Boxing, and Facial Injuries


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Author: Charlotte Elliott / Editor: Charlotte Davies / Codes: A6, CC1, CC10, O9, R3 / Published: 10/03/2020

Using Emergency Medicine skills as a Boxing Ringside Doctor

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Last April saw the England Boxing National Amateur Championships held in Nottingham. As a member of the England Boxing Medical Committee I was invited to sit ringside for the tournament as the Ringside Doctor. Having skills in Emergency Medicine certainly came in handy and partaking in this fulfilled curriculum requirements I never thought I would tick off whilst I was enjoying myself! I worked with a lead consultant in Sports and Exercise Medicine, England Boxing’s team doctor and two GPs with an interest in Sports Medicine.

I got into being the Medical Doctor for amateur boxing about 5 years ago. To be honest I wasn’t really much of a boxing fan but thought it would be cool and a challenge to try to develop my skills outside of the hospital setting. Now, I enjoy evenings when I am not on the shop floor in a boxing gym or sports hall as a member of the boxing officials and am keen to keep up to date with all the big bouts on the television.

Having seen what good boxing can do for young people I am a great supporter of this sport. Working in the Liverpool area there are disadvantaged neighbourhoods where the boxing gym is a hub of positive activity for young people who may otherwise find themselves with nothing to do. It promotes discipline, respect and healthy competitiveness, not forgetting of course reaping the health benefits of exercise.

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My day at the Championships begin at the weigh ins. There are about 60 boxers to weigh in and then have their pre-bout medicals. The medicals are essential to ensure the boxer is fit to fight. I make sure the boxer is feeling well and ask if they have any injuries to declare. I examine their face, their pupillary responses, teeth, jaw and ensure their gum shield fits. I listen into their chest and make sure there is no palpable rib tenderness. Finally, I examine their hands to make sure there are no signs of fractures, open wounds or any other concerns that would put the boxer at risk if they boxed. All boxers have to have a yearly medical and I make sure this is in date.

After this we meet with the paramedics who we will be working with and together we go through the evacuation procedure in the event of a “down boxer”. This forward planning could save a life. We practise how to get a boxer out of the ring and into the ambulance using our evacuation route. Communication, giving clear instructions and working as a team are key skills. It is also novel to experience pre-hospital care in this setting.

Boxing has gained controversy for allowing boxers to not wear headguards. Male boxers born after 2000 have to wear a headguard and all level of female competitors. Most of the boxers at a typical evening of boxing will wear headguards.

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A cross-sectional
prospective observation study looked at the changes in injuries after the
removal of head guards in AIBA competitions which showed a significant decrease
in the number of stoppages when head guards were not worn (1). It did show
though a notable increase in cuts (1). It is thought to be the rotational acceleration of the head which is the
major factor in concussion or mild traumatic brain injury. Head guards provide
padding over the forehead but only a thin strap under the chin. Padding cannot
be added under the chin as this impedes breathing as the boxer keeps the chin
tucked. It is hypothesized that head guards lead to increased rotational force
and subsequent stoppage by increasing the diameter and surface area of the head.
Furthermore, the padding around the eyes limits the boxers vision which could
increase the risk of blows to the head.

The argument also exists that the head guards give a false
sense of safety and so boxers partake in more high-risk behaviours than they would
have done were they not wearing one.

During a bout I may be asked by the referee to check that a boxer is still fit to box. The most frequent request is to check any wounds a boxer sustains. I have to stop a bout because the wound goes into the ‘inverted bell’ area on the face where damage to underlying structures are more dangerous (2) (Figure 1).

Figure 1: The
inverted bell shape. There is a grid over the top to make recording the wounds position

If the cut is bleeding so much that it impedes the boxer’s vision then the boxer is not safe to continue. Most cuts around the eye but not in the inverted bell are acceptable to continue but may need closing after the bout. I get to use Prineo for one wound – a new tissue adhesive for skin closure which I think is quite cool. The boxers can go on to box the next day with this. They cannot box with visible sutures so this is a great alternative where simple glue may not be quite enough and risk bursting again the next day should they get hit in the same area.

Figure 2 (2): The
above wound is near the lower eyelid and so the infraorbital nerve and within
the inverted bell. The bout should therefore be stopped.

Figure 3 (2): The
above is a wound outside of the inverted bell. It does not appear to be
bleeding and so it is not impeding the boxers vision. The boxer would be ok to
continue boxing.

The inverted bell
rule is used to protect structures from being damaged. The most important
structures within this area are the eyes, lacrimal ducts, nose, lips, mouth and
naso-ethmoidal bones. Cuts in this area could have potentially more serious
consequences than cuts outside the zone.

An injury to the lacrimal ducts or lacrimal canaliculi can cause disruption to the normal flow of tears through the ducts. If there is trauma with a wound to this area it may lead to scarring and stenosis which may result in epiphora – an overflow of tears onto the face.

Trauma to the eye may include a ruptured globe, (an ophthalmologic emergency) or a more common corneal abrasion. Any injury that affects the boxer’s vision should be stopped to protect the boxer.

Damage to the
nasoethmoid bone usually results from a forceful blow to the central aspect of
the midface (outside of boxing they may be seen in motor vehicle accidents).
Damage to the region represents a challenging surgical problem due to the
complexity and density of the anatomic components of the area. Long-term
sequelae include blindness, telecanthus, anosmia or a cerebral spinal fluid
fistula. Of interest, less force is needed to cause these fractures than
zygomatic, maxillary or frontal bone fractures. Wounds therefore over this area
should raise the suspicion of a fracture and the boxer cannot continue their

Wounds within the inverted bell area may also impact on the aesthetic appearance of the face. Cuts outside of the inverted bell zone rarely cause any structural damage unless they involve the superficial supraorbital or supratrochlear nerves (both branches of the frontal nerve, a branch of the trigeminal nerve) or the temporal artery. The supraorbital nerve sits laterally to the supratrochlear nerve extending through the eyebrow to the forehead. The supraorbital nerve provides sensory innovation of the forehead, upper eyelid and anterior scalp and the supratrochlear nerve sensory innovation to the inferomedial section of the forehead, the bridge of the nose and medical portion of the upper eyelid.

I also have to check out a few nose bleeds to make sure the boxers are safe to continue, utilising skills learnt on an AIBA Ringside Doctor course. I have limited time to assess and make a decision so it is important I am confident and clear in my decision-making process and communicate this to the referee. This is certainly one area skills from the Emergency Department come in handy.
To assess the nose bleed I first hold the nose and check that there is no sign of acute fracture. By then occluding the soft part of the nose I look at the back of the boxer’s throat to see if blood is present here, suggesting a posterior bleed. If there is evidence of an arterial bleed or an acutely broken nose then the bout is stopped.

Thankfully, there are no ‘down boxers’ to deal with on the day but our practice runs with the paramedics were still beneficial. Concussion assessments remain controversial – and there’s another RCEMLearning blog on concussion coming soon!

After the 3 days
of boxing action I have learnt a lot to take forward and develop myself as a
doctor for England Boxing and on the shop floor. I feel lucky that
my experience in Emergency Medicine helps me with this job. At medical school
we had limited teaching on sports and exercise medicine. Indeed, one study
found that only 40% of medical schools taught any sports and exercise medicine
on the curriculum, despite a record of interest from medical students (9). The
authors argue that sports and exercise medicine should be incorporated into
medical school teaching to promote the benefits of physical activity in
non-communicable disease prevention and chronic disease management.

Being the Ringside
Doctor is advantageous for Emergency Medicine Doctors to develop their non
clinical skills of communication, working in a team, decision making and
leadership in a pre-hospital setting. It also encourages confidence in dealing
with wounds, epistaxis, musculoskeletal injuries and head injuries along with
other clinical competencies. You also get a free night at the boxing with the
best seats in the house ringside!

To find out more about becoming a doctor for England Boxing check out their website: or email:

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Relevant RCEMLearning Links:

  1. Epistaxis – Reference
  2. Epistaxis – Learning Session
  3. Zygomatic and Nasal Injuries – Reference
  4. Zygomatic and Nasal Injuries – Learning Session
  5. Max-Fax Injuries – Blog


  1. Loosemore M, Butler C, Khadri A, McDonagh D, Patel V and Bailes J. Use of Head Guards in AIBA Boxing TournamentsA Cross-Sectional Observational Study. Clinical Journal of Sport Medicine. 2017;27(1):86-88.
  2. AIBA 2016 Medical Rules for Ringside Doctors. 2016. Available from: [Accessed 12th January 2020].
  3. Sport concussion assessment tool – 5th edition. British Journal of Sports Medicine. 2017;51:851-858.
  4. Mistry D and Rainer T. Concussion assessment in the emergency department: a preliminary study for a quality improvement project. 2018. BMJ Open Sport Exerc Med. 2018; 4(1)
  5. Luoto T, Kataja A, Brander A, Ohrman J and Iverson G. Sport concussion assessment tool second edition in an emergency department setting. British Journal of Sports Medicine. 2013;47:1
  6. Zahid A, Hubbard M, Dammavalam V, Balser D, Pierre G, Kim A, Kolecki R, Mehmood T, Wall S, Frangos S, Huang P, Tupper D, Barr W and Samadani U. Assessment of acute head injury in an emergency department population using sport concussion assessment tool 3rd edition. Applied neuropsychology: Adult. 2018;25:2
  7. England Boxing Rule Book. 2019. Available here. [Accessed 10th January 2020].
  8. Loosemore M, Lightfoot J, Palmer-Green D, Gatt I, Bilzon J and Beardsley C. Boxing injury epidemiology in the Great Britain team: a 5-year surveillance study of medically diagnosed injury incidence and outcome. British Journal of Sports Medicine. 2015;49(17):1100-1107
  9. Jaques R and Loosemore M. Sports and exercise medicine in undergraduate training. The Lancet. 2012;380(9836):4-5.


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