The professional wrestling matches at Extreme Rules featured professional wrestlers performing as characters in scripted events pre-determined by the hosting promotion, WWE. Storylines between the characters played out on WWE's primary television programs, Raw and SmackDown.
At WrestleMania 29, Triple H defeated Brock Lesnar in their rematch. Lesnar's manager, Paul Heyman, then issued one final match to settle things between Triple H and Lesnar: a steel cage match at Extreme Rules. On the April 22 episode of Raw in London, England, Triple H accepted the match by assaulting Heyman with a Pedigree. Two weeks later on Raw, Lesnar would respond by coming to WWE headquarters and trashing Triple H's office and attacking nearby employees. The week after on Raw, Triple H would come face to face with Lesnar, goading him in coming into the steel cage. Triple H would gain the upper hand and throw Lesnar into Heyman, resulting in both men retreating up to the ramp.
On the episode of Raw following WrestleMania 29, Alberto Del Rio lost the World Heavyweight Championship to Dolph Ziggler after Ziggler cashed in his Money in the Bank contract to take advantage of Del Rio being injured by Jack Swagger to become the new champion. Del Rio tried to invoke his rematch clause the following week, but was again impeded by Swagger. Senior Advisor Theodore Long then set up a match between Ziggler and Swagger, and Swagger won. SmackDown General Manager Booker T, irate at Long for going above him, rearranged the match into a triple threat match for the championship between Ziggler, Del Rio, and Swagger. On the April 29 edition of Raw, Del Rio's personal ring announcer Ricardo Rodriguez won a triple-threat match over Swagger's mentor Zeb Colter and Ziggler's bodyguard Big E Langston to pick the stipulation for the match, which would be a Ladder match selected by Del Rio. On the May 6 edition of Raw, Del Rio defeated Ziggler via disqualification when Swagger attacked both men with a ladder, resulting in Ziggler suffering a legitimate concussion. Ziggler was removed from the PPV as a result of his injury, and the next week on Raw, Long announced that Del Rio and Swagger would instead wrestle in an "I Quit" match, for the #1 contendership to the World Heavyweight Championship.
A day after Wrestlemania 29 on Raw, John Cena, who defeated The Rock for the WWE Championship, would issue a challenge to anybody to face him for the title after news broke out that Rock would undergo surgery. Mark Henry would come forward and face him in a match for a shot at the title later in the night, but he would lose via count-out. Henry would assault Cena afterward until Ryback seemingly came to save Cena, but Ryback would attack Cena and hold the title up high. A week later, Ryback explained that he was living in Cena's shadow and Cena never helped him against The Shield. Ryback would watch The Shield attack Cena from the ramp. Prior to the April 22 edition of Raw, it was announced that Cena would defend the WWE Championship against Ryback. Later that night, Ryback would confront Mick Foley about his decision to attack Cena. Cena would come and save Foley, but The Shield would come out to attack the two men. Cena retreated up to the ramp to see Ryback get assaulted by The Shield, but he would assault all three members with a chair, forcing The Shield to retreat, and gave Ryback an Attitude Adjustment. On the May 6 edition of Raw, Ryback would make the title match a Last Man Standing Match. Later that night, both John Cena and Ryback would drive away The Shield only for Ryback to attack Cena with a chair in retaliation. A week after on Raw, Ryback would attack Cena and his injured Achilles tendon with a chair following Cena being attacked by The Shield after a six-man elimination match that ended in a disqualification win for Cena.
After Big Show speared all three members of The Shield at WrestleMania 29, Randy Orton tagged himself and that gave The Shield the victory. Afterwards, Big Show knocked out both Orton and Sheamus. Both Orton and Sheamus would get their revenge on Show by defeating him twice in handicap matches on the April 12 edition of SmackDown and the April 15 edition of Raw, but Show would team up with Mark Henry to defeat Sheamus and Orton on the April 19 edition of SmackDown. On the May 3 edition of Smackdown, he defeated Damien Sandow in a singles match only afterwards for Big Show to interfere and Sandow attacked Orton post-match. After defeating Sandow in a second straight singles match three days later on Raw, Show knocked out Orton as Orton was about to head to the locker room. Prior to the May 10 edition of SmackDown, it was announced that Orton and Show would fight in an Extreme Rules match on the pay-per-view.