Strangulation Case Study Highlights Verified Injuries from Sportive “Chokes”

This month the Journal of Emergency Medicine published the latest paper addressing health and safety issues relating to strangulations from grappling sports such as Brazilian Jiu Jitsu, Judo and other martial arts.

The lead author of the paper was Dr. Samuel Stellpflug, an ER Physician and BJJ black belt who is one of the leading experts on the science and safety related to sportive strangulation.

In the paper, titled Cervical Artery Dissections and Ischemic Strokes Associated With Vascular Neck Compression Techniques (Sportive Chokes), the authors reviewed cases where the above types of injuries were linked to sportive strangulation.

The authors interviewed participants who purportedly had artery dissections and ischemic strokes following grappling. With permission they reviewed clinical records and after scrutiny identified 10 participants who met criteria to link these injuries to strangulation techniques from grappling.

These cases were then scrutinized by “age, gender, height, weight, pre-existing medical issues, grappling experience, choking event description,opponent (choker) descriptives, timing and symptoms of the injury, diagnostics, treatment, whether they returned to training after the event, and contact information

In terms of the types of techniques that led to these injuries’ and the trends or lack thereof the authors observed as follows:

There is also no obvious significant trend in the type of choke that occurred during the inciting event. Seven of the 10 chokes reported by the participants were maneuvers executed using the lapel of the BJJ gi to apply bilateral force to the sides of the neck. The exceptions to this were the no-gi or no-lapel chokes in case 1 (north south choke), case 6 (guillotine, although an
Ezekiel was also reported and this can be with the lapel or not), and case 8 (rear naked choke). This apparent lapel
trend is quite possibly biased toward the source of the cases—primarily a group of BJJ practitioners as opposed to a more general grappling group. It is also possible that more training is done in the gi than in no gi. There was also not a trend toward the force being excessive or commentary from participants on voluntarily submitting or tapping later than usual in a choke scenario. Only 1 of the 10 case subjects reported losing consciousness, and only 1 reported excessive duration of the sportive choke.
This series of cases is too small to establish these types of trends statistically, and a larger series could possibly
explore these aspects.

The authors noted that “Although the existing literature suggests that sportive choking does not put practitioners at greater risk than other activities, the literature base is incomplete and more discovery is essential to further characterize the phenomena.”

Below is the full abstract of the study


Strangulation as a fight-finishing maneuver in combat sports, termed “choking” in that context, occurs worldwide millions of times yearly. This activity can be trained safely, but devastating injuries can occur.


Our aim was to present a case series of cervical artery dissections and ischemic strokes associated with sportive choking. Sharing these cases is meant to draw awareness, to assist emergency physicians in caring for these athletes, and to provide a platform for further research.


Institutional Review Board approval was obtained. Participants consented for medical information transfer and anonymous academic reproduction. The minimum medical record information necessary for inclusion was a report of diagnosis-confirming advanced imaging. Participants were contacted for primary information in addition to what the medical records could provide and to confirm some information in the record (e.g., pertinent medical history, demographic characteristics, choking event description, medical care, and commentary on their current health). Medical records and additional first-hand information were reviewed and participants were included if they had a diagnosed dissection or stroke likely associated with a sportive choke.


Ten cases met all criteria for inclusion. There were 5 cases of carotid artery dissection, 3 cases of vertebral artery dissection, and 2 cases of ischemic stroke without dissection. Nine of 10 participants survived and 3 of 10 have returned to submission grappling training.


Cervical artery dissections and ischemic strokes can occur in association with sportive choking. Emergency physicians must be aware of the widespread nature of this activity and must be vigilant in approaching management of patients with symptoms consistent with these injuries.


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