• 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.


  • Ranks sixth among high school boys in participation, with almost 260,000 participants in 10,597 schools (2014–2015)

  • 220 National Collegiate Athletic Association (NCAA) and 53 National Association of Intercollegiate Athletics (NAIA) collegiate wrestling programs in the US

  • 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.

    • Youth wrestling: Hand, wrist, and finger

    • High school wrestlers: Shoulder

    • College wrestlers: 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.

General Principles

Wrestling Styles

  • International wrestling: Freestyle and Greco-Roman

    • Greco-Roman: Wrestlers are not permitted to attack an opponent’s legs.

    • Freestyle has both men’s and women’s divisions.

  • United States youth, high school, and college wrestling: Folkstyle

  • Greco-Roman and Freestyle reward throws more than Folkstyle, which leads to more high-velocity mat injuries, including head and neck injuries and concussions.

  • Folkstyle allows wrestlers to stay in a defensive down position for longer, which leads to more defensive injuries such as shoulder strains and subluxations.

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 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.


  • Governing bodies of wrestling in the US

    • High school

      • The National Federation of State High School Associations (NFHS) is the national advisory organization for state high school athletic organizations. Most states adopt the NFHS rules. However, individual state high school athletic associations retain the power to determine their own state’s rules. Physicians should check with their specific state’s high school athletic association to see if their rules differ from the NFHS rules.

    • College

      • NCAA Wrestling Rules Committee

      • The NAIA and National Junior College Athletic Association (NJCAA) both defer to the NCAA rules for wrestling.

    • International styles (Greco-Roman and freestyle)

      • USA Wrestling is the governing body for international-style events

  • Injury time during matches ( Table 88.1 )

    • Injury time-outs are stoppage of wrestling requested by a coach, wrestler, or referee.

    • Injury time is defined as the cumulative time spent under evaluation and recovery from an injury sustained during the match, including overtime.

    TABLE 88.1


    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

    NFHS: National Federation of State High School Associations; NFHS 2015–2016 Wrestling Rule Book.

    NCAA: National Collegiate Athletic Association; 2015–2016 NCAA Wrestling Rules and Interpretations.

    * Exceeding indicated values results in the wrestler losing the match by injury default.

    Time to recover from the opponent’s illegal action; if the injured wrestler cannot resume wrestling within 2 minutes, he is declared the winner and the opponent is disqualified.

  • Recovery time

    • Time spent under evaluation and recovery from an injury that resulted from an illegal action by the opposing wrestler

  • Bleeding time during matches

    • Time spent stopping the bleeding and cleaning blood from mats, wrestlers, and equipment; 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.

  • Concussions

    • 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.

  • Skin infections (see the Skin Infection section )

Specific Training and Physiology Issues

Weight Classifications

  • Competitors are matched by weight classes in all styles:

    • Men’s freestyle: 6 weight classes

    • Women’s freestyle: 6 weight classes

    • Men’s Greco-Roman: 6 weight classes

    • USA collegiate men folkstyle: 10 weight classes

    • USA collegiate women folkstyle: 8 weight classes

    • USA high school folkstyle: 14 weight classes

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.

Weight Loss and Health Concerns

  • Rapid weight loss of >5% of body mass in 1–2 days is cited as an acute health risk. During 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.

Weight Loss and Performance

  • Impact on performance dependent upon 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.

Weight Management Guidelines and Rules ( Box 88.1 )

  • 1964: NFHS Athletic Associations urged states to pass regulations that included “weight control plans” that would decrease potentially dangerous rapid weight loss methods.

  • 1976: American College of Sports Medicine Position Stand on Weight Loss in Wrestlers called for weight certification based on a preseason measurement of body composition.

  • 1991: Wisconsin becomes the first high school athletic association to implement a mandatory preseason body composition as the basis for weight certification. Minimum weight was based on 7% body fat. A nutrition education program for wrestlers and coaches was included. Subsequent studies found significant decreases in rapid weight loss and weight cycling in Wisconsin high school wrestlers. Michigan instituted a similar rule in 1997.

  • 1997–1998: Deaths of three collegiate wrestlers while attempting rapid weight loss

  • 1998: NCAA implements five rule changes for the 1998–1999 competitive season, including a minimum weight based on 5% body fat and moving weigh-ins to at most 1 hour before competition (see Box 88.1 ).

  • NFHS calls for each individual state high school athletic association to develop a program to “discourage excessive weight reduction and/or wide variations in weight.” This recommendation became a national mandated rule for the 2006–2007 season. However, the NFHS is an advisory organization. Each state athletic association sets its’ own rules and regulations.

  • The NJCAA and NAIA both mandate that their member institutions adhere to the NCAA Weight Management Program for wrestlers.

  • NCAA and NFHS weight management programs both allow for an exception to the minimum body fat certification for athletes who have <5% body fat (NCAA) or <7% body fat (NFHS) at the preseason body composition assessment. These wrestlers are allowed to wrestle at their preseason weight with a statement from a physician that this weight is their “normal” healthy weight.

  • Very unusual for postpubescent wrestlers to have <7% body fat in high school or <5% body fat in college. Studies of wrestlers at NCAA championships found no wrestlers with >5% of body fat, and <5% of wrestlers had <7% of body fat.

  • USA Wrestling governs international-style wrestling tournaments for all age groups. USA Wrestling prohibits several rapid dehydration techniques such as saunas and “hot boxes” and vapor-impermeable suits at their non-Senior level competitions. However, there are no other weight loss rules and there is no minimal weight certification.

Box 88.1

NCAA and NFHS Weight Management Programs *

* The NFHS is an advisory organization. Each state athletic association determines its own specific rules that may or may not incorporate the NFHS recommendations.

  • 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.”

NFHS: National Federation of State High School Associations: NFHS 2015–2016 Wrestling Rule Book.

NCAA: National Collegiate Athletic Association; NCAA Wrestling 2015–2016 and 2016–2017 Rules and Interpretations.

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Jul 19, 2019 | Posted by in SPORT MEDICINE | Comments Off on Wrestling
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