios from China, physios from Mexico. So I think the coolest thing we did recently is put all our sports medicine team under and just talk about the philosophies. Because what I learned in school is not necessarily what my new clinicians learned at school. So really developing our new philosophies that keep evolving and challenging the old ones to make sure we are giving our athletes top care. I know how I treated an ACL when I graduated 20 years ago is not how I treat an ACL now. I mean, the technology we know, the objective measures that we can make informative decisions is so much better. So I think by having these ground rounds, talking about these individualized athletes, not grouping them under one roof as the same person, allows us to have that interdisciplinary, multidisciplinary model where we're constantly challenging old systems, new systems to make sure we're giving the best in class world care.

SPEAKER_01:

Yeah, brilliant. I think I want to pick up on something there actually, Heather. Two things actually you've mentioned that I think both of you have mentioned is one, the measurements. So objective measures, testing. You mentioned it right near the beginning of the podcast and you're saying it's very, very important. Can you just give us a bit of an insight into your thoughts around objective measures and how that's important within your role?

SPEAKER_02:

I find it interesting because in the sporting world, we've always done some form of measures to try and understand things better. When you go then into the wilder domain of the NHS and globally, a lot of times it's not as much. And If somebody comes to you with an injury and you've got another injury and they're both the same, you take a scan, they're both the same, it doesn't tell you how much you can quantify that injury. And because you're working in an environment where the coaches are breathing down your neck to know, can they train now? Can they train tomorrow? You have to have a safety measure to fall back on. And you look at the literature and you look what there is out there. A lot of times what happens is there are things which are not in the literature and you create new things and hopefully publish new things also, which is probably what we've done over the years, even in boxing. But a very simple example is somebody injures their hand and you want to know whether they could train later on today. Also, you want to know whether that's serious and should I send for a scanner or not? Easiest thing is do a hand grip. Squeeze the hand as much as you can. and look at the number and see what pain is associated. What you're seeing there, if there's a significant decrease, is tissue tolerance, which is pain, inability to produce force. And I tell people, it's not strength. You don't lose strength in 30 seconds after an injury. You don't lose strength two days after an injury, not unless you've torn all the tendons and the muscles. But if you whack your hand now, you're going to struggle to open the handle of a door. But you'd like to know about how much. And that's how much becomes a measure of how much somebody is safe to squeeze and punch, if we're talking about a combat athlete. And also, if you're monitoring their progress and you're trying to return them back at the right time, it's giving you the timeline. If you extrapolate those measures over the whole body and you've got certain measures which can help you to understand those things better, then it really helps you. And so if you've got force and you've got range of motion, Two simple things which everybody's learned in some stage at university but forgotten once they've gone into clinical practice. Those are the main things I tend to teach people is, look, do that and you'll understand even an area which you don't understand. Because if somebody comes to you with a hand and you've never seen a hand and you tell them to squeeze something and there's a difference, that amount of difference is already giving you an idea of of where you should go next. So that's, for me, is very important. And it transcends sports, but so important in the sport. And again, my physios, I teach them those things. We make sure we do it well. We do it in the screening to have a baseline. So at least you get an idea of your population. We've got strength and conditioning coaches, which come in together with the physio. So the physical parameters are not physio-y or strength and conditioning. It's actually together. It's a joint collaboration. And I made sure that it is a joint collaboration. In fact, we had some very good chats these last few months to ensure we know what we're going to do over the next four years. So it's not just what we're going to do tomorrow, which is our first day of screening with some of the boxers, but it's making sure we're happy with that. And then what we can do is review that over time and still use similar measures. So, you know, you look and get shoulder. Okay, what measures are we using for the shoulder? What are the primary measures? What are secondary measures if they had a bad injury? And then what will you do later? And again, It's just a piece of the puzzle. So I'm not saying that you stick everything on objective measures. You know, you could have somebody who has very good objective measures, but they still have a lot of pain and you're thinking, what was going on here? And then they get a negative scan and you think, okay, what's going on here? Then you have to think, well, that's not normal, but it's not that we don't expect it. Sometimes you also need to think that some athletes, sometimes there's something going on. I talk about psychosomatic manifestation of pain. It's not like it's some mumbo-jumbo thing. It's like people will have pain, the same as people have phantom pain when you chop off something. But just because you can't find anything on the scan don't mean they don't have something. It just gives you the confidence we haven't found anything significant. And so becomes a conversation with the athlete. Can we push them harder? Are we allowed to? Is it safe? And that becomes an informed decision to be had with the athlete.

SPEAKER_01:

Yeah, I think you hit the nail on the head there, that informed decision. It's information, isn't it? Yeah, absolutely. Heather, what about yourself with objective measures as following on from Ian there?

SPEAKER_00:

I mean, I would say one of the things I always challenge our team is taking those objective measures and then also taking experience, right? Experience, objective measures, match that together to give informative information to the athlete. I think the best thing with objective measures that we've seen with, at least for my athlete population, because they have such a combat mindset that they need to tough things out, right? We've heard coaches all the time tell them, push through it, rub some dirt on it, things like that. This just gives us some... to make better decisions or to get athlete buy-in because that's something that I would say is quite difficult in our population because they do push through a lot of injuries. And they are told to have that combat mindset. So I think giving them a little bit of objective with some evidence of experience gives them a little bit more buy-in and trust, which I think is so critical with this population is having them trust our decisions or the information we're giving them. And that's really how we use that informative data is by showing like exactly like Ian said, if someone can't grip on And their grip strength is significantly reduced. And they're going into a wrestling session. That's a great way for us to say, how are you going to give yourself 100% wrestling? if you really can't even use that hand with X amount percentage deficit that you have. So we might be able to meet in the middle and say, hey, instead, let's do a lower body session during that so we can build on that hand and that pain and things like that that are going on. But I think the best thing about having some objective information, which it's very simplistic, right? Just like We've talked about range of motion, strength, turning that into just measurements that show an athlete where they have something they can work on, maybe why they have pain, and then how to make an informed decision on what kind of training strategies they can do to fill in those gaps so that we can get the outcome that we're looking for.

SPEAKER_01:

Perfect. Brilliant. That's really good actually. I think it's got, as you say, you've not overcomplicated either. And I think a lot of the times there's a perception that sport is full of complexities. And I'm sure in certain circumstances there isn't a lot more complexities, but what you've just described there, I'm sure the listeners are thinking, actually, that doesn't sound so unachievable elsewhere outside of sport. So... There's a call to action if I've ever heard one. The other thing I wanted to mention that you both talked about a little bit is this weight. And with both of your athletes there having to hit a weight, do you ever see any issues with that and increase injury risk around certain times of leading up to fights and bouts? Heather, you're nodding profusely now. I'm going to go straight to you.

SPEAKER_00:

I mean, I can't tell you. We now have it down to most of our injuries start occurring somewhere between four and three weeks out is where we see most of the athletes have to pull out of an event. And what we've really tracked that with our nutrition team is that is when they're starting to deplete nutrition. to come down on their weight, right? So most of their camps are somewhere between an eight and 10 week timeframe. They do try to do a gradual descent, but as we get closer to that fight, we do see them cutting out maybe a little more carbohydrates or taking something else out. When you combine depletion with, that is also where they're trying to peak when it comes to load management, and things like that. When those tend to blend, we see that as where that injury risk significantly increases. We are actually tracking this past year, every athlete pull out, where was the timeframe? What kind of training were they doing? You know, we've seen it with not only if the load management and the depletion occurs, but we also see it when strategies of game planning change. If someone gets hurt, They're pulled out. Now the new opponent is placed in. If their strategies are not, they're not strikers. They're more of a grappling-based athlete. The strategy of that athlete training for that fight also has to change. You put that... that someone maybe who was doing striking their whole camp changing to wrestling. Now they're pulling out carbs, bigger muscle groups need those. Those are huge injury risks for us. And that's really what we see. So nutrition plays such an integral part. And I mean, to the point where I would say our nutrition team is absolutely brilliant and turning it into a science, which people don't even understand, from whether it's weighing what your bones, your fat and your muscle weigh, understanding substrate utilization, like What heart rate do you need to be at to come down? One of the things when we first started, one of the strategies athletes would do was add another session in, whether it was going on the track to do running up and down hills, the big cardiovascular sessions to try to reduce weight. But when we found out some of their substrate utilizations were at a lower heart rate, maybe all they needed to do was a steady state walk on a treadmill instead of a high level treadmill. activity, which then depletes them more. So understanding substrate utilization, understanding sweat rates, heat acclimation, what ounces they sweat at, it is all turned into a huge science. I mean, I have to shout out my nutrition team for being above, I would say what most people know about how nutrition plays a factor. But it definitely if we aren't working together, that is definitely where we see a high level of injury rates occur abroad.

SPEAKER_01:

Yeah, really interesting. Really interesting. Ian,

SPEAKER_02:

how about yourself? If you ask any boxer, they'll tell you the worst part about boxing is the weight. Weight making is not the actual boxing or the training is actually making the weight because it is the toughest thing. They have percentage weights that they have to abide for as a living weight over the year. And then we've got obviously combat weights, you know, when they come down to it. It's important because if you start going beyond your normative weights, you're going to struggle. You're going to make it harder. When boxers have boxed for quite some time, and I think that's any combat sport, you know yourself, you know the body. I think what the nutritionist is there to do is to fine tune things for you, is to help you, is to make you understand the things that you don't understand better. boxers, combat athletes will know when they wake up, what weight they are and how much they lose overnight. Some boxers will lose a kilo and a half. Some boxers will lose 0.8. And especially when you get drier, when you get closer to competition, boxers will hopefully have competed a few times over the years to know that. So most, I think, will have a relatively good idea of what is good practice and bad practice. And I think really what the nutritionist is there to do is substitute foods, for example, to show them the best energy making. You know, as Heather was saying, you know, it's not just about making the weight, but it's about sometimes substituting the right foods. Sometimes you've got people with allergies. So, you know, even people will never think that somebody might be allergic to chicken, but there are people who are sometimes allergic to things like chicken. So what can you do to substitute? Sometimes times you've got vegans. And so, okay, what are you going to do with a vegan to make sure that they get the right level of protein and right level of nutrition? So I think, you know, the role of the nutritionist is to give them that sudden day plan is to help them. And I think when they go to majors, particularly what I think is fantastic about the nutrition is the timing of the food, when to eat. They sit with them at mealtime during competitions to make sure that They have the right portions right. They'll ask them questions. What do you think I should be eating? That's the science that comes with it. You know, there's an art of being around the sport for many years or understanding the subtleties. The science is how far away should you be eating, the different weights, the different ways you can have, and then aligning it also with the goals of the coaches. Does somebody need to put on more muscle mass? Okay, what are you going to do about that? There's somebody to lose lean mass to make the weight because they can't make it. Suddenly we're talking about somebody who needs to shift one kilogram of mass to actually be able to make the weight. And that's not going to come tomorrow. It's going to take time. So it becomes a project. The nutritionist has a big role in being part of the MDT and the plans because they will support strategies around so many things. that are linked to both performance and health. I mean, when it comes to injuries, the best thing our nutritionist says is as long as they're eating a healthy meal, they don't need to eat extra things like supplements and all the other things. People will always go to the supplements straight away. But don't get me wrong. Obviously, you can have your omegas, which are really good because obviously you get lots of the anti-inflammatories components through the fish. And probably those things are good to eat anyway over the years. I'm surprised at why people get injured if they're having so many anti-inflammatory natural foods. So that's why I joke with the nutritionists. I say, well, unfortunately, we still get injuries even with all the good strategies. Even the ones that drink milk, they still break their bones. But at least you've got a basis. Let's be honest. You've got a basis because every time I go to them and say, look, he's got a bone injury. Do they need to take anything else? No, as long as they have a good, healthy meal. And I think that's a great message because I sometimes get parents asking me about children who go to training about starting protein shakes and starting all these extra things. And I say, look, you know what? Our nutritionist, his best suggestion is just to eat healthy and eat varied. So don't start all these extra supplements for your children, especially at that young age. They don't need it. Just eat a nice, healthy, varied diet. So yeah, I think it is a big science though. There's much more to it than meets the eye. There's much more knowledge around the physiology and the processes. We're also involved very closely with our physiologists around relative energy deficiency syndrome with the females. So, you know, really, really important component because together with the doctor, for me, they become that big component of injury management and supports probably having more knowledge than the physios around the injury themselves. So they actually, together with the doctors, help and educate the physios to support any athlete who is creating these injuries, particularly a stress fracture, which is you find out this happened due to repetitive stress, really, or stress reactions, and they're getting these commonalities. So yeah, definitely something where the nutritionist is involved. And last thing to mention, I think very important, particularly in countries where you don't have that natural sunlight, is that vitamin D exposure. So again, together with the doctors, making sure we're doing regular blood tests, checking for people, giving them vitamin D supplementations, and also being careful that you don't over give vitamin D supplementation because you know it's not very much reported and we've not seen any case studies ourselves but you can create the opposite effect with giving too much vitamin D which is actually can cause issues around the uptake of vitamin D in the bones by not making it available in the blood. So, you know, if somebody has already very good levels of vitamin D and somebody gives them lots of tablets to say, look, you know, we'll just have it just in case. So again, our nutritionists will work very closely with the doctors to look at the results and make sure we are giving the right extras, if we are giving the extras, for the right people. with

SPEAKER_01:

appropriate measurements of that by the appropriate MDT. Yeah, fantastic. Brilliant. The time has gone incredibly quickly. I wanted to finish off with something for the listeners here is a piece of advice from each of you on anyone who's listened to this, who thinks that they would like to get involved in combat sports, particularly I'm thinking the physios listening to this. Heather, from your point of view, what tips would you have for anyone thinking, I really want to get involved in this?

SPEAKER_00:

I mean, I think the biggest tips I would say is what I see with our new physios right now understanding that it's not going to be a very straight experience. You know, it's up and down. It's cyclical from an injury standpoint, from a mindset standpoint, it is probably one of the most rewarding athlete populations to work in. But really, it's not going to be a straight return to play. I see so many of our young physios get out of shape that they're not checking these boxes. It's a matter of putting the human in front of you understanding combat sports. So my advice would be to shadow, get out there and really get your feet wet in combat sports to see if this is something you love because I can tell you physios that I've had before that want that very clean return to play sport. Those really clean objective measures aren't always going to get it because that athlete might need to return with a small fracture or with something. My advice is really to get involved as much as you can in the combat world. Dabble your feet in it to see and realize that it's going to be a unique experience and trust, evidence, versus experience matching to have the best outcome if you really want to get involved.

SPEAKER_02:

Pretty tip. Ian, over to you. Combat sports is an amazing environment if it's something you want to do, but don't rush to get into it. If you are a young physio, get experience in many sports because that experience, that varied experience of working in so many different sports, if you can bring that to the table in a combat sport, it's better. As we were saying before with Heather, you see so many different injuries around the whole body that haven't had that experience of so many different areas of working with different athletes. It actually helps better. I think if you're a young practitioner and you're already thinking about having a career in one sport, you don't want to rush. It's a bit like athletes, is it? Sometimes people don't realize that when you start young as an athlete, you probably have been in different sports. And then eventually, yes, you will go to the one sport you want, become more professional, but you probably still maintain other sports anyway, even if it's recreational. Formula One drivers still playing golf and playing football. So they've had some background of doing all these varied skills. So I definitely say that because, first of all, it gives you a comparison too. And the other thing is, when we say we're looking in combat sports, it could be love or hate, depends where you are. It's not always the combat sports. It's not always the sports that you think it is. It's the environment you are in. It's whatever context you are in the world. So again, if you're having a bad experience, try somewhere else. That's the first thing I'd say. If you're having a fantastic experience, brilliant, it doesn't mean that it's always like that. But I can say that also as we get older, one of the things you do is you shape the environment around you too. So if you naturally have non-technical skills and you're really good at that, brilliant, bring them to the table.

SPEAKER_01:

Brilliant bits of advice there. So two things I probably wouldn't have thought you might come up with and I think they're really useful for anyone listening. So once again, thank you both very, very much for your time. It's been brilliant to speak to you both again. I'm looking forward to speaking to you again, I'm sure, at another point, whether it be on the Physio Explained, Physio Discussed podcast that we're running now. So thank you very much both again.

SPEAKER_02:

Thank you. Thank you. Thanks a lot.