Abstract
Background
Wrestling is known to be a sport of relatively high injury incidence, and knee injuries account for a large percentage of those injuries. Treatment of these injuries varies considerably depending on injury and wrestler characteristics, leading to variability in complete recovery and return to sport (RTS). The purpose of this study was to evaluate injury trends, treatment strategies, and RTS characteristics after knee injuries in competitive collegiate wrestling.
Methods
NCAA Division I collegiate wrestlers who sustained knee injuries between January 2010 and May 2020 were identified using an institutional Sports Injury Management System (SIMS). Wrestling-related knee, meniscus, and patella injuries were identified, and treatment strategies were documented to investigate potential recurrent injury trends. Descriptive statistics were used to quantify the number of days, practices, and competitions missed, return to sport times, and recurrent injuries among wrestlers.
Results
Overall, 184 knee injuries were identified. After excluding non-wrestling injuries (n=11), 173 injuries remained (77 wrestlers). The mean age at time of injury was 20.8 ± 1.4 years, and the mean BMI was 25.9 ± 3.8 kg/m2. There were 135 primary injuries (74 wrestlers), which consisted of 72 (53%) ligamentous injuries, 30 (22%) meniscus injuries, 14 patellar injuries (10%), and 19 other injuries (14%). The majority of ligamentous injuries (93%) and patellar injuries (79%) were treated non-operatively, while the majority of meniscus tears (60%) underwent surgery. Twenty-three wrestlers (22%) sustained recurrent knee injuries, of which 76% were treated non-operatively after their initial injury. Recurrent injuries consisted of 12 (32%) ligamentous injuries, 14 (37%) meniscus injuries, eight (21%) patellar injuries, and four (11%) other injuries. Fifty percent of recurrent injuries were treated operatively. When comparing recurrent injuries to primary injuries, recurrent injuries had a significantly longer return to sport time (Recurrent 68.3 ± 96.0 days vs. Primary 26.0 ± 56.4 days, p=0.01).
Conclusion
The majority of NCAA Division I collegiate wrestlers who sustained knee injuries were initially treated non-operatively, and approximately one in five wrestlers sustained recurrent injuries. Return to sport time was significantly increased after a recurrent injury.
Level of Evidence: IV
Keywords: wrestling, knee injury, return to sport
Introduction
Lower extremity injuries represent 30-40% of the total injuries faced by collegiate wrestlers.1 Understanding the nature of lower extremity injuries, as well as the recovery process, is crucial in maintaining an athlete’s short- and long-term health.2 Knee injuries, in particular, account for nearly 25% of all wrestling injuries, which is the highest percent for any single area of the body.1,3,4 Common ailments include prepatellar bursitis, meniscus tears, ligamentous injuries, and others.5-7 When indicated, surgical management of knee injuries often carries a significant recovery burden and complication risk, as compared to conservative management. Frequently cited return to sport (RTS) times for common knee surgeries include 4-6 weeks for meniscus repair and 8-12 months for ACL reconstructions.8,9
In 1986, Wroble et al. investigated patterns of collegiate wrestler knee injuries and identified several factors that affect the incidence and longevity of knee injuries, including the competition environment, duration of season, previous injuries, high-speed maneuvers, team rank, and treatment compliance.5 RTS times after wrestling knee injuries were not assessed. Few studies have evaluated knee injury trends and RTS times in intercollegiate wrestling.2,4,10,11 Better understanding of common knee injuries, treatment patterns, and RTS times will help inform sports medicine providers and wrestlers. The purpose of this study was to evaluate injury trends, treatment strategies, and RTS characteristics after knee injuries in competitive collegiate wrestling.
Methods
National Collegiate Athletic Association (NCAA) Division I collegiate wrestlers who sustained knee injuries between January 2010 and May 2020 were identified using an institutional Sports Injury Management System (SIMS). Wrestling-related knee, meniscus, and patella injuries were identified, and treatment strategies were documented to investigate potential recurrent injury trends. A wrestling-related knee injury was defined as an injury to the knee region that was sustained during a typical maneuver during practice or competition. Data regarding concurrent injuries (ligament + meniscus) were not available. Injuries were categorized as primary (initial injury) or recurrent. A recurrent injury was defined as an identical injury diagnosed on the same knee, regardless of time between injuries. The management of each injury was documented, including all conservative and surgical treatments. Data collected included age, height, weight, weight class, year of eligibility (Freshman, Sophomore, etc.), and laterality of injury. Data regarding race, socioeconomic status, and other social factors were not available. Primary outcomes were the number of days, practices, and competitions missed, time to return to sport, and any recurrent injuries. Return to sport (RTS) time was defined as the number of days between the removal of the athlete from participation and the return to full-contact practice and/or competition activities. Descriptive statistics were used to report the results.
Results
Wrestling Injury Characteristics
Overall, 184 knee injuries were identified. Eleven were excluded as non-sports related injuries, which left a total of 173 injuries from 77 wrestlers. The mean age at time of injury was 20.8 ± 1.4 years. The average BMI was 25.9 ± 3.8 kg/m2. Ninety-five injuries were right-sided and 78 were left-sided. Data regarding the dominant or lead leg was not available. Fifty-seven injuries occurred in a competitive environment while 116 were during practice. There were 103 injuries (60%, 47 athletes) in the lower weight classes (<174 lbs.) and 70 injuries (40%, 30 athletes) in the upper weight classes (≥174 lbs.). Injuries were distributed between years of eligibility relatively evenly (Freshman 39, Sophomore 44, Junior 36, Senior 31, Fifth-year 23). The total distribution of knee injuries identified are presented in Table 1.
Table 1.
Total Knee Injuries in NCAA Division I Wrestlers
| Knee Ligament Injuries | 84 injuries (49%) |
| Lateral Collateral Ligament (LCL) | 40 (48%) - 33 Grade 1, 7 Grade 2, 0 Grade 3 |
| Medial Collateral Ligament (MCL) | 30 (36%) - 18 Grade 1, 11 Grade 2, 1 Grade 3 |
| Anterior Cruciate Ligament (ACL) | 11 (13%) - 1 Grade 1, 1 Grade 2, 9 Grade 3 |
| Posterior Cruciate Ligament (PCL) | 3 (4%) - 2 Grade 1, 0 Grade 2, 1 Grade 3 |
| Meniscus Injuries | 44 injuries (25%) |
| Medial meniscus tears | 23 (52%) |
| Lateral meniscus tears | 17 (39%) |
| Hypermobile posterolateral meniscus | 2 (5%) |
| Medial meniscus cyst | 1 (2%) |
| Meniscus inflammation | 1 (2%) |
| Patellar Injuries | 22 injuries (13%) |
| Bursitis | 12 (55%) |
| Contusion | 6 (27%) |
| Patellar subluxation | 3 (14%) |
| Cartilage damage | 1 (5%) |
Number (%) of total knee ligament, meniscus, and patellar injuries in NCAA Division I wrestlers.
There were 135 primary injuries (74 wrestlers), which consisted of 72 (53%) ligamentous injuries, 30 (22%) meniscus injuries, 14 (10%) patellar injuries, and 19 (14%) other injuries. The other injuries included seven contusions, three hyperextension injuries, two popliteus strains, two cases of ilio-tibial band syndrome, and one each of biceps femoris strain, parameniscal cyst, prepatellar fat pad irritation, puncture wound, and degeneration. Primary knee ligamentous injuries consisted of 37 lateral collateral ligament (LCL), 26 medial collateral ligament (MCL), six anterior cruciate ligament (ACL), and three posterior cruciate ligament (PCL) injuries (Table 2).
Table 2.
Incidence of Primary Knee Injuries in NCAA Division I Wrestlers
| Knee Ligament Injuries | 72 injuries (53%) |
| Lateral Collateral Ligament (LCL) | 37 (51%) - 30 Grade 1, 7 Grade 2, 0 Grade 3 |
| Medial Collateral Ligament (MCL) | 26 (36%) - 18 Grade 1, 7 Grade 2, 1 Grade 3 |
| Anterior Cruciate Ligament (ACL) | 6 (8%) - 1 Grade 1, 0 Grade 2, 5 Grade 3 |
| Posterior Cruciate Ligament (PCL) | 3 (4%) - 2 Grade 1, 0 Grade 2, 1 Grade 3 |
| Primary Meniscus Injuries | 30 injuries (22%) |
| Medial meniscus tears | 17 (57%) |
| Lateral meniscus tears | 12 (40%) |
| Medial meniscus cyst | 1 (3%) |
| Primary Patellar Injuries | 14 injuries (10%) |
| Bursitis | 7 (50%) |
| Contusion | 4 (29%) |
| Patellar subluxation | 2 (14%) |
| Cartilage damage | 1 (7%) |
Number (%) of primary knee ligament, meniscus, and patellar injuries in NCAA Division I wrestlers.
Twenty-three wrestlers (22%) sustained a recurrent injury (38 total injuries), of which 76% were initially treated with non-operative measures after their primary injury. Recurrent injuries consisted of 12 (32%) ligamentous injuries, 14 (37%) meniscus injuries, eight (21%) patellar injuries, and four (11%) other injuries. The other injuries included one each of knee joint arthritis, general pain/ inflammation, knee joint loose bodies, and anterior subluxation. Recurrent knee ligamentous injuries consisted of three LCL, four MCL, five ACL, and no PCL injuries (Table 3).
Table 3.
Incidence of Recurrent Knee Injuries in NCAA Division I Wrestlers
| Recurrent Knee Ligament Injuries | 12 injuries (32%) |
| Lateral Collateral | 3 (25%) |
| Ligament (LCL) | - 3 Grade 2 |
| Medial Collateral | 4 (33%) |
| Ligament (MCL) | - 4 Grade 2 |
| Anterior Cruciate | 5 (42%) |
| Ligament (ACL) | - 1 Grade 2, 4 Grade 3 |
| Recurrent Meniscus Injuries | 14 injuries (37%) |
| Medial meniscus tears | 6 (42%) |
| Lateral meniscus tears | 5 (36%) |
| Hypermobile posterolateral meniscus | 2 (14%) |
| Meniscus inflammation | 1 (7%) |
| Recurrent Patellar Injuries | 8 injuries (21%) |
| Bursitis | 5 (63%) |
| Contusion | 2 (25%) |
| Patellar subluxation | 1 (13%) |
Number (%) of recurrent knee ligament, meniscus, and patellar injuries in NCAA Division I wrestlers.
Treatment of Wrestling Injuries
Overall, the majority of wrestling injuries identified were treated conservatively (n=128, 74%). Eighty-one percent of primary injuries were treated with non-operative measures, and the remaining 26 injuries were treated surgically (19%). The majority of primary ligamentous injuries identified (67, 93%) were treated non-operatively with physical therapy (32 wrestlers), corticosteroid injection (four wrestlers), or other measures (i.e., ice, medication, etc.). The remaining five wrestlers underwent ACL reconstruction. The majority of meniscus tears (18, 60%) were treated operatively, including 13 partial meniscectomies, four meniscus repairs, and one synovectomy. Eleven of 14 patellar injuries (79%) were treated conservatively with either physical therapy, corticosteroid injection, or other measures. Fifty percent of recurrent knee injuries were treated operatively. Four of five (80%) recurrent ACL injuries underwent ACL reconstruction, while 12 of 14 recurrent meniscus tears underwent knee arthroscopy with partial meniscectomy (75%) vs. meniscus repair (25%). Of the eight identified recurrent patellar injuries, six were treated non-operatively, including four with corticosteroid injections or knee joint aspiration.
Return to Wrestling
Overall, mean RTS time was 35.5 ± 69.7 days for all injuries (Table 4). The mean number of practices and competitions missed were 10.1 ± 20.8 and 2.6 ± 5.8, respectively. Mean RTS time for knees treated non-operatively was 12.5 ± 24.7 days vs. 100.9 ± 105.5 days for injuries treated operatively. For ACL injuries, non-operative RTS (n=2) was 161.5 ± 3.5 days, or 5.3 ± 0.1 months, while operative RTS (n=9) was 290.9 ± 46.3 days, or 9.5 ± 1.5 months. All other ligamentous injuries were treated conservatively. There was an average gap between injury and removal from play of 2.3 ± 8.4 days, and for those that underwent surgery, a gap of 36.9 ± 58.5 days between injury and surgery.
Table 4.
Return to Sport Times By Injury Characteristic in NCAA Division I Wrestlers
| Recurrency | N | Mean | SD | Median | Range | P-Value |
|---|---|---|---|---|---|---|
| Recurrent | 38 | 68.3 | 96.0 | 27.0 | 0.0- 361.0 | 0.01 |
| Non-recurrent | 135 | 26.0 | 56.4 | 6.0 | 0.0312.0 | |
| Treatment | ||||||
| Non-operative | 128 | 12.5 | 24.7 | 3.0 | 0.0- 165.0 | <0.001 |
| Operative | 45 | 100.9 | 105.5 | 55.0 | 6.0361.0 | |
| Setting | ||||||
| Competition | 57 | 36.6 | 69.7 | 9.0 | 0.0- 300.0 | 0.89 |
| Practice | 116 | 35.0 | 69.7 | 8.0 | 0.0361.0 | |
| Weight Class | ||||||
| Upper Weight Classes | 70 | 34.3 | 69.0 | 9.0 | 0.0- 361.0 | 0.86 |
| Lower Weight Classes | 103 | 36.3 | 70.1 | 8.0 | 0.0341.0 |
Return to Sport Times By Injury Characteristic, in days. N, number of wrestlers; SD, standard deviation.
There were no differences in RTS time between injuries sustained in the practice and competition environments, nor was there a difference between the upper and lower weight classes. Grade 1 LCL injuries had a significantly shorter RTS than grade 2 or 3 LCL injuries (6.0 ± 6.6 days vs 34.7 ± 22.1 days, or 0.9 ± 0.9 weeks vs 5.0 ± 3.1 weeks, p=0.02). Similarly, Grade 1 MCL injuries had a significantly shorter RTS than grade 2 or 3 MCL injuries (6.4 ± 7.3 days vs 27.7 ± 14.9 days, or 0.9 ± 1.0 weeks vs 4.0 ± 2.1 weeks, p<0.001) (Table 5). Mean RTS time after partial meniscectomy was significantly shorter than meniscus repair procedures (37.0 ± 23.7 days vs. 92.4 ± 58.0 days, p=0.03). When comparing recurrent injuries to primary injuries, recurrent injuries had a significantly longer RTS time (Recurrent 68.3 ± 96.0 days vs. Primary 26.0 ± 56.4 days, p=0.01).
Table 5.
Return to Sport Times of LCL and MCL Injuries by Grade in NCAA Division I Wrestlers
| LCL | N | Mean | SD | Median | Range | P-Value |
|---|---|---|---|---|---|---|
| Grade 1 | 33 | 6.0 | 6.6 | 4.0 | 0.0-20.0 | 0.02 |
| Grade 2/3 | 7 | 34.7 | 22.1 | 39.0 | 3.0-66.0 | |
| MCL | ||||||
| Grade 1 | 18 | 6.4 | 7.29 | 4.5 | 0.0-30.0 | <0.001 |
| Grade 2/3 | 12 | 27.7 | 14.9 | 27.0 | 7.0-55.0 |
Return to Sport Times of LCL and MCL Injuries by Grade, in days. N, number of wrestlers; SD, standard deviation.
Discussion
Knee injuries continue to be one of the most common and significant injuries among collegiate wrestlers. In this study, we found that athletes with knee injuries missed an average of 36 days, but that number varied widely depending on the characteristics of the injury.
This study suggests that a large percent of knee injuries in collegiate wrestlers are acute, non-recurrent injuries that can be treated non-operatively. While more injuries occurred during practice compared to competition, there was no difference in RTS between the two. This could likely be due to the greater time spent in practice but is potentially counterbalanced by the greater intensity of wrestling seen during competition.
Stratification into injury types and recurrent versus primary injuries helped more accurately analyze injury and treatment trends, but decreased study power. Ligamentous injuries were more likely to be primary injuries (52% of all primary injuries versus 32% of all recurrent injuries), whereas meniscus injuries were found to be recurrent more often (22% of primary vs 37% of recurrent), and patellar injuries also followed this trend (10% of primary vs 21% of recurrent). The vast majority of recurrent meniscus injuries were treated with surgery (12 of 14).
Meniscus injuries that were treated non-operatively recovered quicker than surgical cases. Among the surgical cases, those that underwent meniscectomy returned faster than those who underwent meniscus repair. This is expected given the nature and invasiveness of each treatment type. Meniscus repair surgeries require a longer non-weightbearing period to ensure proper healing, and therefore experience more muscle atrophy and associated longer RTS. Knowing this, medical personnel can be assured that among meniscus injuries, RTS times align with the extent of injury and intensity of treatment. Patellar injuries did not show a difference between non-operative and operative treatments, suggesting that less invasive treatment should be performed when possible, as this study found no difference in recovery times.
In this study’s cohort, most ACL injuries were treated operatively while all LCL, MCL, and PCL injuries were treated conservatively. In both LCL and MCL injuries, grade 1 sprains returned to sport quicker than grade 2 or 3 injuries. A larger sample size with a greater variation of treatment is needed to fully appreciate any further differences in RTS as well as other recovery and injury characteristics.
There are several limitations to this study. The retrospective nature of the study limits its applicability to current clinical practice and makes it susceptible to changes in practice and procedures throughout the 10-year time period of chart review. Additionally, this study grouped several injury characteristics and specifics for analysis. This was accounted for by stratifying select injury and treatment variables for subgroup analysis. Identification of patients based off the SIMS database may not have included all injuries within the study’s timeframe and did not include injuries prior to college. Wrestler race, socioeconomic status, and other social factors were not accounted for in this study. Several non-operative injuries lacked imaging and are thus presumptive diagnoses. The number of days missed in this study were reported as the days between removal from play and return to full-contact participation; however, there is the possibility of variation between athletes and injuries including delays in reporting and treatment, the usage of bracing or pain medications, and other similar factors. These inherently impact removal from and return to play and, therefore, RTS. Additionally, timing of treatment and RTS is affected by the timing of the injury relative to the competitive schedule. Finally, this study is limited by its cohort of collegiate wrestlers at a single institution.
Subsequent studies should strive to compare management of knee injuries in wrestlers across several institutions and age ranges to improve external application potential. A larger cohort would also allow expansion on areas that showed variation of treatment, such as meniscus and patella injuries, and would allow for comparison of RTS and management results across several institutions to incorporate varying treatment philosophies.
Conclusion
Knee injuries are common in wrestlers and can lead to significant time away from sport. Each injury is influenced by several factors that can lead to variations in return to sport and should be addressed in the context of each athlete. This study can be used to help guide clinical judgement and adjust treatment algorithms for future knee injuries in wrestlers.
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