Diagnoses for Common Combat Arts Injuries
Walking into a Healthcare Professional's office to discuss an injury can be a daunting experience; especially if you are in discomfort and or pain. Clicking on the body part of concern in the table of content below will provide an overview of the process a Healthcare Professional goes through to diagnose the severity of an injury. Treat it as a guide to what happens at the appointment, not as a way to diagnose yourself at home. Some injuries cannot wait: get emergency care for a deformed limb, bone visible through the skin, bleeding you cannot control, a limb that turns pale, cold or numb, confusion or loss of consciousness after a head shot, or a hot, swollen joint with fever.
LIGAMENT
Physical Exam
The physical exam is important for ligament injuries. Orthopedic doctors can diagnose a ligament injury by a thorough physical exam and with special maneuvers or tests. For example, in ligament injuries of the knee, the anterior drawer test, the Lachman test and the pivot shift test point towards an ACL tear or rupture, though no single test settles it on its own and a swollen, painful knee can be hard to examine at first. For wrist ligament injuries, the doctor checks range of motion, stability and flexibility. Associated joints are tested for range of motion, and muscle strength and power are tested.
Imaging
Ligament injuries are usually diagnosed clinically, from how the injury happened and what the exam shows. Imaging is used to confirm the diagnosis, grade the damage and rule out a fracture when the exam is unclear or the injury looks severe — not every sprain needs a scan. A variety of radiology modalities are used and newer ones are continually being tested.
On ultrasound, an acute ligament sprain often shows a thickened ligament with diffuse hypoechogenicity surrounded by fluid, though this is not always the case. A complete, full-thickness tear is seen as a hypoechoic area that interrupts the ligament fibers and extends across the ligament. As the ligament heals the fluid resolves, but the ligament can stay thick and lax on ultrasound, which demonstrates a stretched ligament. How much a scan shows depends heavily on the skill of the person performing it.
Ligament sprains look broadly similar on MRI wherever they occur in the body. Usually, there is fluid around the ligament in the acute phase, and the damaged ligament appears thickened and lax. A tear shows as fluid crossing the ligament partially or completely, and the course of the ligament is abnormal. Even as the ligament heals, scar tissue makes it look thick or irregular, so the scan report alone does not tell you how well the joint is actually working.
Lab Tests
Blood tests are not used to diagnose ligament injuries.
Read more about the treatment for ligament injuries in our Common Treatment Section.
BONE
Physical Exam
During the physical exam, doctors inspect for signs of an open fracture, ecchymosis, and bruising. These may extend further than the area of the fracture site. They will look for crepitus and pain usually found over the fracture site. They will check for loss of muscle contour. Joint abnormalities are examined. They will also carefully check for neurovascular injury. A comprehensive neurovascular examination is done to rule out nerve injuries. An open fracture, where bone has broken through the skin, is a surgical emergency — go to the emergency department. A closed fracture may cause obvious deformity, but plenty of fractures show only pain, swelling and trouble bearing weight or gripping, so a limb that still looks normal is no proof that nothing is broken. If possible, reflexes, muscle, and range of motion tests are done.
Imaging
Radiographic imaging of all bone injuries begins with plain radiography. In a stress fracture, X-rays may show periosteal and endosteal reaction in the cortical bone, and sclerosis in cancellous bone, but early films are often completely normal. Training on through the pain risks a stress injury progressing to a visible break, which is why bone pain that keeps returning at the same spot needs assessing rather than pushing through.
Changes from a stress fracture typically take two to three weeks or longer to become evident on radiographs, and some never show on plain films at all. Other fractures are usually visible on plain films, described as complete or partial, simple or complex. Often, the plain films are used to grade and classify the fractures.
Multiple views are ordered and usually plain films include the joints above and below the site of the fracture. When the films look normal but the pain continues, cross-sectional imaging is the next step.
MRI is the most sensitive test for early stress injury, showing bone marrow and periosteal edema well before any fracture line appears on X-ray. CT is the better test for fine bone detail: it can pick up occult fractures, map complex fracture patterns, and distinguish solid bone healing from a fibrous union.
On MRI, fractures, periosteal edema and bone marrow edema are all visible, which is why it catches stress injury early. Small bone chips and loose fragments are generally better seen on CT, which shows cortical bone in fine detail, and larger fragments may show on plain films. MRI remains the better choice for the surrounding cartilage, ligaments and marrow.
Three phase bone scans can also be used to image stress fractures. A radioactive tracer is injected and taken up by areas of the bone with high turnover, so the scan is sensitive but not very specific — arthritis, infection and healing bone all light up. It carries a radiation dose, and where MRI is available it has largely taken over.
Lab Tests
In general, laboratory tests have no role to play in diagnosing fractures. In the case of recurrent stress fractures, further investigation is warranted. Vitamin D levels, thyroid-stimulating hormone, parathyroid hormone, serum calcium, magnesium, phosphate levels, and a bone mineral density study are done to rule out other metabolic diseases.
Go through the treatment for bone injuries in our Common Treatment Section.
TENDONS
Physical Exam
To examine tendon injuries, doctors will perform a physical exam. This includes a basic musculoskeletal evaluation and palpation of the involved tendon. Depending on the tendon involved, special tests and maneuvers are done to evaluate and isolate the tendon further. For example, Jobe’s test is done for rotator cuff tendons.
The Yergason test is done for biceps tendonitis. In the above test, the martial artist places the arm at their side. The elbow is flexed at 90⁰ and supinated against resistance. The test is positive if there is referred pain to the bicipital groove. Goniometers are used to check angles. Strength testing is undertaken. Tendinosis is often diagnosed after a history and a physical exam are performed. Injuries are further characterized by specialized further testing.
Imaging
Ultrasound is used frequently for tendon injuries. This is because several interventional procedures to treat tendinosis are done under sonographic guidance. Different frequencies are recommended for optimal visualization and this depends on which tendon is examined.
Common ultrasound findings in tendinosis reveal an increased spacing of the fibrillar lines, reduced echogenicity, thickening of the tendon, and formation of new blood vessels via color Doppler. The MRI is also used to evaluate tendinosis. On MRI, a degenerate tendon usually looks thickened with increased signal inside it; long-standing cases can instead look thin and frayed, sometimes with calcification and wasting of the attached muscle. The fibers may be interrupted, discontinuous, thickened, or lax, and tears are visible on MRI if present.
Lab Tests
Blood tests are not needed to diagnose a straightforward tendon problem. C-reactive protein (CRP) and ESR are ordered when an inflammatory or infected cause is suspected — for instance tendon pain in several joints at once, or pain with fever, redness and heat. They are not very specific tests, but they indicate an inflammatory process in progress.
Learn how tendon injuries are treated in our Common Treatment Section.
NERVES
Physical Exam
The physical exam is important for nerve injuries. This is because most athletes with injuries to the nerves have a characteristic presentation. For example, a martial artist with a radial neuropathy will hold the affected arm with the normal hand. Often with nerve injuries, doctors examine for decreased or absent sensation on different sides of the extremity.
They will also check the range of motion of all the joints. In the arm, this could involve testing the range of motion of wrist, thumb, and fingers. Supination and pronation are checked with and without the aid of gravity. They will text for function and strength. In the extremities, there could be wrist drop or foot drop, which signifies injury to the nerve.
The doctor will also check for other simultaneous injuries that accompany a nerve injury. This could include a dislocation, fractures, and other inflammatory conditions. Sometimes, on a physical exam, the only sign can be weakness, or numbness and tingling while the motor functions remain intact. In that case, a good physical exam is very important.
Imaging
X-rays do not show nerves. They are taken to find the fractures and dislocations that so often accompany a nerve injury, which is why they are usually the first film ordered. Where a compressive or entrapment neuropathy is suspected, MRI or high-resolution ultrasound can show the nerve itself and delineate the injury further.
Electromyograms or nerve conduction studies (EMG/NCS) differentiate nerve versus muscle injury. They measure the speed at which the impulses travel along the nerve. They are also helpful for follow-up management via serial observations to assess the return of nerve function. Many nerve injuries caused by stretch or compression, where the nerve is still in continuity, recover over weeks to a few months — but that depends on the type and severity of the injury, and a nerve that has been cut or torn will not recover on its own. Numbness or weakness that is not improving should be reviewed rather than waited out.
High-resolution ultrasound can also diagnose an entrapment neuropathy, such as compression of the radial nerve at the spiral groove of the humerus.
Lab Tests
Blood tests are not necessary to diagnose nerve injuries.
Go through the treatment for nerve injuries in our Common Treatment Section.
MUSCLE
Physical Exam
The doctor will examine the athlete for bruising and swelling in moderate to severe injuries. They will look for an area of point tenderness or localized tenderness. The proximal attachment to a bone or joint may be tender. Athletes with muscular injuries may experience pain while a range of motion is done, adduction or abduction with or without resistance is tested.
They may also have pain with passive stretching. Doctors will check all these movements and test the muscle strength. The strength or power of the muscle is reduced depending on the degree of injury. In muscle sprains and strains, loss of strength is due to pain. In muscle or tendon rupture or avulsion injury, there may be a complete strength deficit. In the case of muscle rupture, the doctor will look for any visible deformity.
Imaging
X-rays are not needed for most simple muscle strains, and when they are taken they are usually normal. They are ordered when the mechanism or the exam raises the possibility of a fracture or an avulsion injury, where a tendon has pulled a fragment of bone away. Anteroposterior and lateral views are done, with special views requested depending on the muscle — for adductor strains, for example, a frog leg view is advised alongside the AP view of the pelvis. Avulsion injuries are seen on X-rays, which can also reveal stress fractures or other associated fractures.
When a strain is severe, when a complete tear or avulsion is suspected, or when the diagnosis is not clear, MRI is the usual next test. Injury is seen as muscle edema and hemorrhage at the site, and any bone injuries will be further elucidated on the MRI.
Musculoskeletal ultrasound can visualize the tendon and muscle attachments to the bones, muscles, ligaments, and nerves. Ultrasound can identify the area and extent of an injury. It is also helpful for assessing the recovery from an injury.
Lab Tests
Blood tests are not required to diagnose muscle injuries. However, if an athlete develops repeated muscle injury or diffuse muscle pain, CRP, ESR, and CK are tested.
Read about the treatment for muscle injuries in our Common Treatment Section.
JOINTS
Physical Exam
On physical exam, doctors will look for pain in the joint and where it radiates to. They will test if the pain is worse on movement or improves with rest. They will look for swelling, bruising, any deformity of the joint, and tenderness.
The doctors will test for active and passive range of motion. Specific to the joint are various tests where the doctor looks for specific signs. For example, the piano key sign is seen, while the clavicle is elevated and rebounds after inferior compression in the case of distal radioulnar joint injury. All the contributing bones of the joint are evaluated for a possible fracture. A full neurovascular examination is done to test the nerves and vessels.
Imaging
Standard x-rays are done to diagnose joint injuries. Anteroposterior and lateral views of the injured joint are advised, with additional views depending on the joint involved. Films of the uninjured side are sometimes added for comparison, particularly in young athletes whose growth plates can be mistaken for a fracture. For example, in the case of shoulder injuries or injuries to the acromioclavicular joint, the Zanca view is done.
This is an AP view done by tilting the beam 10 to 15⁰ cranially. Comparing the injured joint with the same joint on the other side can help when the diagnosis is uncertain, though it is not done for every injury. Stress views are occasionally used to evaluate displacement of the joint if the diagnosis is unclear with a standard AP view.
For more clarity, an ultrasound or MRI is done for further evaluation.
Usually, with the help of imaging, joint injuries are classified. The classification determines the treatment. In the case of the acromioclavicular joint, the Rockwood Staging System is outlined to guide further treatment.
Lab Tests
In the case of joint injuries, blood tests are not needed for diagnosis unless surgery is planned. If a joint is suspected of being infected, a CBC, ESR, CRP and a basic metabolic panel are done — but normal blood results do not exclude infection. Arthrocentesis, aspirating the joint and sending the fluid for cell count, Gram stain and culture, is the test that settles it. A hot, swollen, intensely painful joint, especially with fever, needs same-day assessment at a doctor or emergency department, because an infected joint can destroy cartilage within days.
Learn more about how joint injuries are treated in our Common Treatment Section.
BURSA
Physical Exam
Doctors will first palpate the bursa to look for pain and tenderness. They will also test the range of motion of the involved joint. They will specially test for active motion since, in many athletes, the bursa may not be painful when the muscles are at rest without activation, especially if they’re not compressing the bursa. In many cases, pain occurs during flexion and not on extension. So, a full range of motion is tested to check the biomechanics involving the bones, muscles, and tissues around the bursa.
If an athlete has chronic bursitis, it may be completely painless, since the bursa has had time to expand and accommodate the increased fluid. As a result, there will be considerable swelling and thickening of the bursa. Therefore, doctors will examine the skin very carefully for trauma, erythema, and warmth. Skin temperature is a useful clue — small studies of olecranon bursitis report that a difference of roughly two degrees centigrade compared with the same bursa on the other arm points towards infection — but it is a pointer, not proof, and aspirating the bursa is what confirms an infected one.
The doctor will look for musculoskeletal imbalances or certain anatomic variants. They will test the strength of the associated joint. There are various examples where anatomy and musculoskeletal imbalances can cause bursitis. For example, chronic back pain can worsen trochanteric bursitis, which can be precipitated by gluteus minimus or medius tendinopathy. Pes planus or flat feet and genu valgum or knock knees can develop pes anserine bursitis. And so the doctor will look for these anatomic variants.
Imaging
Bursitis is typically diagnosed clinically, and imaging is not always needed. It earns its place when the precise cause is unknown, when the bursa is deep, or when infection or a fracture is suspected. Plain film imaging of the affected joint or bursa is done in athletes with trauma, or with swelling and pain over bone. MRI is used to evaluate the deeper bursa, and the bursa can also be visualized via ultrasound.
The benefit of the ultrasound is that it shows real-time images of a joint and the area surrounding the bursa. This provides the opportunity to see changes with active and passive motion.
Ultrasound can also see the cobblestone appearance of the fat overlying a bursa. This is helpful as it differentiates cellulitis from infectious bursitis. Color Doppler can show signs of infection, which look like hyperemia of the bursa and the surrounding tissues.
Lab Tests
Blood tests are not diagnostic of bursitis unless an infectious cause is sought. In that case, CBC and ESR are done. The inflamed bursa is aspirated if septic bursitis or crystalline disease complicates the injury. The aspirated fluid is sent for cell count, Gram stain, culture, glucose, and analysis for crystals.
Go through the treatment for bursa injuries in our Common Treatment Section.
SKIN
Physical Exam
The physical examination of abrasions is important for treatment. Doctors look for the type, size, shape, color, location, size, depth, other associated injuries as well as the presence of extraneous material. Based on this the treatment and medication change.
Imaging
Most abrasions are diagnosed clinically and need no imaging, especially when the graze involves only the top layer of skin. Imaging is ordered when something deeper is suspected — nerve, bone, muscle, tendon or vascular injury — or when grit, glass or another foreign body may be left in the wound, in which case an X-ray or ultrasound is used to look for it. A wound that will not stop bleeding, gapes open, or develops spreading redness, heat and swelling needs to be seen the same day.
Lab Tests
Blood tests are not required to diagnose abrasions. However, if there is deeper injury and delayed healing, CBC and ESR may be done. In some cases, doctors may swab the injury and send it for culture and sensitivity tests just to prescribe the right antibiotics.
Go through the treatment for skin injuries in our Common Treatment Section.
CARTILAGE
Physical Exam
Doctors will look for weakness, instability, or clicking. Certain cartilage injuries are very common with individual sports and so many athletes can have certain common movements that injure the cartilage characteristically. The heavy load placed on the wrist during a swinging action can cause triangular fibrocartilage complex (TFCC) injuries.
So, doctors will test the joint with a range of motion tests. In the wrist, this will include pronation and supination. They could do additional tests that are specific to that cartilage. For example, in TFCC, a TFCC compression test is done. Here, the forearm is in the neutral position and ulnar deviation reproduces symptoms.
The TFCC stress test where a force is applied across the ulna and the wrist is in ulnar deviation causes symptoms. Another test is the Press test where the athlete lifts themselves out of a chair by using the extended wrists. Pain indicates a positive test.
Additionally, there’s the supination test, the piano key test, and the grind test. The supination test identifies a tear where the athlete grabs the underside of a table with the forearms supinated. The piano key test suggests distal radioulnar joint instability. The Grind test indicates a degenerative process where the athlete rotates the forearm and has pain. These are specific tests for the TFCC. Similarly, there are specific tests for various cartilaginous injuries.
Imaging
The initial imaging is always a radiograph to evaluate for fracture. An MRI follows with or without an arthrogram. An arthrogram shows the communication of contrast and directly visualizes a tear. If MRI is contraindicated, a CT is done. Arthroscopy is the most accurate way to diagnose certain cartilage injuries.
Lab Tests
Blood tests are not necessary to diagnose cartilage injuries.
Read more about cartilage injuries in our Common Treatment Section.
SOFT TISSUE
Physical Exam
Doctors will carefully assess athletes with acute blunt trauma. This is to make sure serious injuries are not missed. This assessment is done in the form of primary, secondary, and tertiary surveys with appropriate intervention and resuscitation as required. They will inspect, palpate and percuss as needed.
Since blunt impact injuries are not always visible, especially deeper-seated injuries, the doctors will examine adjacent or underlying subcutaneous soft tissues. This will identify a hemorrhage due to ruptured blood vessels.
Imaging
Depending on the location of blunt impact, X rays may be done initially, and can show free air in the abdomen or chest, which points to a ruptured organ or a punctured lung. In practice a bedside FAST ultrasound is often used first to look for free fluid, and CT is the main test for evaluating hemorrhage and damage to the organs in someone stable enough for the scanner. An MRI provides even better visualization of soft tissues and can demonstrate tears, edema, disruption, and contusions, but it is rarely used in the acute setting. Worsening abdominal or chest pain, breathlessness, dizziness or fainting after a heavy body shot means emergency care, not wait and see.
Lab Tests
A battery of blood tests is done to evaluate the state of function of the organs and metabolic functions. These include complete blood count (CBC), serum chemistries, glucose, serum amylase, urinalysis, coagulation studies, blood typing and cross-matching in preparation for surgery, and arterial blood gases (ABGs) among others.
Review soft tissue treatment approaches in our Common Treatment Section.
DENTAL
Physical Exam
The physical examination involves assessing the tooth socket for foreign material, tooth fragments, and lacerations. It's necessary to evaluate these as they determine tooth replantation. The clinician will also evaluate the surrounding structures for other associated injuries such as lacerations, fractures, and ecchymoses.
Imaging
Imaging usually includes extra and intraoral radiographs. In some cases, CT scans evaluate for alveolar and surrounding fractures, and CT can locate a tooth that has been intruded rather than lost. If a knocked-out tooth cannot be accounted for at all, a chest film may be needed to be sure it has not been inhaled. None of this should hold up treatment: a knocked-out adult tooth is time critical, so handle it by the crown only, keep it moist in milk or saline, and get to a dentist or emergency department within the hour.
Lab Tests
Blood tests are not done to diagnose dental injuries as imaging is diagnostic. However, if an infection is suspected, then a CBC may be done.
Learn how dental injuries are treated in our Common Treatment Section.
VASCULAR
Physical Exam
The physical exam is very important. For all bleeds, irrespective of size, the advanced trauma life support (ATLS) protocol is done. Doctors look for hard signs and soft signs, especially for bleeding in the extremities. The Western Trauma Association (WTA) defines hard signs as expanding hematoma, bruit, thrill, external bleeding, pulselessness, pallor, paresthesia, paralysis, or pain.
Soft signs are a history of arterial bleeding at the scene or en route, neurological deficit occurring in a nerve next to an artery, and a small non-pulsatile hematoma over an artery.
Doctors assess circulation by palpating pulses in the extremities. Hard signs such as pulsatile or uncontrolled bleeding, an expanding hematoma, or a pale, pulseless limb need immediate treatment rather than imaging — call emergency services, press hard on the bleeding point with a cloth, and keep the pressure on until help arrives. If no hard signs are present in the primary survey then doctors look for soft signs for vascular injuries.
Imaging
In athletes who have small vascular injuries and among those who are stable but have abnormal physical exam arteriography, CT arteriography, or duplex ultrasound is ordered.
CT arteriography (CTA) is very sensitive and specific for arterial injuries, especially in the extremities. Standard arteriography is a more invasive study. Duplex ultrasound is an option to evaluate vascular injuries.
Lab Tests
Standard trauma labs include a complete blood count (CBC), electrolytes, BUN, creatinine, amylase, clotting studies — prothrombin time (PT) and partial thromboplastin time (PTT), which are two different tests — blood type and screen (T&S) or type and crossmatch (T&C), urinalysis (UA), and arterial blood gases and lactate.
Learn how vascular injuries are treated in our Common Treatments Section.
Frequently Asked Questions
When Should a Training Injury Send Me Straight to the ER?
Get emergency care for an obviously deformed limb, bone visible through the skin, bleeding you cannot control, a limb that turns pale, cold or numb, confusion or loss of consciousness after a head shot, or a hot, swollen joint with fever. A knocked-out adult tooth is also urgent — keep it moist in milk and see a dentist within the hour. Anything less dramatic can usually wait for a same-day or next-day appointment, but pain that keeps getting worse should be reviewed rather than trained through.
Do I Need an X-Ray for Every Martial Arts Injury?
No. Most simple sprains and muscle strains are diagnosed from how the injury happened and what the physical exam shows, and X-rays are usually normal in a straightforward strain. Imaging is ordered when a fracture, dislocation, avulsion or retained foreign body is suspected, when you cannot bear weight or move the joint, or when symptoms are not settling as expected. Which test fits the question is a decision for the treating clinician, not something to work out yourself.
Why Didn't My X-Ray Show a Stress Fracture?
Plain X-rays are often normal in the early weeks of a stress injury, and some stress fractures never show on them at all. Changes such as new bone along the cortex may take two to three weeks or longer to appear. MRI is the most sensitive test for early stress injury, with CT or a bone scan used in selected cases. A normal X-ray is not permission to keep training on a painful bone.
What Is the Difference Between an MRI, a CT Scan and an Ultrasound?
They answer different questions. CT shows bone in fine detail and is best for small fragments, complex fracture patterns and assessing organ damage after heavy blunt trauma. MRI shows soft tissue best — ligaments, tendons, cartilage, muscle and bone marrow swelling — which is why it picks up stress injury early. Ultrasound images tendons and superficial soft tissue in real time and can guide injections, but its accuracy depends heavily on the operator.
Can Blood Tests Diagnose a Sprain or a Broken Bone?
No. Blood tests do not diagnose sprains, fractures, nerve injuries or cartilage tears. They are used to look for something else going on: infection, an inflammatory condition, or metabolic causes of repeated stress fractures such as low vitamin D. If a joint or bursa may be infected, the fluid itself is aspirated and tested, because normal blood work alone cannot rule infection out.
