Cheerleading has evolved from an activity focused on pumping up crowds at spectator sports to a fast paced, competitive, high-flying, stunting, tumbling extravaganza that includes feats such as basket tosses and pyramids. Modern cheerleading is very popular with 3.6 million active participants annually across all age groups. Cheerleading can include school related teams as well as “all-star” cheer squads which are like a traveling sports team with a focus on competition. Most participants are female, but males also participate especially at the college level. Cheerleading is finally being recognized as a complex sporting activity and becoming more regulated as injuries can and do occur. Cheerleading continues to represent the sport with the highest risk for catastrophic injuries to the head and neck.
Cheerleading injuries vary across all ages, with the youngest (5 to 11-year age group) more at risk than older (>11 years old) cheerleaders. This is thought to be due to a lack of physical maturity and overall motor development that develops after puberty. The most common injuries involve the lower extremity (30 to 37%) then the upper extremity (21 to 26%), head/neck (16-19%), and finally the trunk (7-17%). The most common causes of injury are due to falls from stunts followed by pyramids and then basket tosses. Most injuries occur during practice followed by games, camps, and competitions. Most injuries are minor, but catastrophic injuries in cheerleading continue to be the highest per exposure amongst all sports.
- Head: Concussions make up 4 to 6% of all cheerleading injuries. They are often associated with falls but can also occur during awkward landings from stunts or pyramids and collisions. Concussions are more likely to be sustained by bases and spotters than fliers. Concussion symptoms can include headache, confusion, dizziness, nausea/vomiting, or blurred vision. These symptoms should be evaluated medically. Return to play criteria following a concussion are available, see cheersafe.org for specifics.
- Neck: Neck injuries account for around 15% of all injuries. As previously mentioned, cheerleading continues to be the sport with the highest level of catastrophic injuries per exposure hours. This number has decreased significantly since the “basket toss” rule was put into effect in 2006-2007, where all basket tosses in high school and college cheerleading were banned when on a hard surface.
- Upper Extremity: 45% of upper extremity injuries occur in the elbow and wrist and are more common in the 5 to 11-year age group. Fractures are more common in the upper extremity than the lower extremity. Strains/sprains are the most common injuries followed by contusions, (i.e., bruise) then fractures.
- Lower Extremity: 77% of lower extremity injuries involve the knee and ankle. This includes joint sprains, muscle strains, and bruises/contusions, often from falls off a pyramid, stunt, or during a tumbling pass. Patients 12 to 18 years of age are more likely to sustain a lower extremity injury over the 5 to 11-year age group.
Injury Prevention Tips
- Cheerleading requires flexibility, endurance, and strength. The offseason should focus on maintaining core strength, balance, and stretching to aid with the twisting and turns required. Strength training should focus on weight resistance including body strength exercises given the required gymnastic skills involved.
- For the younger age group, activities should be geared to their physical maturation and skill level. All cheerleaders should attempt stunts based upon their current skill and proficiency prior to performing more challenging stunts.
- It is essential that there are an appropriate number of spotters on the floor during practice and competition for all stunts that are higher than a single level to protect the flyers which are most vulnerable to catastrophic injuries. All cheerleaders should be trained in proper spotting techniques.
- Practices and competitions should be performed on a well maintained and adequately padded surface (i.e., spring floor, foam mat, grass/turf) to cushion falls if they occur. In general, pyramids/tosses/mounts/tumbling should not be performed on hard/wet/uneven surfaces. Following the 2006-2007 year, all basket tosses on hard surfaces (i.e., basketball court) were banned for high school and college cheerleading events.
- It is important that an Emergency Action Plan (EAP) be established during all cheer activities to ensure cheerleader safety. Links through Cheersafe.org are available to guide coaches and participants in developing an EAP specific for their practice setting.
- Coaches should be trained and certified in cheerleading safety programs to best prevent injuries from occurring and ensure the best outcomes for when injuries do occur. They should also ensure that proper safety rules are followed as instituted by USA Cheer, the governing body for cheerleading safety in the United States.
- American Academy of Pediatrics Policy Statement. Cheerleading Injuries: Epidemiology and Recommendations for Prevention. Pediatrics 2012; 130:966-71.
- Hardy I, et al. Cheerleading injuries in children: what can be learned? Paediatrics and Child Health 2017; 22:130-3.
- Yau RK, et al. Catastrophic High School and Collegiate cheerleading injuries in the United States: an examination of the 2006-2007 basket toss rule change. Sports Health 2019; 11:32-9.
- Naiyer N, et al. Pediatric cheerleading injuries treated in emergency departments in the United States. Clinical Pediatrics 2017; 56:985-92.
- Other References
- HealthyChildren.org- Cheerleading
Q: What common injuries occur in Cheerleading?
Mild injuries such as sprains and strains are common in cheerleading, but more significant injuries such as fractures, neck injuries and concussions are possible and should be properly evaluated if there is suspicion for them.
Q: Are there specific safety strategies for cheerleading?
Yes. Practices and competitions should be performed on an appropriate surface. Enough spotters who have been appropriately trained should be present with all stunts/pyramids/basket tosses. Cheerleaders should maintain an appropriate level of strength and flexibility in the off season to assure common injuries that can occur in participation.
Q: After an injury, when can a cheerleader return to competition?
An injured athlete’s symptoms must be completely gone before returning to cheerleading. They should have no pain or swelling with normal range of motion and strength before returning. Athletes should be medically cleared for return to sport following all significant injuries (including concussions).
Q: Are there any ways to prevent overuse injuries in cheerleading?
Yes. There is an increase in overuse injuries in young athletes who focus on just one sport and train year-round. To help prevent overuse injuries, limit the number of teams of participation during a single season. Take regular breaks and consider playing other sports to help with skill development and injury prevention.