Wrestling is a full-contact sport in which two players compete in physical contact within a circular arena 9 m in diameter1. Players repeatedly perform fast and aggressive maneuvers such as takedowns, riding, reversals, escapes, and bar-arm defense to gain scores or avoid losing points2. For this reason, wrestling is classified as a sport with a high risk of time loss (TL) injuries, especially compared to other sports3,4.
An analysis of NCAA ISP data from 2009–2010 to 2014–2015 revealed that wrestling had the highest incidence rate of severe injuries among 25 sports5. Notably, the incidence rate of severe injuries was 1.73 per 1,000 athlete exposures (AEs), accounting for approximately 14.2% of all wrestling injuries5. Moreover, injuries requiring surgery were estimated at 1.4 per 1,000 exposures6. Notably, severe injuries resulting in prolonged loss of time were more likely to occur in the knee, shoulder, and ankle6-8.
In international competitions, there are two distinct styles of wrestling: freestyle and Greco-Roman9. The most significant difference between the two styles is in the body parts allowed to attack the opponent’s body. Greco-Roman wrestling prohibits grabbing an opponent below the waist or using the legs to squeeze the opponent2. Because of these rule differences, there are some discrepancies in injury patterns between the two wrestling styles10,11.
Severe injuries underscore the critical importance of prevention as they detrimentally impact athletes in multiple dimensions4,12-15. To our knowledge, previous studies addressing TL injuries in wrestling have only provided broad information about common injury sites, mechanisms, and types5,7,9,16. Namely, they did not provide detailed information such as specific diagnoses, return to play (RTP) times, and specific activities at the time of injury regarding injuries sustained by wrestlers. Therefore, this study aimed to provide detailed information on the severe injuries experienced by elite wrestlers based on wrestling style.
Approximately 180 wrestlers participated in the tournament to select the Korean national team for the 2022 Asian Games. Among them, 90 male wrestlers from collegiate and professional levels, including 46 Greco-Roman and 44 freestyle, voluntarily participated in this study. Table 1 shows the general characteristics of the study participants. The mean age of the participants was 24.8±3.7 years, with a mean of 11.3±3.7 years of elite athletic career. The players had an average height of 171.8±7.0 cm and a weight of 74.9±11.6 kg. All participants were elite athletes affiliated with collegiate and professional teams officially registered with the Korea Wrestling Federation at the time of participation in the study.
Table 1 . General characteristics of study participants
| Characteristic | Overall | Greco-Roman | Freestyle | p-value |
|---|---|---|---|---|
| No. of patients | 90 | 46 | 44 | |
| Age (yr) | 24.8±3.7 | 24.2±5.2 | 25.3±4.6 | 0.294 |
| Height (cm) | 171.8±7.0 | 172.5±6.9 | 171.1±7.1 | 0.320 |
| Weight (kg) | 74.9±11.6 | 75.5±12.8 | 74.4±10.3 | 0.678 |
| Career (yr) | 11.3±3.7 | 10.7±3.4 | 11.9±3.9 | 0.116 |
| Weight class | ||||
| Light | 68 (75.6) | 31 (67.4) | 37 (84.1) | 0.065 |
| Heavy | 22 (24.4) | 15 (32.6) | 7 (15.9) |
Values are presented as number only, mean±standard deviation, or number (%).
Written informed consent was obtained from participants after a detailed explanation of the purpose and procedures of the study. This study was approved by the Institutional Review Board of Sungkyunkwan University (No. SKKU 2023-12-051).
The data collection period spanned three days, from 13 to 15 May, coinciding with the Korean national team selection tournament. We used a standardized questionnaire to examine the severe injuries experienced by the athletes and employed a random sampling method for data collection. The questionnaire was comprised of three main sections that covered the general characteristics of the participants, severe injuries to the knee, shoulder, and ankle, and post-management of severe injuries.
First, we investigated the demographic characteristics of the study participants, including age, height, weight, athletic career, and competition weight class. Next, we inquired about severe injuries, covering various aspects of each joint. The survey included questions about injury diagnoses, activities at the time of injury (wrestling technical training, competition, physical training/other activities), injury mechanisms (resisting an opponent’s roll, player collision, mat contact, noncontact/overuse), and specific maneuvers causing injury (tackle attack/defense, standing attack/defense, ground attack/defense, physical training/other activities). Finally, we examined post-injury management variables, including the need for surgery, receipt of specialized rehabilitation, medical clearance upon return to training, and RTP time after injury. RTP criteria were defined as the level at which a player could fully participate in team technical training after injury. RTP time was calculated as the period from the date of injury to the date of RTP. If a participant had multiple injuries to the same joint during their elite athlete’s career, participants were asked to report only the injury with the longest RTP time.
“Time loss” refers to limited participation in training and competition due to injury, a term widely used in the sports injury literature to indicate severity. “Severe injuries” refers to those that resulted in a TL of more than 3 weeks, consistent with previous research4,5,17; limited only to those diagnosed by medical professionals in this study. “RTP time” refers to the days from injury to full participation in team technical training. “Resisting an opponent’s roll” is a contact mechanism in which athletes sustain acute injuries while resisting an opponent’s rolling force. Following the recommendations of Park et al.10, participants were classified as light or heavy classes.
Continuous variables were described as means (medians) and standard deviations, while categorical variables were described as frequencies and percentages. A chi-square test or Fisher exact test was used to compare the experience of severe injuries between the two wrestling styles and the characteristics of the severe injuries. A significance level of p=0.05 was used for all statistical analyses. All statistical analyses were performed using IBM SPSS version 25.0 (IBM Corp.).
Table 2 shows the experience rates of severe knee, shoulder, and ankle injuries based on wrestling style. Freestyle wrestlers had a significantly higher rate of severe knee injuries than Greco-Roman wrestlers (χ2=3.872, p<0.001). Otherwise, there were no significant differences in the experience rates of severe injury by wrestling style.
Table 2 . The proportion of severe injuries experienced to the knee, shoulder, and ankle by wrestling style
| Body part | Severe injury experience | Total (n=90) | Greco-Roman (n=46) | Freestyle (n=44) | p-value |
|---|---|---|---|---|---|
| Knee | Yes | 41 (45.6) | 12 (26.1) | 29 (67.4) | <0.001*** |
| No | 49 (54.4) | 34 (73.9) | 15 (34.1) | ||
| Shoulder | Yes | 21 (23.3) | 9 (19.6) | 12 (27.3) | 0.387 |
| No | 69 (76.7) | 37 (80.4) | 32 (72.7) | ||
| Ankle | Yes | 30 (33.3) | 17 (37.0) | 13 (29.5) | 0.456 |
| No | 60 (66.7) | 29 (63.0) | 31 (70.5) |
Values are presented as number (%).
***p<0.001.
Table 3 shows the characteristics of severe knee injuries. Technical training (73.2%) was the primary activity at the time of injury, with medial collateral ligament (MCL) tears (46.3%) being the most common specific diagnosis. Resisting an opponent’s roll (63.4%) was the primary mechanism, with a significant difference between wrestling styles (p=0.006). Tackle attack (36.6%) and tackle defense (17.1%) were the primary maneuvers causing severe knee injuries. There was a significant difference between wrestling styles in the specific maneuvers that caused severe knee injury (p<0.001). Surgery was required in 31.7% of cases, and only 56.1% underwent specialized rehabilitation. Only 31.7% returned to play after medical clearance, with a mean RTP time of approximately 3.5 months (median, 3.0 months).
Table 3 . Comparison of severe knee injury statistics by wrestling style
| Variable | Total (n=41) | Greco-Roman (n=12) | Freestyle (n=29) | p-value |
|---|---|---|---|---|
| Activity type | 0.848 | |||
| Technical training | 30 (73.2) | 10 (83.3) | 20 (69.0) | |
| Competition | 9 (22.0) | 2 (16.7) | 7 (24.1) | |
| Physical training/others | 2 (4.9) | - | 2 (6.9) | |
| Diagnosis | >0.999 | |||
| MCL tears | 19 (46.3) | 6 (50.0) | 13 (44.8) | |
| ACL tears | 7 (17.1) | 2 (16.7) | 5 (17.2) | |
| Meniscus tears | 10 (24.4) | 3 (25.0) | 7 (24.1) | |
| LCL tears | 4 (9.8) | 1 (8.3) | 3 (10.3) | |
| PCL tears | 1 (2.4) | - | 1 (3.4) | |
| Mechanism | 0.006** | |||
| Resisting an opponent’s roll | 26 (63.4) | 4 (33.3) | 22 (75.9) | |
| Player collision | 5 (12.2) | 3 (25.0) | 2 (6.9) | |
| Mat contact | 3 (7.3) | 3 (25.0) | - | |
| Noncontact/overuse | 7 (17.0) | 2 (16.7) | 5 (17.2) | |
| Specific maneuver | <0.001*** | |||
| Tackle attack | 15 (36.6) | 1 (8.3) | 14 (48.3) | |
| Tackle defense | 7 (17.1) | - | 7 (24.1) | |
| Standing attack | 6 (14.6) | 4 (33.3) | 2 (6.9) | |
| Standing defense | 3 (7.3) | - | 3 (10.3) | |
| Ground attack | - | - | - | |
| Ground defense | 6 (14.6) | 6 (50.0) | - | |
| Physical training/others | 4 (9.8) | 1 (8.3) | 3 (10.3) | |
| Post-injury management | ||||
| Surgery | 0.719 | |||
| Yes | 13 (31.7) | 3 (25.0) | 10 (34.5) | |
| No | 28 (68.3) | 9 (75.0) | 19 (65.5) | |
| Rehabilitation | 0.734 | |||
| Yes | 23 (56.1) | 6 (50.0) | 17 (58.6) | |
| No | 18 (43.9) | 6 (50.0) | 12 (41.4) | |
| Medical clearance | 0.719 | |||
| Yes | 13 (31.7) | 3 (25.0) | 10 (34.5) | |
| No | 28 (68.3) | 9 (75.0) | 19 (65.5) | |
| RTP (mo), mean/median | 3.5/3.0 | 2.7/2.0 | 3.9/3.0 |
Values are presented as number (%) unless otherwise specified.
MCL: medial collateral ligament, ACL: anterior cruciate ligament, LCL: lateral collateral ligament, PCL: posterior cruciate ligament, RTP: return to play.
**p<0.01, ***p<0.001.
Table 4 shows the characteristics of severe shoulder injuries. Technical training (71.4%) was the primary activity at the time of injury, with rotator cuff tears (57.1%) being the most common specific diagnosis. Resisting an opponent’s roll (38.1%) was the primary mechanism, followed by player collision (28.6%), and noncontact/overuse (19.0%). Ground defense (38.1%) and tackle attack (33.3%) were the primary maneuvers causing severe shoulder injuries. There was a significant difference between wrestling styles in the specific maneuvers that caused severe shoulder injury (p=0.011). Surgery was required in 23.8% of cases, and only 38.1% underwent specialized rehabilitation. Only 23.8% returned to play after medical clearance, with a mean RTP time of approximately 3.1 months (median, 2.0 months).
Table 4 . Comparison of severe shoulder injury statistics by wrestling style
| Variable | Total (n=21) | Greco-Roman (n=9) | Freestyle (n=12) | p-value |
|---|---|---|---|---|
| Activity type | 0.331 | |||
| Technical training | 15 (71.4) | 5 (55.6) | 10 (83.3) | |
| Competition | 6 (28.6) | 4 (44.4) | ||
| Diagnosis | 0.674 | |||
| Rotator cuff tears | 12 (57.1) | 6 (66.7) | 6 (50.0) | |
| Labral tears | 5 (23.8) | 2 (22.2) | 3 (25.0) | |
| Dislocation/subluxation | 2 (9.5) | - | 2 (16.7) | |
| Impingement | 1 (4.8) | - | 1 (8.3) | |
| GH ligament tears | 1 (4.8) | 1 (11.1) | ||
| Mechanism | 0.504 | |||
| Resisting an opponent’s roll | 8 (38.1) | 4 (44.4) | 4 (33.3) | |
| Player collision | 6 (28.6) | 1 (11.1) | 5 (41.7) | |
| Mat contact | 3 (14.3) | 2 (22.2) | 1 (8.3) | |
| Noncontact/overuse | 4 (19.0) | 2 (22.2) | ||
| Specific maneuver | 0.011* | |||
| Tackle attack | 7 (33.3) | - | 7 (58.3) | |
| Standing attack | 6 (28.6) | 3 (33.3) | 3 (25.0) | |
| Ground defense | 8 (38.1) | 6 (66.7) | 2 (16.7) | |
| Post-injury management | ||||
| Surgery | 0.258 | |||
| Yes | 5 (23.8) | 1 (11.1) | 4 (33.3) | |
| No | 16 (76.2) | 8 (88.9) | 8 (66.7) | |
| Rehabilitation | 0.067 | |||
| Yes | 8 (38.1) | 1 (11.1) | 7 (58.3) | |
| No | 13 (61.9) | 8 (88.9) | 5 (41.7) | |
| Medical clearance | 0.338 | |||
| Yes | 5 (23.8) | 1 (11.1) | 4 (33.3) | |
| No | 16 (76.2) | 8 (88.9) | 8 (66.7) | |
| RTP, mean/median | 3.1/2.0 | 2.0/2.0 | 3.9/3.0 |
Values are presented as number (%) unless otherwise specified.
GH: glenohumeral, RTP: return to play.
*p<0.05.
Table 5 shows the characteristics of severe ankle injuries. Technical training (60.0%) was the primary activity at the time of injury, with lateral ankle sprains (LAS) (83.3%) being the most common specific diagnosis. Noncontact/overuse (33.3%) and resisting an opponent’s roll (33.3%) were the primary mechanisms causing severe ankle injuries. Standing tackle (33.3%) was the primary maneuver that caused severe ankle injuries, followed by tackle attack (23.3%), and physical training/other activities (20.0%). There was a significant difference between wrestling styles in the specific maneuvers that caused severe ankle injury (p=0.002). Surgery was required in 20.0% of cases, and only 33.3% underwent specialized rehabilitation. Only 30.0% returned to play after medical clearance, with a mean RTP time of approximately 2.5 months (median, 2.0 months).
Table 5 . Comparison of severe ankle injury statistics by wrestling style
| Variable | Total (n=30) | Greco-Roman (n=17) | Freestyle (n=13) | p-value |
|---|---|---|---|---|
| Activity type | 0.674 | |||
| Technical training | 18 (60.0) | 9 (52.9) | 9 (69.2) | |
| Competition | 6 (20.0) | 4 (23.5) | 2 (15.4) | |
| Physical training/others | 6 (20.0) | 4 (23.5) | 2 (15.4) | |
| Diagnosis | 0.439 | |||
| Lateral ankle sprain | 25 (83.3) | 14 (82.4) | 11 (84.6) | |
| Deltoid ligament tears | 4 (13.3) | 3 (17.6) | 1 (7.7) | |
| Lisfranc injury | 1 (3.3) | - | 1 (7.7) | |
| Mechanism | 0.806 | |||
| Resisting an opponent’s roll | 10 (33.3) | 5 (29.4) | 5 (38.5) | |
| Player collision | 4 (13.3) | 3 (17.6) | 1 (7.7) | |
| Mat contact | 6 (20.0) | 4 (23.5) | 2 (15.4) | |
| Noncontact/overuse | 10 (33.3) | 5 (29.4) | 5 (38.5) | |
| Specific maneuver | 0.002** | |||
| Tackle attack | 7 (23.3) | 1 (5.9) | 6 (46.2) | |
| Tackle defense | 2 (6.7) | - | 2 (15.4) | |
| Standing attack | 10 (33.3) | 8 (47.1) | 2 (15.4) | |
| Standing defense | 2 (6.7) | - | 2 (15.4) | |
| Ground defense | 3 (10.0) | 3 (17.6) | - | |
| Physical training/others | 6 (20.0) | 5 (29.4) | 1 (7.7) | |
| Post-injury management | ||||
| Surgery | >0.999 | |||
| Yes | 6 (20.0) | 3 (17.6) | 3 (23.1) | |
| No | 24 (80.0) | 14 (82.4) | 10 (76.9) | |
| Rehabilitation | 0.255 | |||
| Yes | 10 (33.3) | 4 (23.5) | 6 (46.2) | |
| No | 20 (66.7) | 13 (65.0) | 7 (53.8) | |
| Medical clearance | 0.123 | |||
| Yes | 9 (30.0) | 3 (17.6) | 6 (46.2) | |
| No | 21 (70.0) | 14 (82.4) | 7 (53.8) | |
| RTP, mean/median | 2.5/2.0 | 2.1/2.0 | 3.0/2.0 |
Values are presented as number (%) unless otherwise specified.
RTP: return to play.
**p<0.01.
This study investigated the experience of severe injuries in elite Korean male wrestlers, focusing on the knee, shoulder, and ankle. The results revealed that 41% of all participants experienced injuries resulting in a TL of ≥3 weeks to the knee, 21% to the shoulder, and 30% to the ankle. Additionally, 26% (24 out of 91 cases) of all severe injuries required surgery. Freestyle wrestlers had a significantly higher rate of severe knee injuries and tended to have longer RTP time than Greco-Roman wrestlers. In particular, the mechanisms and specific maneuvers that caused severe injury differed by wrestling style.
The current study revealed that freestyle wrestlers had a significantly higher rate of severe knee injuries than their Greco-Roman counterparts, which is consistent with the findings of earlier studies that reported a higher incidence of knee injuries in freestyle wrestlers compared to Greco-Roman wrestlers2,11. The findings of the current and previous studies suggest differences in the body parts where severe injuries occur according to wrestling style. It is reasonable to infer that such differences are due to rule distinctions, with freestyle wrestling allowing both upper and lower-body attacks, while Greco-Roman wrestling is restricted to upper-body attacks only10.
In this study, player contact (resisting an opponent’s roll, player collision) was the primary cause of severe injuries to the upper and lower extremities. In particular, resisting an opponent’s roll was the primary mechanism for severe knee and shoulder injuries. These findings are consistent with previous studies, showing that most wrestling injuries result from contact with opponents7,9. Notably, for severe knee injuries, freestyle wrestlers had more injuries while resisting an opponent’s roll, while Greco-Roman wrestlers had more injuries due to the mat contact. To conclude, contact mechanisms are a significant cause of severe injuries in wrestling players, but the specific mechanisms leading to these injuries may vary depending on the wrestling style.
Considering that tackles and standing attacks are takedown maneuvers aimed at bringing the opponent to the ground, this study is consistent with previous research in terms of maneuvers that cause injuries7-9. Additionally, this study found significant differences in specific maneuvers that caused severe injuries between wrestling styles. Freestyle wrestlers had higher rates of severe injuries during tackle activities, while Greco-Roman wrestlers had more severe injuries during standing attacks and ground defenses. These differences are explained by freestyle wrestlers primarily using grappling techniques that target the lower body, while Greco-Roman wrestlers emphasize head/neck or upper body techniques2.
The most common severe knee injuries among the wrestlers in this study were MCL tears, meniscus tears, and anterior cruciate ligament (ACL) tears. These findings are consistent with Ford et al.18, who analyzed knee injuries in the National Collegiate Athletic Association (NCAA) Injury Surveillance Program wrestlers and found a high incidence of ligament, meniscus, and patella injuries. At the same time, 31% of severe knee injuries and 24% of severe shoulder injuries required surgery in this study. Notably, 100% (seven cases) of ACL tears, 50% (three cases) of meniscal tears, and 75% (three cases) of labral tears required surgery. The current findings are similar to the injury patterns reported by Otero et al.6, who reported that NCAA wrestlers most frequently underwent meniscal repair/debridement, ACL reconstruction, and labral tear repair surgery.
Concerning post-injury management, we found that more than half of the athletes did not receive specialized rehabilitation after severe injuries. In addition, approximately 70% of athletes returned to training without a medical clearance. Considering these inappropriate behaviors, proper diagnosis and specialized rehabilitation by medical professionals before returning to play may be a critical strategy to facilitate wrestling athletes’ recovery and prevent reinjury.
Freestyle wrestlers in this study showed a longer RTP time trend than Greco-Roman wrestlers after severe injuries. These findings are partially consistent with the study by Park et al.10, which showed a higher likelihood of serious injury in freestyle wrestlers than in Greco-Roman wrestlers. However, due to the limited research comparing severe injuries between wrestling styles, further research in this area is warranted.
We included wrestling-related activities and other non-wrestling activities in the survey to reflect the characteristics of Korean wrestlers, who frequently engage in physical training and other activities. The results showed that ankle injuries were also common during physical training and other activities, accounting for 20% (six cases) of all severe ankle injuries. Remarkably, four cases of LAS occurred during short soccer warm-ups before the team training. Restricting such extracurricular activities alone can directly prevent unnecessary ankle injuries in wrestlers.
This study has clinical significance as the first to analyze severe injuries in elite wrestlers according to wrestling style. However, the limitations of this study include the following: First, this study used retrospective recall to investigate experiences of severe injury. As a result, players’ reports may have been over- and underestimated. Second, while one player may sustain multiple severe injuries to the same body region, we only received responses to the single most severe injury, potentially leading to an underestimation of injury occurrence rates. Third, the athlete’s career and level of performance are important factors influencing injury incidence rates due to their association with AEs. Examining injury rates using prospective study designs is necessary to reduce bias due to the athlete’s career and game exposures. Finally, we only looked at severe knee, shoulder, and ankle injuries. Therefore, information on injuries to other body parts needs to be included.
In conclusion, the current findings suggest that the nature of severe injuries experienced by wrestlers may vary by wrestling style, highlighting the importance of developing injury prevention and management strategies tailored to each wrestling style. Future research should include more comprehensive epidemiological studies to better understand the severe injuries suffered by wrestlers.
No potential conflict of interest relevant to this article was reported.
We thank all the Korean elite wrestling athletes who participated in this study.
Conceptualization, Methodology, Project administration: all authors. Data curation, Investigation, Resources: S Yoo, S Yoon. Formal analysis, Funding acquisition, Software, Supervision, Validation, Visualization: MS. Writing–original draft: MS, S Yoo. Writing–review & editing: MS.
