Dear Editor, I read with interest the article written by Dr. G.J. Buse entitled, No holds barred sport fighting: a 10 year review of mixed martial arts competition published in the 6 February 2006 edition of your journal. As a researcher focused on injury prevention, I have recently been part of a research group reviewing data from both mixed martial arts competitions and professional boxing and enjoyed reading the information presented by Dr. Buse. In an article published in October 2005 in the Southern Medical Journal, our research group attempted to define the overall injury rate of athletes participating in professional boxing. We reviewed data from the fight cards published by the Nevada State Athletic Commission and noted any injury comments recorded by the ringside physicians. Our research demonstrated an overall injury rate of 17. injuries per 100 boxer-matches with 11.3% of those matches ending in knockout. In an attempt to compare boxing injuries to mixed martial arts (MMA) injuries, we did a review of the fight cards for MMA matches using the same protocol as for the professional boxing matches. Our data--to be published soon by The Journal of Sports Science and Medicine--indicate that the overall injury rate for MMA matches is similar to professional boxing and the knockout rate is almost half that of professional boxing. In reviewing Dr. Buse's data, I would have liked to have seen a comparison of injury rates before and after the sanctioning of the sport in September 2001. Though MMA began in the United States in 1993, these first fights only superficially resemble MMA matches today and were really very different competitions. Sanctioning brought about many rule changes that mandated weight classes, time limits for rounds and matches, and eliminated many of the most dangerous techniques including stomps, head butts, and groin attacks. Combining MMA matches prior to sanctioning with the sanctioned matches of today is confusing and is not helpful in attempting to determine the true injury risk for participants in these competitions. It should also be noted that although there were five deaths in the boxing ring in the United States during 2005, there has never been an MMA death in the United States. The death cited by Dr. Buse occurred in an unregulated event during 1998 in the Ukraine. MMA fighters in the United States now must pass all the prefight screening tests of professional boxers and are supervised by referees and ringside physicians. It is important not to lump MMA competitions with the infamous "Toughman" competitions--a "sport" that matches amateur participants against trained fighters using "one size fits all" protective gear and often supervised by chiropractors and other untrained medical staff--when comparing MMA to other combat sports. While MMA has never had a casualty in the United States, at least 12 deaths have resulted from Toughman competitions. MMA also has some rules that seem to be an improvement over professional boxing. The fact that MMA has no "standing eight count" enabling a concussed participant time to recover and continue fighting is a tremendous step toward diminishing traumatic brain injury. Furthermore, by allowing leg and arm attacks opponents have a more diverse target area and do not focus solely on attacking the head, and if in trouble, a participant can "tap out" to signify his desire to end the match. In our study, the "tap out" was the second most common means of ending a bout and ended approximately 30% of matches.2 Last, most MMA matches are far shorter than boxing matches. Sanctioned MMA events usually consist of three 5 minute rounds as compared to the usual ten to twelve rounds of boxing. In sum, mixed martial arts competitions are a controversial subject in today's sporting world and while no one would argue that these events are safe, it is important that we in the medical and research communities stay disciplined in our response to these subjects. I am thankful that your journal has taken an active role in seeking to determine the inherent risks of MMA competitions, and I hope that it will continue giving balanced and constructive suggestions regarding MMA and other such controversial subjects. Sincerely, Gregory H. Bledsoe MD, MPH Assistant Professor Department of Emergency Medicine The Johns Hopkins University School of Medicine Baltimore, Maryland Suck it, John McClain. Cliffs: MMA is statistically safer than boxing.