Martial arts, such as karate and tae kwon do, have become very popular in recent years for both adults and children. Karate and tae kwon do have been promoted as excellent activities for maintaining good health and fitness. People frequently perform these activities after school or work.
Given that the foot and ankle account for at least 10 percent of the total injuries sustained in the martial arts — and may even be higher due to the lack of reporting of many digital injuries such as contusions, toenail trauma and uncomplicated fractures — most podiatrists are likely to encounter these athletes in their offices.
Students of the martial arts practice kicking and punching to improve their techniques and power. Students start with simpler kicks and work up to more difficult techniques. Attempting a more difficult kick without the appropriate training will often cause injury. The culmination of all the training efforts occurs during sparring matches either at the student’s martial arts school or in a tournament. Sparring too early without the proper training is also a common cause of injury.
The student becomes injured due to either a lack of balance, flexibility, strength or speed. For example, one can kick and punch while standing in one location or while moving. The ability to deliver an appropriate kick or punch depends on the student’s flexibility and balance. In delivering a front snap kick, which requires an upward movement of the foot and leg, lack of hamstring flexibility can either reduce the effective height of the kick or tear the hamstrings while the athlete executes the kick. A lack of balance while performing this move will cause the support foot to be loaded without stability. This can produce sprains or strains of the foot and ankle.
Strength and speed also play a role for those who participate in the martial arts, especially when they attempt sparring. The ability to move in and execute an attack on an opponent and retreat prior to being attacked is critical. If an athlete lacks speed and strength, the opponent has the ability to execute countermeasures. The countermeasures may throw the initial aggressor off balance, which can result in an injury.
Blunt force trauma and sprains are the two basic categories of martial arts injuries that occur in the foot. Blunt force trauma injury is a direct result of the foot hitting another solid object. The object could be a sparring bag, a board, an opponent or other firm objects used in the practice of martial arts. Students frequently use heavy canvas sparring bags for kicking and punching in order to improve strength and technique. If one dorsiflexes the digits as opposed to plantarflexing the digits while striking the bag with a roundhouse kick, this improper technique will result in blunt force trauma.
Boards varying from 1/2 inch to 1 inch in thickness are used as part of promotion tests as a student passes to the next level throughout the training experience. The boards are lined up (either singularly or in multiples) and students use their hands or feet to break them. If the student has not built up the power, speed or accuracy to strike the board with the correct technique, there can be resulting trauma to the foot or hand. Martial arts instructors assess each student to determine the level of breaking skill. Inappropriate execution on the part of the student can be very painful.
Misjudging the opponent’s intended next move can result in trauma. Normally, students step back from the kick and prepare to counter the kick with another kick. This cannot always be executed as trained due to the speed of the opponent. The consequences of missing a step or inappropriately positioning the foot while attacking or retreating from an opponent can be trauma to the ankle and foot, resulting in a sprain or fracture.
As a result of blunt force trauma, the martial arts student may suffer a fracture, a contusion or a laceration. Fractures require early diagnosis and immobilization to expedite healing. The most common foot fractures occur as spiral oblique injuries of either the digits or the metatarsals. They are usually the result of the torsion generated by the impact of the moving foot hitting a fixed object such as an opponent.
If one suspects a fracture, do not allow the athlete to continue the competition. Further trauma from competition can convert a simple non-displaced fracture into a displaced, comminuted fracture or even a compound fracture.
If a martial arts athlete sustains an acute injury, instruct him or her not to move from the fallen position on the mat. It usually takes at least a few minutes until the initial shock of the injury wears off before even a cursory examination has any real value in determining the extent of the injury. If one suspects a fracture, immobilize the injured part or at least move the athlete without moving the injured area. Apply ice and elevate the limb after achieving initial immobilization.
Do not permit athletes to resume any martial arts activity that may subject them to blunt force trauma until the fracture is completely healed, which is usually eight weeks. The athlete should engage in appropriate exercises to maintain strength and flexibility during the bone healing process.
Contusions, which are usually less severe than fractures, are a common result of sparring or board breaking. While sparring, the student wears a chest protector, a helmet and a mouth guard as well as pads on the arm, hand, foot and lower leg. During sparring, one must perform each kick and punch in a fraction of a second to be effective. From a tactical standpoint, when students see an opening in the opponent’s defense, they will usually execute three to four moves sequentially to further reduce the opponent’s defenses. However, the opponent will also counter the attack. Both participants are vulnerable when each is trying to anticipate the other’s move.
Advancing opponents often cut short well-intentioned kicks, which land in an unintended area. A kick meant for the opponent’s torso might land on a non-padded upper thigh area, resulting in a thigh contusion. Any non-padded area such as the thigh or knees can now be a vulnerable target.
Accordingly, the common areas to receive contusions are:
• the lateral aspect of the foot when one performs a sidekick (driving the lateral portion of the foot into the board);
• the plantar metatarsal heads when one performs a forward snap kick (kicking the plantar forefoot forward and upward); and
• the plantar calcaneus when one performs a turn kick.
If the student misses the center of the board or does not deliver enough force with the kick, the end result will be pain. If the error is large enough, the martial artist will have a significant contusion or fracture. Contusion injuries may have symptoms for up to six weeks although one can usually recommend an early return to martial arts activities.
Lacerations need immediate attention in order to stop any bleeding and assess the level of severity. A common laceration is the result of the nail plate impacting the distal tuft of the digit. Another laceration is the result of the nail plate being forcibly lifted off the nail bed.
Both of these lacerations commonly occur when athletes kick the sparring bag or while they are sparring. While these lacerations usually do not result in any permanent disability, both these injuries are very painful and require podiatric intervention to excise the damaged nail plate. The athlete must also learn to dress the involved toe and apply protective padding to the toe to promote both healing and the ability to resume martial arts activities.
Ankle sprains occur most often in the martial arts during sparring when the student is changing positions rapidly. The most common type is the lateral ankle sprain. Sudden changes in direction during sparring can result in the student being caught off balance. A slow progression of training is essential to promote increased balance, flexibility and strength while reducing the risks of foot and ankle sprains. Pay careful attention to the sprain in order to rule out a fracture.
Disability from an ankle sprain can last four months or more. It is essential that all ankle injuries be totally healed before permitting the martial arts athlete to return to rigorous activities such as performing difficult maneuvers or competitive sparring. The athlete should have a pain-free ankle, subtalar joint range of motion and be capable of walking and running without a limp. There should be equal and symmetrical ankle proprioception for both limbs. One can assess this by evaluating athletes as they hop on one leg. These athletes should also have symmetrical muscle strength in the three muscle compartments of both limbs. One can determine this via manual muscle testing.
A common sprain to the foot is a hyperextension injury to the first MPJ. This sprain is usually the result of sparring and changing directions rapidly. The hallux becomes forcibly dorsiflexed while the athlete lunges forward to attack an opponent, resulting in a sprain of the first MPJ.
While most of these injuries are mild, be aware there are severe cases in which the sesamoids may be partially or completely torn from their bed. A forced dorsiflexion of the proximal phalanx against the first metatarsal head may also result in a fleck of cartilage being shorn from the metatarsal head. The hyperextended first MPJ sprain can last up to four months or longer. During this time, one should follow initial immobilization with physical therapy as this is essential for maximum recovery.
Dr. Caselli (pictured) is a staff podiatrist at the VA Hudson Valley Health Care System in Montrose, N.Y. He is also an Adjunct Professor at the New York College of Podiatric Medicine and is a Fellow of the American College of Sports Medicine. 
Dr. Rzonca is a Staff Podiatrist at the VA Hudson Valley Health Care System, Montrose, N.Y. He is a Former Chairman of the Department of Orthopedic Sciences at the New York College of Podiatric Medicine. Dr. Rzonca is a black belt candidate in tae kwon do.
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3. Muller-Rath R, Bolte S, Petersen P, Mommsen U: Injury profile in modern competitive karate--analysis of 1999 WKC-Karate World Championship Games in Bochum. Sportverletz Sportschaden 2000 Mar;14(1):20-24