Epidemiology of Injuries during Judo Tournaments

Objective To determine the injury incidence proportion, distribution of injuries by anatomical location; injury type; injury severity, time loss; mechanism and situations of injuries; and the relative risk of injuries by gender, age, and weight categories during judo tournaments. Study Design. It is a systematic review. Data Sources. A systematic review of the literature was conducted via searches in PubMed, EMBASE, Web of Science, CINAHL, SPORTDiscus, Google Scholar, and PEDro. Eligibility Criteria. All original studies on the incidence of injuries during judo tournaments were included. Results Twenty-five studies were included out of the 1979 studies. Using the modified AXIS tool score for quality assessment, seven were rated as having good quality, nine were rated as having fair quality, and four were rated as having poor quality. The injury incidence proportion during tournaments ranged from 2.5% to 72.5% for injuries requiring medical evaluation and 1.1% to 4.1% for injuries causing time loss (i.e., inability to continue game participation). The most commonly reported injury location was the head, followed by the hand, knee, elbow, and shoulder. The most frequent types of injury were sprains, followed by contusions, skin lacerations, strains, and fractures. In judo tournaments, injuries were more often sustained during standing fights (tachi-waza) than in ground fights (ne-waza). Conclusion The tournament injury incidence proportion ranged from 2.5% to 72.5% for injuries requiring medical attention and 1.1% to 4.1% for injuries causing time loss. The head was the most frequently injured body part, and sprain was the most frequent injury type. However, current reports on injuries during judo tournaments are heterogeneous and inconsistent, limiting our understanding of in-match injury risks. Future studies should utilize the guidelines of the International Olympic Committee consensus meeting statement on the methodological approach to injury reporting. We recommend a judo-specific extension of this statement to fit the unique features of judo sports practice.


Introduction
Judo is a worldwide popular sport with more than 20 million practitioners in 200 countries [1].It is a full-contact sport with a relatively high incidence of injury during tournament participation.Te reported tournament injury incidence proportion is highly variable and ranges from 11.2 to 29% [2].Te reported injury incidence rate per 1000 athlete exposures (in fghts) ranges from 41.2 to 81. 6 [2].Its competition rules have changed several times in the past two decades [3,4].Some of these rule changes were specifcally meant to reduce injuries.However, the efect of these rule changes on the injury incidence is unknown.Epidemiological data on judo injuries in tournaments can guide injury prevention programs and help researchers evaluate the efect of rule changes on the injury incidence.
Two previous systematic reviews describe the epidemiology of judo injuries.Pocecco et al. [2] published a comprehensive summary of judo injuries in competition and training in 2013.Te most common injury type was a sprain, followed by strain and concussion.Te most afected body locations were the knee, shoulder, and hand/fngers.Bromley et al. [5] published a systematic review on injury in Olympic combat sports (judo, taekwondo, wrestling, and boxing) in 2017.Tey included prospective studies of injury and illness lasting more than 12 weeks sustained in training and competition.For judo, they found an injury incidence rate of 4.2 per 1000 hours.Te body locations with the highest incidence proportion of injury were the lower back, shoulder, and knee.Men had higher injury incidence rates than women.
Terefore, to conclude, there is currently no systematic review that describes the currently existing literature on injuries during judo tournaments.We decided to focus on injuries during judo tournaments specifcally because the injury incidence and injury characteristics in judo training cannot be extrapolated to competition, and the injury incidence proportion during judo tournaments is high, as with most combat sports [24,25].Terefore there is a need for preventive strategies.Te burden of sport-specifc injuries can guide future injury prevention programs and can help researchers evaluate the efect of rule changes on injury occurrence.Moreover, it is useful for organisers and medical personnel of judo tournaments to have information regarding the injury incidence and the location and type of injuries during judo tournaments.With this epidemiological information, they can prepare themselves properly and arrange sufcient medical personnel and material for the tournament.Te aim of this study was to systematically review the injury incidence proportion, distribution of injuries by anatomical location, injury type, injury severity, and time loss, mechanism and situations of injuries, and the relative risk of injuries by gender, age, and weight categories during judo tournaments.

Methods
Tis systematic review was performed by following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) protocols [26] to ensure appropriate reporting.Te protocol is registered in the international prospective register of systematic reviews (PROSPERO) to provide transparency (ID number 181147) [27].
2.1.Outcome Measures.Te primary outcome was the injury incidence proportion during judo tournaments.Secondary outcome measures were the distribution of injuries by anatomical location; injury type; injury severity, time loss; mechanism and situations of injuries; and the relative risk of injuries by gender, age, and weight categories.

Injury Defnition.
Te injury defnitions were categorised, according to the categorisation of Clarsen and Bahr [28], into [1] injuries for which medical assistance was sought, [2] injuries leading to time loss, and [3] other injury defnitions or not specifed.Te frst injury defnition category was "any musculoskeletal complaint newly incurred due to competition during the tournament that received medical attention regardless of the consequences with respect to absence from competition or training" or variations of this defnition.Te second injury defnition was "all injuries that resulted in an interruption of practice (competition or training)."Other injury defnitions, which did not ft in "requiring medical attention" or "leading to time loss," are mentioned in the injury defnition table.Injuries are described in terms of the injury incidence proportion, a proportion of the injured athletes to the total number of athletes per tournament (%), or injury incidence rates per 1000 athlete exposures.

Eligibility Criteria.
All original studies that were published in a peer-reviewed journal and described the incidence of injuries during judo tournaments were considered eligible for inclusion.Exclusion criteria were as follows: articles written in languages other than English, German, Dutch, or French.Reviews, case report studies, and anecdotal reports were excluded.Furthermore, articles about Paralympic or visually impaired judo were excluded.Studies that used the injury data from the same tournament as another study were excluded.Studies that only reported data about one specifc injury type were also excluded.

Search Strategy.
We searched for terms on "judo" and "injuries" or synonyms for injuries (full-search strings are available in Appendix).Te following databases were selected for the search: PubMed, EMBASE, Web of Science, CINAHL, SPORTDiscus, Google Scholar, and PEDro.For Google Scholar, we listed the results by relevance and used the frst 200 results for analysis.Tis method was described by Bramer et al. [29] in their study on the optimal database combination for systematic literature reviews.Te reference lists of all included publications and relevant systematic reviews were checked, and forward citation searches were performed.

Study Selection.
After the search was completed, all duplicates were removed.Two authors (JM and AvG) independently screened all titles and abstracts found in the 2 Translational Sports Medicine search and assessed them for eligibility, using the web application, Rayyan QCRI.[30] After the frst selection was made, full-text articles from all articles were retrieved.Te aforementioned authors then read all the articles and made the fnal selection.Te selection process is further described in Figure 1.In case of disagreement, a consensus was sought through discussion among the two authors.
2. For injury types and locations, we listed the three most common types and locations of each study in a fgure.We did not perform a quantitative data synthesis (meta-analysis) because the included studies had diferent study designs, injury defnitions (i.e., outcome measure), and populations and were therefore too heterogeneous with regard to group size, population (level of competition), and efect size that we deemed it likely this could cause both clinical and statistical heterogeneity [33].
For diferences in the injury incidence between age, gender, and weight classes, which were mentioned in the included studies, we considered a p value less than 0.05 to be statistically signifcant.

Study Selection and Study Characteristics.
Te search was performed on 14 November 2022. Figure 1 shows the fow diagram of the selection process of the search.Twenty-fve studies were included in this systematic review.Table 1 provides a summary with descriptive study characteristics, with a total of 361,581 athletes (ranging from 83 to 316,203 per study).

Critical Appraisal.
Twenty-fve articles were included, of which nine were rated as having good quality (score > 18), ten were rated as having fair quality (score 12-18), and six were rated as having poor quality (score < 12).Te mean quality rating was 15 ± SD of 4.4 (64% of the maximum score) and ranged between 4 (17%) and 20.25 (86%).Te results of the critical appraisal are presented in Table 3 and in a colour-coded table with the risk of bias assessments per question in Supplementary Appendix B.

Injury
Incidence.Twenty-one of the twenty-fve included studies described the injury incidence proportion with a range from 1.1% to 72.5% in all three injury defnition subgroups (Table 4).First, the incidence proportion for "injuries requiring medical attention" ranged between 2.5% and 72.5%.Second, for injuries leading to time loss, the tournament incidence proportion ranged between 1.1% (>7 days of time loss) and 4.1% (not completing a contest in a tournament).Tird, studies with other injury defnitions reported an injury incidence proportion between 2.6% and 28.9%.Fifteen studies reported the injury incidence rate per 1000 athlete exposures (IIRAEs) or the total number of fghts, by which we could calculate the IIRAE.Te reported IIRAE ranges from 10.9 to 109 for injuries requiring medical attention and 4.2 to 60 for injuries causing time loss.
Te studies by Lystad et al. and Cierna et al. were the only two studies that reported the injury incidence per 1000 minutes.Cierna et al. found a total of 10.9 injuries per 1000 minutes of exposure.Te injury incidence during the Olympic Games found by Lystad et al. was 9.6 per 1000 minutes, i.e., 576 per 1000 hours.

Injuries Requiring
In-Hospital Evaluation.Six studies described the number of injuries that required further evaluation in a hospital.Te number of injuries that required Translational Sports Medicine evaluation in a hospital ranged from 1.5 (Ikumi et al.) [13]to 12.8 (Chirazi and Babiuc) [17] per 1000 athlete exposures.Rousseau et al. [8] and Dah and Djessou [39] described 2.3 and 2.6 hospital treatments per 1000 athlete exposures, respectively.Blach and Smolders [20] described that 0.48% of all competitors needed transportation to a hospital, and they did not describe hospital transportations per 1000 athlete exposures.

Injury Location.
Eighteen studies described the distribution of injuries across body locations.Te three most common injury locations for each study are listed and shown in Figure 2. Te studies by Frey et al. [14], Maciejewski and Pietkiewicz [10], Ikumi et al. [13], and Phillips et al. [37] did not further specify the number of upper and lower limb injuries.Te study by Dah and Djessou [39] showed incomplete and conficting results for injury locations.Most studies mentioned that head and neck injuries were the most common (N � 7) or second most common (N � 4).Other locations that were frequently injured were the hand, knee, elbow, and shoulder.

Injury Type.
Nineteen studies described the distribution of injuries across injury types.Te three most common types of injuries for each study are mentioned in Figure 3. Te studies by Miarka et al. [9], Dah and Djessou [39], Phillips 4 Translational Sports Medicine      Translational Sports Medicine et al. [37], and Pierantozzi and Muroni [41] used an injury location classifcation that could not be modifed according to the classifcation used by Bahr et al. [31].A joint sprain was the most common injury overall.Other frequent injury types, in the order of decreasing frequency, were muscle contusions, lacerations, muscle injuries, and fractures.Te study by Frey et al. [14], which only reported injuries leading to time loss, reported the highest relative incidence of joint sprains (66.8%) and fractures (15.6%).

Injury Mechanisms and Situations.
Six articles described the mechanisms and situations of injuries in judo tournaments (Table 5).All articles reported that most of the injuries occurred during standing fght (tachi-waza) situations (ranging between 50.0% and 84.9%) compared to ground fghts (ne-waza) (ranging between 0.0% and 33.3%).Four articles mentioned a third situation category for prohibited actions or when the situation was not clear.Te incidence proportion for this category, "other," ranged from 3.8% to 28%.
Te most common injury mechanism during standing fghts is when the judo athlete is being thrown (ranging between 6.7% and 37.0%, the most common mechanism in three studies).Subsequently, performing a throw (ranging between 6.7% and 34%) and grip fghts (kumi-kata) (ranging between 6.3% and 32.4%, both common mechanisms in two studies) cause most injuries.Te most frequent mechanisms in ground fghts where injuries occurred are armlocks (ranging between 3.7% and 13.3%).Choking injuries occurred in up to 8.8% of the mechanisms, possibly resulting in loss of consciousness.Injuries caused by prohibited actions occurred in up to 7.0%.

Distribution of Injuries across Genders.
Twelve articles described the diferences between the injuries sustained by men and those sustained by women in judo tournaments (Supplementary Appendix C).Te infuence of gender on the injury incidence proportion during judo tournaments is inconsistent.On the one hand, six articles concluded that men were more prone to injuries than women (the incidence of injuries among men ranged between 1.04% and 14.3%).On the other hand, six articles registered more injuries during judo tournaments among women (the incidence of injuries among women ranged between 1.33% and 12.0%).

Distribution of Injuries across Age Categories.
Four articles presented a clear distinction between youth (less than 18 years old) and adult (18 years old and older) athletes with regard to the distribution of injuries (Supplementary Appendix D). Adult athletes (the incidence ranged between 1.3% and 21.0%) sustained more injuries than youth athletes (the incidence ranged between 0.9% and 14.4%) during judo tournaments, according to three out of four articles.However, this diference did not reach statistical signifcance (Maciejewski and Callanta [11]), or the statistical signifcance was not mentioned in the article.

Distribution of Injuries across Weight Categories.
Six articles reported the distribution of injuries across the three main subgroups of weight categories, namely, lightweights, middleweights, and heavyweights.However, six studies did not use the same categorisation for these weight categories.Terefore, the results are inconsistent (Supplementary Appendix E).  8 Translational Sports Medicine   Translational Sports Medicine

Discussion
Tis systematic review focusses on the epidemiology of injuries in judo tournaments.We included twenty-fve articles, of which nine were rated as having good quality, ten were rated as having fair quality, and six were rated as having poor quality.Te tournament injury incidence proportions ranged from 6.8% [35] to 72.5% [39] for injuries requiring medical attention and 1.1% [14] to 4.1% [42] for injuries leading to time loss.Te most commonly injured location overall was the head, followed by the hand, knee, elbow, and shoulder.A sprain was the most common injury type, followed by contusions, lacerations, strains, and fractures.

Injury Defnition.
Te most frequent (n � 16) injury defnition used was "a physical complaint, for which assistance was sought from a tournament healthcare professional," or variations of this defnition [6, 7, . Tis defnition is very practicable in its use and provides insight into the workload of health care professionals who encounter at a judo tournament.An inherent limitation of this defnition is that it does not take injury severity into account.Tis is important because many minor injuries that meet this defnition cause limited impairment and have no or little efect on athlete performance.
A common example is a fnger laceration for which a bandage is applied.Te use of this defnition might overestimate the incidence of injuries irrelevant to the participant, which raises the question whether the use of time loss as criterium for injury is more appropriate in judo.Both defnitions underestimate relevant overuse injuries since most athletes continue to participate despite medical problems.None of the studies defned injury irrespective of the need for medical attention or time loss nor used an athlete's perspective on injuries.We suggest using a modifed version of the Oslo Sports Trauma Research Centre Questionnaire [43] for all participants in future studies, to take injury severity into account and make sure that injuries without medical attention are registered as well.

Injury Incidence.
Te large variation in injury defnitions explains a great proportion of the wide variety in reported injury incidences.For injuries requiring medical attention, the reported injury incidence proportion varied between 2.5% [35] and 72.5% [11] for all competitors.For injuries leading to time loss, the reported incidence proportion ranged between 1.1% [14] and 4.1% [42] for total competitors, with four out of fve studies reporting an injury incidence proportion between 1.1% [14] and 2.6% [8,36].
In the past two decades, judo competition rules have changed several times.Tese rule changes consisted of a change in duration of the contest, scoring system, golden score, and gripping rules [3].Furthermore, some specifc actions were prohibited in order to reduce injuries.Te current competition rules are designed to ensure that judo causes as little trauma as possible [4].In our review, we did not evaluate the efect of rule changes on the injury incidence.Te variation in the methodological approach, injury defnition, and relatively small sample size of some of the included studies will make it difcult to evaluate this efect with the current literature.
Te incidence rates of injury in judo are higher than the reported injury incidence rates in Brazilian jiu-jitsu (BJJ).Scoggin et al. [44] reported an injury incidence rate of 9.2/ 1000 exposures requiring medical attention in eight statewide BJJ tournaments in Hawaii.In our review, not all studies reported the injury incidence rate per 1000 athlete exposures (IIRAEs).Te studies that did so reported an IIRAE between 22.7 [13] and 115 [39] for injuries requiring medical attention.Te diference in BJJ may be caused by the fact that BJJ matches take place on the ground (newaza) for a larger part of the contest than in judo, while most injuries occur during standing fghts (tachi-waza) [9,10,36,38,41,42].Te injury incidence rate in judo is lower than in mixed martial arts (MMAs).In a recent systematic review, Lystad et al. [45] described an IIRAE between 110.4 and 473.5 per 1000 in MMA in their systematic review, but reporting of injury defnitions in the included studies was inconsistent.Te diference in the injury incidence is likely due to the fact that, in MMA, striking and kicking is allowed, and MMA matches consist of multiple rounds and therefore a longer duration of the athlete's exposure.
In another systematic review by Lystad et al., the injury incidence during three consecutive Olympic Games (2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016) in judo was compared with the incidence in the other olympic combat sports, taekwondo, boxing, and wrestling, respectively [21].Te observed IIRAEs, in descending order, were 76.6 in boxing, 46.4 in taekwondo, 34.0 in judo, and 22.7 in wrestling, respectively.In this study, the injury incidence rates in sports that involve kicking and striking are also higher than those in judo.

Injury Location.
Te most frequently injured body location in the included studies was the head.Tis is diferent [3,4] from the results of Pocecco et al., who reported the knee, shoulder, and hand/fngers to be most commonly injured.For injuries leading to time loss, Translational Sports Medicine however, the head was not the most afected injury location in our review.In the study by Frey et al. [14], in which only injuries leading to time loss were reported, 3511 injuries occurred in 316203 competitors.Only 54 of these injuries were head traumas with loss of consciousness, another 54 were fractures of the face, and 47 cases were of loss of consciousness resulting from a choke.Tese injury incidence proportions of the head are much smaller than those in other studies, suggesting that a large proportion of the reported head injuries in other studies consist of minor traumas such as lacerations and contusions that do not result in time loss.Tis is applicable to hand injuries as well.Moreover, although hand injuries were common in the included studies that used medical attention as part of the injury defnition, the hand injury incidence proportion was less than 4% in an online survey for severe injuries with more than three weeks of time loss in 4659 judokas according to Akoto et al. [46].In our systematic review, the knee and shoulder were also frequently injured body locations.Tis is consistent with the fndings of Akoto et al. [46], who found the knee and shoulder to be the most afected body parts (both 23% of all severe injuries), and this is also in line with the study by Kim et al. [23], in which they reported on a four-year prospective injury surveillance study at the training centre in South Korea for national-level athletes and found knees and shoulders to be the second and third most frequently injured body locations.In contrast to our systematic review, they found the lower back to be the most frequently injured body part (10.9%).Tis diference may be caused by the fact that judokas might not seek medical attention for overuse injuries and injuries with a gradual onset during a tournament.
Te elbows were among the top three most commonly injured body parts in three of the included studies [9,17,36].Tese injuries were relatively common in the studies by Akoto et al. [46](reported by >4% of all athletes) and Kim et al. [23] (7.5% of all injuries) as well.

Injury Type.
A sprain was mentioned as the most frequent injury type in most studies.For injuries causing time loss, a sprain was reported to be the most frequent injury type in all studies except for the study by Pieter et al. [38].Frey et al. [14] reported sprains in 66.8% of all injuries, James and Pieter [36] in 100%, Pieter et al. [38] in 33.3%, and Rousseau et al. [8] in 57.6%.For lacerations and contusions, which are the second and third most common injury types overall, frequencies are higher for injuries requiring medical attention than those for injuries leading to time loss.All the three studies that compared injuries between male and female athletes found more knee sprains (including anterior cruciate ligament injuries and medial collateral ligament injuries) in female athletes [14,36,38].Tis may be due to anatomical diferences, hormonal diferences, and diferences in joint laxity.Frey et al. [14] reported more elbow dislocations in female athletes, while male athletes were more prone to shoulder dislocations.Miarka et al. [9] proposed that these sex diferences might be related to the fghting style, with male judokas being more aggressive, having more full-body contact with their opponents, and having more contact with the mat.Tis is consistent with the fnding of Didace et al. [16], who reported more contusions and distortions in woman and more fractures in men.

Injury Mechanisms and Situations.
Six articles described the mechanisms and situations of injuries in judo tournaments [9,10,36,38,41,42].All articles reported that most injuries occurred during standing fght (tachi-waza) situations compared to ground fght ones (ne-waza).Tis is likely caused by the fact that, considerably, more time is spent in tachi-waza than in ne-waza [47].Furthermore, throws (performing a throw and being thrown) carry a relatively high injury risk given the force and speed they require, as well as the impact of the mat, respectively.Two studies [13,38] reported that, during grip fghts (kumi-kata), male athletes are exposed to more hand and fnger injuries requiring medical attention.Contrarily, female athletes spend relatively more time in ground fghts [47] causing elbow dislocations or medical collateral ligament elbow injuries caused by armlocks [14].In standing fghts, more upper limb injuries were reported in female athletes than in male athletes after being thrown [42].

Strengths and Limitations.
Te main strength of this systematic review is that we used an extensive search strategy with broad search terms in fve diferent electronic databases.Database searching was supplemented by extensive hand-searching of all references of the included studies.We performed a quality assessment of the available literature and took the injury defnition into account when analysing the study results.
Limitations of the literature include lack of uniformity in injury defnitions and classifcation of injury types, locations, severity, mechanisms, and weight categories.Because of the heterogeneity of the total group (with diferent injury defnitions, populations, level of competitions, group sizes, and exact outcome measures), we considered a formal meta-analysis of limited additional values.We were able to calculate the percentage of injured competitors per tournament but were unable to calculate the number of injuries per 1000 athlete exposures for every study due to missing data.Te latter is a more efcacious way of defning the injury incidence, as the number of fghts per competitor and tournament can vary widely.Te injury incidence defned as injuries relative to time will be even more efcacious as we are aware that not all athlete exposures are equal.Nevertheless, this timerelated injury defnition was not feasible for the current available literature.
Te quality of the scientifc methods used in diferent studies varied.We measured quality by using a new critical appraisal tool based on the AXIS tool [32].Tis is an objective way to rate studies and reduce the risk of nonsystemic bias.
A possible publication bias is that the included studies were mostly based on high-level tournaments.Terefore, the Translational Sports Medicine current data might not be representative for tournaments on a lower level.4.7.Future Directions.A uniform, reliable, and valid methodological approach can contribute to better injury surveillance studies in judo.Tis can help researchers develop better injury prevention protocols to mitigate preventable injuries and evaluate the efect of rule changes on the injury incidence.In 2020, the International Olympic Committee published a consensus statement regarding the methodology for injury surveillance studies [31].Based on the IOC consensus statement, authors anticipated that sport-specifc statements would provide further recommendations; this has been recently performed by Verhagen et al. for tennis [48].Te IOC consensus statement cannot be generalized to judo because judo has variable lengths of contests, a variable number of contests per tournament, specifc mechanisms, throws and situations in which injuries occur, and specifc individual variables such as the weight class, competition level, and grading system for the belts that judokas wear.In addition, there are some judospecifc injuries, such as loss of consciousness by strangulation, which do not conform to the injury-type categories proposed in the IOC statement.Terefore, we recommend a judospecifc extension of this IOC statement.Tis judo-specifc consensus statement should contain the following methodological topics: injury defnitions, data collection methods, athlete exposure and study population characteristics, a classifcation of injury types, severity, body locations, and injury mechanisms and situations.We propose a broad injury definition in order to register any physical complaint from or during a tournament, irrespective of time loss or medical attention.Injuries should then be further classifed as injuries with or without time loss.Data analysis could be performed more easily by video analysis.

Conclusion
Te tournament injury incidence rate per 1000 athlete exposures ranged from 10.9 to 115 for injuries requiring medical attention and 4.2 to 60 for injuries causing time loss.Te tournament injury incidence proportion ranged from 2.5% to 72.5% for injuries requiring medical attention and 1.1% to 4.1% for injuries causing time loss.Te head was the most frequently injured body part requiring medical attention, and a sprain was the most frequent injury type.Tere was a heterogeneous methodological approach and inconsistent reporting of data in various included studies.We advise future studies to follow the guidelines of the IOC consensus meeting statement on the methodological approach to injury reporting [31].Furthermore, a judo-specifc extension of this statement is suggested in order to achieve an optimal uniformity in the methodological approach and make the results useful for injury prevention programs.

Figure 1 :
Figure 1: PRISMA fow diagram of the study selection.
physical complaint sustained by a competitor irrespective of the need for medical attention or time loss from activities, or which caused an exclusion from sports-related activities for at least 4 loss: all relevant traumatic injuries that resulted in an interruption of practice (either in competition or training) for more than 1 weekInjury surveillance systemGreen et al. 2007 3 Other: a situation in which the judoka either requested medical treatment or was unable to continue a injuries were managed by attending ringside doctors during the competition.Because the recording of injuries was at the discretion of attending ringside doctors, no strict operational injury defnition was imposed in this study Video analysis by ringside doctors Park et al. 2021 2 Time loss: the failure of participation in competitions or trainings for at least 24 physical complaint, which is caused by transfer of energy that exceeds the body's ability to maintain structural and/or functional integrity, which is sustained by a player during a match, irrespective of the need for medical attention or time loss from activities

Figure 2 :
Figure 2: Most common injury locations based on the top 3 of each study (shown in percentage of the total number of injuries per study).

Figure 3 :
Figure 3: Most common injury types based on the top 3 of each study (shown in percentage of the total number of injuries per study).Corresponding articles: Blach (a) � Blach and Malliaropoulos, Blach (b) � Blach and Smolders, Maciejewski (a) � Maciejewski and Callanta, and Maciejewski (b) � Maciejewski and Pietkiewicz.
*Number of competitors is not provided; solely, 18470 athlete exposures (AEs) are provided.

Table 2 :
Injury defnitions used in each study.

Table 3 :
Modifed AXIS scores and allocated quality rating for the included articles.

Table 4 :
Injury incidence rates and proportion and incidence proportion of injuries leading to time-loss.
*12 competitors were lost to follow-up.* * Te authors analysed only 124 of the fghts during 4 international tournaments.

Table 5 :
Distribution (in percentages) of the mechanisms and situations of injuries.