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Doctors, commissions disagree on MMA’s new kidney strike rules

The ABC’s MMA rule changes are due to come into effect on January 1st, but there is disagreement about their safety. Iain Kidd investigates.

Birmingham Hospital Conducts Kidney Transplant Photo by Christopher Furlong/Getty Images

The unified rules are no more, and two rule changes are to blame. Come January 1st, there will be two distinct versions of the "unified" rules being followed by different states. This follows a controversial "package voting" method used to pass all proposed changes at the 2016 association of boxing commissions conference.

The first rule change will reduce the number of situations in which a fighter is considered a “downed” fighter, which will likely lead to more kicks/knees to the head of fighters getting up from the floor. This rule change came about to try to solve the problem of fighters “gaming” the system and looking for fouls by touching the ground.

The other change is one legalizing heel strikes to the kidneys, and as best I can tell, there’s no specific problem this change is designed to solve at all, so I decided to investigate.

Most strikes to the kidney are currently legal in MMA. In a recent interview the NJSACB’s Nick Lembo, who had a hand in crafting the original unified rule of MMA, said this was due to a number of factors, which essentially boiled down to inadvertent strikes being almost unavoidable and deliberate strikes having a large number of potential defenses. In other combat sports, such as boxing and kickboxing, all kidney strikes are illegal blows.

Kidney strikes are singled out because the kidney is a vulnerable vital organ that has a limited capacity to heal. Minor kidney damage can be repaired by the body, but any damage that results in the destruction of nephrons, microscopic structures vital to kidney function, is permanent. The kidney cannot regrow destroyed nephrons, meaning kidney function is likely to be impaired permanently.

This is especially concerning in the context of MMA, since we know fighters regularly undergo rapid, significant weight-cuts that already tax and strain the kidneys. Even a “perfect” cut, directed by a professional, is an inherently dangerous and unhealthy event that stresses the kidneys. It’s extremely likely that at least some fighters step into the cage with kidneys especially vulnerable to trauma.

I contacted the ABC medical committee, who approved the rule change, to find out what evidence they used when coming to their decision. I was told there was no report written on the issue, nor was there any list of studies or evidence gathered by the commission and presented as evidence to commissions. There was also no study performed or referenced by the committee examining the effect of heel kicks to the kidney ahead of their approval of the change.

In an email response I was informed that there had been a perusal of studies as related to kidney injuries in martial artists, though there was no report referencing them:

So let’s go back to the first part of medical decision making – review of the research. There are only a few case reports of traumatic kidney (or adrenal gland) injuries from martial arts. One case report was from a full-force kick to the area, another case report was from a series of sequential falls to the area, and one large study of marital artists showed no kidney injuries at all. Again, it’s important to point out that, according to my present search, none of these were due to the kind of heel kicks in question here. So the concern about this being a common or even relevant injury is likely unfounded. In other words, there are no reported injuries of this specific kind.

The commission doctor was also kind enough to describe the physiological factors at play, and stated that heel kicks to the kidney would not be powerful enough to cause kidney damage. When I asked how the committee determined the force of blows to the kidney would not be significant enough to cause damage. I was told:

“The force required to damage a kidney is really truly significant -- we are talking major trauma. There is no practical way for a grounded heel strike to even come close to the degree of force required. It's pretty much not even a realistic consideration. As such no studies about bouts with heel kicks and kidney damage have been done, and if they were it would likely be a waste of time.

I then asked, “Was any consideration given to fighters potentially having impaired kidney function due to weight cutting, or due to previous renal failure, and the effect mild traumatic events may have on their kidneys versus healthy kidneys?”

To which the reply was:

The issue of dehydration and other kidney issues is a separate discussion.

The decision making process was described thusly:

So, in summary, 1. Reviewing the anatomy of the leg and the physiologic forces of this type of kick reveals that it is a very low force kick, especially relative to other kicks and blows in the sport. 2. A review of the literature failed to turn up any significant numbers of kidney injuries from this type of kick. 3. A review of the vast experience of a few dozen ringside physicians from the ABC Medical Committee and the Association of Ringside Physicians revealed no observed previous injuries of this type.”

Dr Michael Kelly disagreed with the change in an email to ABC members, stating:

Based on the available medical literature, the changes allowing heel kicks to the kidneys and blows to the head of an athlete with two feet and one arm on the ground jeopardize fighter safety.

Not surprisingly, there is a complete lack of medical evidence that blunt kidney trauma is safe. In fact, the medical literature is quite clear that blunt kidney trauma can cause: kidney contusions, capsular tears, parenchymal damage and chronic kidney dysfunction leading to hypertension and kidney failure. [1] [2] Combat sports participants have also been documented to suffer from undiagnosed kidney injuries including renal dysfunction, contusions, and kidney masses all of which make the fighter more vulnerable to blunt kidney trauma. [3] [4] [5]

The ACSC, a smaller collection of state athletic commissions (who are also part of the ABC), released its own statement on the disputed rules. The ACSC medical committee consists of a urologist, a nephrologist and a former ABC medical commission chair among others. The ACSC committee disagreed with the ABC committee, and stated that if anything, less kidney strikes should be allowed, and listed many possible consequences of allowing more kidney strikes.

Nick Lembo, the former ABC MMA chairman who was involved in crafting the original unified rules of MMA and sanctioning some of the first legal mixed martial arts bouts in the United States, had this to say:

I've never had a fighter request [kidney strikes be legalized]. On the other hand, we have had fighters not make it to the weigh-ins because of kidney issues due to weight-cutting. We've had fighters fail pre- and post-fight medicals due to kidney issues... In one case a fighter was hospitalized after taking 30 heel strikes to the kidney. You should see the post-fight urine on some of these fighters - sometimes it looks like mud. It's dark brown and there's kidney damage already.

Current association of boxing commissions president Mike Mazzulli stated:

I stress that this rule change was changed with the association of ringside physicians present, Dr Lovelace, the president of the ARP, was present and spoke at the conference. Our rules committee has over 100 years of experience in the industry, from referees to fighters to judges to commissioners.

If we do need to readdress these rules, we will. The ABC is going to address every rule every year, just like the MLB. Every year the committee will review every single rule to see what is in the best interests of the sport. MMA is the fastest growing sport in the world, and the ABC is part of it. We want to make sure that the industry moves forward.

I’m still left unsure about the impetus for the rule change in the first place. No one seems to think it will have a significant impact on the fight. Dr Larry Lovelace even provided an anecdote suggesting fighters can completely ignore heel kicks to the kidney:

Big John McCarthy told the ABC conference about a time when he was giving a lecture and the question of heel strikes surfaced. He invited the questioner to come up on stage; assume the guard and strike John "at will" while he continued to give his lecture. John continued to lecture while this guy beat him in the flank. It was annoying but that's all. Eventually the guy got tired and stopped. Randy Couture stated that he was never hurt when it was done to him. Jeremy Horn agreed.

If the change won’t be significant, if the strike doesn’t hurt or have any impact on the fight, even if the risk of health problems is minimal, is it really worth changing the rules? We’re about to have a situation where different states have markedly different rules - more so than any time in over a decade. Somehow, that cost doesn’t seem worth it.