Descriptive Epidemiology of Collegiate Men's Wrestling Injuries: National Collegiate Athletic Association Injury Surveillance System, 1988–1989 Through 2003–2004

Abstract

Objective: To review 16 years of National Collegiate Athletic Association (NCAA) injury surveillance data for men's wrestling and identify potential areas for injury prevention initiatives.

Background: From 1988–1989 through 2003–2004, 17% of NCAA schools sponsoring varsity men's wrestling programs participated in annual Injury Surveillance System (ISS) data collection.

Main Results: Patterns of injury were consistent with the person-to-person, combative contact between wrestlers. The musculoskeletal system and head were the most vulnerable areas during competitions; skin infections are a continuing concern in the practice environment. The incidence of injuries in practices exhibited no significant increase over time, a positive trend that may be consistent with the influence of the recent NCAA weight management rules.

Recommendations: Expansion of the present ISS to include indirect causes of injury, such as weight loss practices, would strengthen the analysis of data. Efforts by referees to be vigilant for potentially dangerous holds and by athletic trainers to improve wrestler and mat hygiene should be continued.

T he sport of wrestling has a history dating back to ancient times as one of the original Olympic sports. The National Collegiate Athletic Association (NCAA) conducted its first men's wrestling championship in 1928. Participation in NCAA wrestling has declined slowly since the 1970s. In the 1988–1989 academic year, 286 schools were sponsoring varsity NCAA men's wrestling teams, with 6969 participants. By 2003–2004, the number of varsity teams had decreased 23% to 224, involving 5943 participants. ¹ Participation decreased in all 3 divisions during this time but particularly in Divisions I and III.

SAMPLING AND METHODS

Over the 16-year period from 1988–1989 through 2003– 2004, an average of 17% of schools sponsoring varsity men's wrestling programs participated in annual NCAA Injury Surveillance System (ISS) data collection ( Table 1). The sampling process, data collection methods, injury and exposure definitions, inclusion criteria, and data analysis methods are described in detail in the “Introduction and Methods” article in this special issue. ² Data on skin infections are included in this report because these conditions represent a serious health issue for collegiate wrestlers.

Table 1. School Participation Frequency (in Total Numbers) by Year and National Collegiate Athletic Association (NCAA) Division, Men's Wrestling, 1988–1989 Through 2003–2004*.

RESULTS

Match and Practice Athlete-Exposures

The average annual numbers of matches, practices, and athletes participating for each NCAA division, condensed over the study period, are shown in Table 2. Division I annually averaged 10 more practices than Division II and 28 more than Division III. The average number of matches was similar across divisions. Division I averaged 2 more practice participants than Division II and 5 more than Division III. The average number of match participants was similar across divisions.

Table 2. Average Annual Matches, Practices, and Athletes Participating by National Collegiate Athletic Association Division per School, Men's Wrestling, 1988–1989 Through 2003–2004.

Injury Rate by Activity, Division, and Season

Match and practice injury rates over time combined across divisions are displayed with 95% confidence intervals in Figure 1. A nonsignificant increase in the average annual match (1.3%, P = .21) and practice (0.5%, P = .42) injury rates occurred over the sample period. Over the 16 years, the rate of injury in a match situation was more than 4 times higher than in practice (26.4 versus 5.7 injuries per 1000 athlete-exposures [A-Es], rate ratio = 4.6, 95% confidence interval [CI] = 4.4, 4.8).

Figure 1. Injury rates and 95% confidence intervals per 1000 athlete-exposures by matches, practices, and academic year, men's wrestling, 1988–1989 through 2003–2004 (n = 3097 match injuries and 6626 practice injuries). Match average annual change = 1.3%; time trend, P = .21, 95% confidence interval = −0.8, 3.5. Practice average annual change = 0.5%; time trend, P = .42, 95% confidence interval = −0.8, 1.9 .

The total number of matches and practices and associated injury rates condensed over years by division and season (preseason, in season, and postseason) are shown in Table 3. Over the 16-year period, 3097 injuries from more than 12 000 matches and 6626 injuries from more than 58 000 practices were reported. Match injury rates differed by division, with injury rates significantly higher in Divisions I and II than in Division III. Preseason practice injury rates were almost twice as high as regular-season practice rates (8.3 versus 4.7 injuries per 1000 A-Es, rate ratio = 1.8, 95% CI = 1.7, 1.9, P < .01), and preseason match injury rates were higher than in the regular season (rate ratio = 1.5, 95% CI = 1.3, 1.8, P < .01).

Table 3. Matches and Practices With Associated Injury Rates by National Collegiate Athletic Association Division and Season, Men's Wrestling, 1988–1989 Through 2003–2004*.

The NCAA enacted multiple rule changes following 3 wrestling fatalities in the 1997–1998 academic year (see the “Commentary” section), and despite these changes, the injury rate in matches did not change. The match injury rate in 1998– 1999 to 2003–2004 was 27.4 injuries per 1000 A-Es, compared with 25.7 per 1000 A-Es for 1988–1989 to 1997–1998, a nonsignificant increase of 1.7 injuries per 1000 A-Es (95% CI = −0.3, 3.6), or 5.6% ( P = .09). No significant change was apparent in practice injury rates between the 2 time periods ( P = .14).

Body Parts Injured Most Often and Specific Injuries

The frequency of injury to 5 general body areas (head/neck, upper extremity, trunk/back, lower extremity, and other/system) for matches and practices with years and divisions combined is shown in Table 4. More than 40% of all match injuries and 31% of all practice injuries were to the lower extremity. The upper extremity accounted for 26% of match injuries and 20% of practice injuries, whereas almost 17% of match injuries and 13% of practice injuries involved the head and neck.

Table 4. Percentage of Match and Practice Injuries by Major Body Part, Men's Wrestling, 1988–1989 Through 2003–2004*.

The most common body part and injury type combinations for matches and practices with years and divisions combined are displayed in Table 5. All injuries that accounted for at least 1% of reported injuries over the 16-year sampling period were included. In matches, knee internal derangements (22.9%), ankle ligament sprains (7.5%), shoulder strains (5.5%), and concussions (4.8%) were frequent injury categories. In practices, skin infections, primarily to the head and face, accounted for the largest percentage of time loss events (17.2%). Knee internal derangements (14.8%), ankle ligament sprains (7.3%), and shoulder strains (3.7%) also were notable categories. Compared with practices, a participant had 9 times the risk of sustaining a concussion in a match (1.27 versus 0.14, rate ratio = 9.1, 95% CI = 7.3, 11.3), more than 7 times the risk of sustaining a knee internal derangement in a match (6.03 versus 0.84, rate ratio = 7.2, 95% CI = 6.5, 7.9), and nearly 5 times the risk of sustaining an ankle ligament sprain in a match (1.97 versus 0.41, rate ratio = 4.8, 95% CI = 4.1, 5.6).

Table 5. Most Common Match and Practice Injuries, Men's Wrestling, 1988–1989 Through 2003–2004.

Mechanism of Injury

The 3 primary injury mechanisms—player contact, other contact (eg, benches, mat), and no contact—in matches and practices with division and years combined are demonstrated in Figure 2. Most match injuries (55.0%) resulted from player contact, whereas other contact (primarily mat) accounted for 22.9% of injuries. The majority of practice injuries (63.6%) involved player contact.

Figure 2. Match and practice injury mechanisms, all injuries, men's wrestling, 1988–1989 through 2003–2004 (n = 3097 match injuries and 6626 practice injuries). “Other contact” refers to contact with the mat. Injury mechanism was unavailable for 2% of game injuries and 6% of practice injuries. A total of 1631 infections were not included in this analysis.

Severe Injuries: 10+ Days of Activity Time Loss

The top injuries that resulted in at least 10 consecutive days of restricted or total loss of participation and their primary injury mechanisms combined across divisions and years are shown in Table 6. Time losses of 10+ days were, for this analysis, considered a measure of severe injury. Approximately 34% of match injuries and 28% of practice injuries restricted participation for at least 10 days. In matches, knee internal derangements accounted for 29.8% of all severe injuries, followed by various shoulder ailments (9.6%) and ankle ligament sprains (6.1%). In practices, knee internal derangements (24.3%), skin infections (8.6%), and ankle ligament sprains (4.7%) were the primary categories for severe injuries. Most severe injuries resulted from player contact or contact with the mat.

Table 6. Most Common Match and Practice Injuries Resulting in 10+ Days of Activity Time Loss, Men's Wrestling, 1988–1989 Through 2003–2004.

Sport-Specific Issues

Practice-related skin infections since 1993–1994 are described in Figure 3. Approximately 20% of all practice injury events were associated with skin infections, primarily herpes simplex and ringworm.

Figure 3. Skin infections in practices, men's wrestling, 1993–1994 through 2003–2004 (n = 1151).

Match weight classes at time of injury are displayed in Figure 4. The percentage of injuries by weight class from 1988– 1989 through the 1997–1998 season is seen in Figure 4A. Injuries appear relatively evenly distributed, with slightly higher percentages in the middleweight classes. In January 1998, the weight categories were increased by 6 to 7 lb (2.72 to 3.18 kg) per weight class as a partial response to 3 fatalities associated with “making weight” that season. The percentage of injuries by weight class starting with the 1998–1999 season is seen in Figure 4B. A similar trend of relatively even distributions of injuries across weight classes is apparent.

Figure 4. Match weight classes at time of injury, men's wrestling. A, Percentage of injuries by weight class, 1988–1989 through 1997– 1998 (n = 1946). B, Percentage of injuries by weight class, 1998–1999 through 2003–2004 (n = 1151). Heavyweight = 198 to 285 lb (n = 1151).

Match activity at the time of injury is shown in Figure 5. The largest percentages of injuries were associated with direct contact during a takedown (42.3%).

Figure 5. Match activity at time of injury, men's wrestling, 1988– 1989 through 2003–2004 (n = 3097). Infections are included in these values.

COMMENTARY

The results of this investigation illustrate several trends in injury data collected using the NCAA ISS from 1988–1989 to 2003–2004. Although the number of teams competing in the NCAA has declined in the past 16 years, the number of participants per team has increased. Division I wrestlers practiced more than Division II and Division III wrestlers did, but the number of competitive matches remained consistent among the 3 NCAA divisions.

Musculoskeletal Injuries

The incidence of injury was twice as common during preseason (matches and practices) as during the competitive season, which may reflect poorly planned attempts to quickly reduce total body weight for an upcoming season. In collegiate wrestlers, the difference between preseason and regular-season body weights has been reported to be approximately 10%. ^{3, 4} Although weight loss could ultimately lead to an increase in preseason injury rates, the data revealed no relationship between weight division and injury frequency, a finding that supports previous results. ^5–10

The pattern of musculoskeletal injuries reflects the combative requirements of wrestling and the intensity of competition. Due to the nature of wrestling, we expected to see most injuries occurring during direct contact and competitive matches. ^{11, 12} Injuries most likely occur as a result of combative moves from a standing position during takedown, with injury locations representing the attack points (knee, ankle, shoulder, and head) of the competitors. Wrestling positions that constitute risk factors for injury are the defensive positions during the takedown, followed by the down position. ¹³ From 1988– 1989 to 2003–2004, the largest number of injuries occurred during a takedown. During matches, 40% of the injuries occurred to the lower extremity. Efforts by referees to be alert to potentially dangerous holds may improve safety and serve to reduce all of these types of injuries. Concussions were more likely during matches than practices, occurring primarily from an opponent's head, elbow, or knee colliding with the head during a bad takedown attempt. Consistent with previous research, contact with the mat resulted in the greatest number of practice injuries. ¹¹ Interestingly, approximately one fourth to one third of the practice and competitive injuries resulted in more than 10 days of time loss. Knee injury during contact with a teammate or opponent was the most common cause of serious injuries during matches and practices.

Skin Infections

Over the study period, skin infections in men's wrestling practice demonstrated a nonsignificant 1.7% average annual increase ( P = .30, 95% CI = −1.5, 5.1; data not shown). In practices, skin infections represented the most commonly reported time-loss condition, accounting for more than 17% of reported events. (Because wrestlers with skin infections cannot participate in matches, it is not surprising that these conditions are more common in practices.) These and other data ¹⁴ have shown skin infections to be responsible for a significant proportion of time-loss injuries at the collegiate level. ¹⁴ The risk of contagion has resulted in specific policies by the NCAA and the National Federation of State High School Associations before an athlete can participate. ^{15, 16} These guidelines include examination by qualified physicians and/or certified athletic trainers for communicable diseases before the competition. Open wounds and infectious skin conditions that cannot be adequately protected are considered cause for medical disqualification from matches and practices. These guidelines, which make identification and treatment imperative, coupled with decreased contact with contagious pathogens among the wrestlers and with the mats, may serve to reduce skin infections.

Catastrophic injuries

Information is limited on the mechanisms and prevention of direct, traumatic catastrophic wrestling injuries. ^{6, 17, 18} A comprehensive review of wrestling injuries reported to the NCAA ISS from 1985 to 1996 found only 1 report of a catastrophic injury. ⁵ We also need to keep in mind that the small number of catastrophic injuries may reflect the fact that the ISS is a surveillance database and not a mandatory registry and, thus, does not capture all incidents. However, 35 incidents in scholastic and collegiate wrestlers were reported to the National Center for Catastrophic Sports Injury Research over the 18-year period from 1981 until 1999. ¹³ Although much of our attention has been focused on noncatastrophic and indirect injuries resulting from weight loss, direct catastrophic incidents do affect wrestlers. ^{12, 19–22} The incidence of catastrophic injuries at the high school level is higher than at the collegiate level. The greater total number of high school wrestlers participating annually and their decreased skill level as compared with collegiate wrestlers could explain this finding. ^5–9 Emergency action plans need to be established and implemented for match and practice venues.

Weight-Loss–Related Injuries

The problem of weight-loss–related injuries in wrestlers has been described extensively. ^19–23 Some elite collegiate wrestlers, as well as less-skilled wrestlers, reduce body weight immediately before the match and then gain weight afterward. ²³ One month into the start of the 1997 collegiate wrestling season, 3 wrestlers died during attempted rapid weight loss. The wrestlers had restricted food and fluid intake while exercising vigorously and wearing vapor-impermeable suits in hot environments. ²⁴ These cases highlight the extreme extent of rapid weight loss undertaken by wrestlers trying to make weight ^{25, 26} and the inherent dangers. In January 1998, the NCAA implemented a Wrestling Weight-Certification Program in an attempt to curb the unsafe weight fluctuation practices of college wrestlers during the competitive season. These changes were consistent with recommendations from the American College of Sports Medicine. ²⁷ They included adding 6 to 7 lb (2.7 to 3.2 kg) per weight class, modifying weigh-in procedures, and mandating a wrestler's weight class certification early in the season, thus eliminating any incentive for detrimental weight loss during the season. ^{21, 28} One limitation of the present data set is our inability to infer indirect causes of injury resulting from attempts to cut or make weight for competition.

Although the effect of the NCAA rule changes on weight management and injury is still being determined, ^{23, 29, 30} the match injury rate showed a small nonsignificant increase since the NCAA instituted its weight management rules. How these rule changes may have affected injuries in the long term is unclear.

Summary

In summary, these data show patterns of injury consistent with the person-to-person, combative contact between wrestlers. Musculoskeletal and head injuries directly reflect the most vulnerable areas during attack, and skin infections are a continuing concern in the practice environment. Efforts by referees to be vigilant for potentially dangerous holds and by athletic trainers to improve wrestler and mat hygiene should be continued.

DISCLAIMER

The conclusions in the Commentary section of this article are those of the Commentary authors and do not necessarily represent the views of the National Collegiate Athletic Association.