The author would like to acknowledge the work of Aaron Monseau, MD, on the previous edition’s chapter.


  • 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. Women’s wrestling was added to the Olympics in 2004.


  • Ranks seventh among high school boys in participation, with almost 250,000 participants in 10,843 schools (2018–2019).

  • Girls’ participation in high school wrestling has increased 3.5 times since 2009–2010 and almost doubled since 2014–2015, with 21,124 participants from 2890 high schools in 43 states (2018–2019).

  • A reported 249 National Collegiate Athletic Association (NCAA), 68 National Association of Intercollegiate Athletics (NAIA), and 62 junior college (JUCO) men’s wrestling programs and 69 4-year college and 7 JUCO women’s wrestling programs in the United States in 2020.

  • High school boy injury rate of 2.38/1000 athletic exposures (AEs) per High School (HS) Reporting Information Online System (2005–2006 through 2013–2014 seasons)

  • College male injury rate of 9.28 injuries/1000 AEs per NCAA Injury Surveillance System (2004–2005 through 2013–2014 seasons).

  • Most common site of injury differs depending on level of competition.

    • Youth wrestling: Hand, wrist, and finger

    • High school: Head/face and shoulder

    • College wrestlers: Knee

  • Most injuries occur during practices, but injury rate is much higher during competitions for both HS (1.91/1000 AE practice, 3.70/1000 AE competition) and college (7.02/1000 AE practice, 27.59/1000 AE competition).

  • Injury rates appear to be rising for both HS and college wrestlers, primarily because of increased reporting of concussions.

  • Concussion rate in HS boys wrestling (4.83/10,000 AE) is fourth highest among boy HS sports. Reports differ on the relative risk of concussion in men’s collegiate wrestling, ranging from first to fourth highest concussion rate in collegiate sports.

  • Approximately 7% of injuries are the result of illegal moves.

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

General Principles

Wrestling Styles

  • International wrestling: Freestyle and Greco-Roman

    • Greco-Roman: attacking opponent’s legs is not permitted

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

  • USA youth, HS, 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 be 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, whereas most wrestlers practice in shorts or sweatpants and a t-shirt.

    • Loose-fitting practice clothes can cause injuries (e.g., finger dislocations), so most wrestlers will tuck shirts into shorts and pant legs into socks.

  • Wrestling shoes provide a light, but supportive, point of traction on a wrestling mat, which can be slippery when wet.

  • Wrestling mats have greatly improved over the last 25 years and have become much more durable.

  • Headgear is required in college and HS wrestling but is almost never worn in the international styles.

  • Supportive braces will have to be approved by the referee and will likely be denied if there are any metallic pieces palpable because of the possibility of injury to the opponent.


  • Governing bodies of wrestling in United States

    • High School

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

    • College

      • NCAA Wrestling Rules Committee

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

      • Women’s Collegiate Wrestling Association (WCWA) is the governing body for women’s collegiate wrestling.

      • The NCAA designated women’s wrestling as an Emerging Sport for Divisions I, II, and III in 2020.

    • International styles (Greco-Roman and freestyle)

      • USA Wrestling is the governing body for international style events

  • Injury time during matches ( Table 88.1 )

    • Injury timeouts are stoppage of wrestling requested by a coach, wrestler, or referee.

    • Injury time is defined as the cumulative time spent being evaluated and recovering from an injury sustained during the match, including overtime.

    Table 88.1
    Injury Allowances per Wrestling Match a
    NFHS NCAA USA Wrestling
    Injury Time-Outs 2 2 Unlimited
    Cumulative Injury Time 90 sec 90 sec Unlimited
    Blood Time 5 min Unlimited Unlimited
    Concussion Evaluation Counts toward injury time Unlimited Unlimited
    Recovery Time b 2 min 2 min Unlimited
    NCAA, National Collegiate Athletic Association. 2020–2021 NCAA Wrestling Rules and Interpretations; NFHS, National Federation of State High School Associations. NFHS 2020–2021 Wrestling Rule Book.

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

    b 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 being evaluated and recovering from an injury that resulted from an illegal action by the opposing wrestler

  • Bleeding time during matches

    • Time spent stopping bleeding and cleaning blood from mats, wrestlers, and equipment. Distinct from injury or recovery time.

    • NCAA does not limit bleeding time. Referee, in consultation with medical personnel, has authority to stop match and declare nonbleeding wrestler the winner by medical default if bleeding becomes excessive or causes an inordinate number of timeouts.

  • Concussions

    • By NFHS, NCAA, and USA Wrestling rules, referee has the responsibility to stop the match if a concussion is suspected.

    • NCAA makes 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 “Skin Infections” section)

Specific Training and Physiology Issues

Weight Classifications

Competitors are matched by weight classes in all styles:

  • Men’s freestyle: 6 weight classes (Olympics), 10 weight classes (World Championships)

  • Women’s freestyle: 6 weight classes (Olympics), 10 weight classes (World Championships)

  • 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 give them a competitive advantage.

  • Eighty-five percent of US HS 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 HS and college wrestlers lose an average of 3.5–5.5 kg of weight in week preceding 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.

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