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From the American Academy of Pediatrics

Many Cheerleading Injuries Preventable, Pediatric Group Says

The increased popularity of cheerleading as a competitive, year-round sport involving complex acrobatic stunts has been accompanied by a steady increase in the number and severity of injuries, many of which could be prevented by taking simple safety precautions, says the American Academy of Pediatrics.

In a new policy statement,1 the AAP is urging coaches, parents and school officials to follow injury-prevention guidelines, develop emergency plans and ensure that cheerleading programs have access to the same level of qualified coaches, medical care and injury surveillance as other sports.

While the injury rate remains low relative to other sports, the number of catastrophic injuries continues to climb. "That is an area of concern and needs attention for improving safety." says pediatric sports medicine specialist Cynthia LaBella, MD, FAAP, member of the AAP Council on Sports Medicine & Fitness and co-author of the new guidelines.

Although most high schools and colleges have cheerleaders, the fact that 21 state high school athletic associations do not recognize cheerleading as a sport, and that competitive cheer is not on the NCAA's list of sponsored sports. works to deny athletes valuable protection against injuries, including qualified coaches, well-maintained practice facilities, access to certified athletic trainers, mandated sports physicals and injury tracking.

Injury statistics 

From 1990 to 2003, the number of U.S. cheerleaders age 6 and older increased by roughly 600,000, from 3 million to 3.6 million. Since 2007, there have been about 26,000 cheerleading injuries in the U.S. annually.   Although most are sprains and strains to the lower extremities, because cheerleading can include fast-paced floor routines and physically demanding skills, including pyramid building and lifting, tossing, and catching athletes in the air, head and neck injuries are not uncommon. 

These stunts account for 42 percent to 60 percent of all cheerleading injuries, and 96 percent of all concussions. Cheerleading is one of the highest risk sporting events for direct catastrophic injuries that can result in permanent brain injury, paralysis or death, with cheerleading accounting for an astounding 66 percent of all catastrophic injuries in high school female athletes over the past 25 years.

Risk factors 

Risk factors for cheerleading injuries include:

  • previous injury
  • cheering on hard surfacesCheerleading huddle
  • higher body mass index
  • performing complicated stunts, and 
  • inadequate coaching. 
As in other sports, cheerleading injury rates increase with competition level and age. Collegiate cheerleaders have a higher rate of injury than middle and high school competitors.

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 the new guidelines. "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.  Cheerleeding Injuries: Epidemiology and Recommendations for Prevention.  Pediatrics 2012: DOI 10.1542/peds.2012-2480 (online ahead of print)(accessed October 22, 2012).
Source: American Academy of Pediatrics
Posted October 22, 2012; Updated October 26, 2012 to reflect response of National Federation of State High School Associations