Participation in sports provides many social and physical benefits but is not without considerable risk of injury.1,2 However, wrestlers may dismiss such injuries as subtle and associated with the normal stress of the sport, potentially leading to delayed diagnosis and chronicity. Rupture of the anterior cruciate ligament is a common injury that is not often diagnosed on initial healthcare consultation most commonly associated with activities of soccer, rugby, and skiing, which may give rise to a higher incidence of medial meniscal tearing and secondary chondral damage.3 In football, delayed reporting of concussions is associated with a recovery time prolonged by almost 5 days, carrying with it the potential of long-term neurological and cognitive sequelae.4,5 Thus, prompt diagnosis and treatment of injuries is vital for protecting athletes from long-term harm.

Despite the relatively high frequency of injuries in wrestling, delayed presentation of wrestling injuries has not been well characterized.6 The inherent culture of the sport and rigor of competition days may contribute to the downplaying of serious injuries with fear of removal from competition. To our knowledge, previous studies have been limited to case reports or have occasionally noted the percentage of wrestling-related injuries that are delayed.7,8 One study found that 6.2% of patients with wrestling-related concussions did not present to emergency departments (EDs) on the same day the injury occurred.8

The purpose of this study was to examine the characteristics of delayed (D) and same-day (S) presentations to US EDs for wrestling-related injuries in middle and high-school athletes between 2000 and 2019. We hypothesized the greatest number of injuries would occur on days of competition and delayed injury presentation would involve subtle injuries less noticeable to coaches or parents (ie, concussions, sprains, and strains) as compared with gross deformities such as fractures or lacerations.

Methods

We retrospectively identified cases of wrestling-related injuries in the Consumer Product Safety Commission's National Electronic Injury Surveillance System (NEISS). The NEISS database documents product or activity-related injuries presenting to US EDs. The database is a publicly available, deidentified, weighted survey that serves as a nationally representative probability sample of designated US hospital EDs, from which weighted national estimates and sampling errors for queries may be derived. Since its inception, the database has been used for a multitude of reliable and reproducible epidemiological studies on injury-related ED visits.9,10 Specific data collection methodologies and quality control precautions are available on the Consumer Product Safety Commission's webpage.11,12

Variables

The NEISS database includes the following variables in each annual survey sample: the date of treatment; case record number; age, sex, and race/ethnicity of the patient; injury diagnosis; body part affected by the injury; disposition; product involved in the injury; location where the injury occurred; whether fire or motor vehicles were involved in the injury; whether the injury was work-related; and a short, free-text narrative of the circumstances surrounding recorded injuries and details regarding final diagnoses.

Selection Criteria

We initially identified all patients presenting to a US ED during the scholastic wrestling season (December to February, or “in-season”) between 2000 and 2019 with any wrestling-associated injuries (Product Code: 1270–WRESTLING [ACTIVITY, APPAREL OR EQUIPMENT]), which yielded 11,268 entries. Next, free-text case narratives were searched to identify and exclude cases unrelated to wrestling. These included the following activities: sumo wrestling; mud wrestling; World Wrestling Entertainment, Inc. wrestling; and any description of a patient wrestling with a sibling, friend, or parent in a non-sports setting (eg, on the couch and horsing around at home). We identified 472 cases unrelated wrestling, leaving 10,796 unique cases amounting to 396,854 weighted national estimates of wrestling-associated injuries presenting to US EDs for our final analyses. The narrative section was individually analyzed to identify the day of the week on which the injury occurred and the number of days from injury occurrence to presentation to the ED. Demographics, injury type, and day of injury were compared for delayed and same-day presentations.

Statistical Analyses

All national weighted estimates, standard errors, simple univariate regression statistics, and 95% confidence intervals (CIs) were calculated by using the svyset function in Stata/IC 15.1 statistical software (StataCorp LLC). Significances of trends and group comparisons were determined using adjusted Wald tests, given the use of weighted survey data.

This study was exempt from institutional review board review because it does not meet the definition of human subject research. This is because our analysis uses deidentified survey data that are freely published and publicly accessible on a government website.

Results

The mean number of wrestling-related injuries presenting to US EDs per year was 1,110 (95% CI, 591 to 1,630). The annual estimated national number of such injuries between 2000 and 2019 is summarized in Supplemental Table 1 (https://links.lww.com/JG9/A340). No notable change was observed in the number of injuries between the entire study period from the 2000 to 2001 wrestling season (n = 2,521; 95% CI, 1,212 to 3,830) through the 2018 to 2019 season (n = 1,910; 95% CI, 1,072 to 2,749). Therefore, no specific trend can be declared.

The number of days since injury before presentation to a US ED is presented in Supplemental Table 2 (https://links.lww.com/JG9/A340). Most of the case narratives did not specify the date of injury relative to presentation (90.1%; 95% CI, 87.3% to 92.4%). For cases with specified injury dates in narratives, more patients presented more than 1 day after injury (n = 659 [5.6%]; 95% CI, 4.3% to 7.1%) compared with those on the same day of injury (n = 420 [4.3%]; 95% CI, 3.1% to 5.9%), but this difference was not statistically significant.

The day of the week on which wrestling-related injuries occurred is demonstrated in Figure 1, stratified by the number of days between injury occurrence and presentation (zero days versus ≥1 day). The highest proportion of injuries occurred on Saturday for patients presenting on both the same day as the occurrence of injury (29.6%; 95% CI, 24.3% to 35.5%; P < 0.001) and ≥1 day since the injury (28.2%; 95% CI, 22.4% to 34.8%; P < 0.001).

Figure 1:

Graph showing percentage of wrestling-related injuries sustained on a given day of the week in patients aged 11 to 18 years presenting to US emergency departments from December through February between 2000 and 2019, stratified by days passed since the initial injury presentation. #: Zero days since injury before presentation indicates that the patient was explicitly stated to have sustained the injury on the same day during which the patient chose to present to the emergency department; ***: P < 0.001; CI: 95% confidence interval; unfilled circular marker: The estimate is considered potentially unstable because of the number of unweighted cases from the sample frame totaling <20, the weighted national estimate totaling <1,200, or coefficient of variation >33%. Therefore, no confidence intervals are provided. Instead, the unstable percentage estimate is provided for reference purposes only.

Because most of the narratives did not specify a date of injury, we compared the demographics of the no date–specified and date-specified subpopulations to determine whether they were similar and whether the date-specified population was representative of the overall population. We compared the composition of the populations for age (zero to 18), sex, race (White, Black, Hispanic, other, or not specified), and disposition (treated and released or treated and admitted). The only statistically significant difference we found in making this comparison was in the proportion of 18-year-old patients included in the population (no date–specified: 8.2%; 95% CI, 7.2% to 9.3%; date-specified: 5.9%; 95% CI, 4.5% to 7.8%; P = 0.008). For all other demographic characteristics, we did not find statistically significant differences. Although the date-specified subpopulation represents only 10% of the overall population, it is demographically similar to the rest of the population with no date–specified.

Supplemental Table 3 (https://links.lww.com/JG9/A340) compares the demographic characteristics of the subpopulations presenting on the same day of the injury and those presenting on later days. Most of the patients were male (same day: 94.7%; 95% CI, 89.1% to 97.5%; delayed: 95.9%; 95% CI, 93.5% to 97.4%; P = 0.552). Race was most often reported to be White (same day: 63.6%; 95% CI, 49.3% to 75.8%; delayed: 58.5%; 95% CI, 49.9% to 66.5%; P = 0.267), although the race of roughly one-quarter of patients was not specified (same day: 25.4%; 95% CI, 14.9% to 39.9%; delayed: 22.9%; 95% CI, 14.1% to 34.9%; P = 0.498). Only 16-year-old patients differed in the day of presentation relative to injury, with more 16-year-old patients presenting ≥1 day after injury than those on the same day of injury occurrence (same day: 14.6%; 95% CI, 11.6% to 18.3%; delayed: 20.8%; 95% CI, 17.6% to 24.3%; P = 0.011). Regarding patient disposition status, nearly all patients were treated and subsequently discharged directly from the ED on the same day of presentation (same day: 98.8%; 95% CI, 96.5% to 99.6%; delayed: 98.3%; 95% CI, 96.5% to 99.3%; P = 0.644).

The types of injuries sustained and anatomic regions most commonly affected are listed in Supplemental Table 4 (https://links.lww.com/JG9/A340). The most commonly affected region was the head and neck, with patients more likely to present on the same day as the injury (same day: 26.2%; 95% CI, 21.4% to 31.7%; delayed: 20.0%; 95% CI, 16.5% to 24.1%; P = 0.011). The most common diagnoses were strains and sprains, which presented more often ≥1 day after the injury occurred (same day: 29.6%; 95% CI, 23.6% to 36.3%; delayed: 37.1%; 95% CI, 31.4% to 43.3%; P = 0.049), and fractures, which presented more often on the same day as the injury (same day: 18.9%; 95% CI, 15.0% to 23.5%; delayed: 11.5%; 95% CI, 8.3% to 15.6%; P = 0.019).

Discussion

Our study presents the notable number of wrestling-related injuries presenting to US EDs with an estimated incidence of 1,110 injuries annually. This is the first study of its kind to compare same-day versus delayed presentations of wrestling-related injuries. Importantly, athletes with fractures and injuries to the head and neck were more likely to present to an ED on the same day of injury occurrence, whereas athletes with strains/sprains, and those specifically in the 16-year-old age group, were more likely to have a delayed presentation. This is in alignment with our hypothesis that injuries readily observable by parents or coaches, such as fractures or injuries to areas such as the head or neck, would be more likely to present on the same day as the injury.

Our results can be compared with previous studies on wrestling-related injuries. Kroshus et al13 also identified the head/face as the most commonly injured site in high-school wrestlers. However, their research suggested the differences between injuries in high-school and collegiate wrestlers limited the scope of their findings. Similar to our study, Agel et al14 and Powell et al15 observed much higher injury rates on match days compared with practice in a retrospective analysis of collegiate wrestling-related injuries.

To our knowledge, this is the first study to identify a unique injury presentation in the 16-year-old age group specifically. One hypothesis is that this particular age group may have delayed presentations because of their place on the team. In the United States, 16-year-old athletes are often in their second or third year in high school and this is a crucial time to prove oneself to earn a position on the varsity team. Furthermore, literature has suggested that health-related risk taking may be rewarded in athletes, which might explain why this age group may uniquely hide injuries resulting in delayed presentation to EDs.16-18 Reporting symptoms of injury or removing oneself from play could lead to missing crucial time in practice or competition.

The differences in injury types and locations for same-day and delayed presentations could be related to the ability of coaches and parents to detect the injury. Injuries that would be more apparent to an observer (fractures and injuries to the head and neck) were associated with same-day presentations, whereas strains and sprains were associated with delayed presentations. Self-reported symptoms are an important component of injury diagnosis, and previous studies have demonstrated that athletes may hide or underreport symptoms to avoid missing play time, especially with concussions.19-22 Previous literature has demonstrated factors associated with nondisclosure as male sex, participation in a high-risk sport, and pressure from a coach to play after sustaining a hit.23 Given that common motivations for nondisclosure are not wanting to leave the game or practice and not wanting to let the team down, the greater burden of responsibility to identify wrestling injuries may be borne by coaches, trainers, and parents.24 This includes injuries that may be thought of as more benign, such as strains or sprains, with misdiagnosis leading to delayed treatment and increased risk of reinjury and long-term sequelae.25

We recommend several strategies for reducing the delayed presentations of wrestling injuries. Parents, coaches, and medical personnel should check in regularly with athletes during and after strenuous Saturday competitions, when most injuries occur. Concussion checks may also prove valuable with parents and athletes given adequate information to identify early symptoms. Furthermore, an open culture of injury reporting among athletes and their teammates should be encouraged to prevent delayed presentation leading to long-term chronic sequelae, reinjury, and associated morbidity.

Inherent to the utilization and analysis of national injury data, our study has several limitations. The primary limitation of our analysis is that the date of injury had to be retrieved from the narrative provided for each entry, and this information unfortunately was not included in many of the narratives. In addition, the NEISS database only contains presentations to US EDs. Given that some injuries, such as sprains or abrasions, may be treated outside of ED settings and may be treated by athletic trainers or without formal medical treatment, our data likely under-represent the totality of wrestling-related injuries. In addition, we chose to restrict our study to “in-season” injury presentation, leaving the potential for off-season injuries to be missed and injuries sustained during the wrestling season but presenting later in the off-season.

Conclusion

A notable proportion of adolescent athletes report delayed presentations to EDs with wrestling-related injuries. We identified that such injuries are typically sustained on Saturdays, which classically comprises a tournament competition day where athletes may wrestle in multiple matches with limited recovery time. This study further identifies the need for greater awareness and vigilance by parents, coaches, and medical personnel with respect to detecting subtle or atypical signs of injury in at-risk middle and high-school wrestlers, especially during competitions with multiple matches in a single day.

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