It will likely go down as the biggest moment of the year in MMA.
After all the trash talk and hard feelings, the grudge match between Jorge Masvidal and Ben Askren at UFC 239 in July lasted all of five seconds. Masvidal stopped Askren square in his tracks with a daring flying knee immediately after the opening bell. Askren, retreating to his natural instincts as a wrestler at Masvidal’s charge, got caught ducking for a takedown and took the blow flush across the jaw. He fell to the canvas unconscious, muscles going stiff as referee Jason Herzog dove in to keep the gleeful Masvidal from landing additional strikes.
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“One of the greatest knockouts you’ll ever see!” shouted UFC play-by-play announcer Jon Anik as T-Mobile Arena in Las Vegas devolved into bedlam.
The sequence became an instant classic. It was the fastest finish in UFC history, propelling Masvidal to sudden heights of fame and into his ensuing “BMF title” fight against Nate Diaz earlier this month at UFC 244.
Yet there’s still much about what happened during those five seconds that remains a mystery. While the effects of Masvidal’s handiwork on Askren’s exterior were plain to see, medical science is still grappling with what physically happens inside the body during a knockout, why the brain reacts the way it does and why certain people are affected differently than others.
“There’s a lot of unknown about what exactly is going on in the brain (during a knockout),” said the Cleveland Clinic’s Aaron Ritter, the co-primary investigator in the clinic’s ongoing study into repetitive head impacts on athlete health. “We have theories (but) we still don’t know why people go to sleep. We still don’t really know what is necessary for life. These questions regarding the brain are a little bit unknown, but they’re fascinating — and I think that’s where a lot of the research and science comes in.”
When an object such as a fist, foot or knee collides with the human skull hard enough to cause mild traumatic brain injuries like concussions, it traditionally results in two types of impact, Ritter said. The first is an acceleration-deceleration impact and can cause the brain to move through its protective cerebrospinal fluid in the closed chamber of the skull. Sometimes the brain collides with the hard, interior surface of the cranium, causing damage to its exterior gray matter structures.
The second kind of impact is rotational, which can force the brain to wobble or quiver, sending shockwaves through the entire organ. These impacts can penetrate deeper into the brain and harm the organ’s interior structures, Ritter said, sometimes going far enough to impact the brainstem, which controls consciousness.
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“The brain’s way to protect itself is to encase itself in this fortress of the skull,” Ritter said. “When these forces penetrate the skull, it’s basically like shaking a mold of Jello. There’s no exoskeleton to the brain at all, so when you have any sort of force to the brain, it wiggles like a piece of jelly mold, and there’s nothing to really stop those forces. So, those forces can actually penetrate pretty deep, especially the rotational forces.”
At the cellular level, these impacts disrupt the delicate chemical balance the brain is constantly working to maintain. When brain cells are damaged by the biomechanical force of impact, they purge themselves of certain chemicals like calcium and glutamate. The sudden loss of those chemicals, Ritter hypothesized, can force the cells to become depolarized, to lose their electrical gradient.
Meanwhile, the body begins rushing blood to the brain in an effort to protect it and begin repairing any damage. It’s believed that one or a combination of these factors can cause an athlete to lapse into unconsciousness, Ritter said, but nobody knows for sure how or why.
Nor can doctors really explain the seemingly unique role of the chin and jaw in knockout blows. While every fighter and fan understands that the chin is perhaps the most vulnerable spot to get hit, the reasons why don’t seem entirely obvious. Ritter guessed it’s because of the jaw’s exposed location on the skull, protruding downward, mostly unprotected by the sturdier structures of the head. A shot to the jaw, then, might cause a tremendous amount of force and channel it directly to the nearby brainstem.
“When you’re hit in the jaw, it can create a lot of these rotational forces that can get transmitted to the parts of the brain,” Ritter said. “The part of the brain that controls consciousness is really in the brainstem. It’s a lot lower down. So, we always think about the face, but really the part of the brain that controls wakefulness and things of that nature is more toward the base of the skull. So, a hit to the jaw, there’s more rotational force and it’s closer to the brainstem.”
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Reasons why some fighters have “better chins” and appear to be able to withstand harder impacts to the jawline also isn’t really understood, Ritter said. It could be as simple as a particular fighter possessing a thicker jaw bone or thicker bones in the skull. Again, though, that’s all just theoretical at this point.
For obvious reasons, it can be difficult to study the exact mechanisms of the knockout as they happen, Ritter said. Many of the laboratory studies that are done are conducted on rodent models and the brains of mice and rodents are structured and organized much differently than the human brain, so it can make extrapolating results difficult.
But researchers continue to examine what specific forces cause knockouts and how the body responds. During the first eight years of its athlete study, the Cleveland Clinic has amassed data on over 800 current and former athletes from a variety of sports, including MMA and boxing. It’s believed to be the largest study of its kind into the lasting effects of combat sports on brain health.
“(Knockouts) are messing up that basic, vital function of the body, which is sleep and wake, and we really don’t understand that,” Ritter said. “We know that’s controlled primarily by the brainstem. So, it’s in the most protected part of our head and when we’re messing with that, that really shows us that we’re going against basic biology.”
“We have theories (but) we still don’t know why people go to sleep.” — Aaron Ritter, Cleveland Clinic (Jeff Bottari / Zuffa LLC / Getty)Vern Reynolds has worked as a ringside doctor in Ohio for more than a decade and estimates he’s staffed between 250 and 300 boxing and MMA events during that time. A former athlete himself who has spent time teaching at Ohio State University, Reynolds often provides the first line of care for athletes who suffer knockouts in the ring or cage.
Talk to him for just a few minutes and you realize working the fights will keep you on your toes.
“Unique things happen,” he said, in the rapid-fire staccato of a man used to reacting quickly, “so you’ve got to pay attention.”
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Reynolds has seen all manner of injury during his time as a ringside physician, from cuts and broken bones to knockouts. One thing he emphasizes is: every case and every athlete is different. Sometimes in a fight, a doctor has to know who he’s treating in order to react appropriately. Whether or not a fighter is an amateur or professional, the age of the athlete and how much damage they’ve taken throughout their career can all factor in.
“I’m fortunate enough to work with a lot of these guys over and over and over,” Reynolds said. “Some of these guys, if you see they tend to get knocked out quicker these days than they did last year, I’m a little more cautious with them … I think I have a good gauge on how to handle each one of these (fighters) individually. Each person is different. I’d stop one fight for one guy at a different spot then I would do it for another fighter.”
When it comes to treating knockouts as they happen in the cage, the ringside doctor doesn’t instantly have the luxury of MRI scans or other advanced tests. Those can come later, but in the initial moments after a fight-ending blow, the immediate in-ring evaluation is conducted with the tools Reynolds carries with him.
Reynolds said he’ll first check a KO’d fighter’s eyes to make sure the pupils are the same size and reacting appropriately to light. If they’re not, it could be a sign that a more serious brain injury has occurred. Reynolds will also work with the referee or other ringside officials to keep the downed fighter in place as they come to. As many fight fans know, being the first to arrive on the scene of a disoriented and injured fighter can occasionally be dangerous.
“They can be out anywhere from, say, 30 seconds to three minutes,” Reynolds said, “but when they wake up, they don’t realize what’s happened. Sometimes they think they’re still fighting a fight. So, you have to be careful. A lot of times, they’re tackling me or going after the ref.”
Fighters are often off-balance or suffering from impaired motor skills in the immediate wake of a knockout. Given that the brain is such a complex organ, Ritter said, the complicated network of neurons and cells that work in concert to control the body’s many fine motor skills can be disrupted by sudden trauma. It often takes some time for an athlete to find their bearings.
Once the fighter is conscious and able to move to their feet or to a stool, Reynolds said he’ll ask them a series of questions to determine their level of disorientation. If and when they are able, they are moved outside the cage — usually under the watchful eyes of cornermen — so Reynolds can conduct a more thorough, full-body examination and re-evaluate their condition.
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If anything seems amiss, if the fighter is experiencing nausea or headaches that seem out of the ordinary, Reynolds will send them to the hospital right there. But if a fighter doesn’t appear to be suffering any unusual ill effects from the knockout, they’ll return to the locker room to rest and recover pending further inspection.
By rule as the ringside doc, Reynolds has to stay in the front of the house to watch the ongoing fights. If he’s worried about a particular fighter, however, he’ll send paramedics to the backstage area to monitor them and Reynolds himself might stop by during an event’s intermission to follow up.
Here too, he said, one of the most important factors is tailoring the treatment to individual fighters. To know if an athlete is behaving strangely or experiencing any worrisome side effects after a bout, it helps to be familiar with that fighter’s normal personality and capabilities. Reynolds said he often talks to family members or cornermen to see if they feel like a fighter is acting strangely in the wake of a knockout.
If they are, Reynolds will send them to the hospital or tell those close to them to keep a careful eye on the fighter over the next day or two and head to the emergency room if anything seems amiss.
At this point, Reynolds said Ohio has standardized many of its post-fight medical suspensions, usually mandating that a fighter who has been knocked out spend 30 to 60 days recovering and sometimes get cleared by an MRI before they can return to training or competition.
On fight night, however, the ringside doctor is the first on the scene, so it’s important to err on the side of caution.
“Time is of the essence,” Reynolds said. “So, when (something more severe) happens, I ship those guys (to the hospital) right away, just to be safe. I’d say that only happens one time out of 10, but I’d rather be safe than sorry in this sport.”
In the days and weeks following a fight, Ritter said the care of an athlete who has suffered a concussion is often based around the symptoms they exhibit. Common fallout from knockouts or other TBI includes an array of indicators such as mental fogginess, memory loss, insomnia, headaches, irritability and light sensitivity. Those symptoms have to clear up over an extended period before an athlete can be cleared to return to training.
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The extent of the injury and the recovery can depend on a number of variables, including the severity and number of impacts suffered and whether or not an athlete has suffered previous concussions, Ritter said.
“We don’t understand why certain people have certain symptoms, but it’s likely a response to a lot of inflammation in the brain …,” he said. “We know pretty clearly about what (symptoms) fall under post-concussion syndrome, but everybody’s different and there’s very clear guidelines that are being established about when people can return.”
The most significant immediate health risk in the wake of a knockout usually comes from swelling in the brain, Ritter said. In the rare occurrence where you see fighters stay down for long periods after knockout losses and sometimes even get carried from the cage or ring on a stretcher, it’s likely because blood vessels in the brain were damaged by the strikes and resulted in swelling.
Severe swelling inside the closed box of the skull can be a serious problem and cause the brain to herniate and result in a coma or even death, Ritter said. To prevent that, doctors can remove a piece of the skull to allow enough room until the swelling goes down.
“The main complication of the traumatic brain injury, when it does result in ring death and things of that nature, is the swelling problem,” Ritter said. “Most head traumas themselves are not severe enough to cause swelling, but they do cause a lot of damage to the cells. How long the symptoms last usually depends on how quickly the brain regenerates and can clean up the inflammation that has occurred.”
Askren, for example, seemed to get lucky. He was able to walk — albeit unsteadily — from the cage under his own power in the wake of his KO loss to Masvidal. He was medically suspended by the Nevada State Athletic Commission until September with an order for no contact until mid-August.
Askren was back doing media around a few days after the knockout and publicly appeared not to have suffered any lasting damage. It’s believed he has now fully recovered from the incident and has even fought again since: losing to Demian Maia via submission last month.
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Meanwhile, studies continue as the Cleveland Clinic and others seek to provide insight into combat sports’ effects on the health and well-being of athletes. For now, however, many of the mysteries surrounding one of MMA’s most common and celebrated finishes – the knockout – remain unsolved.
(Top photo: Stephen R. Sylvanie / USA TODAY Sports)
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