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Original Research
Progress in Cheerleading Safety
Update on the Epidemiology of Cheerleading Injuries
Presenting to US Emergency Departments, 2010-2019
Amy L. Xu,* BS, Krishna V. Suresh,* BS, and R. Jay Lee,*
†
MD
Investigation performed at The Johns Hopkins University School of Medicine, Baltimore,
Maryland, USA
Background: Although the athleticism required of cheerleaders has increased, the risks of cheerleading have been less studied as
compared with other sports.
Purpose: To update our understanding of the epidemiology of cheerleading-related injuries.
Study Design: Descriptive epidemiology study.
Methods: We analyzed the National Electronic Injury Surveillance System (NEISS) for cheerleading-related injuries pre-
senting to nationally representative emergency departments (EDs) in the United States from January 2010 through December
2019. Extracted data included patient age and sex, injury characteristics (diagnosis, body region injured, time of year, and
location where injury occurred), and hospital disposition. Using patient narratives, we recorded the cheerleading skills,
settings, and mechanisms that led to injury. NEISS sample weights were used to derive national estimates (NEs) from actual
case numbers.
Results: From 2010 to 2019, a total of 9868 athletes (NE ¼350,000; 95% CI, 250,000-450,000) aged 5-25 years presented to US
EDs for cheerleading injuries. The annual number of injuries decreased by 15%, from 982 (NE ¼35,000; 95% CI, 27,000-44,000) to
897 (NE ¼30,000; 95% CI, 18,000-42,000) (P¼.048), corresponding to a 27% decline in the injury rate per 100,000 cheerleaders
(P<.01). The annual number of injuries caused by performing stunts decreased by 24%, from 240 (NE ¼8700; 95% CI, 6700-
11,000) to 216 (NE ¼6600; 95% CI, 4000-9200) (P¼.01), with a 36% decline in the corresponding injury rate per 100,000
cheerleaders (P<.01). Despite these decreases, annual incidence of concussions/closed head injuries increased by 44%, from
128 (NE ¼3800; 95% CI, 2900-4700) to 171 (NE ¼5500; 95% CI, 3400-7700) (P¼.02), and patients requiring hospital admission
increased by 118%, from 18 (NE ¼330; 95% CI, 250-410) to 24 (NE ¼720; 95% CI, 440-1000) (P<.01). The hospital admission
rate increased by 9.0% (P¼.02).
Conclusion: The number of cheerleading-related injuries presenting to US EDs decreased from 2010 to 2019. However, the
incidence of concussions/closed head injuries and hospital admissions increased, suggesting that further measures are needed to
improve safety for cheerleaders.
Keywords: cheerleading; closed head injury; concussion; emergency department; hospital admission
Cheerleading is one of the most popular sports in the
United States, with more than 3 million participants annu-
ally.
26
The technical skills involved in cheerleading routines
have continued to grow in difficulty, and the public’s aware-
ness of the athleticism required has increased.
10,32,38
As the
difficulty of the sport increases, cheerleaders have become
more susceptible to injury. In 2012, approximately 37,344
pediatric cheerleading-related injuries presented to emer-
gency departments (EDs) nationwide, corresponding to a
rate of 64 injuries per 100,000 children and adolescents.
23
In addition to the high overall rate of injury, cheerleading
also presents a high risk of catastrophic injury.
5,6,18,20
In
fact, cheerleading injuries account for more than half of the
catastrophic injuries experienced by female athletes at the
high school and college levels, surpassing the rate of cata-
strophic injuries caused by football among male athletes.
22
Despite the indisputable risks of cheerleading, the sport
receives less attention in the medical literature as com-
pared with other sports of similar or lower risk
level.
3,13,15,27
A lack of awareness of the physical demands
ofthesportmaycontributetothelimitedcheerleading-
related research, with multiple studies incorrectly charac-
terizing cheerleading as a noncontact, individual (as
opposed to team) sport.
19,28,31,43,46,49
Few epidemiologic
The Orthopaedic Journal of Sports Medicine, 9(10), 23259671211038895
DOI: 10.1177/23259671211038895
ªThe Author(s) 2021
1
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studies have assessed cheerleading characteris-
tics,
12,16,19,23,33,35-37
with the most recent study performed
analyzing data through 2012.
23
All of these studies have
reported an increase in injury rates, which was speculated
to relate to the sport’s increase in athleticism and a
delayed implementation of safety measures. Recently, all
levels of cheerleading, from elementary to collegiate and
recreational to competitive, have undergone regulation
changes. Many of these regulations were designed to
increase safety without diminishing the athleticism of the
sport and may result in changing injury patterns.
16,21
The primary purpose of our study was to assess
cheerleading-related injury patterns from 2010 to 2019 in
terms of athlete demographic characteristics, injury inci-
dence annually and per 100,000 cheerleaders, injury type,
body region injured, mechanism of injury, injury setting/
event type, and disposition from the ED.
METHODS
Data Sources
The National Electronic Injury Surveillance System
(NEISS), operated by the Consumer Product Safety Com-
mission (CPSC), is a public database of injuries that pre-
sent to EDs in the United States. Information in this
database is supplied by 100 hospitals, each with at least 6
beds and an ED, selected as a representative probability
sample of the more than 5300 US hospitals with EDs. Each
hospital has staff trained to enter injury codes, demo-
graphic data, and treatment plans for each patient.
30
Patients are deidentified and assigned CPSC codes that
indicate the activity or product involved in injury. National
estimates (NEs) can then be calculated by summing the
number of cases presenting to each ED and using a multi-
plier based on hospital size and number of similar-sized
hospitals across the United States. All database entries are
also accompanied by a free-text narrative summarizing the
patient encounter, which provides more detail for the con-
text of injury.
For injury rates, the annual number of US cheerleaders
was gathered from available Cheerleading Participation
Reports produced by the Sports and Fitness Industry
Administration (SFIA).
39
Participation data are reported
by year and obtained via online interviews with a represen-
tative, nationwide sample. Results are then weighted to
reflect the US population according to the US Census
Bureau. SFIA reports have been used reliably in previous
epidemiological studies to provide participation numbers
for injury rate calculation.
8,17,41
Patient Cohort
This study was deemed exempt from approval by our insti-
tutional review board. Using the code 3254 (cheerleading
activity, apparel, or equipment), we identified 10,097
cheerleading-related injuries that presented to NEISS EDs
from 2010 to 2019. A total of 9868 cases were included in
our analysis after 229 cases were excluded. Cases were
excluded if the narrative indicated that injuries were from
noncheerleading activities, such as gymnastics, dance, or
drill/flag team participation, or that cheerleading only sec-
ondarily exacerbated a previous injury. Narratives reveal-
ing the diagnosis to be a condition in which sports
participation would not influence presentation, such as
appendicitis and anaphylaxis, were also excluded. The fol-
lowing text is an example of a narrative we included in our
analysis: “12 YOF [12-year-old female] at cheerleading
practice did back handspring landed awkwardly on R
[right] foot dx [diagnosis] ankle sprain.” The following is
an example of an excluded narrative: “11 YOF [11-year-
old female] slipped and fell into a pool and injured foot then
went to cheerleading and the foot pain got worse dx [diag-
nosis]: foot pain.” For narratives without sufficient details
describing cheerleading-specific injury mechanism, setting,
skill, or stunt position, cases were included and noted as
“unknown” for the incomplete variables. All narrative
interpretations were reviewed for accuracy by the first
author (A.L.X.), who has more than 12 years of cheerlead-
ing experience.
Data Collection
Patient Characteristics. For each injury, we extracted
data on patient sex and age. Age (with corresponding cheer-
leading level) was categorized as follows: 5-11 (elementary
school level), 12-18 (middle/high school level), and 19-25
(collegiate level). The first 2 age groups also correspond to
the most popular age range for all-star cheerleading (5-18
years).
44
Injury Setting. The season of injury was categorized as
winter (December-February), spring (March-May), sum-
mer (June-August), or autumn (September-November).
Setting where the injury occurred was categorized as
school, place of sports/recreation, home, other setting
(farm/ranch, street/highway, other public property, or
industrial place), and unknown. From the patient narra-
tive, we categorized cheerleading-specific settings as team
practice, cheerleading camp, cheerleading competition,
noncheerleading sports event (eg, football game), tryouts,
“other” (including nonregulated situations in which
†
Address correspondence to R. Jay Lee, MD, Department of Orthopaedic Surgery, The Johns Hopkins University, 601 North Caroline Street, Baltimore,
MD 21287, USA (email: editorialservices@jhmi.edu).
*Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Final revision submitted April 21, 2021; accepted May 25, 2021.
One or more of the authors has declared the following potential conflict of interest or source of funding: R.J.L. has received education payments from
Arthrex and hospitality payments from Vericel. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted
an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
Ethical approval for this study was waived by John Hopkins University (IRB00258468).
2Xu et al The Orthopaedic Journal of Sports Medicine
cheerleading skills are performed, such as home), or
unknown setting.
Injury Mechanism. Using the narrative for each case, we
recorded 3 additional details about the cheerleading con-
text that led to injury. First, we categorized the mechanism
of injury as a fall, a collision with another athlete, a colli-
sion with an object, performing a skill incorrectly (such as
landing a tumbling pass on an inverted ankle), overexer-
tion, multiple mechanisms (involving >1 mechanism), or
unknown mechanism. Second, we categorized cheerleading
skills as “stunts” (including partner stunts, pyramids, and
basket tosses, all of which involve 1 or more athletes sup-
ported by 1 other athlete), tumbling, jumps/kicks, nonspe-
cific training (including stretching, running, and
conditioning), or unknown skill.
45
Third, if the injury
involved a stunt, the narrative was assessed to determine
the patient’s position as a base (one who holds, lifts, or
tosses another cheerleader; we also included spotters in
this category, who protect the upper body of a top person
[herein, “flyer”] during stunts) or a flyer (one who is sup-
ported during a stunt).
45
Injury Characteristics. Injury types were categorized as
follows: concussion/closed head injury (CHI), dislocation,
fracture, skin injury (laceration or avulsion), soft tissue
injury (hematoma, abrasion, or contusion), sprain/strain,
or other injury type. Injured body regions were categorized
as head/neck (face, eye, ear, mouth, head, and neck); upper
extremity (shoulder, upper and lower arm, elbow, wrist,
hand, and finger); trunk (upper and lower trunk and pubic
region); lower extremity (upper and lower leg, knee, ankle,
foot, and toe); nonspecific region (multiple body regions
involved); and unknown region. Joint involvement was also
analyzed using the categories of ankle, elbow, knee, and
wrist. (The NEISS coding manual does not have codes spe-
cific to shoulder and hip injuries of the joint itself.)
ED Disposition. Disposition from the ED was catego-
rized as follows: released after evaluation with or without
treatment, treated and admitted/transferred to another
hospital/held for observation, left against medical advice,
or dead on arrival to the ED.
Statistical Analysis
Data were analyzed using SPSS Statistics, Version 27.0
(IBM). NEs were calculated from actual case numbers
using sample weights provided by the CPSC, which are
based on ED size and geographic location. An estimate may
be unstable if the estimated frequency is <1200, the actual
sample size is <20, or the coefficient of variation is >30%.
24
All estimates reported herein are stable unless otherwise
noted.
Injury rates per 100,000 cheerleaders were calculated by
dividing annual national injury estimates from NEISS by
annual national participation estimates from SFIA. A lin-
ear regression was performed to assess injury trends over
time. Chi-square tests and calculation of relative risks
(RRs) with 95%CIs were used to compare trends among
age groups, cheerleading skills leading to injury, and stunt
positions. P<.05 was considered significant.
RESULTS
Demographic Characteristics
A total of 9868 cases, corresponding to a NE of 350,000 (95%
CI, 250,000-450,000) patients (98%female) aged 5-25, were
treated for cheerleading-related injuries in US EDs from
2010 to 2019, equating to approximately 35,000 (95%CI,
25,000-45,000) injuries per year. Mean patient age was 14 ±
3.6 years, with most patients (80%) aged 12-18 (Tables 1
and 2). When comparing data from 2010 and 2019, the pro-
portion of patients aged 12-18 decreased significantly (from
81%to 76%;P<.01), whereas the proportions of patients in
the younger and older categories increased. During the
same period, the proportion of male patients increased sig-
nificantly (from 1.4%to 3.4%;P<.01). Only 1598 patient
narratives (16%) provided detail on all cheerleading-
specific variables studied.
Injury Incidence: Annually and per 100,000
Cheerleaders
From 2010 to 2019, the annual incidence of cheerleading-
related injuries declined by 15%, from an estimated 35,000
(95%CI, 27,000-44,000) to 30,000 (95%CI, 18,000-42,000)
(P¼.048), and the rate of injury per 100,000 cheerleaders
declined by 27%(P<.01). When analyzing the subset of
injuries sustained when performing stunts, we found sig-
nificant decreases in the annual number of injuries, from
8700 (95%CI, 6700-11,000) to 6600 (95%CI, 4000-9200)
(24%;P¼.01) and the rate per 100,000 cheerleaders
(36%;P<.01) (Table 3).
Injury Setting
Most injuries occurred at a place for sports/recreation
(52%); 31%occurred at school, and 1.1%occurred in homes.
Injuries were most commonly sustained during cheerlead-
ing practice (39%) (Table 2). When comparing data from
2010 and 2019, we found an increase in the annual percent-
age of injuries occurring during practice (from 32%to 49%;
P<.01). Injuries occurred most frequently during autumn
(44%).
Injury Mechanism
Falls accounted for 31%of injuries, followed by collisions
between 2 athletes (19%) and landing a skill incorrectly
(5.9%). Regarding cheerleading skills, injuries were caused
most commonly by stunts (25%), followed by tumbling
(11%). Of the stunt-related injuries, 44%occurred to bases
and 39%to flyers.
Stunts were more likely than other skills to result in
injury to the head/neck (RR, 1.8; 95%CI, 1.8-1.9) and to
cause concussion/CHI (RR, 2.1; 95%CI, 2.1-2.2). Injury pat-
terns were also significantly different between stunt posi-
tions (base vs flyer) for all body regions and injury types
(P<.01) except head/neck injuries (P¼.21). Bases were
more likely to sustain wrist injuries (RR, 4.8; 95%CI, 4.4-
5.2), injuries to the upper extremity (RR, 1.8, 95%CI,
The Orthopaedic Journal of Sports Medicine Epidemiology of Cheerleading Injuries, 2010-2019 3
1.8-1.9), and sprains/strains (RR, 1.5; 95%CI, 1.5-1.6).
Meanwhile, flyers were more likely to sustain ankle inju-
ries (RR, 7.9; 95%CI, 7.1-8.8), lower-extremity injuries
(RR, 3.4; 95%CI, 3.2-3.6), and concussions/CHIs (RR, 1.5;
95%CI, 1.5-1.6). Compared with other cheerleading skills,
tumbling was 1.8 (95%CI, 1.8-1.8) times as likely to result
in upper-extremity injury. When tumbling, risks of injuries
were higher to the elbow (RR, 2.8; 95%CI, 2.7-2.9) and
wrist (RR, 1.3; 95%CI, 1.3-1.4). Tumbling was also 1.9
(95%CI, 1.9-2.0) times as likely to result in fractures com-
pared with all other skills combined. The proportion of total
injuries from collisions with another athlete decreased from
TABLE 1
Patient and Injury Characteristics of Cheerleading-Related
Injuries Among Athletes Aged 5-25 Years Treated in US
EDs, NEISS (2010-2019)
a
Characteristic
No. of
Cases
NE
n(%)
b
95%CI
Study sample 9868 350,000 (100) 250,000-450,000
Patient Characteristics
Age group, years
c
5-11 1815 56,000 (16) 41,000-73,000
12-18 7704 280,000 (80) 200,000-360,000
19-25 349 14,000 (3.9) 10,000-17,000
Sex
Female 9644 340,000 (98) 250,000-440,000
Male 224 7900 (2.2) 5700-10,000
Injury Characteristics
Injury type
Sprain/strain 3731 130,000 (38) 96,000-170,000
Concussion/CHI 1632 58,000 (16) 42,000-74,000
Fracture 1200 42,000 (12) 31,000-54,000
Soft tissue 1103 38,000 (11) 28,000-49,000
Skin 236 8700 (2.5) 6300-11,000
Dislocation 194 6700 (1.9) 4900-8600
Other 1772 65,000 (18) 47,000-83,000
Body region injured
Head/neck 3065 110,000 (31) 79,000-140,000
Upper extremity 2773 100,000 (29) 74,000-130,000
Lower extremity 2773 95,000 (27) 69,000-120,000
Trunk 1111 39,000 (11) 28,000-50,000
Nonspecific 124 4800 (1.4) 3500-6100
Unknown 22 630 (0.18)
d
460-810
Joint involvement
Ankle 1176 40,000 (11) 29,000-51,000
Knee 956 33,000 (9.5) 24,000-42,000
Wrist 666 25,000 (7.2) 18,000-51,000
Elbow 439 15,000 (4.4) 11,000-20,000
Disposition
Released from ED 9586 340,000 (97) 250,000-430,000
Admitted/transferred 228 8100 (2.3) 5900-10,000
Left against
medical advice
53 2000 (0.56) 1400-2500
Dead on arrival
to ED
1 4.8 (0.001)
d
3.5-6.1
a
CHI, closed head injury; ED, emergency department; NE,
national estimate; NEISS, National Electronic Injury Surveillance
System.
b
Percentages may not sum to 100 and estimates may not sum to
350,000 because of rounding error.
c
Mean ±SD age was 14 ±3.6 years.
d
Potentially unstable estimate.
TABLE 2
Further Injury Characteristics of Cheerleading-Related
Injuries Among Athletes Aged 5-25 Years Treated in US
EDs, NEISS 2010-2019
a
Characteristic
No. of
Cases
NE
n(%)
b
95%CI
Cause of Injury
Mechanism
Fall 3095 110,000 (31) 80,000-140,000
Collision with another
athlete
1881 68,000 (19) 49,000-87,000
Performing a skill
incorrectly
590 21,000 (5.9) 15,000-26,000
Overexertion 336 12,000 (3.4) 8600-15,000
Multiple mechanisms 301 10,000 (2.9) 7400-13,000
Collision with an object 68 1900 (0.54) 1400-2400
Unknown 3597 130,000 (37) 94,000-160,000
Skill
Stunt 2498 89,000 (25) 65,000-110,000
Tumbling 1094 40,000 (11) 29,000-51,000
Nonspecific training 358 12,000 (3.5) 8800-16,000
Jump/kick 218 7400 (2.1) 5400-9400
Unknown 5700 200,000 (58) 150,000-260,000
Stunt position
c
Base 1084 39,000 (44) 29,000-50,000
Flyer 970 34,000 (39) 25,000-44,000
Unknown 442 15,000 (17) 11,000-19,000
Injury Setting
Location
Place of
sports/recreation
5075 180,000 (52) 130,000-230,000
School 3096 110,000 (31) 80,000-140,000
Home 111 3700 (1.1) 2700-4800
Other 75 2800 (0.80) 2000-3600
Unknown 1511 52,000 (15) 38,000-67,000
Setting
Practice 3834 140,000 (39) 98,000-170,000
Cheerleading
competition
180 10,000 (2.9) 7300-13,000
Noncheerleading
sports event
196 6900 (2.0) 5000-8800
Cheerleading camp 180 6500 (1.8) 4700-8300
Tryouts 42 1600 (0.45) 1100-2000
Other 56 1900 (0.54) 1400-2400
Unknown 5260 190,000 (54) 140,000-240,000
Season
d
Autumn 4183 150,000 (44) 110,000-200,000
Winter 2503 90,000 (25) 65,000-110,000
Spring 1335 44,000 (12) 32,000-55,000
Summer 1847 64,000 (18) 46,000-82,000
a
ED, emergency department; NE, national estimate; NEISS,
National Electronic Injury Surveillance System.
b
Percentages may not sum to 100 and estimates may not sum to
350,000 because of rounding error.
c
For known stunt-related injuries, n ¼2498.
d
Autumn, September-November; winter, December-February;
spring, March-May; summer, June-August.
4Xu et al The Orthopaedic Journal of Sports Medicine
19%in 2010 to 17%in 2019 (P<.01), whereas the propor-
tion caused by performing a skill incorrectly increased from
2.4%to 8.4%(P<.01). Injuries from tumbling increased as
well (7.3%to 11%;P<.01). Notably, the proportion of inju-
ries occurring among bases versus flyers was not signifi-
cantly different (P¼.29).
Injury Characteristics
Injury Types. Sprains/strains accounted for 38%of all
injuries, followed by concussions/CHIs (16%), fractures
(12%), and soft tissue injuries (11%) (Table 1). The inci-
dence of concussions/CHIs increased by 44%(P¼.02)
(Figure 1). We found no significant change in the concus-
sion/CHI rate per 100,000 cheerleaders (P¼.21). The pro-
portion of annual injuries comprising fractures decreased
from 12%in 2010 to 9.3%in 2019 (P<.01). Similarly,
sprains/strains decreased from 44%to 33%(P<.01). The
proportion of annual injuries occurring at places of sports/
recreation, such as gymnasiums, increased from 37%in
2010 to 54%in 2019 (P<.01).
Distribution according to age group differed significantly
for all injury types (P<.01), except skin injuries (P¼.19).
Patients aged 5-11 were 1.15 (95%CI, 1.1-1.2) times as
likely as patients aged 12-18 and 1.3 (95%CI, 1.2-1.3) times
as likely as patients aged 19-25 to be diagnosed with a
concussion/CHI. Patients aged 12-18 were 1.2 (95%CI,
1.2-1.2) times as likely to sustain fractures than the other
2 age groups combined, and patients aged 19-25 were 1.1
(95%CI, 1.1-1.2) times as likely to sustain sprains/strains
than the other 2 age groups combined.
Injured Body Regions. Injuries to the head/neck were
the most common (31%), followed by the upper extremities
(29%), lower extremities (27%), and trunk (11%). Joint inju-
ries accounted for 32%of all injuries, with ankle injuries
being the most common (11%) (Table 1). Distribution by age
TABLE 3
Trends in Cheerleading-Related Injuries That Presented to US EDs, NEISS 2010-2019
a
Parameter
2010 2019
Change From 2010 to
2019, %
Slope (m),
n/year P
No. of
Cases Estimate (95%CI)
No. of
Cases Estimate (95%CI)
Incidence
Total injury 982 35,000 (27,000-44,000) 897 30,000 (18,000-42,000) 15 730 .048
Stunt injury 240 8700 (6700-11,000) 216 6600 (4000-9200) 24 290 .01
Concussion/CHI 128 3800 (2900-4700) 171 5500 (3400-7700) 44 250 .02
Admission 18 330
b
(250-410) 24 720
b
(440 -1000) 120 70 <.01
Rate
c
Total injury 1100 (840 -1300) 800 (490-1100) 27 470 <.01
Stunt injury 270 (210-330) 180 (110-250) 36 12 <.01
Concussion/CHI 120 (91-150) 150 (90-210) 24 Nonlinear .21
Admission 10 (7.8-13) 19 (12-27) 9.0 1.6 .02
a
CHI, closed head injury; ED, emergency department; NEISS, National Electronic Injury Surveillance System.
b
Potentially unstable estimate.
c
Rate per 100,000 cheerleaders.
AB
Figure 1. Comparison of total cheerleading-related injuries versus concussions/CHI that presented to US EDs from 2010 to 2019.
(A) Annual concussion/CHI numbers continued to increase despite decreasing total injury incidence from 2010 to 2019. (B) Total
injury rate per 100,000 cheerleaders decreased, whereas the concussion/CHI rate remained stable during the study period. Blue
line, total injury; CHI, closed head injuries; yellow line, concussion/CHI.
The Orthopaedic Journal of Sports Medicine Epidemiology of Cheerleading Injuries, 2010-2019 5
group differed significantly for all joint injuries and body
regions (P<.01), except for trunk injuries (P¼.13).
Lower-extremity injuries were most common among
patients aged 19-25 (31%), whereas head/neck injuries
were most common among patients aged 5-11 (32%).
Patients aged 19-25 were 1.2 (95%CI, 1.1-1.2) times as
likely to sustain lower-extremity injuries as younger
patients. Patients aged 5-11 were 1.1 (95%CI, 1.1-1.1)
times as likely as patients aged 19-25 to sustain head/neck
injuries. When comparing data from 2010 and 2019, we
found significant increases in the percentages of head/
neck injuries (28%-33%) and lower-extremity injuries
(27%-31%) and a significant decrease in upper-extremity
injuries (32%-25%)(P<.01 for all).
ED Disposition
Most injured cheerleaders (97%) were released from the ED
after evaluation. Overall, 2.3%were admitted, kept for
observation, or transferred to another medical facility, and
0.56%left against medical advice. One patient was dead on
arrival to the ED in 2019 after falling from a stunt during
competition. Table 4 lists cases that led to hospital admis-
sion. The annual number of patients admitted/transferred
to a hospital increased significantly by 118%(P<.01), and
the admission rate per 100,000 cheerleaders increased by
9.0%(P¼.02) (Table 3).
DISCUSSION
Understanding the profile of sport injuries demanding
acute care is critical for implementing safety protocols and
aiding physicians in advising on sport participation. From
2010 to 2019, an estimated 350,000 athletes aged 5-25 years
presented to EDs in the United States for cheerleading-
related injuries. The annual number of injured athletes
declined significantly by 15%, but the numbers of concus-
sions/CHIs and hospital admissions increased significantly.
The distribution of injuries also shifted to favor male
patients, occur at places of sports/recreation, and result
from tumbling. To our knowledge, our study is the first
report a national decrease in cheerleading injuries over
time.
The most recent and comprehensive analysis of NEISS
data included data from 1990 to 2012. Naiyer et al
23
reported a 243%increase in cheerleading injury incidence
during the 23-year period, citing a rise in the number of
cheerleaders and increase in sport athleticism as primary
explanations. From 2010 to 2019, cheerleading has contin-
ued to increase in the difficulty of stunts and tumbling
skills being performed. The sport has also expanded, with
participation rising from 3.2 million in 2010 to nearly 3.8
million in 2019.
26
Despite these trends, we found a signif-
icant 27%reduction in injury rate when accounting for the
number of cheerleaders participating annually in the sport.
As the risks associated with cheerleading have become
more apparent, the number of rule changes designed to
increase safety for recreational, scholastic, and all-star
cheerleaders of all experience levels has increased. For
example, 2 recent safety regulations instituted by USA
Cheer (the national governing body of cheerleading)
25
increase the number of athletes involved in tossing and
catching flyers when performing inverted skills (when
flyers’ feet are held above their heads) during a pyramid
and require a spotter for stunts involving only 1 base. These
changes were enacted in 2018, which is the year for which
we found the largest decrease in injury incidence and rate.
Regulations typically target stunts, likely because of evi-
dence suggesting that basket tosses and pyramids are the
skills most likely to cause injury.
4,6,9
This focus of recent
regulations on stunts is consistent with our finding that the
number of injuries caused by stunts declined significantly
during the past decade. This explanation also aligns with
the findings of Yau et al,
47
who reported a 4-fold reduction
in catastrophic cheerleading injuries after the implementa-
tion of a rule prohibiting the performance of basket tosses
on hard surfaces during the 2006-2007 cheerleading sea-
son. Together, these results suggest the effectiveness of
national organizations’ efforts to enhance safety.
Despite the overall decrease in national injury incidence,
we found a continued increase in the incidence of
cheerleading-related concussions/CHIs. This finding aligns
with those of previous studies, which report a high and
increasing risk of concussions/CHIs as cheerleading has
TABLE 4
Cheerleading-Related Injuries That Presented to US EDs
and Required Hospital Admission/Transfer, NEISS 2010-
2019
a
Type of Injury No. of Cases
Head, neck, or spine 96
Concussion/CHI 50
Skull/facial fracture 10
Vertebral fracture 9
Sprain/strain 6
Contusion 4
Unspecified pain or injury 17
Upper extremity 87
Fracture
Forearm 32
Elbow 24
Humerus 20
Hand/wrist 5
Dislocation 2
Sprain/strain 1
Unspecified pain or injury 3
Lower extremity 18
Tibial/fibular fracture 7
Ankle/foot fracture 3
Femoral fracture 2
Slipped capital femoral epiphysis 2
Sprain/strain 1
Unspecified pain or injury 3
Other
b
29
a
CHI, closed head injury; ED, emergency department; NEISS,
National Electronic Injury Surveillance System.
b
Other injuries were asthma, heat exhaustion, cardiac arrhyth-
mia, rhabdomyolysis, seizures, chest pain, and syncope.
6Xu et al The Orthopaedic Journal of Sports Medicine
developed.
42,47
Our findings are consistent with previous
findings of stunts as the primary skills placing athletes at
risk of concussions/CHIs,
33
with flyers having a signifi-
cantly higher risk than bases. The high rates of concus-
sion/CHI may reflect increased reporting, or they may
indicate that the increased regulation cannot eliminate the
inherent risk associated with the sport. It is essential to
note that concussion rates in other sports during the same
period also increased, but increased mostly to a lesser
extent than we found for cheerleading.
2,7,14,29,50
Thus,
although universal factors, such as increased diagnosis and
sensitivity, may partially explain our temporal trends,
cheerleading-specific elements likely play a role. Moreover,
the continued increase in concussions/CHIs may explain
the significantly higher number of patients who were
admitted or transferred after ED evaluation in 2019.
Except for fractures, which decreased significantly during
the study period, concussions/CHIs were the most common
diagnosis requiring inpatient care. Concussions/CHIs
accounted for 22%of hospital admissions between 2010 and
2019. This represents an increase since 2002-2007, when
Jacobson et al
12
reported only 7 cases of CHI and no con-
cussions requiring hospital admission (13%of total admis-
sions) during that period. The increase we found may also
reflect greater vigilance and caution of health care provi-
ders in risk stratifying head injuries, particularly in chil-
dren, because the consequences of such injuries have been a
featured point of sports medicine in recent years.
11
Furthermore, our findings reflect changes in the sport. A
larger proportion of injuries occurred in male cheerleaders
in 2019 compared with 2010, aligning with an increase in
participation by boys and men.
48
From 1990 to 2012, most
injuries occurred at schools.
23
From 2010 to 2019, most
injuries occurred at places of sports/recreation, such as pri-
vate gymnasiums, with an increase from 37%to 54%. This
shift may reflect increased participation in competitive
cheerleading, such as all-star programs, that require non-
scholastic practice settings. This transition may be associ-
ated with a rise in attention to this type of cheerleading in
the media. In contrast to common beliefs,
9,33,34
bases have a
similar or higher risk of injury than flyers. This is consis-
tent with our results, with 44%of stunting injuries occur-
ring to bases versus 39%to flyers. The number of tumbling
injuries also increased during the study period. These find-
ings may reflect that many regulations target the safety of
flyers.
1
Increasing focus on bases and tumbling skills dur-
ing safety training may help further reduce injury rates.
The results of our study are limited by the information
contained in the NEISS database, which may not be gen-
eralizable to a larger population given its small hospital
sample size. A small proportion of entries provided data
on all variables studied because narratives were often
vague and did not describe the full extent of the circum-
stances surrounding the injury. Narratives and our inter-
pretation of them are also prone to error, so the accuracy
of cheerleading-specific variables derived from narra-
tives may be especially limited. The lack of specificity
of the narratives precluded more detailed analysis, such
as distinguishing among basket tosses, pyramids, and
partner stunts, or determining the type of cheerleading
(recreational, scholastic, or all-star) involved. Another
inherent weakness is that the NEISS database does not
account for individuals who sustain multiple injuries and
does not provide information that would enable control of
confounding factors, such as coach certification and athlete
experience. Furthermore, the NEISS data set does not
include minor or chronic injuries or fatal, onsite injuries.
More experienced cheerleaders have a high incidence of
overuse injuries, but these injuries are typically treated
in a clinic rather than an ED.
40
Thus, the numbers provided
by NEISS are likely an underestimation of the true inci-
dence of injury in cheerleaders. Finally, the SFIA partici-
pation reports cover participants aged 6 years or older,
which may include athletes older than 25, and would omit
those who are 5 years old. As a result, the annual injury
rates presented may be under- or overestimations, but this
would be true for data of all years, and the important trends
reported would remain.
Our study provides an update on recent injury patterns
in cheerleading and shows the progress made during the
past decade regarding safety in a sport known to cause
injury. Although overall annual injury numbers have
decreased, the incidence of severe acute injuries continues
to rise. Increased education on injury prevention is needed
for coaches and athletes alike, particularly regarding con-
cussions/CHIs. Health care providers should also be aware
of the sport’s prevalent injuries and the circumstances sur-
rounding them to better counsel these athletes. Our study
suggests that cheerleading demands more attention in
sports medicine, and our findings can serve as a foundation
for future studies of cheerleading injury risk.
ACKNOWLEDGMENT
For their editorial assistance, the authors thank Jenni
Weems, MS, Kerry Kennedy, BA, and Rachel Box, MS, in
the Editorial Services group of the Johns Hopkins Depart-
ment of Orthopaedic Surgery.
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