Injuries in Collegiate Wrestlers at an Elite Division I NCAA Wrestling Program: An Epidemiological Study

Abstract

Background

Injury is common in the sport of wrestling. More than 6000 athletes compete in NCAA wrestling yearly. Despite this popularity, little is known about the epidemiology of wrestlers’ injuries and factors affecting return to competition. We hypothesized that patterns of injury and associated factors influence return to participation.

Methods

Retrospective database review of one Division I NCAA wrestling program over nine seasons (2002 to 2011).

Results

From 2002 to 2011, 125 wrestlers were varsity participants at a single NCAA Division I program. Among these wrestlers, there were 4275 exposures per year on average. We identified 1034 musculoskeletal injuries, skin injuries, and concussions in 120 athletes (96% of participants). Eighty-two percent of athletes missed at least one day secondary to these injuries, while 69% were unable to compete in at least one match. The injury rate was estimated at 19.6 (SD 16.5) per 1000 exposures. The rate of injuries requiring surgery was estimated at 1.4 (SD 2.1) per 1000 exposures. Weight class, record, age at injury, and eligibility status did not affect the rate or type of injury. A significant difference was noted in the athletes who returned to competition following surgery. Athletes who returned to competition after surgical treatment for an injury ultimately competed in more matches (62.4 vs 18.2, p < 0.001), had more wins (45.2 vs 12.1, p<0.001) and a higher win percentage (67.5 vs 51.2 p < 0.01) than those who did not return following surgery.

Conclusion

Return to competition in collegiate wrestling is dependent on many factors in addition to severity of injury and surgery type. There is a positive association between return to sport and success as a collegiate wrestler. Our findings will be helpful to wrestlers and coaches in guiding expectations after injury.

Level of Evidence: Level 4 diagnostic

Introduction

Wrestling is a physically demanding sport in which injury is common. Despite recent declines in participation,¹ it remains a popular sport at the collegiate level. In the 2011-12 season, 6622 athletes competed at the NCAA Division I, II and III levels.¹ There have been several previous studies regarding the epidemiology of injuries in wrestling.^2-7 These have been primarily reviews of national injury databases,⁸ or focused at the high school,^9,10 primary school,¹¹ or Olympic levels.⁷ There have been no published reviews of injuries from a single collegiate wrestling team in the modern era, and little data has been published regarding surgical treatment of wrestlers and the factors associated with return to competition following surgery. The purpose of this study is to describe the patterns of injury and associated factors in collegiate wrestlers, and examine the effect of surgical treatment on return to participation in one Division I NCAA wrestling program over nine seasons (2002 to 2011).

Methods

Institutional review board (IRB) approval was obtained for this study. We conducted a retrospective review of training room and medical records of all injuries sustained by athletes on the wrestling team of a single NCAA Division I program during the 9 seasons from 2002 to 2011. All injuries were entered into the Sports Injury Monitoring System (SIMS - Med Sport Systems, Dimondale, Michigan) by an athletic trainer at the time of injury. SIMS is a computerized database in which details of the injury and injured athlete are entered. This database is monitored by the university as well as the wrestling conference.

The electronic medical records of injured athletes were reviewed to determine which injuries required surgical intervention and the date of surgery if applicable. Publically available competition records¹² were used to determine the dates that the athlete participated in varsity competition, confirm their weight class at the time of injury, as well as determine their overall win/loss record.

Definitions

An injury was defined as any skin problem, musculoskeletal problem or systemic illness that occurred during practice or competition and resulted in a visit to an athletic trainer or physician. Concussions or neurologic injury suffered as a result of these events were also included as an injury. A season was defined to reflect the academic year from August 1 to July 31 of the next year. The athlete’s eligibility was defined using years one through five, with the final year (senior) eligibility listed as 5, and the inclusion of an additional year of eligibility as a freshman if a red-shirt year was taken. Weight class is defined by the highest weight class the wrestler competed in during a given year based on the official team roster. In the time period of this study, there was a change in heavyweight from 285 to 275 lbs, and these weight classes were combined for statistical purposes. An exposure was defined as participation in one of the 144 NCAA-sanctioned yearly practices or matches in which a wrestler participated. Injuries based on anatomic region were recorded if experienced as a result of any team-related activity such as matches, practices, or strength and conditioning sessions.

Injuries and conditions requiring medical attention were entered prospectively at the time of injury by athletic trainers into SIMS during the 9 seasons from August 2002 to July 2011. This injury data from the SIMS database was reviewed by two of the authors and systemic illnesses or injuries not related to team activities such as practices or matches were excluded. The injuries were categorized by body part injured. (Table 1) If an athlete was unable to compete or practice as a result of the injury, this was also recorded into SIMS as the data became available.

Table 1.

Distribution of Injuries and Number of Injuries Resulting in Missed Time and Surgery by Body Part

	All injuries		Injuries Causing Missed Time		Injuries that Required Surgery		Average Year of Eligibility
Location of injuries	Number	%	Number	%	Number	%
Skin	181	17.5	63	16.4			2.8
Knee	177	17.1	97	25.2	43	58.1	2.8
Head and Face	173	16.7	18	4.7	3	4.1	2.7
Shoulder	101	9.8	46	11.9	17	23.0	2.5
Foot and Ankle	80	7.7	37	9.6	2	2.7	2.5
Spine, cervical	62	6.0	16	4.2			3.0
Spine, lumbar	55	5.3	16	4.2			3.0
Chest wall (not spine)	33	3.2	20	5.2			2.8
Hand and Wrist	32	3.1	12	3.1	2	2.7	2.7
Brain	30	2.9	28	7.3			2.5
Thigh	28	2.7	8	2.1	2	2.7	2.6
Elbow	27	2.6	13	3.4	2	2.7	2.9
Hip	17	1.6	4	1.0	2	2.7	2.6
Systemic	16	1.5	3	0.8	1	1.4	2.0
Spine, thoracic	10	1.0	1	0.3			2.9
Abdomen	7	0.7	3	0.8			1.9
Otero	5	0.5	0	0.0			3.2
TOTAL	1034		385		74		2.7

1=RS Freshman

2=Freshman

3=Sophomore

4=Junior

5=Senior

Using information from official team rosters, the athlete’s age, year of eligibility, and weight class on the date of injury were obtained. Eligibility and weight wrestled were determined for each athlete and year by the official season summary published online.

Exposures were calculated using team competition data to determine total number of matches competed in by rostered athletes, and it was assumed that all athletes on the roster were eligible to participate in the 144 NCAA-allowed team practices per year. Statistical analyses were performed to identify significant associations between demographic characteristics of the injured wrestler, individual records, and injury variables. For purposes of analysis, we grouped weight classes into three categories including Low (125,133,141), Middle (149,157,165), and High (174,184,197,285) weight athletes.

The Mantel-Haenszel 2 test and Tukey-Kramer adjustments for multiple comparisons were used to analyze for significant trends in the relationship of age, eligibility status, weight class, and competition statistics in relation to the frequency and location of injuries. Additionally, we examined the data for trends indicating whether or not these injuries required surgery, and if the injured athlete was able to return after surgery. The relative risk (RR) of injury was also calculated for year of eligibility and weight class. For all analyses, p < 0.05 was considered statistically significant.

Results

In the nine seasons from 2002 to 2011, 125 athletes were varsity participants in Men’s Wrestling at a single NCAA Division I institution. We identified 1034 musculoskeletal injuries, skin injuries, and concussions in 120 athletes (96% of participants). Eighty-two percent (102/125) of athletes missed at least a single day secondary to these injuries, while 69% (86/125) were unable to compete in at least one match. The average number of exposures per year was calculated at 4275 for all athletes. The injury rate was estimated at 19.6 (SD 16.5) per 1000 exposures. The rate of injuries requiring surgery was estimated to be 1.4 (SD 2.1) per 1000 exposures.

Ages of participants ranged from 18 to 25 years old, with 99.3% of the wrestlers being between 18-23. Eligibility status was fairly evenly divided between the five years, with slightly fewer redshirt freshmen and seniors (61 and 50, respectively) versus years two (79), three (72), and four (65) in eligibility.

There was no association found between age or eligibility and risk of suffering an injury, location of injury, missed time or missed competition (Table 2). Of those injured wrestlers who required surgery, neither age nor eligibility status was noted to have a significant effect on return to competition following surgery, although 3 of the 9 injured wrestlers in their final year of eligibility elected to delay procedures until the conclusion of their career.

Table 2.

Characteristics of Injuries

Characteristic	All injuries	Injuries Causing Missed Time	Injuries that Required Surgery
Age at Injury	20.7 (1.4)	20.8 (1.4)	20.8 (1.5)
Average Eligibility	2.7 (1.3)	2.7 (1.3)	2.8 (1.3)
Number of Injuries per Athlete	8.6 (6.9)	-	-
Days on Injury List	13.6 (38.0)	36.5 (55.2)	109.2 (77.4)
Competitions Missed	1.6 (4.3)	3.6 (6.3)	8.9 (10.4)
Practices Missed	4.1 (10.6)	10.8 (15.1)	25.0 (23.4)

*Number in parenthes SD

With regard to weight class, there was no significant difference noted between injury frequency, time missed following injury, or location of injury when the three groups of weight classes were compared. Similarly, there was no difference in relative risk of injuries sustained that required surgery (RR = 1.2 to 1.5). There was, however, a higher percentage of middle-weight wrestlers who did not return after injuries which required surgery (12/29) when compared to the low (2/19) or high (3/17) weight wrestlers. (P=0.04) (Table 3)

Table 3.

Distribution of Injuries and Surgery by Weight Class

Weight Class	# of Participants in 9 Years	All injuries		Injuries that Required Surgery
		Number of Injuries	Risk per 1K Exposures	Number of Injuries	Risk per 1K Exposures
Low weights (125, 133, 141)	101	293	17.4 (12.2)	23	1.4 (2.1)
Mid Weights (149, 157, 165)	128	399	19.5 (15.7)	31	1.5 (2.2)
High Weights (174, 184, 197, 285)	99	342	22.2 (21.0)	20	1.2 (2.0)
Total	328	1034	19.6	74	1.4

*SD in parentheses

There were 74 surgeries performed on 48 wrestlers during the time of our data collection (Table 4). Following 72% of these interventions (52/74), the injured athlete returned to compete following the surgery. The most common surgeries performed were meniscus repair/debridement (21), ACL reconstruction (15), and labral tear repair in the shoulder (10). There were no significant differences observed between type of surgery and likelihood of returning to competition.

Table 4.

Characteristics of Wrestlers With Surgery Comparing Wrestlers Who Return to Those Who Do Not Return

	TOTAL #	Wrestles Who Return	Wrestles Who Do Not Return	Surgery after 5th Year
Total Surgery	74	53	17	4
Knee Surgery	43	32	9	2
Meniscus	21	15	6
ACL	15	11	2	2
Cartilage	2	2
Infection	2	1	1
Bursectomy	2	2
PLC	1	1
Shoulder Surgery	17	12	4	1
SLAP Repair	10	6	3	1
Bankart	3	3
Capsulorrhaphy	2	1	1
Bursectomy-other	1	1
Muscle repair	1	1
Other Surgery	14	9	4	1
Fracture	8	5	3
Hip Impingement	2	1		1
Hamstring	2	1	1
Bursectomy	1	1
Infection	1	1
Weight Class
Low		19	2	2
Mid		17	12	2
High		17	3
Number of matches		62.4 (48.0)	18.2 (23.4)	p-value 0.00052
# of winning matches		45.2 (37.5 )	12.1 (18.2 )	p-value 0.00083
Record Win %		67.5 (19.6 )	51.2 (23.9 )	p-value 0.01275
Practices Missed		21.0 (22.4)	32.8 (19.2)	p-value 0.05
Competitions Missed		7.4 (9.5)	11.9 (10.5)	p-value NS
Days on Injury List		101.7 (71.0)	124.0 (10.5)	p-value NS
Eligibility status		2.6 (1.2)	2.9 (1.3)	p-value NS
AGE at injury		20.6 (1.5 )	20.9 (1.4 )	p-value NS

Number in parenthesis is SD

Eligibility status: 1 = RS Freshman 2 = Freshman 3 = Sophomore 4 = Junior 5 = Senior

Low weights 125, 133, 141

Mid weights 149, 157, 165

High weights 174, 184, 197, 285

The athletes in our cohort competed in an average of 43 varsity matches, with 29 wins and an overall win loss percentage of 68%. There was no significant difference noted in rate of injury, location of injury, or percentage of injuries requiring surgery between athletes with differing numbers of matches, competitions, or win/loss percentages. A significant difference was noted however in those athletes who returned to competition following surgery, showing athletes that returned ultimately competed in more matches (62.4 vs 18.2, p < 0.001), had more total wins (45.2 vs 12.1, p<0.001) and a higher win loss percentage (67.5 vs 51.2 p < 0.01) than those who did not return following their intervention. (Table 4)

Discussion

The rate of injury per exposure in our study (19.6 per 1000) is similar to national data previously described through review of the NCAA Injury Surveillance System,⁸ and in other published reports of injury at the collegiate level.⁵ Previous authors have described high rates of injury,⁵ often attributed to the competitive nature of the sport.¹³ In previous studies, a majority of injuries sustained occurred in the knee and shoulder, and skin injuries were third.⁸ In our study, however, lacerations and infections of the skin were the most common injury encountered, and the second most likely to result in missed participation time. (Table 1) Of non-skin musculoskeletal injuries, injuries followed a similar pattern with knee and shoulder as the most commonly injured structures.

Similar to findings of Jarrett, et al,⁵ no statistical significance was found in injuries to specific weight classes. Similar to the previous publication, our data shows a non-significant trend of higher injury numbers in middle-weight wrestlers. Year of eligibility and athlete age at the time of injury were noted to be non-significant, which mirrors previous results as well.⁵ It was interesting to observe that despite some evidence that younger athletes and those in earlier years of eligibility in other sports show predilection to injury,¹⁴ this was not evident in our cohort.

Perhaps the most interesting finding of our study was that despite having similar rates and locations of injuries as well as similar incidence of surgery, there was great disparity in the rates of return to competition amongst wrestlers with differing win percentages, total number of wins, and total number of matches. Namely, of the wrestlers who required surgery for their injury, those who ultimately returned to competition wrestled in a greater number of matches, had a higher number of total wins, and had a higher overall win percentage.

One possible explanation for these findings reflects the increased dedication to sport of those athletes able to achieve better records. The factors that motivate an athlete who has suffered a relatively significant musculoskeletal injury to return to the sport that cause it are complex, but our findings certainly lend credence to the theory that those who are more successful may be more devoted to the sport despite setbacks such as serious injury requiring surgery. Nevertheless, caution should be exercised in drawing conclusions from studies where return to sport is the primary outcome of a surgical intervention, since as was previously described, the factors that contribute to return are complex.

Another hypothesis presented by Yoon, et al ¹⁵ points to physical differences among Olympic wrestlers with better winning percentages. Perhaps wrestlers who are more successful are more likely to return to competition after surgery because of a genetically superior ability to heal. Previous authors have also suggested there is a psychological component in return to sport following ACL surgery that can be difficult to quantify.¹⁶

Limitations of our study include the nature of retrospective data collection, and the possibility of errors in reporting the injuries in the SIMS database. Additionally, the physical and psychological factors that affect return to competition are complex, so caution should be used when applying general data of this nature to individual athletes. Finally, injury evaluation and medical treatment at one institution may not be generalizable.

In summary, collegiate wrestling is a physically demanding sport with a high rate of injury. National injury databases may underestimate the prevalence of “minor” injuries such as skin laceration or infection, although these can have a significant impact on participation. Return to competition following injury is dependent on many factors including severity of injury and requirement of surgery, but the most predictive factor in return to competition after surgery is win percentage. Wrestlers, coaches, and physicians should use this data to guide expectations regarding return to competition after injury.