As a long-time boxing coach and promoter in Duluth, Chuck Horton knows first-hand the importance of protecting the fighters who already sacrifice so much for this sport. Please read this entry from Don Muzzi M.D. where he breaks down the science behind injuries and brain damage that are too often a product of boxing.

Don Muzzi M.D. Certified Ringside Physician 


Boxing is a sport that is associated with an element of risk. Although there are several types of injuries that are peculiar to pugilism, the injury that poses greatest risk in boxing is the potential for trauma to the brain. Brain injury in boxers has always been recognized as a significant problem among ringside physicians, referees, commissions, and trainers. Recently the media 

Don Muzzi & Chuck HortonAnd general public have become sensitive to this issue as well. Awareness and understanding surrounding brain injury and boxing is a matter of importance in order to protect the athletes involved in boxing. 

There were 339 fatalities in professional boxing from1950 to 2007. Virtually all of these deaths have been related to head trauma and subsequent damage to the brain. As a subset of the 339 fatalities only 120 ring deaths occurred from 1983 to 2007. The apparent reduction in the death rates in boxing since 1983 has been in large part because of increased regulation, rule changes and medical supervision. All of these efforts have focused on reducing the number of blows to the head that an athlete sustains during a bout and throughout the course of their career.

One way to understand the effects of repeated trauma to the brain is through analogy. Think of the brain as a sphere of jello wrapped in a sheet and encased within in a stainless steel jello mold. The sphere of jello represents the brain, the sheet the Dura, and the stainless steel mold the skull. When a boxer suffers a blow to the head the brain shakes back and forth inside the skull causing injuries to both sides of the brain. 

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Brain injury in boxing can be divided into two basic categories: 

  1. Acute Brain Injury 
  2. Chronic Brain Injury 

Acute Brain Injury

Acute brain injury is an injury to the brain that occurs during a bout. In other words, the injury is temporally related to the blow. One category of acute brain injury is known as a concussion or mild traumatic brain injury. A concussion occurs when a blow to the head shakes the brain violently inside the skull. As the brain shakes a series of chemical, metabolic, and blood flow changes essentially cause a “short circuit” in the brain, which results in a transient disruption of normal brain function. This disruption in brain function can manifest itself in a boxer as, headache, nausea, vomiting, visual disturbances, confusion, balance issues, gait abnormalities, and loss of consciousness. It is important to understand that greater than 95% of concussions do not involve loss of consciousness. Symptoms generally dissipate in 7 to 10 days but can go on as long as three weeks. In rare instances a boxer may develop a post concussion syndrome. In these cases symptoms can persist for greater than 3 months. During the time period when a boxer is still symptomatic from a concussion, he or she is susceptible to a serious and a potential fatal brain injury, in the event of another strike to the head. Therefore, it is of paramount importance that a ringside physician has the ability to recognize when a concussion has occurred. In the event of a concussion, the ringside physician must stop the bout and provide immediate and appropriate medical care. 

Another category of acute brain injury is subdural hematoma. Remember our jello mold analogy from earlier. The sheet in that analogy is called the Dura. The Dura is a tough tissue that covers the surface of the brain and separates the brain from the skull. Their are a series of veins called “bridging veins” that exist between the Dura and the brain surface. After a blow to the head the brain essentially violently shakes inside the skull causing the small bridging veins to tear, thus resulting in bleeding and clot formation. This collection of blood and clot is known as a subdural hematoma. If not diagnosed and treated immediately, this bleeding may causes severe pressure in the brain and may even result in death of the boxer. In fact most deaths that occur in the ring are secondary to a subdural hematoma. Symptoms of a subdural hematoma are similar to those of a concussion. However, they are generally more severe and increase in severity over a short period of time. In the case of a subdural hematoma seconds count. This is a true medical emergency. The boxer must be transported to the hospital immediately by ambulance with full “lights and siren”. 

The last category of an acute brain injury commonly seen in boxers is a cerebral contusion. A cerebral contusion is simply a “brain bruise”. Basically minimal bleeding has taken place in very small blood vessels in the brain. Cerebral contusions usually are the result of a deceleration impact. In other words when the head hits the canvas as a fighter falls. Symptoms of a cerebral contusion are similar to that of a concussion and a cerebral contusion is generally self-limiting. As in a concussion symptoms generally resolve in a short period of time. 

Although there are other types of acute brain injuries the three previously discussed types encompass more than 98% of acute brain injuries that occur in boxing. Keep in mind that these injuries are not mutually exclusive. A concussion, hematoma and contusion can occur independently or in combination. 

Don Muzzi Brain Damage

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Chronic Brain Injury 

Chronic brain injury is a significant problem that can occur in professional boxers. As stated before, acute brain injury is an injury that occurs as the result of one specific blow to the head or bout. Chronic brain injury, on the other hand, occurs after a brain is exposed to repetitive concussive and sub-concussive blows to the head over a long period of time. This condition is currently known as Chronic Traumatic Encephalopathy (CTE). It was first described in 1928 in a paper published in the Journal of the American Medical Association. Previous names for CTE were Dementia Pugilistica, “Punch Drunk Syndrome”, and Chronic Traumatic Brain Injury. 

Chronic Traumatic Encephalopathy generally becomes apparent in a boxer later in life after he or she has retired. The peak incidence of CTE occurs when a boxer is in his or her fifties. Approximately 20% of professional boxers will develop CTE. 

In CTE chemical reactions in the brain that take place over a long period of time that cause brain cells to essentially unravel. Because of these structural changes, nerve cells can no longer function and the boxer will manifest a variety of symptoms. These symptoms include, emotional liability, which can manifest as mood swings, personality changes, and fits of anger, depression, and/or suicidal ideation. Other symptoms include movement disorders such as, tremor, difficulty walking, and shuffling. Often, patients with CTE also develop cognitive disorders, which may cause them to experience memory impairment, difficulty thinking and learning. These symptoms can progress to severe dementia, which can leave a patient helpless and ultimately may result in premature death. Risk factors predisposing a boxer to developing CTE are primarily related to exposure. Specifically, the greater the number of strikes to the head that a fighter sustains in his or her career the greater the chance they have of developing CTE. Also, experiencing a greater the number of knockouts or technical knockouts predisposes a fighter to developing CTE. Boxers who are sluggers instead of technicians and those boxers who “can take a punch” are more likely to fall victim to CTE. Also, the longer a career one has had in boxing, the older he or she is at retirement, and the greater the number of fights he or she participates, the greater the athletes chance of developing CTE will be. There is also a genetic predisposition that may make a boxer more likely to develop CTE. It is important to recognize that not all boxers respond to the same amount of trauma in the same way. Some humans possess a gene that does not allow the brain to repair itself after injury as well as it does in people who do not have this gene. This population boxers with this gene is more likely to develop CTE. 

There is no treatment for CTE. The mainstay of treatment is therefore prevention, specifically limiting the number of blows to the head a boxer sustains over his or her career. The greater the number of unregulated and non-medically supervised events a boxer participates the greater his or her chances of developing CTE will be. Knowing when it is time for a boxer to retire from the sport is essential in the prevention of CTE. 

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In summary boxing is an admirable sport. It presents the athlete with formidable challenges. It requires aerobic training, anaerobic training, strength training and techniques that are second to no other athletic endeavor. Participation in boxing requires disciplined thought and disciplined actions. Accordingly boxing teaches young men and women both physical and mental discipline. 

Protecting the boxer is a team effort. Referees, commissions, trainers, and ringside physicians have a responsibility to possess an awareness and understanding of potential brain injuries in boxers. A fund of knowledge and sensitivity regarding head injuries associated with boxing in the community of officials involved in the sport will afford the athletes an increased level of protection. For this reason unregulated boxing events should not be allowed or supported by fans. 

After reading this article commissioners and ringside physicians should appreciate the importance of maintaining a close alliance. Additionally I believe that in the interest of protecting boxers, it would be beneficial for the Association of Boxing Commissions and the Association of Ringside Physicians to develop a strong and trusting relationship. Sharing each other’s perspective, literature, and concerns would strengthen combative sports and above all else protect the combatants. Transparency, as well as open and honest communication between these organizations will protect both the boxer and the integrity of the “Sweet Science”. 

 Author: Dr. Don Muzzi


To learn more about Duluth boxing and self-defense, check out Chuck Horton’s other website.