Why I Support Amateur Boxing
Ed Friedlander MD
erf@kcumb.edu

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I'm a medical doctor, board-certified in anatomic and clinical pathology. Since the mid-1990's, I have operated the world's largest free online personalized health information service. From time to time, parents have written asking me whether they should allow their sons to participate in amateur boxing.

When I lived in Tennessee, one of my closest friends was Don Arwood MD, a past Golden Gloves champion. In 2003, my own student Josh Durham, a current Golden Gloves heavyweight champion, invited me to be the volunteer ringside physician at a match. I was impressed with the concern that everybody showed for the young people and their safety. I have chosen to continue my involvement.

Whatever "consensus documents" my professional colleagues draft, there will always be many young males who want to engage in amateur boxing. This is in spite of much concern, by physicians and others, that amateur boxers could get the same kind of brain damage that is so familiar in professional career boxers.

In my opinion, the health risks of today's amateur boxing, properly supervised, have been exaggerated badly enough to justify my speaking out in the sport's defense.

Of course, here and everywhere, I'm speaking only for myself.

I have no intention of discussing the "moral issues" in a sport where the object is to hit your opponent. The ways in which boxing is like, and unlike, contact sports such as hockey or American football are obvious. In particular, George Lundberg MD, a fellow-pathologist, has taken a very strong stand against all boxing as inherently both unsafe and immoral. Many decent people will agree, and I'm basically with him on professional boxing.

On the other hand, many young men (and some young women) love the boxing milieu, and find it to be their preferred environment for staying physically fit and for building friendships. Better in the ring than in bars or drug-houses. And like it or not, in our world, the only way you avoid being badly hurt is for you or a friend of yours to be able and willing to hurt back. Force will always govern human affairs, and the best for which we can hope is that this will be the force of just law. But in areas where the law does not reach -- including some places in the U.S. -- a young man can live peaceably only if he is known to be able to fight. It's not nice, but it's a fact of life.

By temper and upbringing, I'm a man of peace. I have only struck one other person in anger, and he richly deserved it. I surprised myself. I also frightened myself. Since then, I have never even carried a Swiss army knife. So my defense of the sport is not motivated by a bellicose disposition. I have enjoyed doing the boxer's fitness routine but am not interested in learning to spar. I also skydive. This is an "extreme" sport which has a much higher risk of injury and death than amateur boxing. (The risk is lower for folks like me who always play safe.) But being a skydiver still places me at less risk than the fact that I drive an automobile.

Most any discussion of amateur boxing will include an explanation of the rules that protect the participants. I'm glad to be part of this protection. Especially, today's amateur boxers are very much aware of second-impact syndrome, and after even the slightest suspicion of a first concussion, there is a mandated month out of the ring. Should it happen again, the intervals are successively longer.

The most important statement by a physicians' group on amateur boxing is the 1997 policy statement of the American Academy of Pediatrics, through its Committee on Sports Medicine and Fitness. You may find this in Pediatrics 99: 314-5, 1997. The committee acknowledges that the rate of obvious head injury is actually lower in amateur boxing than in football, rugby, or ice hockey. However, the academy singles the sport out for condemnation because "intentional head injury" is the "primary objective".

According to the academy, "Recent studies have shown that amateur boxers still are at risk for acquiring cognitive abnormalities and/or focal neurologic deficits." The only science which the academy cites to support this claim is five published studies.

I obtained and reviewed all five papers. Here is what they actually say.

I do not find the Academy's own sources sufficient to justify their harsh warning about the risks of brain damage from amateur boxing. The lone article that mentions "focal neurologic [deficits]" doesn't mean what physicians in the U.S. would assume it means. And except for the uncontrolled study where there was selection for people who wanted a neurologic exam, real "cognitive abnormalities" seem conspicuous by their absence. I would invite my readers to obtain the articles themselves via interlibrary loan and find out who's telling the truth.

To their credit, the Academy also cites two papers where the authors looked hard and could find no effects.

They might also have cited the paper by Porter and Fricker in Clin. J. Sport. Med. 6: 90-6, 1996 (no measurable effect whatever). "There is accumulating evidence that amateur boxing is not associated with chronic traumatic encephalopathy but longer term prospective studies are needed."

The public is deluged with claims about health risks, real and bogus. Any study is "news", and today's public recognizes that many (perhaps most) such claims will soon be discredited. Where the relationship holds up and the risk gets accepted as real by the scientific community, the hazard typically produces a single, easily-characterized illness. And the heavier the exposure, the greater the risk proves to be. Every medical student knows this distinguishes the junk from the real stuff.

I am genuinely concerned about the risks of subtle eye injuries to amateur boxers. Amateur boxing gloves lack the thumbs which used to cause blunt trauma to the eyes. But eye injury is an area where there is still considerable discussion. Older studies show up to 75% prevalence of old eye injury, most especially retinal tears. A newer survey of elite Turkish boxers showed only one of twenty with an eye injury (Br. J. Sport. Med. 36: 428, 2002). The vast majority of these never produce any loss of vision. However, a retinal detachment is catastrophic, and the story of Sugar Ray Leonard is well-known. It would seem wise for the boxer's primary care physician to do a dilated eye examination at the routine annual physical exam.

"Boxer's knuckle" is blunt trauma to the metacarpophalangeal joint, usually the first. There are a few papers about its management.

Individuals who choose to participate in amateur boxing know that there is some risk. (And of course, it should always be a free choice.) Especially, I would urge participants to have yearly retinal examinations. The risk of death is commensurate with other risks which we accept routinely. I could find nothing to indicate that amateur boxing (unlike professional boxing) places its participants at measurable risk for long-term brain damage.

Actually, I would much prefer to have my own son participate in amateur boxing than ride a bicycle in downtown Kansas City. I hope you found my notes helpful. And should you or one of your family members choose to box, I hope there will always be a good physician at ringside.

Ringside PHysicians -- organization of physicians concerned with safety

Postscript: The Ringside Exams

Each boxer has had a complete physical exam within the previous year, and also gets checked by a physician just before an event. Here's the pre-boxing checkup that I use, and the thinking behind it.

After an uneventful fight, here's what I do.

More Reading

West. J. Med. 172: 396, 2000, a rehash of Br. J. Sport. Med. 33: 426-9, 1999. From the bioethicists at McGill. Anti-boxing stuff, which tries to explain why doctors telling people not to box (politically correct) is not medical paternalism (politically incorrect). The mere presence of a sport physician at a boxing match lends an air of legitimacy to behavior that is medically and ethically unacceptable. As a medical school teacher, I have often pointed out that when "ethics" doesn't focus on facts, it's nothing but common mud-slinging.

Br. J. Neurosurg. 16: 96, 2002. Acute subdural hematomas in a boxer.

Br. J. Sports Med. 35: 390-5, 2001. Crash-dieting and self-dehydration make amateur boxers crabby and don't help their performances.

Int. J. Sports Med. 21: 551-5, 2000. Boxing raises plasma S100-B, which somebody might suggest is a marker for brain injury, but running a 25 km race does exactly the same thing.

Gastroenterology 119: 507-11, 2000. The famous article documenting transmission of hepatitis C "during bloody fisticuffs".

Eur. Heart J. 20: 900-3, 1999. Review of sports deaths caused by unrecognized cardiac lesions. Includes an amateur boxer dead from hypertrophic cardiomyopathy.

Clin. J. Sport Med. 6: 97-101, 1996. Review of amateur boxing injuries in Ireland. Education of coaches, and the introduction of qualified athletic trainers where appropriate, may help correct the situation in which boxers do not receive appropriate treatment for their injuries. Such measures would be facilitated by an increased level of medical interest and an adoption of a more cooperative stance by those medical associations that have condemned [boxing] from a position of supposed moral and intellectual superiority.

Clin. J. Sport Med. 6: 97-101, 1996. Prospective study of amateur boxers. There was no evidence of neuropsychological impairment in the boxers as compared with socioeconomically, educationally and age-matched controls, and there was no association between boxing exposure and performances in any of the neuropsychological tests used.

Military Medicine 164: 68-70, 1999. Boxing injuries, including three serious acute intracranial injuries among 180,000 marines participating.

J. Med. Ethics 24: 3-4 and 56-60, 1998. Freedom to box.

Clinics in Sports Medicine 17: 155, 1998. Reviews both professional amateur boxing deaths, and how they have decreased thanks to better safety measures. The statistics in this article reinforced my concerns about professional boxing, but I found the material on amateur boxing today to be reassuring.

Eur. J. Ophth. 7: 174-180, 1997. Boxers generally do have old asymptomatic eye injuries.

Br. Med. J. 316: 1813, 1998. A professor at a business school (!) urges physicians to boycott all boxing. The author asserts that the idea that amateur boxing is safer than professional boxing is "challenged". My experience with left-wing agitprop is that "challenged" means "attacked for ideological reasons without any basis in fact". That's what it means here.

JAMA 278: 136-140, 1997. Having APOE epsilon4 places a professional boxer at far greater risk of dementia pugilistica.

Clinical J. Sport Med. 6: 90-6, 1996. There is accumulating evidence that amateur boxing is not associated with chronic traumatic encephalopathy but longer term prospective studies are needed.

JAMA 276: 954, 1996. "Boxing: does the size of the prize affect the drain on the brain?" A physician writes to Dr. Lundberg, agreeing with his position on professional boxing but pointing out the relative safety of amateur boxing and citing the Swedish work. Dr. Lundberg remains skeptical and cited a then-recent Golden Gloves death.

Br. Med. J. 309: 474, 1994. An anesthesiologist suggests that non-anesthesiologist physicians not attempt to intubate an unconscious boxer.

Br. Med. J. 308: 1620, 1994. Head injury in sport, with algorithms. Unconscious longer than 5 minutes, disorentation, or any focal neurologic sign mandates transport to the hospital.

USA Boxing, formerly the American Amateur Boxing Federation. Not much here yet.
USA Boxing, New York region
Amateur Boxing News, by Melanie Ley
Amateur Boxing News, by Melanie Ley
International Amateur Boxing Association
Amateur Boxing FAQ -- "the safest of all contact sports"; "a proven deterrent to delinquency". This squares with my experience.

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Follow-Up:

In June 2003, I received this note from a colleague.

Read your internet article today. I, too, support amateur boxing and volunteer as a ringside physician for amateur boxing and this is why:

Self Esteem
Most of our local amateur boxers (Phoenix, AZ) are hispanic and live in less than ideal neighborhoods which are saturated with any numbers of "negative lifestyle choices". Boxing offers them an identity and the confidence to make wiser choices.

Physical Conditioning
Physical fitness is recognized by the medical community as very important. For any number of reasons, young men may choose to not participate in team sports. Individual sports, such as boxing, are ways for them to become fit and, perhaps, to develop fitness habits that persist for a lifetime.

Structure
Boxing requires that the student (boxer) listen to and respect the teacher (trainer). Lack of respect in the gym results in expulsion. They learn that actions have results. This may not be the case in school. Teachers and school administrators will put up with a lot more nonsense than boxing trainers. In the gym, they are in a situation where they are exposed to role models that may be more positive than the ones at home or school or on the street corner with their pals. In addition, They box in a very structured environment. The discipline of training, the rigidity of the rules and the need to show respect for the officials all combine to develop the habits of a good citizen.

Supervision and Safety
Amateur boxers are supervised constantly by qualified officials. USA Boxing has made explicit that athlete safety is their primary concern and must be the primary concern of everyone involved. This may not be the case in other sports where points are the more important goal.

Inevitability
Amateurs and professionals will box. It is legal and it is a way for people to make money. It is better that they do it with qualified professional at the ringside. The stance by the AMA seems to condemn boxing without giving credit to the physicians who volunteer to make it safer.

Thank you for your commitment to amateur boxing and the safety of boxing athletes. I must tell you that I take some pride in being a pariah.

George E. Palmer, III, DO

More follow up: In October, 2007, three researchers from the English Institute of Sport presented a review in the BMJ (British Medical Journal) concluding that "there is no strong evidence to associated chronic traumatic brain injury with amateur boxing" (BMJ 335: 809, 2007). The authors reviewed previous studies and noted "quality of evidence was generally poor". Click here or here.

In July 2011, Pediatrics 2011; 128;e1 published "Epidemiology of Sudden Death in Young, Competitive AThletes Due to Blunt Trauma. The series covered the USA data for 30 years. The worst problem by far is American football, especially when players are sent back to play after concussions. (I make sure this doesn't happen when I'm around amateur boxing.) The authors mentioned "certain sports with relatively low participation rates also seem to be associated with considerable risk." They did NOT mention amateur boxing (12 deaths) but did cite pole vaulting (22 deaths).