February 2017

Martial arts students at risk for lower extremity injury, sequelae     

Traumas increase with age, skill level


By Chris Klingenberg

Martial arts participation has numerous benefits for children and adolescents, but it also has its risks—including lower extremity injury, according to a recent clinical report and literature review published by the American Academy of Pediatrics’ (AAP) Council on Sports Medicine and Fitness.

The authors noted lower extremity injuries have been associated with karate and taekwondo. Both martial arts emphasize kicking, and lower extremity injuries can result from kicking, or being kicked.

Because most research on martial arts and injury risk has been done in adults, the AAP council issued the clinical report to help pediatric clinicians generalize findings to their younger patients. It was published in the December issue of Pediatrics.

“Children and adolescents should only participate in martial arts classes or competitions supervised by instructors with appropriate training regarding proper teaching of the particular activity and understanding of a child’s limitations based on age, maturity, stature, and experience,” said Rebecca Demorest, MD, a pediatric and young adult sports medicine physician with Webster Orthopedics in Oakland, CA, and first author of the clinical report. “Martial arts competition and contact-based training should be delayed until children and adolescents have demonstrated adequate physical and emotional maturity during noncontact preparation and compe­- tency with noncontact forms, movements, and techniques.”

Instructors need to understand a kid’s age-, maturity-, stature-, and experience-based limits.
—Rebecca Demorest, MD

In a 2007 study, an estimated 128,400 children aged 17 years or younger (mean age, 12.1 years; 73% male) were treated in US emergency departments for martial arts-
related injuries between 1990 and 2003, with most injuries (79.5%) attributable to karate.

On the plus side, martial arts injuries are generally not life-threatening, as the most common injuries include abrasions, contusions, sprains, and strains. Also encouraging is that younger martial arts participants seem to have a lower risk of injury than their older, more experienced counterparts, according to studies cited in the AAP report, though the authors wrote that more research on relationships between skill level, age, and injury risk is needed.

A 2005 study spanning five martial arts disciplines (Shotokan karate, Aikido, taekwondo, kung fu, and tai chi) found people aged 18 years or older were four times more likely to sustain an injury than those younger than 18 years; competitors with at least three years of experience were two times more likely to sustain injury than less experienced competitors. Participants younger than 18 years doubled their risk of injury with every two additional hours of training per week after the first three hours, and those training for more than three hours per week had an overall increased injury risk.

A 2013 study of Australian amateur taekwondo athletes found those younger than 10 years had an overall lower injury rate per 1000 athletic exposures compared with all other age groups; however, when adjusting for exposure time, the 10- to 14-year-old age group had a higher injury risk per minute of exposure compared with the open division.

Although lower extremity martial arts injuries in children may seem minor, not taking them seriously can have negative consequences for both health and performance, said Chris Koutures, MD, a pediatric and sports medicine specialist in private practice in Anaheim Hills, CA, and a coauthor of the AAP clinical report.

“Coming back to martial arts too soon after a lower extremity injury can prolong pain, limit full participation, and potentially increase the risks of a more serious injury or a new injury, especially if the athlete is trying to protect the injured body part,” Koutures said. “I have seen martial arts athletes plateau or even regress in the progression towards high belts and competitive success due to unresolved injuries. I also can see where, for example, a foot injury that isn’t fully healed leads to a knee injury, as the athlete has changed kicking or standing technique and is putting abnormal force on the knee.”

However, young martial arts athletes should be able to continue training, at least in some form, while waiting for lower extremity injuries to heal.

“I am always a big component of ‘what can the athlete do’ and making appropriate modifications in training to help deal with injury recovery,” Koutures said. “With lower extremity injuries, most of these do not require a complete removal from training. There are upper body forms and drills that can be done, both from a standing [but no jumping, contact or impact] or even a sitting position if needed. Good sports medicine professionals can help create a modified plan and communicate with instructors. You can also look at number of repetitions [perhaps do fifty percent of kicks or jumps] or limit sparring but allow more form work.”

Chris Klingenberg is a freelance writer based in Massachusetts.           


Demorest RA, Koutures C, Council on Sports Medicine and Fitness. Youth participation and injury risk in martial arts. Pediatrics 2016;138(6).

Yard EE, Knox CL, Smith GA, Comstock RD. Pediatric martial arts injuries presenting to emergency departments, United States 1990-2003. J Sci Med Sport 2007;10(4):219-226.

Zetaruk MN, Violan MA, Zurakowski D, Micheli LJ. Injuries in martial arts: A comparison of five styles. Br J Sports Med 2005;39(1):29-33.

Lystad RP, Graham PL, Poulos RG. Exposure-adjusted incidence rates and severity of competition injuries in Australian amateur taekwondo athletes. Br J Sports Med 2013;47(7):441-446.

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