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Cheerleading: High Rates of Catastrophic Injuries and Concussions

Here are some of the key statistics about concussions and catastropohic injuries in cheerleading. 

  • Cheerleading carries the highest rate of catastrophic injury in sports.[1]Cheerleading pyramid
  • Cheerleading accounts for fully two-thirds (66%) of all catastrophic injuries in female athletes.[1]
  • According to data from the Consumer Product Safety Commission, cheerleading has experienced a sharp rise in the number of emergency room visit since 1980,[2] with the number of ED visits as follows:
    • 1980: 4,954
    • 1986: 6,911
    • 1995: 16,982
    • 2000: 22,603
    • 2002: 24,675 (351 of which, or 1.4%) being concussion-related.
  • A 1-year study of cheerleading-related injuries in the U.S. [3] reported that:
    • 6% of the total were concussions (as noted below, another more recent study [8] reported that over 20% of all cheerleading injuries, at least in high school cheer, were concussions);
    • 84% occured in practices as opposed to games or during competition (which is in sharp contrast to other sports, where injuries most often occurs in games, not practices)(consistent with recent data [8]; and
    • 96% of concussions were stunt or stunt-related (consistent with another study [8] showing 90% were stunt-related).
  • A 2009 study [4]  found that:
    • 60% of injuries were stunt-related (a significantly lower percentage than reported in two other studies [3,8]); and
    • Most injuries occurred while the cheerleader was basing or spotting for another participant.
  • In an 11-year prospective multiple-sport study of 25 high schools [5] found that:
    • cheerleading accounted for 4.9% of reported concussions.
    • the concussion rate was increasing at an annual rate of 26%
  • A 2012 study of concussions in twenty high school sports[8] found that: 
    • cheerleaders were ten times more likely to sustain concussions in practice (21) than in competition (2)
    • a concussion rate for cheerleaders of 1.4 per 10,000 athletic exposures (one game, competition, or practice)
    • concussions represented 20.3% of total injuries;
    • concussions most commonly resulted from player-player contact (65.2%) and player-surface contact (34.8%)
      • Those concussions sustained as a result of player-player contact were most commonly from contact with the elbow (33.3%), knee (20.0%), or head (20.0%) of another person.
      • The activity associated with 90.9% of concussions was a stunt (ie, toss, lift, etc) most commonly with a 3 triple base (43.5%), or extended (ie, above shoulder level) (48.7%). Half of the concussions were spotted by a teammate, while 45.5% did not have a spotter, and 4.5% were spotted by a coach.
  • In a study reviewing incidents of catastrophic cheerleading injuries reported to the National Center for Catastrophic Sports Injury between 1982 and 2002 [6]  researchers found that:
    • 29 of the 39 injured athletes were cheerleaders
    • collegiate cheerleaders had a rate of head injuries five times higher than senior high cheerleaders
    • 18 of the 27 (66.67%) reported catastrophic injuries involved head injury, including:
      • 16 cases of cerebral edema or hematoma (89%)
      • 13 skull fractures (72.22%); and
      • 2 deaths. 
  • A 2013  study [7]  reported that
    • 85 of 138 concussed junior and senior high female cheerleaders (62%) reported an increase in the number of concussion symptoms on the Post-Concussion Symptoms (PCS) scale compared to their own baseline within 1 week of injury;
    • 46% had at least one score on the ImPACT computerized neurocognitive test which decreased by a statistically significant amount from their baseline;
    • 75% demonstrated a decline from baseline when both neurocognitive and symptom status were considered.
    • Of the 60 concussed cheerleaders who denied any increase in symptoms, 33% (20 out of 60) had at least 1 ImPACT composite score that declined by a statistically significant amount, meaning, the authors said, that "the addition of neurocognitive testing identified 33% more of the athletes as having a reliable baseline change after injury." 

Reducing injury risk with simple steps 

"Most serious injuries, including catastrophic ones, occur while performing complex stunts such as pyramids, according to Jeffrey Mjaanes, MD, FAAP, FACSM, member of the AAP Council on Sports Medicine & Fitness and co-author of a 2012 policy statement by the American Academy of Pediatrics on cheerleading injuries.[1] "Simple steps to improve safety during these stunts could significantly decrease the injury rate and protect young cheerleaders."

The AAP report, echoing rules enacted by the American Association of Cheerleading Coaches and Advisors and the National Federation of State High School Associations, recommends the following steps to improve safety in the sport:

  • Cheerleading should be designated as a sport in all states, allowing for benefits such as qualified coaches, better access to medical care and injury surveillance.
  • All cheerleaders should have a pre-season physical (e.g pre-participation physical evaluation or PPE) before participating in a cheerleading program, and have access to qualified strength and conditioning coaches.
  • Cheerleaders should be supervised by qualified coaches who have been trained and certified in proper spotting for gymnastics and partner stunts, safety measures, and basic injury management.
  • Cheerleaders should be trained in proper spotting techniques and only attempt stunts after demonstrating appropriate skill progression.  
  • Spotters and bases should have adequate upper body and core strength and balance to support flyers.
  • Technical skills, such as pyramids, mounts, tosses and tumbling should be performed only on a spring/foam floor or grass/turf, never performed on hard (vinyl floors, concrete, asphalt), wet or uneven surfaces, and pyramids should not be more than 2 people high and should only be performed with spotters.
  • Coaches, parents and athletes should have access to a written emergency action plan (EAP).  Whenever possible, a certified athletic trainer or physician should be present at practices and competitions.
  • Any cheerleader suspected of having a head injury should be removed from practice or competition and not allowed to return until he or she has clearance from a health professional.
  • Coaches, parents, and officials should be knowledgeable regarding the cause, prevention, recognition, and response to concussion.

NFHS Response

In a written statement responding to the AAP's guidelines and recommendations, the National Federation of State High School Associations (NFHS) said that it that "agree[d] with many of the recommendations," and pointed to its efforts over the past 20 years to minimize risk for high school cheerleaders, beginning with publication of its first guidelines for sideline cheerleading in 1988, which became the basis for the NFHS Spirit Rules Book, first published in 1992.  

The NFHS went on to state that it "also recognizes the need for properly educated and trained coaches," pointing to the introduction in 2009 of two online education courses designed for spirit coaches: a 2009 "Spirit Safety Certification," developed with the American Association of Cheerleading Coaches and Administrators (AACCA), designed to provide information and advice to help spirit coaches assess and make changes to their current safety program, with the goal to minimize the risks involved in cheerleading, followed a year later by the "Fundamentals of Coaching Cheer and Dance" course designed to help coaches with skills and tactics, including a review of philosophy, communication techniques and risk management. Both courses, said the NFHS, "have been instrumental in educating spirit coaches, with more than 15,000 courses delivered since their debuts."   

The NFHS also agreed that injury surveillance was important to help prevent future injuries, noting that, since 2009, cheerleading has been included in the High School Sports-Related Injury Surveillance Study, commissioned by the NFHS and compiled by Dr. Dawn Comstock, principal investigator for the Center of Injury Research and Policy at Nationwide Children's Hospital in Columbus, Ohio, The and has been working for 30 years with the National Center for Catastrophic Injury Research at the University of North Carolina-Chapel Hill to collect catastrophic injury data on cheerleading.  Noteworthy, said the NFHS, was the fact that, in 2011-12, cheerleading injury rates were 0.57 per 1,000 athlete exposures; 17th out of the 20 sports studied.  

With respect to concussions, the NFHS pointed to the addition of language to all its rules books - including spirit - specifying how athletes should be treated when suspected of having a concussion. The guidelines include being immediately removed from activity and being examined by an appropriate health-care professional before returning to activity. In addition, the NFHS said that its free online course "Concussion in Sports - What you Need to Know" has been taken by almost 600,000 individuals.

"The NFHS strives to minimize risk for all high school athletes, including cheerleaders. The spirit community - administrators, coaches, parents and cheerleaders - should know that this support system of rules, education and research exists to provide a safer environment for all cheerleaders," the statement concluded. 

1. American Academy of Pediatrics Council on Sports Medicine and Fitness. Policy statement. Cheerleading injuries: epidemiology and recommendations for prevention. Pediatrics 2012;DOI 10.1542/peds.2012-2480 (online ahead of print)(accessed October 22, 2012).

2. Mueller FO. Cheerleading injuries and safety. J Athl Tr. 2009;44:565-6.

3. Shields BJ, Smith GA. Epidemiology of cheerleading fall-related injuries in the United States. J Athl Tr. 2009;44:578-85.

4. Shields BJ, Fernandez SA, Smith GA. Epidemiology of cheerleaders' stunt-related injuries in the United States. J Athl Tr. 2009;4:586-94.

5. Lincoln AE, Caswell SZ, Almquist JL, Dunn RE, Norris JB, Hinton RY. Trends in concussion incidence in high school sports: a prospective 11-year study. Am J Sports Med. 2011;39:958-63.

6. Boden BP, Tracchetti R, Mueller FO. Catastrophic cheerleading injuries. Am J Sports Med. 2003;31:881-8.

7. Lovell MR, Solomon GS. Neurocognitive Test Performance and Symptom Reporting in Cheerleaders in Concussions. J Pediatrics 2013. DOI: 10.1016/jpeds.2013.05.061 (epub September 2013).

8. Marar M, McIlvain NM, Fields SK, Comstock RD. Epidemiology of Concussions Among United States High School Athletes in 20 Sports. Am J Sports Med 2012;40(4):747-755.

Posted September 16, 2013