Original Research

Injury Patterns, Risk Factors, and Return

to Sport in Brazilian Jiu Jitsu
A Cross-sectional Survey of 1140 Athletes
Maximilian Hinz,* MD, Benjamin D. Kleim,* MD, Daniel P. Berthold,* MD, Stephanie Geyer,* MD,
Christophe Lambert,† MD, Andreas B. Imhoff,*‡ MD, and Julian Mehl,* MD
Investigation performed at the Department of Orthopaedic Sports Medicine, Klinikum rechts der
Isar, Technical University of Munich, Munich, Germany

Background: Brazilian jiu jitsu (BJJ) is a growing martial art that focuses on grappling techniques.
Purpose: To quantify the 3-year incidence of BJJ-related injuries and detect common injury patterns as well as risk factors among
those practicing BJJ. It was hypothesized that there would be a high incidence of injuries, they would be caused by submissions in
sparring situations, and they would occur predominantly at the extremities.
Study Design: Descriptive epidemiology study.
Methods: Active BJJ athletes were invited to take an English-language online survey developed by orthopaedic surgeons together
with BJJ athletes and a sports scientist. Data were recorded regarding athlete demographics, sporting activity level, injuries within
the past 3 years that caused at least a 2-week time loss, injury mechanisms, and return to sport.
Results: Overall, 1140 responses were received from 62 different countries; 88.9% of all athletes were male, and 63.9% were
regular competitors. Within the investigated cohort, 1052 injuries were recorded in 784 athletes, for an injury incidence of 308 per
1000 athletes per year. The lower extremity (45.7%) and upper extremity (30.2%) were predominant sites of injury, with injuries to
the knee (27.1%) being the most common. The most frequent knee injuries were meniscal injuries (n ¼ 65), anterior cruciate lig-
ament (ACL) tears (n ¼ 36), and medial collateral ligament injuries (n ¼ 36). ACL tears were especially associated with long time
frames for return to sport. Most injuries occurred during sparring (77.6%) and were caused by submissions (29.7%) and takedowns
(26.4%). Competing regularly (P ¼ .003), older age (P < .001), and higher belt rank (P ¼ .003) were significant risk factors for injury.
Conclusion: Injury incidence was high among BJJ athletes surveyed, with 2 out of 3 athletes reporting at least 1 injury within a 3-
year period that caused a 2-week absence from training. Most injuries occurred during sparring, and we believe that a high
potential for injury reduction lies in drawing awareness to common injury patterns and sites in athletes.
Keywords: BJJ; martial arts; sports injuries; injury prevention; grappling; return to sport; knee injury; shoulder injury

Brazilian jiu jitsu (BJJ) is a unique martial art that Studies that have been conducted on the epidemiological
emphasizes grappling techniques, in contrast to sports characteristics of injuries in other martial arts, such as
such as boxing that focus on striking. In a BJJ match, judo, boxing, taekwondo, Shotokan karate, and wres-
athletes aim to secure superior positioning and immobilize tling,1,4,11,14,15,19,26 indicate that injury rates and sites of
the opponent by applying chokeholds and joint locks. injury may differ between martial arts.9,30 Data on the epi-
Rooted in Kodokan judo, BJJ was developed in the early demiology, mechanisms, and the prevention of injuries in
20th century and is associated with the Gracie family from BJJ are still relatively limited.
Rio de Janeiro, Brazil. In 1993, Royce Gracie won the first Moriarty et al17 and Petrisor et al21 investigated BJJ-
Ultimate Fighting Championship, an event in which ath- related injuries in both training and competition and found
letes with different martial art backgrounds compete in that injuries occur commonly in BJJ: The studies reported a
hand-to-hand combat. Royce Gracie’s success brought high injury prevalence (9/10 athletes sustaining at least 1
mainstream popularity to BJJ.23,27 injury)21 and a 6-month injury incidence rate of 59.2%.17
Both studies also examined the most common site of injury,
The Orthopaedic Journal of Sports Medicine, 9(12), 23259671211062568
with Moriarty et al reporting the knee and Petrisor et al
DOI: 10.1177/23259671211062568 reporting the upper extremity and neck to be the most
ª The Author(s) 2021 common. Other studies focused on injuries sustained

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1
2 Hinz et al The Orthopaedic Journal of Sports Medicine

during competition or training exclusively. Scoggin et al23 The survey comprised 3 sections. Participant data (sex,
collected data on injuries occurring during competitions, country of residence, age, height, weight) were collected in
including injury mechanisms and specific diagnoses. Their the first section. The second section focused on training expe-
reported injury incidence was 9.2 per 1000 match participa- rience and exposure: years of training, belt rank, training
tions, with the elbow being the most injury-prone joint. hours per week, and competition frequency and level. Addi-
McDonald et al16 similarly compiled data on injuries, with tionally, data were collected on preventive measures that
the exception of injury mechanisms, and focused on those were taken by athletes to reduce the risk of injury. The third
injuries occurring in training. The investigators found that section contained questions related to injuries. Athletes were
the hand, fingers, foot, toes, arm, and elbow were the most asked to report injuries in the last 3 years of participating in
commonly affected body regions. BJJ. Injury was defined as any musculoskeletal problem
Although some studies provide more knowledge on BJJ that occurred during training or competition. To limit this
injury occurrence and site of injury, they lack information to significant cases, we specified injuries causing an
on injury diagnoses and mechanisms. Those that have absence in training for at least 2 weeks. All injuries were
reported on diagnoses and mechanisms did so within a lim- self-reported and required no verification by a specialist.
ited scope of BJJ activity (training vs competition). It has With each reported injury, athletes were asked to specify
yet to be determined which movements lead to specific the injury location (head, neck, shoulder, upper arm,
pathologies and in which phase of training or competition elbow, forearm, wrist, hand, fingers, thorax and trunk,
they occur for a large cohort. Additionally, beyond the spine, upper back, lower back, hip, thigh, knee, calf, ankle,
injury itself, the current literature also lacks information foot, toes) and mechanism; time frames for return to activ-
on postinjury data, such as BJJ injury-specific return-to- ity, sport, and competition; and behavioral changes that
sport rates. were adopted after the injury occurred to prevent future
In the present study, we aimed to quantify the 3-year injuries. To keep the survey short and participation rates
incidence of BJJ-related injuries and detect common injury high, we limited the number of reportable injuries to 3.
patterns and risk factors among those practicing BJJ. We For each injury, we recorded the time frame needed to
also set out to review the effectiveness of any measures that achieve the following milestones:
athletes take to prevent injuries and identify postinjury
behavioral adaptations. It was hypothesized that there  Return to activity (eg, running, biking, swimming,
would be a high incidence of injuries with a minimum lifting weights)
absence from training of 2 weeks, the injuries would be  Return to technique training (no sparring, just drills)
caused by submissions in sparring situations, and they  Return to full-contact training or sport (sparring
would occur predominantly at the extremities. included)
 Return to competition
The results were categorized into the following time inter-
METHODS vals: (1) <1 month, (2) 1 to 3 months, (3) 3 to 6 months, (4) 6
Development of the Survey and Data Collection to 9 months, (5) 9 to 12 months, (6) >1 year, and (7) return to
activity not yet achieved. A total of 8 athletes with recurrent
A survey of injuries incurred during BJJ was developed by injuries were excluded from the return-to-sport analysis to
orthopaedic surgeons together with BJJ athletes and a create a homogeneous and comparable subgroup.
sports scientist. After an initial pilot survey, the final
67-item questionnaire (see Supplementary Material) was Statistical Analysis
presented using a commercial website for online surveys
(SurveyMonkey; Momentive Europe Unlimited). It was Quantitative data were represented by mean ± standard
shared by members of the public, specifically BJJ athletes, deviation (SD) for normally distributed data and by median
through social media platforms (Reddit, Facebook, Insta- (interquartile range) for data that were not normally dis-
gram, Beltchecker), where BJJ practitioners were asked tributed. Normal distribution was tested using the Shapiro-
to participate. The online survey was open for 61 days Wilk test and graphically confirmed. Categorical variables
between June and August 2020. Study approval was were described by absolute and relative frequencies.
obtained by the ethics committee of our institution, and all A hierarchical linear regression model performed in
data were collected anonymously. 3 stages was used to determine risk factors for the number

‡
Address correspondence to Andreas B. Imhoff, MD, Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of
Munich, Ismaninger Straße 22, 81675 Munich, Germany (email: [email protected]).
*Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
†
Department of Trauma and Orthopedic Surgery, University of Witten/Herdecke, Cologne Merheim Medical Center, Cologne, Germany.
Final revision submitted July 20, 2021; accepted September 3, 2021.
One or more of the authors has declared the following potential conflict of interest or source of funding: This study was sponsored by AGA (Association for
Arthroscopy and Joint-Surgery; Zurich, Switzerland). The study sponsors had no influence on the collection, analysis, or interpretation of the data or the
decision to submit the work for publication. A.B.I. is a consultant for Arthrosurface and Medi Bayreuth and receives royalties from Arthrosurface and Arthrex.
AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and
disclaims any liability or responsibility relating thereto.
Ethical approval for this study was obtained from the Technical University of Munich (reference: 180/20 S).
The Orthopaedic Journal of Sports Medicine Injuries in Brazilian Jiu Jitsu 3

of accumulated BJJ-related injuries over the 3-year period athletes (88.9% male) from 62 countries were eligible for
before completion of the survey. Stage 1 consisted of partic- final analysis. The mean age of the athletes was 31.7 ±
ipant factors (sex, age, height, and weight), stage 2 encom- 7.9 years. The data indicated that 728 (63.9%) athletes com-
passed factors related to training and competition (belt peted at least once per year; further, 424 (37.2%) competed
rank, training hours per week, and competition frequency at a regional level championship, 138 (12.1%) at a national
per year), and stage 3 was comprised of measures under- championship, and 166 (14.5%) at an international
taken to prevent injury (sleeping, eating, and training championship.
habits and other measures). The number of injuries accu-
mulated over the 3-year time period was defined as the Injury Incidence
dependent variable. Statistical analysis was performed
using SPPS 26.0 software (IBM). Independent variables Within the 3-year period that this survey covered, 356
with P < .05 were defined as significant. (31.2%) athletes stayed injury free, 556 (48.7%) reported
1 injury, 188 (16.6%) reported 2 injuries, and 40 (3.5%)
reported 3 injuries with an absence from training of
RESULTS >2 weeks according to this study’s definition of injury. With
1052 injuries reported, an incidence rate of 308 injuries
Study Population per 1000 athletes per year was determined. The most
commonly injured body regions were the lower (45.7%) and
A total of 1517 athletes participated in this survey. After the upper extremity (30.2%), specifically the knee (27.1%)
the exclusion of incomplete questionnaires, data from 1140 and shoulder (14.6%).
TABLE 1
Overview of Injury-Causing Mechanisms Mechanism of Injury

Injury Mechanism and Description n (%) Injury mechanisms are shown in Table 1. Most injuries
occurred during submissions (29.7%), takedowns (26.4%),
Submission and guard passes (24.0%). In guard, both athletes are on
My opponent was attempting a submission 246 (23.4) the ground with 1 athlete attempting to use his legs to
Armbar 55 control his opponent while the other athlete is attempting
Kimura 31
to overcome this defense in order to reach a more domi-
Heel hook 27
I was attempting a submission on my opponent 66 (6.3)
nant position, a technique known as a guard pass. Within
Triangle choke 19 injuries occurring during submissions, the majority were
Rear naked choke 8 sustained by the submitted individual (78.9%), whereas a
Armbar 7 minority occurred in the athlete applying the submission
Takedown (21.1%). Submission techniques that caused the most
I was taken down 178 (16.9) injuries to the individual they were applied to were the
I was taking my opponent down 100 (9.5) armbar (22.4%), the kimura (12.6%), and the heel hook
Guard pass (11%) (Figure 1).
I was passing guard 107 (10.2)
My opponent was passing my guard 145 (13.8)
Sweep Injury Timing
I was sweeping my opponent 45 (4.3)
I got swept by my opponent 40 (3.8) The majority of injuries occurred during sparring (n ¼ 816;
Other 115 (11.8) 77.6%). Competition and technique training/drilling led to
injury in 101 (9.6%) and 120 (11.4%) cases, respectively.

Figure 1. Overview of the 3 submission techniques that most often caused injury to the athlete against whom they were performed. (A)
Armbar: the attacker (white) applies pressure on the defender’s elbow (black), causing hyperextension. (B) Kimura: the attacker forces
the defender’s shoulder into forceful internal rotation. (C) Heel hook: the attacker causes rotation of the foot, ankle, and lower leg.
4 Hinz et al The Orthopaedic Journal of Sports Medicine

90 84 84
80
71
70 65

60

50 46 45
No. of Injuries

41
40 36 36 36

30

20

10

0
Knee Rib Injury Shoulder Meniscus Ligamentous Neck Back Elbow ACL Tear MCL
Injury, (Bruise, Injury, Injury Ankle Injury, Injury, Injury, Tear/Injury
Unspecified Contusion, Unspecified Injury Unspecified Unspecified Unspecified
Fracture)

Figure 2. Most common injuries in all participants. ACL, anterior cruciate ligament; MCL, medial collateral ligament.

A comparably lower number of injuries occurred during Risk Factors

warm-ups (n ¼ 15; 1.4%).
Participant Factors. From the hierarchical linear regres-
sion model, older age was determined to be a significant
Frequently Specified Injuries risk factor (P < .001) for injury over a 3-year time period.
Other participant factors showed no significant association
The most commonly reported injuries are shown in with injury incidence (Table 3). Participant variables
Figure 2. Table 2 shows return-to-sport data for the accounted for 2% of the variability in injury incidence
5 most frequently specified injuries: anterior cruciate (R2 ¼ 0.020).
ligament (ACL) tear, ligamentous ankle injury, medial Factors Related to Belt Rank, Training, and Competition
collateral ligament (MCL) injury, meniscal injury, and Behavior. Training experience and weekly training hours
rib injury (bruise, contusion, fracture). showed no association with the number of injuries accumu-
Including recurrent injuries, a total of 36 ACL tears lated. However, taking part in competitions was a signifi-
were reported by 35 athletes; in 36.1% of instances, the cant risk factor (P ¼ .003). In contrast to athletes who did
ACL tear was the result of takedowns, affecting the not participate in competitions (36.1%), who had on average
taken-down athlete. Ligamentous ankle injuries (ie, ankle
0.76 ± 0.72 injuries, competitive athletes (63.9%) had 1.01 ±
sprains) were reported in 46 cases by 45 athletes. The
0.80 injuries. Belt rank also had a significant correlation
majority (60.9%) of ligamentous ankle injuries occurred
with injury incidence (P ¼ .003). Athletes with a white belt
during submissions, predominantly during toeholds (14
(the lowest rank; 36.3% of all athletes) had the lowest inci-
athletes) (Figure 3), straight ankle locks (8 athletes), and
dence of injury (0.73 ± 0.69), whereas brown-belt athletes
heel hooks (6 athletes). A total of 36 MCL injuries or tears
(the second highest rank; 6% of all athletes) had the highest
were reported by 36 athletes. More variation in injury
number of injuries (1.22 ± 0.84) (Table 4). Variables related
mechanism was observed for MCL injuries and tears com-
to belt rank as well as training and competition behavior
pared with other injuries: 10 injuries (27.8%) were attrib-
accounted for 5% of the variability in injury incidence
uted to submissions, equally divided between the
(R2 ¼ 0.050).
submitting and submitted opponents, and 6 injuries
Factors Related to Injury Prevention. Measures taken
(16.7%) occurred each in taken-down opponents and pass-
for injury prevention, specifically dietary, sleep, and mobil-
ing opponents. Of all 65 meniscal injuries reported by 61
ity- and strength training-related activities, showed no sig-
athletes, 18 (27.7%) resulted from takedowns, equally
nificant impact on injury incidence over the 3-year period
divided between the participants performing the take-
(Table 5). However, factors related to injury prevention
down and the participants who were taken down. Further-
accounted for 6.3% of the variability in injury incidence
more, 16 (24.6%) occurred during guard passes, with 11 of
(R2 ¼ 0.063).
those occurring in the athletes whose guard had been
passed and 5 in the athlete performing the guard pass.
Finally, a total of 82 athletes reported 84 rib injuries. Behavioral Adaptations After Injuries
The majority of these injuries occurred in athletes
whose guards were passed (29.8%) or who were taken Athletes were asked about single behavioral changes that
down (23.8%). had been implemented after each injury to prevent further
The Orthopaedic Journal of Sports Medicine Injuries in Brazilian Jiu Jitsu 5

TABLE 2
Return-to-Sport Data for the 5 Most Common Injuriesa

Ligamentous Ankle MCL Meniscal Rib Injury (Bruise,

ACL Tear Injury Injury Injury Contusion, Fracture)
Time to Return (n ¼ 34) (n ¼ 44) (n ¼ 36) (n ¼ 57) (n ¼ 80)

Return to activity (eg, running, biking, swimming, lifting weights)

<1 mo 9 (26) 23 (52) 13 (36) 23 (40) 34 (43)
1-3 mo 12 (35) 17 (39) 19 (52) 17 (30) 37 (46)
3-6 mo 9 (26) 2 (5) 3 (8) 11 (19) 5 (6)
6-9 mo 3 (8) 1 (2) 1 (3) 3 (5) 3 (4)
9-12 mo 1 (3) 0 0 1 (2) 1 (1)
>1 y 0 0 0 1 (2) 0
Not yet achieved 0 1 (2) 0 1 (2) 0
Return to technique training (no sparring)
<1 mo 4 (12) 25 (57) 8 (22) 11 (19) 20 (25)
1-3 mo 5 (15) 13 (30) 19 (53) 20 (35) 52 (65)
3-6 mo 8 (24) 3 (7) 6 (17) 18 (32) 6 (8)
6-9 mo 10 (29) 1 (2) 1 (3) 1 (2) 1 (1)
9-12 mo 4 (12) 0 0 4 (7) 1 (1)
>1 y 2 (6) 1 (2) 1 (3) 3 (5) 0
Not yet achieved 1 (3) 1 (2) 1 (3) 0 0
Return to full-contact training (sparring included)
<1 mo 2 (6) 14 (32) 4 (11) 5 (9) 9 (11)
1-3 mo 3 (9) 16 (36) 12 (33) 13 (23) 48 (60)
3-6 mo 6 (18) 9 (20) 13 (36) 19 (33) 19 (24)
6-9 mo 4 (12) 2 (5) 4 (11) 9 (16) 4 (5)
9-12 mo 9 (26) 0 1 (3) 4 (7) 0
>1 y 8 (24) 0 1 (3) 5 (9) 0
Not yet achieved 2 (6) 3 (7) 1 (3) 2 (4) 0
Return to competition
<1 mo 1 (3) 4 (9) 2 (6) 3 (5) 7 (9)
1-3 mo 0 6 (14) 2 (6) 2 (4) 9 (11)
3-6 mo 2 (6) 11 (25) 6 (17) 6 (11) 14 (18)
6-9 mo 5 (15) 3 (7) 5 (14 9 (16) 4 (5)
9-12 mo 1 (3) 0 2 (6) 6 (11) 2 (3)
>1 y 11 (32) 0 2 (6) 2 (4) 1 (1)
Not yet achieved 14 (41) 20 (45) 17 (47) 29 (51) 43 (54)
a
Data are reported as number (%) of participants. Recurrent injuries were excluded from the return-to-sport analysis. ACL, anterior
cruciate ligament; MCL, medial collateral ligament.

injuries (Table 6). For the athletes who reported making incidence significantly. Additionally, athletes who competed
behavioral adaptations, the 3 most common measures regularly and were older had significantly more injuries.
reported were stretching more (20.3%), fighting with less
intensity (12.4%), and tapping—accepting the opponent’s
victory via a “tapping” hand motion—earlier (10%). How-
Incidence and Common Sites of Injury
ever, in 18.6% of cases, no adaptations were made. The 3-year injury incidence rate of 68.8% in our study
population can be compared only to the 6- and 12-month
DISCUSSION injury incidence rates reported by 2 previous studies16,17
because, to our knowledge, there are no published 3-year
Key Findings incidence rates on BJJ injuries. McDonald et al16 reported a
12-month injury incidence of 85.7%, with the hand/fingers,
Injury incidence was high among the studied BJJ athletes, foot/toes, arm/elbow, and knee being the most common
with 2 out of 3 athletes sustaining at least 1 injury, defined injury sites among their cohort (86.4% male; 59.3% compe-
as an absence from training of at least 2 weeks, over the last titors). These numbers may differ from our study’s findings
3 years. Among BJJ injuries, the lower and upper extrem- due to the fact that McDonald et al combined foot/toe and
ity, specifically the knee and shoulder, were the most hand/finger as 1 injury site each. Those investigators also
common sites of injuries. The majority of all injuries looked exclusively at injuries occurring during BJJ training
occurred during sparring. Fewer than 1 of 10 injuries only, which may not display the whole spectrum and
occurred during competition. Belt rank influenced injury quantity of BJJ-related injuries. Moriarty et al17 reported
6 Hinz et al The Orthopaedic Journal of Sports Medicine

TABLE 4
Hierarchical Linear Regression Model of Risk Factors for
Injury in Brazilian Jiu Jitsu (BJJ): Belt Rank, Training,
and Competition Behaviora

Independent Variable Injury Incidence P Value

BJJ belt rank .003

White belt (n ¼ 414) 0.73 ± 0.69
Blue belt (n ¼ 396) 0.96 ± 0.77
Purple belt (n ¼ 171) 1.10 ± 0.86
Brown belt (n ¼ 68) 1.22 ± 0.84
Black belt (n ¼ 91) 1.09 ± 0.86
Training hours per week .890
1-5 h (n ¼ 630) 0.86 ± 0.75
6-10 h (n ¼ 418) 1.02 ± 0.81
11-15 h (n ¼ 67) 0.97 ± 0.93
16-20 h (n ¼ 13) 0.69 ± 0.63
20 h (n ¼ 12) 1.00 ± 1.04
Competition frequency per year .003
None (n ¼ 412) 0.76 ± 0.72
Figure 3. Illustration of the toehold. Attacker (white) puts the 1-2 competitions (n ¼ 515) 0.98 ± 0.78
defender’s (black) ankle into hypersupination. 3-4 competitions (n ¼ 129) 1.10 ± 0.83
5 competitions (n ¼ 84) 1.07 ± 0.90
TABLE 3 a
Incidence is expressed as mean ± SD. Bolded P values indicate
Hierarchical Linear Regression Model of Risk Factors for significant difference between groups (P < .05).
Injury in Brazilian Jiu Jitsu: Participant Factors

Independent Variable Injury Incidence P Value

The differences in these findings may be attributed par-
Sex .898 tially to the fact that the definition of injury varies greatly
Men (n ¼ 1104) 0.92 ± 0.78 among epidemiological studies on BJJ injuries. For exam-
Women (n ¼ 126) 0.93 ± 0.81 ple, das Graças et al5 defined BJJ injuries as “any symp-
Age < .001 tomatic manifestation of pain, or physical dysfunction,
Injured group (n ¼ 784) 32.46 ± 7.78 due to training practice or . . . competitions.” Moriarty
Noninjured group (n ¼ 356) 30.12 ± 8.01
et al,17 in contrast, defined injuries more stringently as
Height .938
Injured group (n ¼ 784) 174.04 ± 20.21
complete abstention from BJJ training or any other phys-
Noninjured group (n ¼ 356) 174.63 ± 20.28 ical activity for >1 week and/or moderate modification of
Body weight .645 BJJ training and sporting activities for >2 weeks and/or
Injured group (n ¼ 784) 82.10 ± 17.87 evaluation by a medical professional. Thus, the difference
Noninjured group (n ¼ 356) 81.16 ± 17.96 in these definitions is likely to be a major reason for the
difference in the injury rates reported. We exclusively
a
Incidence is expressed as mean ± SD. Bolded P value indicates
collected data on injuries necessitating an absence from
significant difference between groups (P < .05).
training for at least 2 weeks, which may lead to an under-
estimation of absolute injury numbers. Through our def-
a 6-month injury rate of 59.2%. The knee was the most inition, however, the nature of such disruptive injuries
commonly injured site (20.8%), which is consistent with the and their most frequent mechanisms can be well
results of the present study. Regarding injury prevalence, explained. To our knowledge, this is the first study that
Petrisor et al21 reported an injury prevalence of >90% collected comprehensive injury data (occurrence in train-
among BJJ athletes, in whom more injuries were sustained ing vs competition, injury mechanism, diagnosis, and
in training than in competition, aligning with our findings. return to sport) in a large cohort. Beyond BJJ-exclusive
Silva et al24 reported that novice athletes (white- and studies, Stephenson and Rossheim25 investigated BJJ,
blue-belt athletes by definition) sustained injuries more judo, and mixed martial arts (MMA) injuries that were
frequently in training than in competition, and advanced treated in US emergency departments. Whereas judo
athletes (purple, brown, and black belt) vice versa. Accord- practitioners mainly experienced leg injuries, MMA and
ing to Scoggin et al,23 data on 8 statewide BJJ tournaments BJJ athletes seeking medical service in emergency
in Hawaii, USA, showed that of all orthopaedic injuries, the departments mainly had head injuries (43% and 21%).
elbow joint was the most injury-prone site (38.9%) and the Because of the injury severity typically observed in emer-
knee was the second-most frequent site of injury (15.2%). gency departments, their data showcase the difference in
The findings reported by the aforementioned studies indi- severe injuries across each sport rather than the total
cate that the common sites of injury may differ between spectrum of injuries (mild to severe) associated with
training and competition. each sport.
The Orthopaedic Journal of Sports Medicine Injuries in Brazilian Jiu Jitsu 7

TABLE 5 TABLE 6
Hierarchical Linear Regression Model of Risk Factors for Behavioral Changes Implemented by
Injury in Brazilian Jiu Jitsu: Preventive Measuresa Athletes After Injurya

Independent Variable Injury Incidence P Value Change No. of Responses (%)

Increased hours of sleep per night .371 Stretching more 214 (20)
With measure (n ¼ 453) 0.90 ± 0.79 Fighting with less intensity 130 (12)
Without measure (n ¼ 687) 0.94 ± 0.78 “Tapping” faster or earlier 102 (10)
Meditating .656 More training within BJJ 97 (9)
With measure (n ¼ 171) 0.92 ± 0.80 More training outside of BJJ 87 (8)
Without measure (n ¼ 969) 0.92 ± 0.68 Less training within BJJ 58 (6)
Taking a nap .177 Implementation of strength training 20 (2)
With measure (n ¼ 241) 0.89 ± 0.78 Eating healthier food 15 (1)
Without measure (n ¼ 899) 0.93 ± 0.78 Sleeping more 12 (1)
Improving sleep quality .573 Training less outside of BJJ 1 (<1)
With measure (n ¼ 281) 0.91 ± 0.81 Other 116 (11)
Without measure (n ¼ 859) 0.93 ± 0.77 Nothing 196 (19)
High protein intake .227
a
With measure (n ¼ 520) 0.94 ± 0.80 BJJ, Brazilian Jiu Jitsu.
Without measure (n ¼ 620) 0.90 ± 0.77
High fruit and vegetable intake .363
With measure (n ¼ 344) 0.97 ± 0.84
takedowns (13.9%) to be injury-prone movements. This cor-
Without measure (n ¼ 796) 0.90 ± 0.76 relates with the findings of the present study, in which
High carbohydrate intake .102 these 2 techniques are also frequently the cause of injury.
With measure (n ¼ 120) 0.83 ± 0.80 However, due to the rules of the competitions that Scoggin
Without measure (n ¼ 1020) 0.93 ± 0.78 et al studied, heel hooks,2 a major cause of injuries in our
Eating fewer processed foods .616 findings, were not allowed. Competitions with a limited set
With measure (n ¼ 413) 0.98 ± 0.84 of rules therefore give a limited spectrum of injury mechan-
Without measure (n ¼ 727) 0.89 ± 0.75 isms in BJJ. In our study, 29.7% of all injuries occurred
Vegetarian, plant-based, or vegan diet .568 during submissions. This is not unexpected, as submissions
With measure (n ¼ 105) 1.00 ± 0.85
aim to render the opponent unable to fight and ultimately
Without measure (n ¼ 1035) 0.92 ± 0.77
Mobility training (eg, yoga, stretching) .131
tap out, forfeiting the match. However, as a close second in
With measure (n ¼ 624) 0.97 ± 0.80 our findings, takedowns constituted 26.4% of all injuries.
Without measure (n ¼ 516) 0.87 ± 0.76 This is notable because these movements do not aim to
Weight or strength training .988 injure the opponent but rather aim to gain a superior posi-
With measure (n ¼ 619) 0.94 ± 0.80 tion and earn points in competition settings. In other mar-
Without measure (n ¼ 521) 0.90 ± 0.77 tial arts where takedowns are the primary objective, a
Hot and/or cold baths or therapy .275 higher injury rate from takedowns is expected. For
With measure (n ¼ 215) 1.01 ± 0.83 instance, takedowns constitute the main mechanism of
Without measure (n ¼ 925) 0.90 ± 0.77 injury in wrestling20 and in judo, a sport primarily focused
Other .692
on throwing movements with some grappling elements.
With measure (n ¼ 36) 0.97 ± 0.84
Without measure (n ¼ 1104) 0.92 ± 0.78
Being thrown by an opponent in judo constitutes the most
common cause of injury. 7,22,28 In an effort to lower
a
Incidence is expressed as mean ± SD. takedown-related injuries, studies have shown that a lack
of falling skills may be associated with injuries,8,10 whereas
improvement of break-fall techniques may lower the risk of
Injury Timing and Mechanism severe injuries.18,22 However, despite the unnecessarily
high rate of takedown injuries in BJJ as shown by our
In the present study, 77.6% of all injuries occurred during
study, Moriarty et al found no correlation regarding
sparring, with only a small minority occurring during com-
instruction on break-falling and injury risk for BJJ
petition (9.6%). This rate of injuries sustained in competi-
athletes.
tion is considerably lower than that in other martial arts
such boxing (57%), judo and karate (*70%), and wrestling
(90% of all catastrophic injuries occurring in competi- Risk Factors
tion).3,13,29 Additionally, our study showed that more than
half (56.1%) of all injuries were caused by takedowns and Our findings indicated that belt rank, higher age, and com-
submissions. By contrast, Moriarty et al17 reported that peting regularly were significant risk factors for injuries.
most injuries occurred during a scramble or transition Moriarty et al17 found that an increase in training years
(58.5%) whereas only a minority of injuries were caused and body weight lowered the injury risk, whereas an
by submissions (15.2%) and takedowns (5.9%). Scoggin increase in training days per week and status as an instruc-
et al23 assessed injuries during BJJ competitions and found tor increased injury risk. Das Graças et al5 also found age to
submissions (22.2%), specifically the armbar (13.9%), and be a significant risk factor (P < .05), as adolescent athletes
8 Hinz et al The Orthopaedic Journal of Sports Medicine

(aged 12-17 years) had a lower injury risk than adult (aged reported 3 injuries (40/1140 athletes). Additionally,
18-30 years) and master (aged >30 years) athletes. Their because the title of this survey was “Injuries in Brazilian
analysis of current factors for retrospective sports injuries Jiu Jitsu,” athletes with injuries may have found participa-
showed age and global flexibility of the posterior static mus- tion more relevant than those who had not experienced any
cle chain to be the most predictive variables for injuries in injuries. This possible selection bias may have inflated the
BJJ (P < .05). Female sex and sport exposure time were the reported incidence of injuries. Finally, within this study,
most predictive variables for the onset of injuries in adoles- preventive measures were not shown to influence the num-
cent athletes (P < .05). Within adults, belt rank was also ber of injuries occurring in a 3-year time period. Prospec-
significantly associated with injuries in BJJ (P ¼ .031). tive long-term studies are needed to evaluate injury
Therefore, the findings of das Graças et al indicating belt prevention measures for primary prevention as well as the
rank and age as significant risk factors for injury incidence efficacy of postinjury behavioral adaptations described in
align with the present study. Kreiswirth et al12 analyzed this study to prevent future injury occurrence.
the incidence of joint injuries during a World Champion-
ship in No-Gi BJJ, a subdiscipline where athletes compete
in athletic clothing instead of a gi (a kimono) and, notably, CONCLUSION
gripping opponents’ clothing is not allowed. Their study
showed that more experienced athletes (brown and black Study findings indicated that injury incidence in BJJ is
belt) had a higher risk of injury than less experienced ath- high, with 784 of 1140 athletes (68.8%) reporting at least
letes (blue and purple belt). Due to the different ruleset of 1 injury requiring a 2-week absence from BJJ training in a
this subdiscipline and the fact that the lowest experience 3-year time frame. The most commonly injured sites were
level was excluded (white-belt athletes cannot compete in the lower (45.7%) and upper extremity (30.2%), specifically
the No-Gi tournament examined in the study), extrapola- the knee (27.1%) and shoulder (14.6%). Of all knee injuries,
tion of these data to classic BJJ is limited. Studying martial meniscal injuries (n ¼ 65), ACL tears (n ¼ 36), and MCL
arts beyond BJJ, Zetaruk et al 30 compared 5 different tears or injuries (n ¼ 36) were most common. Because most
sports (Shotokan karate, aikido, taekwondo, kung fu, and injuries occurred in sparring (77.6%), there is a high poten-
tai chi) and found athlete age >18 years, training experi- tial for lowering injury risk in BJJ by improving the safety
ence >3 years, training time >3 hours per week, and mar- in sparring. Education about injury frequency during sub-
tial art style to be significant risk factors for injury missions and their mechanisms can help athletes become
incidence. more aware of high-risk movements that may lead to
injury. Additionally, because most injuries occur during
submissions, safe practices, such as tapping out early (and
Limitations allowing time for a tap-out), should be encouraged to reduce
One of the limitations of the retrospective data used in this the likelihood of injury. This may be achieved by emphasiz-
study was that all injuries, diagnoses, severity level, and ing the learning experience that sparring provides over the
time frames for return to activity, sport, and competition focus on winning that is typically encouraged for
were self-reported and may not have been confirmed by a competition.
medical professional. This limits the accuracy of the
reported injuries and diagnoses. Accuracy may further be ACKNOWLEDGMENT
affected by respondents’ recall capability. For instance,
Gabbe et al6 reported a decline in recall accuracy as the The authors thank Christian Soetebier and Jan Knütter for
level of detail requested increased. Their findings showed their contribution as the Brazilian jiu jitsu athletes in the
that when respondents were asked to report on injuries photographs.
that occurred in the past 12 months, only 61% of athletes
were able to record the exact number, body region, and
diagnosis of each injury sustained. Nonetheless, the time
frame covered in our study was set to 3 years in order to Supplemental material for this article is available at
obtain a detailed picture of the epidemiology of injuries in http://journals.sagepub.com/doi/suppl/10.1177/23
BJJ and analyze the return to sport after these injuries. 259671211062568.
The return-to-sport analysis was limited by recent injuries
that were still in the healing process at the time of data
collection, which could not be differentiated from those
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