Though wrestlers are often good enough actors to make you believe they're actually injured when they're just selling, a ref showing the "X" symbol indicates that it's not a storyline injury. One of the first instances of the "X" being used in 2024 was in a match on "WWE SmackDown" where "WWE NXT" call-up Carmelo Hayes faced Grayson Waller. The referee put up the signal after an awkward spot off the top rope that reportedly had both men banged up. Theory had Hayes set up for a seated Spanish Fly, but when he rotated during the move, the back of his opponent's head hit his forehead, causing enough concern that the match was stopped. It was later revealed that Theory suffered facial contusions, but neither were concussed.

Another instance of the "X" being used came during an episode of "WWE Raw," also at the beginning of the year, which saw Imperium's Ludwig Kaiser and a recently-returned Giovanni Vinci take on Kofi Kingston and Jey Uso. Kingston hit Vinci with a dropkick during the match, and connected with his face. Vinci collapsed following the impact. The referee threw up the "X," and the Imperium member was helped to the back.

Injuries can happen any time, and former WWE star Enzo Amore suffered one during the opening match of a premium live event in 2016. At Payback, Amore was sent neck-first into the bottom rope when he was supposed to be sent flying out of the ring. He was knocked unconscious after he landed awkwardly on the outside after being caught up in the ropes, and the referee threw up the "X." Amore was stretched out of the match and suffered a concussion.