Kevin Mangum, D.O. is a board certified primary care sports medicine and family medicine physician who treats non-operative orthopedic conditions including wrestling Injuries.

Wrestling Summary

Wrestling is widely considered to be the world’s oldest sport, dating back to the ancient Greeks. It is a worldwide sport, with particular popularity in Eastern Europe, the Middle East, Asia, and North America. Men’s wrestling was an original Olympic sport, whereas women’s wrestling was added to the Olympics in 2004. It is also a very popular high school sport that ranks sixth among high school boys in participation, with almost 260,000 participants in 10,597 schools (2014–2015). There are 220 National Collegiate Athletic Association (NCAA) and 53 National Association of Intercollegiate Athletics (NAIA) collegiate wrestling programs in the USA.

Wrestling is a contract sport, which unfortunately has a higher rate of injury than non-contact sports. The injury rate among high school boys who wrestle is 2.50 per 1000 athletic exposures, which is the second highest injury rate in high school male sports and is approximately the same as that in soccer. The injury rate in male college athletes is 7.25 injuries per 1000 athletic exposures as per the NCAA Injury Surveillance System.

The most common site of injury differs depending on the competition level. In youth wrestling, it is the hand, wrist and finger. In high school wrestlers, it’s the shoulder. In college wrestlers, it’s the knee. Approximately 7% of injuries result from illegal moves.

Skin infections are the most common reason wrestlers seek medical attention and account for most of the time lost from competitions and practices.

What are the wrestling equipment and safety issues?

Most wrestling matches are contested in a singlet, which is a tight, one-piece uniform, while most wrestlers practice in shorts or sweatpants and a T-shirt. Looser-fitting practice clothes can cause injuries such as finger dislocations when they are loose; hence, most wrestlers will tuck their shirts into their shorts and even tuck their pant legs into socks. Wrestling shoes provide a light, but supportive point of traction on the wrestling mat, which can be slippery when wet. Wrestling mats have greatly improved over the past 25 years and have become much more durable. Headgear is required in college and high school wrestling, but is almost never worn in international wrestling events. Supportive braces will have to be approved by the referee and will likely be denied if there are any metallic pieces palpable owing to the possibility of injury to the opponent.

Wrestling Weight Management

Wrestlers have traditionally wrestled in the lowest weight class possible in the belief that this will provide them a competitive advantage. 85% of US high school wrestlers lose over 10% of body weight to achieve their competitive wrestling weight. In-season weight loss occurs through frequent weight cycles involving rapid weight loss and then weight gain after a competition. Surveys have found that high school and college wrestlers lose an average of 3.5–5.5 kg of weight in the week preceding a match. Most commonly used method of rapid weight loss is sweating combined with fluid and caloric restriction. Diuretics, laxatives, and vomiting are less frequently used, with 1%–5% of wrestlers using these methods.

What are the health concerns for rapid weight loss in wrestlers?

Rapid weight loss of >5% of body mass in 1–2 days is cited as an acute health risk. During the 1997–1998 season, three collegiate wrestlers died from complications of rapid weight loss. Long-term consequences of frequent weight cycling are unknown. Impaired growth, eating disorders, and obesity have been proposed but not consistently found in longitudinal studies.

How does weight loss affect performance in wrestling?

Weight cycling and rapid weight loss can affect performance and is dependent upon the level of dehydration, glycogen stores, time for replenishment (i.e., time between the weigh-in and the competition), and number of same-day matches. Dehydration of 2%–3% has limited effects on muscle strength and anaerobic power. Glycogen-depleted wrestlers reach a performance limiting level of glycogen within 7 minutes of wrestling. Replenishment of glycogen stores takes 24–48 hours. Therefore, glycogen depletion can have a profound impact on performance during a multiple-match day (e.g., a tournament). Weight loss of 3%–6% body fat over 3–4 days even without dehydration significantly reduces the average work performance for tasks as short as 6 minutes.

The National Federation of State High School Associations (NFHS) and National Collegiate Athletic Association (NCAA) have proposed guidelines to prevent injuries associated with rapid weight loss and weight cycling. However, each state athletic association determines its own specific rules that may or may not incorporate the NFHS recommendations.

What are the recommended weight management guidelines for wrestlers?

Preseason establishment of minimum weight based on lean weight assessment
NFHS: 7% body fat (boys), 12% body fat (girls)
NCAA: 5% body fat (men)
Urine specific gravity (Usg) at initial weight certification
NFHS: Usg < 1.025
NCAA: Usg < 1.020
Not more than 1.5% body mass loss per week
Weigh-ins must occur within an hour of the start of dual meets (2 hours for tournaments)
The use of laxatives, diuretics, emetics, excessive food and fluid restriction, self-induced vomiting, impermeable (plastic or rubber) suits, hot rooms, hot boxes, steam rooms, and saunas is prohibited.
NFHS: The weight management program should include “a nutritional component developed at the local level.”

What is the injury timing in wrestling?

Injury time-outs are the stopping of wrestling requested by a coach, wrestler or referee during the wrestling match. Injury time is defined as the cumulative time spent under evaluation and recovery from an injury sustained during the match, including overtime.

	NFHS	NCAA	USA Wrestling
Injury Time-Outs	2	2	Unlimited
Cumulative Injury Time	90 seconds	90 Seconds	Unlimited
Blood Time	5 minutes	Unlimited	Unlimited
Concussion Evaluation	Counts toward injury time	Unlimited	Unlimited
Recovery Time	2 Minutes	2 Minutes	Unlimited

Recovery time is the time spent under evaluation and recovery from an injury that resulted from an illegal action by the opposing wrestler. Bleeding time during matches is the time spent stopping the match due to bleeding and cleaning blood from mats, wrestlers, and equipment; it is distinct from injury or recovery time. The NCAA does not limit the bleeding time. The referee, in consultation with medical personnel, has the authority to stop the match and declare the nonbleeding wrestler the winner by medical default if the bleeding becomes excessive or causes an inordinate number of time-outs. The referee has the responsibility to stop the match if he/she suspects a concussion according to the NFHS, NCAA, and USA Wrestling rules. The NCAA makes a distinction between injury time and time spent evaluating a concussion. Medical personnel have unlimited time to evaluate a wrestler suspected of sustaining a concussion. This time does not count against the wrestler’s injury time or recovery time.

What are the most common skin infections in wrestlers?

Wrestlers are at an increased risk for skin infection because of two main factors. Repetitive skin trauma causes a breakdown in the natural skin barriers to infection and close and prolonged exposure to potential infectious agents of the skin. Most commonly infected areas are the head, neck, and face, which are the areas of maximum skin-to-skin contact. Primary transmission is via skin-to-skin contact and not from mats and other environmental sources. In college wrestlers, herpes simplex virus (HSV) is the skin infection responsible for the most lost wrestling time, followed by bacterial and fungal skin infections. Wrestlers with skin infections should be withheld from contact with other wrestlers until it is determined that they are no longer infectious. Both the NCAA and NFHS have specific criteria for return to competition after a wrestler has been diagnosed with an infectious skin condition. The designated on-site physician or certified athletic trainer for a competition may exclude any wrestler deemed infectious even with documented appropriate treatment from the wrestler’s personal or team physician (NCAA and NFHS).

Some of the most common wrestling skin infections are Herpes Gladiatorum (HG), Common Warts, Molluscum Contagiosum, Impetigo, Folliculitis, Carbuncle, Cellulitis and Tinea Gladiatorum. If you are having any skin conditions that are concerning or that need evalutation, please make an appointment with Dr. Kevin Mangum Kevin Mangum, D.O. is a board certified primary care sports medicine and family medicine physician who treats non-operative orthopedic conditions, sports medicine and family medicine conditions.

What is an auricular hematoma or cauliflower ear in wrestlers?

Auricular hematoma (“cauliflower ear”).
Kevin Mangum, D.O. is a board certified primary care sports medicine and family medicine physician who treats non-operative orthopedic conditions including wrestling Injuries.

An auricular hematoma happens after a blunt trauma to the ear that can cause accumulation of blood in the subperichondrial space between the perichondrium and the auricular cartilage, resulting in a hematoma. The perichondrium carries the blood supply to the auricular cartilage. The formation of a hematoma separates the perichondrium from the cartilage, thereby interrupting the blood supply. If persistent, an auricular hematoma can result in cartilage death. Over time, new abnormal cartilage with fibrosis will form, resulting in the characteristic deformity known as cauliflower ear.

Treatment usually includes removing the blood and preventing re-accumulation; for acute hematomas, blood can be removed by aspiration with an 18-gauge needle. Hematomas may have to be evacuated through an incision. Removal of the blood leaves a potential space into which blood will rapidly re-accumulate with even minimal trauma. Therefore, treatment should include a technique to prevent blood re-accumulation. Most effective technique uses absorbable mattress sutures to close the space. Outcomes have been excellent, and wrestlers may immediately return to wrestling. Only trained sports medicine providers should attempt treatment.

How do you prevent auricular hematomas or cauliflower ear? The NFHS and NCAA mandate wearing a headgear while wrestling to prevent direct auricular trauma, but this rule is generally only enforced during official matches. International-style wrestling (freestyle and Greco-Roman) does not require headgear.

What are common Head and Face Injuries in wrestlers?

Eyebrow lacerations make up the largest proportion of lacerations and are typically the result of the two wrestlers striking heads. A knee or elbow to the brow is also a common cause of lacerations.

A sports medicine provider will control the bleeding and protect wound by placing gauze over wound and tightly wrap head with an elastic tape under an athletic tape. Ferric subsulfate (Monsel) solution and/or skin glue can control bleeding. However, these substances can complicate subsequent repair and healing. Ferric subsulfate solution creates necrotic subcutaneous tissue that potentially increases the risk of infection if sutured over. After the match, suturing the wound will allow the wrestler to continue wrestling and minimize subsequent bleeding. Vertical mattress sutures are particularly useful to withstand large amounts of tension placed on a wound during wrestling.

Epistaxis or nose bleeds are extremely common. they are usually unilateral and anterior involving Kiesselbach’s plexus. The sports medicine provider will examine to ensure that there is no septal hematoma. Within a match, bleeding can usually be controlled with insertion of a folded cotton roll to apply compression to the bleeding septum. NFHS allows 5 minutes of cumulative blood time per wrestler per match, beyond which the wrestler is disqualified. No blood time limit in NCAA wrestling. After the match, persistent bleeding can be stopped by vasoconstriction with 0.05% oxymetazoline nasal spray that can be directly applied to the bleeding or used to soak a cotton roll that is placed in the nose for 4–5 minutes. Directly visualized bleeding vessels can also be stopped by gentle cautery with silver nitrate. Septal hematoma needs immediate drainage to prevent cartilage death. Refer to an otolaryngologist if the on-site healthcare provider is not experienced in management. Petroleum jelly can be spread on the septum to reduce dryness.

What are the most common Lower Limb Injuries in wrestling?

Prepatellar Bursitis is very common in wrestlers. The prepatellar bursa lies directly anterior to the patella and can be easily injured with direct trauma, most commonly from repeated striking of the knee on the mat. The bursa can fill with fluid and/or blood. It can be swollen and tender area just anterior to the patella; may be associated erythema and warmth of the skin. Typically, the knee is tender but not painful. Range of motion is normal, with pain only in full flexion because of stretching of the bursa; must distinguish infectious bursitis from traumatic bursitis. Infections occur through a breakdown in the overlying skin. Traumatic bursitis should not be aspirated because of the risk of introducing an infection. However, consider aspiration if infection is suspected. Bursal fluid should be sent for Gram stain and culture. Treatment for prepatellar bursitis focuses on reducing the irritation of the bursitis through suspension of activity and wearing a knee pad; typical neoprene knee pads used often in wrestling will likely not provide enough padding once traumatic bursitis has developed; hence, a large, volleyball-style knee pad is usually required. Off the mat, an elastic bandage or a simple neoprene or elastic knee sleeve will maintain compression and reduce the swelling and pain of bursitis. A week or two of immobilization and avoidance of direct trauma has been recommended to shorten the course of the injury, but many wrestlers will choose to practice and compete. Once the swelling of the bursa has resolved, the wrestler should continue to wear a knee pad to prevent recurrence. Surgical bursectomy can be considered for wrestlers who develop chronic bursitis.

Medial Collateral Ligament (MCL) Sprains are also very common. Medial collateral ligament (MCL) of the knee is the major stabilizer against valgus force and is frequently placed under great stress in the sport of wrestling. Treatment protocols for MCL injuries that emphasize early controlled motion and protected weight bearing have been found to be successful in returning athletes to full function. A hinged brace can be used to protect against valgus stress and external rotation. Return to wrestling is based on a functional assessment of the athlete more than a specific time frame. When a hinged knee brace has been utilized after a sprain, it may be used in wrestling competition if appropriately padded, which must be approved by the referee before a match.

What are the most common Upper Limb Injuries in wrestling?

Shoulder Subluxation/Dislocation are common wrestling injuries. Shoulder injuries are common in wrestling due to extreme anterior flexion, abduction, and external rotation that occurs frequently. These positions may lead to subluxation or dislocation. A wrestler with a glenohumeral dislocation will present in acute pain with the arm typically held in a fixed position in slight internal rotation and abduction. It is extremely important to assess neurovascular status in these patients. The sports medicine provider will check the axillary nerve which covers the sensation over lateral aspect of shoulder and the brachial plexus by checking hand strength and sensation.

The ease of reduction is related to the amount of spasm of the surrounding shoulder musculature, which is often directly related to the amount of time since the injury. Therefore, prompt reduction has the advantage of avoiding muscular spasm and decreasing neurovascular compromise. The choice of reduction technique should be based on the familiarity and comfort level of the physician. Certain older techniques, such as the Kocher and Hippocrates methods, have been associated with more postreduction complications and should be avoided. Immobilization in a sling for 3 weeks recommended by certain orthopedic surgeons after a first dislocation; physical therapy for rotator cuff strengthening and neuromuscular training; surgery after an acute dislocation has been shown to reduce the risk of recurrence; referral to orthopedic surgeon to discuss the potential risks and benefits of surgery should be considered.

In order for the athlete to return to wrestling, full rotator cuff strength and absence of apprehension sign is needed. Prevention of these injuries should include shoulder flexibility, shoulder joint stiffness may increase the risk of injury in wrestlers; rotator cuff strengthening and neuromuscular control.

Finger dislocations are also another common wrestling injury. The proximal interphalangeal joint is the most common dislocated finger joint. Medial-to-lateral plane dislocation: One or both of the collateral ligaments of the finger are damaged. Volar-to-dorsal plane dislocation: Volar capsular ligament is injured. The sports medicine provider will check neurovascular examination; assess for phalange shaft fracture. Reduction can be attempted before radiographs if no bony tenderness or notable deformity of the phalanges; buddy tape or splint after reduction. The wrestler may return to play with buddy taping if no significant fracture or neurovascular injury is present.

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Wrestling Injuries