TY - JOUR
AU - IDF, Uriel Dreyfuss, MC
AB - ABSTRACT Background: Krav-Maga (KM) is a unique Israeli hand-to-hand combat system, designed to teach soldiers self-defense in true-to-life situations. With the increase in military Israel Defense Force (IDF) units participating in KM training in recent years, the number of injuries incurred in KM has also increased. The purpose of our report is to describe the prevalence and pattern of these injuries. Methods: Instances of KM injury were taken from IDF patients' computerized clinical records over a 1-year period. Data pertaining to the type, location, and severity of the injury, as well as data relating to soldier's gender and age were collected from the charts. “Moderate” injury was defined as injury necessitating absence from military activity for more than 1 week; “major” injury was defined as injury necessitating surgical intervention. Findings: During the year 2014, 916 soldiers complaining of 946 traumatic injuries sustained during KM training were evaluated in IDF clinics. The vast majority of injuries (95%) occurred in male soldiers, and most injured soldiers (92%) were between the ages of 18 and 22. The upper limbs were the most frequently injured body parts, with the fingers, hands, and wrists being the most involved regions (31%) followed by the shoulder (16%). Injury severity was mild in most cases. However, 64 soldiers (6.7%) were moderately injured and major injuries necessitating surgical treatment occurred in 33 cases (3.5%). Discussion: KM involves both striking and grappling elements, and we assume that injuries result from both fighting forms. With striking styles, such as boxing and kickboxing, hand and wrist are the prevalent injury locations; with grappling styles such as wrestling, strain and sprain injuries of large joints are most prevalent. Head and neck injuries, a major concern in martial arts sports, were not identified as significant problems in KM. To minimize participant injury, preventative measures should focus on improving protective equipment, especially of the hand, as well as warm up and training technique modifications, and shoulder strengthening exercises. BACKGROUND The definition of “hand-to-hand combat” is any physical confrontation between two or more persons, without the use of firearms. In the 1940s, the Jewish defense forces developed a hand-to-hand combat technique that in later years developed into a close range fighting system known as “Krav-Maga” (KM) in Hebrew, or contact combat in English. KM is a unique Israeli combat system, which integrates striking, takedowns, choking, and joint lock techniques derived from striking and grappling martial arts, including boxing, judo, and taekwondo. KM is designed to give soldiers effective tools for actual situations such as knife attacks, kidnap attempts, or weapon abduction when hand-to-hand combat is needed (Fig. 1). KM training also helps mold a “fighter personality” by building self-confidence, determination, and aggression. KM has gained in popularity as it also teaches noncombatants to defend themselves in potentially highly dangerous situations. It is now a combat method taught to every soldier in the Israeli Defense Forces (IDF). FIGURE 1. View largeDownload slide Typical simulation in KM—a soldier being attacked with a knife defends himself from the assailant and simultaneously hits back. FIGURE 1. View largeDownload slide Typical simulation in KM—a soldier being attacked with a knife defends himself from the assailant and simultaneously hits back. The philosophy behind KM is self-defense, teaching soldiers to identify an imminent threat quickly, deal with, and neutralize the threat, while simultaneously using offensive and defensive maneuvers, and finally disengaging to a safe place. Another approach is offensive KM in which the soldier initiates an attack using KM techniques to aid another person, or as part of his mission. This approach is characterized by aggressive use of any means necessary to achieve the objective, involving use of physical force where there is concern for human life. Training for KM begins with learning basic technical skills, followed by simulated scenarios, in which there are elements of surprise, high-impact, strenuous “enemy” attacks. To train a KM fighter to respond efficiently and appropriately, extensive practice of the principles and basic skills are needed. The optimal way of achieving this goal in the army is by generating sufficient instructional sequences during basic training and having periodic repetitions throughout military service. The amount and intensity of training varies depending on the nature of the military framework, with Special Forces having more hours of training than other infantry, armored, or combat support units. Most soldiers practice KM techniques, but only a very small group of soldiers engage in actual KM activities. As in contact sports, the potential for injury is high in KM training; therefore, the use of protective equipment including helmet or head guard, jockstrap, chest guard, teeth guard, boxing gloves, limb guards, and a soft training surface during training is necessary. KM training is mandated by Regulation 19 of the infantry and paratrooper officers' code of 2016. This regulation outlines the topics to be covered, the amount of training required for the various military frameworks, defines qualifications needed to instruct KM, and the safety requirements needed. Despite the use of protective gear, military physicians have witnessed increased numbers of KM-related injuries as the number of military IDF units participating in KM training has increased. To the best of our knowledge, there have been no studies to date describing epidemiologic KM-related injury data. Understanding the type and mechanism of injuries from specific activities is invaluable for sports medicine professionals, both for treating patients and for designing injury prevention programs. Thus, the main objective of our report is to describe and evaluate the prevalence and patterns of injury in KM. We hypothesized that the most prevalent injuries would be sustained to the upper and lower limbs, with particular emphasis on finger and hand injuries resulting from repeated striking of the opponent. METHODS This retrospective cohort study was approved by the IDF Institutional Review Board. Instances of KM injury were taken from IDF patients' computerized clinical records over a 1-year period (2014). We searched for the term KM or its acronyms, and those records containing data related to traumatic injuries incurred during KM training were reviewed. Overuse injuries were not included. Data pertaining to the type, location, and severity of the injury, as well as data obtained from the Office of Human Resources, relating to soldier's gender, age, type of duty (combat or noncombat), and front-line or support position, were collected from the charts. “Moderate” injury was defined as injury necessitating absence from military activity for more than 1 week; “major” injury was defined as injury necessitating surgical intervention. FINDINGS Because of IDF policy, we are unable to publish the number of active duty soldiers during the period of the study. Thus, morbidity is described as incidence, with no mention of population size. According to Regulation 19 of the infantry and paratrooper officers' code of 2016, every soldier in the IDF receives 3 hours of KM training as part of noncombat basic training, and 12 hours for combat units' basic training. Soldiers who go through further training as combat class commanders are trained for an additional 4 to 7 hours, and officers receive an additional 3 to 6 hours. During their routine service, noncombat soldiers receive a 1-hour refresher class every 6 months, whereas infantry units do this every 2 months. In most units, KM training is taught by junior commanders who have been trained and are qualified to conduct these classes. This is in addition to their primary role in the unit. Between January 1, 2014, and December 31, 2014, 916 soldiers complaining of 946 traumatic injuries sustained during KM training were evaluated in IDF clinics. The vast majority of injuries (95%) occurred in male soldiers, and most injured soldiers (92%) were between the ages of 18 and 22. Most injuries (73%) were sustained by combat soldiers, and occurred more often (76%) in the support units. Upper limbs were the most frequently injured body parts, with fingers, hands, and wrists (31%) being the most involved region, followed by the shoulder (16%). Lower extremities were involved 26% of the time with knees being the most commonly involved, followed by the foot and ankle. Head, face, and neck injuries, and back and chest injuries occurred at a lower rate (Table I). TABLE I. Prevalence of Injuries Incurred in Krav-Maga Training Body Region  Number of Injuries  N (%)  N  Head and Neck  96 (10)      Concussion     6   Scalp and Face     74   Neck     16  Torso  109 (12)      Back     38   Chest     69   Abdomen     2  Upper Extremity  495 (52)      Shoulder     151   Arm     4   Elbow     20   Forearm     24   Hand and Wrist     152   Finger     144  Lower Extremity  246 (26)      Groin     31   Thigh     15   Knee     99   Leg     21   Ankle     37   Foot     43  Total  946 (100)     Body Region  Number of Injuries  N (%)  N  Head and Neck  96 (10)      Concussion     6   Scalp and Face     74   Neck     16  Torso  109 (12)      Back     38   Chest     69   Abdomen     2  Upper Extremity  495 (52)      Shoulder     151   Arm     4   Elbow     20   Forearm     24   Hand and Wrist     152   Finger     144  Lower Extremity  246 (26)      Groin     31   Thigh     15   Knee     99   Leg     21   Ankle     37   Foot     43  Total  946 (100)     View Large TABLE I. Prevalence of Injuries Incurred in Krav-Maga Training Body Region  Number of Injuries  N (%)  N  Head and Neck  96 (10)      Concussion     6   Scalp and Face     74   Neck     16  Torso  109 (12)      Back     38   Chest     69   Abdomen     2  Upper Extremity  495 (52)      Shoulder     151   Arm     4   Elbow     20   Forearm     24   Hand and Wrist     152   Finger     144  Lower Extremity  246 (26)      Groin     31   Thigh     15   Knee     99   Leg     21   Ankle     37   Foot     43  Total  946 (100)     Body Region  Number of Injuries  N (%)  N  Head and Neck  96 (10)      Concussion     6   Scalp and Face     74   Neck     16  Torso  109 (12)      Back     38   Chest     69   Abdomen     2  Upper Extremity  495 (52)      Shoulder     151   Arm     4   Elbow     20   Forearm     24   Hand and Wrist     152   Finger     144  Lower Extremity  246 (26)      Groin     31   Thigh     15   Knee     99   Leg     21   Ankle     37   Foot     43  Total  946 (100)     View Large Most hand and wrist injuries were relatively mild, consisting of sprains, strains, and abrasions. However, 45 fractures of the hand and wrist bones were diagnosed, most specifically the scaphoid bone, followed by other carpal and metacarpal bone fractures (Table II). TABLE II. Fractures of the Hand and Wrist in Krav-Maga (N = 28) Fractured Bone  N  Distal Radius  1  Ulnar Styloid  2  Scaphoid  12  Triquetrum  2  Trapezoid  1  Thumb Metacarpal  2  Metacarpals 2–5  7  Fractured Bone  N  Distal Radius  1  Ulnar Styloid  2  Scaphoid  12  Triquetrum  2  Trapezoid  1  Thumb Metacarpal  2  Metacarpals 2–5  7  View Large TABLE II. Fractures of the Hand and Wrist in Krav-Maga (N = 28) Fractured Bone  N  Distal Radius  1  Ulnar Styloid  2  Scaphoid  12  Triquetrum  2  Trapezoid  1  Thumb Metacarpal  2  Metacarpals 2–5  7  Fractured Bone  N  Distal Radius  1  Ulnar Styloid  2  Scaphoid  12  Triquetrum  2  Trapezoid  1  Thumb Metacarpal  2  Metacarpals 2–5  7  View Large There was a high incidence of finger involvement, with a total of 144 finger injuries. The thumb was involved at a higher rate than the other fingers. The majority of finger injuries were contusions, 83 of the thumb and 35 of other fingers. Phalangeal fractures were less common, with 7 thumb fractures and 10 fractures of other fingers reported. Other finger injuries included thumb collateral ligament tears (4 cases), finger dislocation (1 case), cut wounds (3 cases), and flexor digitorum profundus tear (1 case) (Jersey finger). The shoulder region was identified as a vulnerable area in KM training, resulting in shoulder instability in about one-third of cases (12 first traumatic dislocations, 11 recurrent dislocations, and 24 subluxations). Other significant shoulder injuries included 5 cases of superior labrum, anterior to posterior (SLAP) tears, and 2 cases of supraspinatus tendon tear. Head and neck injuries occurred less frequently, with lacerations and contusions occurring predominantly around the scalp and face. Six incidents of minor brain concussions as well as one case of cervical disc extrusion and one case of central cord injury in a soldier with congenital cervical stenosis were the most serious injuries diagnosed in the head and neck region. Overall, 168 of 946 injuries (18%) required referral to a hospital for further treatment; 64 soldiers (6.7%) were moderately injured; 33 soldiers (3.5%) sustained major injuries necessitating surgical treatment. The most frequent indication for surgical treatment was shoulder instability, superior labrum, anterior to posterior, or tendon tear (21 cases). Other indications for injuries requiring surgery were hand fractures (5 cases), knee cruciate ligament tears (3 cases), ankle fracture, testicular hematoma, nose fracture, and flexor digitorum profundus tear (1 case each). DISCUSSION Our study shows that the shoulders, hands, and fingers in particular, are the most vulnerable body regions in military KM training. Several studies describe injury incidence and patterns incurred in martial arts sport activity.1,2 These studies show that the head and face are the most prevalent areas injured, followed by upper extremity injuries, and that laceration was the most prevalent type of injury.3 Possley et al4 described injury patterns in Modern Army Combatives among U.S. soldiers at a relatively small military installation with less than 10,000 personnel. In their study, the knee in particular was the most frequently injured body part, followed closely by the shoulder and the lumbar spine. The hand was involved in only 5.1% of cases. KM activity differs from other martial arts, as its purpose in general is not to overcome and take control of the opponent, but to strike, daze, and overwhelm the opponent in order to disengage to a safe place. KM has no rules regarding what is permitted during the fight, so injury incidence and patterns may be different from those in traditional martial arts training. One might expect that because “no rules” applies to KM fighting, there would be more serious injuries to the head, face, or groin. However, findings from our study show the contrary to be true. Because of the use of protective gear to increase safety while training, lacerations, in general, and facial lacerations, in particular, were relatively rare. Head injuries and brain concussions are serious results of contact sports, boxing in particular.5,6 Porter6 noticed that cerebral injury in boxing was reported only in competition and because most soldiers train but do not compete in KM, they do so using protective helmets or head guards; therefore, serious head injuries, such as concussions, were rarely found during the study period. Cervical injuries are another major concern in martial arts, with rates varying from 0.2 to 6%.1,4,7 The mechanism of cervical injury in martial arts is probably related to the take-down maneuvers, and because the purpose of KM is not necessarily to knockout or takedown the opponent, cervical injuries were also rare in our study group. Finger, hand, and wrist were the most vulnerable body region in KM training. This is similar to injury patterns in boxing,5 where the hand incurs a high rate of injury, probably as a result of repeated and high-impact forces. Although most hand injuries were mild, a substantial number of hand fractures that occurred during KM training had a significant impact on the ability of the soldiers to perform their duties, especially as combat soldiers. Interestingly, we identified the radial ray of the hand (thumb, first metacarpal, and scaphoid) as most vulnerable in KM. Unlike traditional boxing, KM training integrates hand striking with open or closed palms against an opponent or an improvised punching bag, usually without the use of boxing gloves (Fig. 2). In many cases, a duffel bag filled with sleeping bags is used as the target. Striking with an open palm might be the reason for the high prevalence of damage to the radial aspect of the hand. The high incidence of hand and wrist injuries in KM suggests that efforts should be made to devise better materials that reduce the transfer of impact forces during a strike, as well as improving striking techniques to protect the radial ray of the hand. FIGURE 2. View largeDownload slide Hand striking with open palm against an opponent. FIGURE 2. View largeDownload slide Hand striking with open palm against an opponent. The shoulder was also identified as vulnerable in KM, with a significant amount of primary or recurrent shoulder dislocations or subluxations. Shoulder dislocation has a major impact on a soldier's army service, as the policy of the IDF is that following an injury such as this, the physical profile of the soldier is lowered, and the soldier is not allowed to continue combat duties for 1 year. The upper extremities have been documented to be vulnerable in combat sports, with dislocations, particularly of the shoulder, being more common in nonstrike sports.8 Unlike boxing, wrestling involves grappling and maneuvering the opponent, frequently resulting in extreme positioning of the joints. The forces and positions encountered in wrestling may frequently result in elongation of the muscles and ligaments beyond their physiologic range and this may lead to dislocation. We do not know if the soldiers who suffered shoulder instability during KM training were injured while striking or while being maneuvered. This question may be answered by a more detailed inquiry into circumstances of the injury, as this may have implications on training techniques. The probability of combat soldiers sustaining injuries is about 3 times higher than noncombat soldiers. We assume that KM injuries occur more frequently among soldiers who engage in more intensive KM training. Army bases, where basic and advanced training takes place and where most KM training is conducted, are not defined as “front-line training bases.” Therefore, most injuries occurred in what are classified as “support units.” The vast majority of KM injuries occurred in male soldiers. Although mandatory draft into the IDF is gender neutral, most female soldiers are usually not assigned to combat positions, and certainly not in Special Forces units, where most intense KM training takes place. Because the mandatory military draft is from 18 years of age, this explains the high prevalence of injuries incurred from the ages of 18 to 22. This study has a number of limitations. First, it is observational and retrospective in nature, and thus has the weaknesses inherent in such studies. It is subject to recall bias of soldiers regarding the circumstances of their injury, and because many treating physicians were involved in documenting the data, it lacks uniformity in defining injury type and location on the body. As there is no comprehensive database documenting all traumatic injuries sustained in the IDF, and our information was retrieved from patients' clinical records, we were not able to document the exact injury mechanism. In addition, we did not find exact data on lost training time in the clinical records. Therefore, we triaged our data by number of injuries sustained, and not by injury severity, although we did specify the number and types of serious injuries sustained in each body region. Second, only the cases in which the injured soldier referred to a military clinic, and only the cases in which the physician noted that the complaints were the result of KM training were retrieved. Mild cases, where the soldier did not refer to a clinic, and cases in which the physician did not mention that the injury was the result of KM training were not included. In many cases of hand injuries, initial symptoms are mild and delays in referral to clinic and diagnosis are common. Therefore, the number of injuries we documented is probably an underestimation of the true number of KM injuries. Finally, the data were collected from all soldiers in the IDF, from various units with various skills and various demands. We were able to differentiate between combat and noncombat soldiers, but could not differentiate injury patterns between units with high-level combat requirements, such as front-line special forces and infantry who receive more, higher level, KM training, and combat support units, who receive limited KM training, usually only during their basic training period. CONCLUSIONS KM involves both striking and grappling components, and we assume injuries result from both combat forms. With striking styles, such as boxing and kickboxing, hand and wrist are the prevalent injury locations; with grappling styles, such as wrestling, strain and sprain injuries of large joints are most prevalent. Head and neck injuries, a major concern in martial arts sports, were not identified as significant problems in KM. As the number of training injuries increased, the burden of medical treatment, as well as loss of training days, and even dropout from combat military service increased. Preventative measures should focus on improving protective equipment especially of the hand, as well as warm up and training technique modifications and shoulder strengthening exercises, to further minimize injury to these locations. This study, together with further research on the mechanism of upper extremity injuries and their risk factors, may form the basis for designing measures that are likely to reduce the future risk and severity of KM-related injuries. ACKNOWLEDGMENTS MAJ Daniel Ben Dov and Danny Netzer from the Doctrine and Research Branch, Combat Fitness Department of the IDF, are gratefully acknowledged for their collaboration in preparing the manuscript. REFERENCES 1. Ngai KM, Levy F, Hsu EB: Injury trends in sanctioned mixed martial arts competition: a 5-year review from 2002 to 2007. Br J Sports Med  2008; 42( 8): 686– 9. Google Scholar CrossRef Search ADS PubMed  2. Bledsoe GH, Hsu EB, Grabowski JG, Brill JD, Li G: Incidence of injury in professional mixed martial arts competitions. J Sports Sci Med  2006; 5: 136– 42. Google Scholar PubMed  3. Lystad RP, Gregory K, Wilson J: The epidemiology of injuries in mixed martial arts: a systematic review and meta-analysis. Orthop J Sports Med  2014; 2: 2325967113518492. Google Scholar CrossRef Search ADS PubMed  4. Possley DR, Johnson AE: Musculoskeletal injuries sustained in modern army combatives. Mil Med  2012; 177( 1): 60– 3. Google Scholar CrossRef Search ADS PubMed  5. Loosemore M, Lightfoot J, Palmer-Green D, Gatt I, Bilzon J, Beardsley C: Boxing injury epidemiology in the Great Britain team: a 5-year surveillance study of medically diagnosed injury incidence and outcome. Br J Sports Med  2015; 49( 17): 1100– 7. Google Scholar CrossRef Search ADS PubMed  6. Porter M, O'Brien M: Incidence and severity of injuries resulting from amateur boxing in Ireland. Clin J Sport Med  1996; 6( 2): 97– 101. 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TI - Prevalence and Patterns of Injury Sustained During Military Hand-to-Hand Combat Training (Krav-Maga)
JF - Military Medicine
DO - 10.7205/MILMED-D-17-00015
DA - 2017-11-01
UR - https://www.deepdyve.com/lp/oxford-university-press/prevalence-and-patterns-of-injury-sustained-during-military-hand-to-IyLd1O31O7
SP - e2005
EP - e2009
VL - 182
IS - 11
DP - DeepDyve
ER -