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Read a great article and interview with Doctor Sherry Wulkan, one of MMA's premier ringside physicians.  Dr. Wulkan is a staple at NJ MMA shows, both pro and ammy, and it's always a great pleasure for me to hang out with her.   We've gotten to know each other pretty well over the past couple of years, but that didn't prevent me from "accidently" introducing her to the crowd as Doctor "Shelly" Wulkan last week at the Asylum Fight League show. Gee, I wonder how that happened?  (*cough Nick Luscious Lembo cough*).

Here's the article:

Boxing is still a male dominated sport, so I always take note when a ring side official is a woman. And at the Golden Gloves, working amongst the men, was a very attractive and approachable Doctor, who walked around with authority and a clear sense of humor. I had the honor of meeting Dr. Dr. Wulkan Wulkan at GG’s the last night they played at MSG. She was ready for some tough questions. Some of her answers will please you, you may disagree with others, but all of what she says is interesting, articulate and evocative. What a privilege it is sharing her views on boxing, life and humanity.

Jill:  What brought you to boxing?

Dr. Wulkan:  My father was a big boxing fan. As a young child, I thought boxing was too brutal, but as I learned more about the sport, I began to see it as a fast, athletic chess game. After the birth of my second child, someone suggested that I try boxing and kickboxing to get back in shape. I had always been athletic, but interested in more passive, individual sports (swimming, tennis, horseback riding), so I was a bit skeptical.

After my first lesson I was hooked: I developed a whole new level of respect for the dedication, conditioning and athleticism of these competitors.   My coach was also the partner of a local kickboxing promoter, so I began sitting ringside at their shows.  Eventually I began working with USA Boxing, took their certification examination, became a member of the AAPRP (American Association of Professional Ringside Physicians), and was accepted on both the New Jersey Athletic Control Board and the New York State Athletic Commission.

Jill:  Do you have issues reconciling your feelings about health and your involvement in a combative sport?

Dr. Wulkan: None, as long as I’ve done my job to the best of my ability. It’s taken a lot of serious sole searching to “feel clean” about my stance, especially because my colleagues who oppose combat sports pose this question to me frequently. In my opinion, it is the job of a physician, no matter what the “high risk” activity, to educate a patient about the potential short and long term risks of his/her behavior, to guide his/her choices based on the participant’s particular history, (successes, defeats, set-backs, reality of goals) in addition to ensuring access to the highest level of medical care (short and long term).

To me, there is no difference in a patient’s decision to sky or cliff dive, smoke, drink excessive amounts of alcohol, have unprotected sex, or participate in boxing.  It should be the participant’s choice, as long as he/she has been well informed, has been given the time to think about, and to ask and discuss any pertinent questions, and has appropriately weighed the risk/benefit ratio of the chosen activity. It would be a serious mistake and a breach of medical ethic if doctors were to sit in judgment of every activity in which our patients engaged. Amateurs pose more of a problem than professionals, since ringside physicians often meet the contestants for the first time at an event, and since the quality of the promotions vary considerably.  My threshold for “pulling” a fighter from an amateur show is low; if I suspect the fighter is ill prepared, does not fully understand the potential repercussions of his/her actions, or has a medical condition which manifests at the pre-fight physical, I will not clear that competitor.

Several young uninsured fighters have come to my office for free medical evaluation, have been treated, and have been cleared for participation in other amateur shows. Those who argue that boxing and other combat sports just promulgate violence in our society and should therefore be outlawed seem to me to be arbitrarily singling out something incomprehensible to them, or which perhaps reflects a “darker” side of our “humanistic democracy” that some would prefer remain buried. The analogy I like to draw is to that of a parent with a child who has a personality traaggravates the adult; instead of looking inwardly and trying to address the problem, he/she looks for a scapegoat and “blames the child”. Violence in our society is rampant. Many prime time television series portray violence, movies are riddled with violence, the internet is inundated with pornography and mutilation and our news reports are filled with reports of wars, hate crimes, and racism, and stories about corrupt politicians and religious leaders, sports “role models” who cheat, and economic icons who have undermined, not only our, but the entire world’s financial market. Paradoxically, we are becoming an ever increasingly regulated society.

Perhaps the popularity of pugilistic sports at this time is a by-product of the frustration many people feel and a healthy outlet for that frustration.  Whatever the etiology of its current regard, pugilistic sports have been around with varying degrees of popularity since the earliest societies.  As a medical community, it is our job to make the sport as safe as possible (to the best of our current medical knowledge) for individuals, and to continue to do research about the short and long term effects of combat sports on participants.  Perhaps some of what we learn may cross over to other disciplines.

Jill:  Have you witnessed any changes during your tenure in the sport?

Dr. Wulkan: From a medical standpoint, the biggest changes that have occurred are technological: the ability to share medical information between commissions, the ability to rapidly diagnose and treat injuries, the ability to carry out basic science research that will hopefully, make boxing a safer activity during a fighter’s career so that he/she will be able to fulfill other life goals free from long term repercussions from having participated in this sport.

I have witnessed the growth of the sport of mixed martial arts, both at the amateur and professional levels. I have worked over 70 mixed martial arts events for the New Jersey Athletic Control Board. The shows have included promotions by the UFC, IFL, ProElite, Bodog, Ring of Combat, Cage Fury and Extreme Challenge, among others. I do not believe one needs to be either a boxing fan or an MMA fan; there is room enough for both combat sports.

Jill: From the vantage point of a physician, what do you see as the leading cause of ring injuries (in the gym and in the arena)?

Dr. Wulkan:  Usually, fight night injuries range from facial lacerations to nasal, orbital hand or rib fractures.  Occasionally, we see a dislocated shoulder.  Concussions may occur, and may vary in severity depending on the mechanism of injury, the number of undefended punches prior to the referee’s halting the bout, ring years, prior history of concussion, state of hydration, etc.

Jill: In general, do think ringside physicians are properly prepared and certified for the many possibilities?

Dr. Wulkan: The requirements for ringside physicians vary from state to state. I am a member of both the New York State Athletic Commission and the New Jersey State Athletic Control Board, and am very fortunate to be able to work ringside as part of a team of highly committed, competent and knowledgeable ringside doctors (M.D.s and D.O.s).

In some jurisdictions, medical extenders (physician’s assistants, chiropractors) have been allowed to sit ringside, and at some venues, emergency medical services are not on sight. I have worked most often in New Jersey, where some of the requirements to be a ringside physician include graduating from an accredited allopathic or osteopathic medical school, being a licensed physician in good standing in the state in which one practices, being board certified in the specialty in which one has trained, CPR certification, familiarity with sports medicine and combat sports injuries, and the satisfactory completion of an apprenticeship with a Commission appointed ringside physician (minimum of five regulated shows). Physicians sitting ringsidemedical procedures, and certain aspects of neurology, orthopedics and ophthalmology.

USA Boxing has a training and certification program offered in Colorado Springs with a rigorous board examination at its conclusion.  The AAPRP (American Association of Professional Ringside Physicians) holds an annual meeting, and has a certification examination. One caveat: Having certification does not make someone a good ringside physician; knowledge of the sport, clinical experience, and clinical acumen do.  Ultimately, to date, it is the doctor’s responsibility to keep him/herself well versed clinically.

Jill:  Given the controversy, what are your views on weigh-ins and ringside fluids?

Dr. Wulkan:  The topic of dehydration in combat sports is one of great interest to me: trying to educate amateur fighters with whom I work about the potential detrimental effects of “traditional” gym weight cutting methods, one of my greatest frustrations. In general, there seems to be a great disparity between the level of understanding of the proper way to cut weight between professional and amateur combat sports participants.

High profile fighters have access to, and the means to hire, expert ancillary staff including sports nutritionists. This is not necessarily the case at some of the LBC level clubs. “Traditional” weight cutting methods are still being used; young athletes have said they have lost 10-15 lbs one –two days prior to an event by sitting in saunas wearing rubber suits. Re-hydration efforts at this level are often haphazard at best. As an aside, carbohydrates are also frequently eliminated from the diet in order to “cut up” and drop weight quickly, but carbohydrate (glucose) is the sole fuel for the brain, and muscle glycogen (the preferred fuel for muscle activity) requires carbohydrates in the diet to replenish stores after activity.

Drastic weight cutting may diminish a fighter’s reaction time, and may therefore increase his/her risk of injury. Rapid dehydration of as little as 2-3% body weight may diminish peak performance by as much as 5-7%.  Age and gender seem also to be a factor; older combatants and women seem to be more greatly affected. Traditionally, only water has been allowed in the corner; more recently the question as to whether sports drinks (electrolyte drinks) should be permitted to be administered by corners between rounds has been raised.  It is unlikely that electrolyte drinks should be necessary in shorter scheduled bouts; in ten round bouts electrolyte drinks may provide an advantage over water. Logistically, this may become a problem. Would the Commissions provide the sports drinks to the fighters to keep things fair?  Which one? (The carbohydrate content of sports drinks affects athletes of different ages differently: a carbohydrate content of greater than 5-7% may cause cramping in older athletes). How would a fighter train if only certain states allowed sports drink repletion and not others?

Jill: As a woman, any particular issues?

Dr. Wulkan: It would probably be best to interview the fighters themselves to determine whether it bothers them to be attended to by a female physician.  However, in my 12 years as a ringside doctor, my being female has never seemed to have been either an advantage or a disadvantage.  I have dealt with athletes (professional and high amateurs) in a variety of sports: tennis, hockey, and football, soccer, and swimming and diving, boxing, kickboxing, muay thai, and mixed martial arts. Combat sports athletes have always treated me with the utmost respect. Occasionally I have had a fighter appear surprised, again, more at the amateur level than at the pro level; amateurs have asked whether “I’ve done this before”, but I have always interpreted the question more as meaning, “do you know enough to help me if I need help”?  Fair question.

Historically, the ringside physician, independent of gender, has traditionally been viewed as “someone to get byfrequently masked an injury or didn’t disclose an illness during the history.  Those attitudes seem to be evolving. When ringside doctors work many shows, the fighters develop a comfort level that lends itself to disclosure.  In fact, camps often call well in advance of a show in order to try to remedy a medical issue prior to an event, or, if necessary, to pull a fighter in time for a promoter to get an appropriate replacement.  Many combat sports participants have begun to realize that taking care of a medical issue promptly may, in the long run, allow greater career longevity.

Jill:  What other positions do you hold? Honors and Awards?

Dr. Wulkan: Positions: Physician, New Jersey State Athletic Control Board Physician, New York State Athletic Control Board Medical Chair, ABC MMA Rules Committee Team Physician, Serra –Longo Professional MMA Team Internist, Sport Events Specilist, ProHEALTH Care Associates, New Hyde Park, N.Y. Medical Director, Long Island Sports Care, Inc. Former co-Direcor, Montefiore Medical Center Emergency Room, Bronx, N.Y. Former Medical Advisor, Women’s Tennis Association Medical Attending, U.S. Open, Queens, N.Y. Consultant and Ringside Physician – FDNY Boxing Physician, Wounded Warrior Project Medical Attending, Hofstra University, Uniondale, N.Y. Pre-Competition Sports Clearance Physicals – Lacrosse, Soccer, Hockey, Volleyball, Basketball, Football, Wrestling. Former Medical Director, Big East Swimming and Diving Competition – hosted by St.John’s University, Queens, N.Y. Former FINA Representative for International Athletes Traveling to the Tri-state Region Sports Medicine Consultant – United Nations International School, Manhattan, N.Y. Consultant – United Nations International School, Queens, N.Y.-  Protocols for Catastrophic Events Member, ACSM Certified – USA Boxing (FACRP) Member, AAPRP.

Jill: Do you believe the government should regulate boxing?

Dr. Wulkan:  Yes, a government body, such as an athletic commission should regulate and oversee all combative sports.

Jill:  Compared to their male counterparts, do you believe there are any clear differences and risks that women take when they enter the ring?

Dr. Wulkan:  An article entitled Boxing, wrestling, and martial arts related injuries treated in emergency departments in the United States, 2002-2005 was published in the ©Journal of Sports Science and Medicine (2007) 6(CSSI-2), 58-61., 751 boxing injuries were  evaluated in United States Hospital Emergency Rooms over three years. The authors concluded, “The overall injury rate for combat sports does not appear to be higher than in popular non-combat sports.”  John Butler, M.D.,, PhD. wrote an article reviewing Aiba’s Women’s World Championship boxing tournament that took place in Ningbo China in November of 2008. Two hundred thirty seven women competed in 207 bouts. No boxer suffered loss of consciousness.

The incidence of concussion was reported as less than 1%, although the criteria seemed somewhat subjective. (Concussion was defined as anyone who received strong blows to the head from padded gloves)”. There were no hand injuries, no lacerations, 2 nosebleeds, and 2 minor facial bruises. The author concluded that “women’s boxing is a safe sport”. Bledsoe and Levi (South Medical Journal, volume 98, 994-998, 2005) reviewed 524 boxing matches in Nevada.  They found that female boxers tended to have fewer injuries than male boxers (1.2 injuries per 100 rounds for females vs. 3.4 injuries per 100 rounds for males). They also noted that fighters who lost by knock out had twice the injury rate of combatants who lost by other means. (decision, TKO). Women’s fights almost always went to decision. rate in female fighters paralleled the rate of knock outs and technical knockouts.

An Italian study also published in 2005 followed over 600 women combatants who practiced Olympic style boxing and compared their rate of injury with that of their male counterparts.  The findings of the Italian study were in accordance with that done in Nevada by Bledsoe et al. In my opinion, comprehensive prospective studies following cohorts of female boxers (both professional and amateur) for at least 15 years need to be done to determine whether the potential long term complications of combat sport participation parallel those of their male counterparts.

A study presented by Stephanie Doyle at the American Orthopedic Society for Sports Medicine 2008 Annual Meeting concluded that female soccer players and soccer players with a prior incidence of concussion recuperate more slowly than males and players without a history of concussion.  In addition, females perform worse than males on post-concussion testing according to this study.

One current theory suggests that the greater neck and torso musculature of males dissipates forces better than does the female body structure, thus protecting male players from concussive illness. (Soccer players were chosen because of the lack of use of helmets and because the rules are the same for males and females).  Based on these data, we may need to follow our female combat sports participants closely for early signs of cognitive function changes. There may be chronic health risks unique to female fighters: One example is the so called “Female Athletic Triad”.  The triad consists of amenorrhea, weight loss and osteoporosis.

Classically, women who participate in weight class sports or those who need to wear revealing sportswear are more at risk for this syndrome.  Psychological problems may include anxiety disorders and a decreased ability to concentrate, symptoms which could obviously predispose a boxer to increased risk of injury. Endocrine, skeletal, reproductive, digestive and central nervous system problems have been attributed to this eating disorder. Electrolyte and fluid imbalances may occur and can potentially predispose a fighter to heart arrhythmias. Other physical signs which may be relevant to female boxers are dry skin (predispose to lacerations), slow healing times, stress fractures and the potential for increased rates of bone fractures in general.

Several other issues are unique to female fighters: Sparring and breast implants:  There are some jurisdictions which do not allow women with breast implants to take in combat sports.  Better studies need to be done about the risk of illness from silicone implants when ruptured.  Saline implant rupture should not directly cause an increased risk of disease, but the need for surgical revision always poses the potential for complications (from anesthesia, infection etc). In addition, revision is costly.  If a woman wears an adequate chest protector, it should help mitigate the problem.  Again, as long as the fighter is aware of the risk –benefit ratio, I do not believe a woman with saline implants should be prevented from fighting. Trauma and breast cancer:  I know of no good studies which state that there is an increased risk of breast cancer with trauma. However, trauma to the breast may cause microcalcifications which can complicate breast cancer diagnosis.

Pregnancy: I believe pregnancy testing should be mandated.  I bring pregnancy testing kits to all my amateur events (USA boxing requires an affidavit saying the fighter is not pregnant) and ask the participants to cooperate if they give a history of sexual activity.  Although the uterus lies very low in the pelvis during the first trimester, some young amateur athletes may not realize they may be pregnant; they may assume a missed period is due to high intensity training.  Hormonal variation during pregnancy may cause changes in ability to concentrate as well as tendon laxity.  It is therefore incumbent upon the  It is unlikely that the reproductive organs would be injured in a boxing match.  The ovaries are not tethered; they move.  As stated before, a normal uterus sits very low in the pelvis and should not even be in the target range of a legal blow.

I have picked up two potentially dangerous gynecologic problems in the past several years during pre-fight physicals, and one early pregnancy. A good history and a high index of suspicion are key.  The two girls with gynecologic problems were successfully treated, and, after appropriate recovery periods, were cleared for participation in amateur competition. The pregnant athlete decided to carry the baby to term, and was lost to follow-up.

Jill: A proud moment?

Dr. Wulkan: My proudest moment was witnessing Dr. Michael Kelly, one of the best ringside physicians in the country, speak about his close friend, Nick Lembo, at Lembo’s induction into the New Jersey Boxing Hall of Fame.

Jill: A frustration?

Dr. Wulkan: It is always difficult to tell a fighter that he/she should strongly consider retirement.

Jill: Anyone(s) who was particularly inspiring?

Dr. Wulkan: Dr. Richard Istrico, who took time out of his busy schedule to mentor me, and Dr. Michael Kelly, who I regard as one of the top ringside physicians in the country. Drs. Joseph Estwanik, Robert Cantu, and Barry Jordan, pioneering researchers in ringside medicine. Dr. Margaret Goodman, former medical chair of the Nevada State Athletic Commission, and a great female ringside physician role model.

Special thanks to former Commissioner Larry Hazzard, and DAG Nick Lembo, of the New Jersey State Athletic Control Board, and to Melvina Lathan of the New York State Athletic Commission, for giving me the opportunity to serve as a Commission Physician in these states.

My coach, and good friend, Ray Longo, who has trained Golden Gloves winners and world title holders in kickboxing and mixed martial arts. Thank you for taking the time to analyze fights with me, and for trusting me to sit ringside at your promotions with Louis Neglia.

Although not a ringside physician, special thanks to Dr. Irving Glick, one of the fathers of Sports Medicine, who just recently passed away. Dr.Glick’s humble demeanor, phenomenal bedside manner, intelligence and humor were surpassed by none.

The WBC wishes to thank Dr. Wulkan for taking the time to educate us on her life as a premier Ringside Physician.

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