ArticlePDF Available

Progress in Cheerleading Safety: Update on the Epidemiology of Cheerleading Injuries Presenting to US Emergency Departments, 2010-2019


Abstract and Figures

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 presenting 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 = 350,000; 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 = 35,000; 95% CI, 27,000-44,000) to 897 (NE = 30,000; 95% CI, 18,000-42,000) ( P = .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 = 8700; 95% CI, 6700-11,000) to 216 (NE = 6600; 95% CI, 4000-9200) ( P = .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 = 3800; 95% CI, 2900-4700) to 171 (NE = 5500; 95% CI, 3400-7700) ( P = .02), and patients requiring hospital admission increased by 118%, from 18 (NE = 330; 95% CI, 250-410) to 24 (NE = 720; 95% CI, 440-1000) ( P < .01). The hospital admission rate increased by 9.0% ( P = .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.
Content may be subject to copyright.
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,*
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-
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.
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.
In addition to the high overall rate of injury, cheerleading
also presents a high risk of catastrophic injury.
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.
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
A lack of awareness of the physical demands
related research, with multiple studies incorrectly charac-
terizing cheerleading as a noncontact, individual (as
opposed to team) sport.
Few epidemiologic
The Orthopaedic Journal of Sports Medicine, 9(10), 23259671211038895
DOI: 10.1177/23259671211038895
ªThe Author(s) 2021
This open-access article is published and distributed under the Creative Commons Attribution - NonCommercial - No Derivatives License (
licenses/by-nc-nd/4.0/), which permits the noncommercial use, distribution, and reproduction of the article in any medium, provided the original author and source are
credited. You may not alter, transform, or build upon this article without the permission of the Author(s). For article reuse guidelines, please visit SAGE’s website at
studies have assessed cheerleading characteris-
with the most recent study performed
analyzing data through 2012.
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.
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.
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.
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).
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.
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
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:
*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.
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).
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%.
All estimates reported herein are stable unless otherwise
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.
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
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
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
Patient and Injury Characteristics of Cheerleading-Related
Injuries Among Athletes Aged 5-25 Years Treated in US
EDs, NEISS (2010-2019)
No. of
Study sample 9868 350,000 (100) 250,000-450,000
Patient Characteristics
Age group, years
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
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)
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
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)
CHI, closed head injury; ED, emergency department; NE,
national estimate; NEISS, National Electronic Injury Surveillance
Percentages may not sum to 100 and estimates may not sum to
350,000 because of rounding error.
Mean ±SD age was 14 ±3.6 years.
Potentially unstable estimate.
Further Injury Characteristics of Cheerleading-Related
Injuries Among Athletes Aged 5-25 Years Treated in US
EDs, NEISS 2010-2019
No. of
Cause of Injury
Fall 3095 110,000 (31) 80,000-140,000
Collision with another
1881 68,000 (19) 49,000-87,000
Performing a skill
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
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
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
Place of
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
Practice 3834 140,000 (39) 98,000-170,000
180 10,000 (2.9) 7300-13,000
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
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
ED, emergency department; NE, national estimate; NEISS,
National Electronic Injury Surveillance System.
Percentages may not sum to 100 and estimates may not sum to
350,000 because of rounding error.
For known stunt-related injuries, n ¼2498.
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
Trends in Cheerleading-Related Injuries That Presented to US EDs, NEISS 2010-2019
2010 2019
Change From 2010 to
2019, %
Slope (m),
n/year P
No. of
Cases Estimate (95%CI)
No. of
Cases Estimate (95%CI)
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
(250-410) 24 720
(440 -1000) 120 70 <.01
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
CHI, closed head injury; ED, emergency department; NEISS, National Electronic Injury Surveillance System.
Potentially unstable estimate.
Rate per 100,000 cheerleaders.
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).
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
The most recent and comprehensive analysis of NEISS
data included data from 1990 to 2012. Naiyer et al
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.
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)
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.
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,
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
Cheerleading-Related Injuries That Presented to US EDs
and Required Hospital Admission/Transfer, NEISS 2010-
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
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
CHI, closed head injury; ED, emergency department; NEISS,
National Electronic Injury Surveillance System.
Other injuries were asthma, heat exhaustion, cardiac arrhyth-
mia, rhabdomyolysis, seizures, chest pain, and syncope.
6Xu et al The Orthopaedic Journal of Sports Medicine
Our findings are consistent with previous
findings of stunts as the primary skills placing athletes at
risk of concussions/CHIs,
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.
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
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.
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.
From 1990 to 2012, most
injuries occurred at schools.
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,
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
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.
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.
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.
1. American Association of Cheerleading Coaches and Administrators.
2018-2019 AACCA School Cheer Safety Rules. Accessed September
24, 2020.
2. Amoo-Achampong K, Rosas S, Schmoke N, et al. Trends in sports-
related concussion diagnoses in the USA: a population-based analy-
sis using a private-payor database. Phys Sportsmed. 2017;45(3):
3. Bagnulo A. Cheerleading injuries: a narrative review of the literature. J
Can Chiropr Assoc. 2012;56(4):292-298.
4. Boden BP. Direct catastrophic injury in sports. J Am Acad Orthop
Surg. 2005;13(7):445-454.
5. Boden BP, Prior C. Catastrophic spine injuries in sports. Curr Sports
Med Rep. 2005;4(1):45-49.
6. Boden BP, Tacchetti R, Mueller FO. Catastrophic cheerleading inju-
ries. Am J Sports Med. 2003;31(6):881-888.
7. Buzas D, Jacobson NA, Morawa LG. Concussions from 9 youth orga-
nized sports: results from NEISS hospitals over an 11-year time frame,
2002-2012. Orthop J Sports Med. 2014;2(4):2325967114528460.
The Orthopaedic Journal of Sports Medicine Epidemiology of Cheerleading Injuries, 2010-2019 7
8. Buzzacott P, Schiller D, Crain J, Denoble PJ. Epidemiology of mor-
bidity and mortality in US and Canadian recreational scuba diving.
Public Health. 2018;155:62-68.
9. Currie DW, Fields SK, Patterson MJ, Comstock RD. Cheerleading
injuries in United States high schools. Pediatrics. 2016;137(1):
e20152447. doi:10.1542/peds.2015-2447
10. Greenspan RE. Cheer shows competitive cheerleading is almost as
dangerous as football. So why isn’t it officially considered a sport?
Accessed February 8, 2021.
11. Homme JJL. Pediatric minor head injury 2.0: moving from injury
exclusion to risk stratification. Emerg Med Clin North Am. 2018;
12. Jacobson NA, Morawa LG, Bir CA. Epidemiology of cheerleading
injuries presenting to NEISS hospitals from 2002 to 2007. J Trauma
Acute Care Surg. 2012;72(2):521-526.
13. Jones S, Almousa S, Gibb A, et al. Correction to: Injury incidence,
prevalence and severity in high-level male youth football: a systematic
review. Sports Med. 2019;49(12):1901.
14. Kerr ZY, Chandran A, Nedimyer AK, et al. Concussion incidence and
trends in 20 high school sports. Pediatrics. 2019;144(5):e20192180.
15. Kilic O, Maas M, Verhagen E, Zwerver J, Gouttebarge V. Incidence,
aetiology and prevention of musculoskeletal injuries in volleyball: a
systematic review of the literature. Eur J Sport Sci. 2017;17(6):
16. LaBella CR, Mjaanes J. Cheerleading injuries: epidemiology and
recommendations for prevention. Pediatrics. 2012;130(5):966-971.
17. Lemme NJ, Ready L, Faria M, et al. Epidemiology of boxing-related
upper extremity injuries in the United States. 2018;46(4):503-508.
18. Luckstead EF, Patel DR. Catastrophic pediatric sports injuries.
Pediatr Clin North Am. 2002;49(3):581-591.
19. McCarthy MM, Bihl JH, Frank RM, et al. Epidemiology of clavicle
fractures among US high school athletes, 2008-2009 through 2016-
2017. Orthop J Sports Med. 2019;7(7):2325967119861812.
20. Mueller FO. Catastrophic head injuries in high school and collegiate
sports. J Athl Train. 2001;36(3):312-315.
21. Mueller FO. Cheerleading injuries and safety. J Athl Train. 2009;44(6):
22. Mueller FO, Cantu RC. Catastrophic Sports Injury Research.
Accessed September 24, 2020.
23. Naiyer N, Chounthirath T, Smith GA. Pediatric cheerleading injuries
treated in emergency departments in the United States. Clin Pediatr
(Phila). 2017;56(11):985-992.
24. National Electronic Injury Surveillance System (NEISS) Online. Expla-
nation of NEISS Estimates Obtained Through the CPSC Web-site.
Accessed September 24, 2020.
25. National Governing Body for Sport Cheering in the United States. USA
Cheer’s Position Paper on Cheer Safety & Title IX. Accessed Septem-
ber 24, 2020.
26. Outdoor Foundation. 2019 Outdoor Participation Report. Accessed
September 25, 2020.
27. Pfirrmann D, Herbst M, Ingelfinger P, Simon P, Tug S. Analysis of
injury incidences in male professional adult and elite youth soccer
players: a systematic review. J Athl Train. 2016;51(5):410-424.
28. Pfister T, Pfister K, Hagel B, Ghali WA, Ronksley PE. The incidence of
concussion in youth sports: a systematic review and meta-analysis.
Br J Sports Med. 2016;50(5):292-297.
29. Schallmo MS, Weiner JA, Hsu WK. Sport and sex-specific reporting
trends in the epidemiology of concussions sustained by high school
athletes. J Bone Joint Surg Am. 2017;99(15):1314-1320.
30. Schroeder T, Ault K. The NEISS sample (design and implementation)
1997 to present. Accessed September 24, 2020.
31. Schulz MR, Marshall SW, Mueller FO, et al. Incidence and risk factors
for concussion in high school athletes, North Carolina, 1996-1999.
Am J Epidemiol. 2004;160(10):937-944.
32. Sherman E. Why don’t more people consider competitive cheerlead-
ing a sport? The rigorous activity is dominated by female athletes—
and is growing in legitimacy and popularity. Accessed February 8,
33. Shields BJ, Fernandez SA, Smith GA. Epidemiology of cheerleading
stunt-related injuries in the United States. J Athl Train. 2009;44(6):
34. Shields BJ, Smith GA. Cheerleading-related injuries in the United
States: a prospective surveillance study. JAthlTrain. 2009;44(6):
35. Shields BJ, Smith GA. Cheerleading-related injuries to children 5 to 18
years of age: United States, 1990-2002. Pediatrics. 2006;117(1):
36. Shields BJ, Smith GA. Epidemiology of cheerleading fall-related inju-
ries in the United States. J Athl Train. 2009;44(6):578-585.
37. Shields BJ, Smith GA. Epidemiology of strain/sprain injuries among
cheerleaders in the United States. Am J Emerg Med. 2011;29(9):
38. Smith M. Cheerleading has changed, so should our attitudes.
Accessed February 11, 2021.
39.Sports&FitnessIndustryAssociation.Cheerleading Participation
Report 2020. Accessed September 24, 2020.
40. Stracciolini A, Casciano R, Friedman HL, Meehan WP III, Micheli LJ. A
closer look at overuse injuries in the pediatric athlete. Clin J Sport
Med. 2015;25(1):30-35.
41. Swain TA, McGwin G. Yoga-related injuries in the United States from
2001 to 2014. Orthop J Sports Med. 2016;4(11):2325967116671703.
42. Tsushima WT, Siu AM, Ahn HJ, Chang BL, Murata NM. Incidence and
risk of concussions in youth athletes: comparisons of age, sex, con-
cussion history, sport, and football position. Arch Clin Neuropsychol.
43. Tsushima WT, Siu AM, Yamashita N, Oshiro RS, Murata NM. Com-
parison of neuropsychological test scores of high school athletes in
high and low contact sports: a replication study. Appl Neuropsychol
Child. 2018;7(1):14-20.
44. U.S. All Star Federation. 2020-2021 USASF Cheer Age Grid.
Accessed April 14, 2021.
45. U.S. All Star Federation. USASF Glossary, 2015-16. Accessed Octo-
ber 27, 2020.
46. Wells EK, Chin AD, Tacke JA, Bunn JA. Risk of disordered eating
among Division I female college athletes. Int J Exerc Sci. 2015;8(3):
47. Yau RK, Dennis SG, Boden BP, 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(1):
48. Young B. More male students sign up for high school cheerleading
squads. Accessed September 24, 2020.
49. Young TE, Chen M.One-year concussion prevalence in Marion
County, Florida high school athletes. JChiroprMed. 2016;15(3):
50. Zuckerman SL, Kerr ZY, Yengo-Kahn A, et al. Epidemiology of sports-
related concussion in NCAA athletes from 2009-2010 to 2013-2014:
incidence, recurrence, and mechanisms. Am J Sports Med. 2015;
8Xu et al The Orthopaedic Journal of Sports Medicine
... 7 Each year, approximately 35,000 cheerleading-related injuries, most commonly involving the extremities, are treated in emergency departments across the United States. 172 Specifically, cheerleading accounts for 65% of all catastrophic injuries-defined as severe spinal, spinal cord, or cerebral injuries-occurring in female athletes. 9,102 Such catastrophic injuries present acutely, but most injuries sustained in cheerleading are chronic and related to overuse. ...
... 26,114,127 Similar to the risk of sustaining a catastrophic injury, the risk of sustaining a concussion in cheerleading has increased as the sport has evolved in difficulty and complexity. 103,134,172 This increase may also be related to greater reporting and awareness of concussions in recent years, as seen with other sports. 119 The national incidence of concussion has increased by >900% since 2000, from approximately 600 concussions that year (2.7% of all cheerleading injuries presenting to US emergency departments) to approximately 5500 concussions (18%) in 2019. ...
... 119 The national incidence of concussion has increased by >900% since 2000, from approximately 600 concussions that year (2.7% of all cheerleading injuries presenting to US emergency departments) to approximately 5500 concussions (18%) in 2019. 9,103,134,172 Of note, cheerleading's concussion rate has continued to increase while the sport's overall injury rate has decreased. 172,173 Concussions are the most common head injury in cheerleading, and 96% are secondary to stunt-related incidents. ...
Full-text available
Cheerleading is a highly popular youth sport in the United States and has been increasingly recognized in recent years for its athleticism and competitive nature. The sport has changed dramatically since its inception. When the sport of cheerleading was first developed, its primary purpose was to entertain crowds and support other athletes. Today, cheerleaders are competitive athletes themselves. Cheerleaders, most of whom are in the pediatric age group, and their parents commonly approach orthopaedic surgeons and sports medicine physicians with questions regarding the risks associated with participation in the sport. Appropriate clinical guidance is especially important for athletes returning to the sport after an injury. However, unlike other popular sports (eg, football, basketball, and volleyball), the intricacies of cheerleading are not well-known to those outside the sport, including many health care providers. Previous studies have reported on the epidemiological patterns of injuries associated with cheerleading and how such aesthetic sports affect the body, finding that fractures and concussions are prevalent and that catastrophic injuries are more common than in most other sports. Here, we provide an evidence-based discussion of 10 pertinent topics regarding cheerleading and its risks to the musculoskeletal system. The purpose of this review is to provide a comprehensive resource for orthopaedic surgeons and sports medicine physicians who care for these athletes.
... Unfortunately, cheerleading is also a very dangerous sport, with catastrophic injuries (i.e., skull, brain, or spinal cord injuries) occurring (3,(9)(10)(11) in addition to more common injuries that also occur in other sports (i.e., strains, sprains, fractures, dislocations) (10,12,13). In addition to acute injuries, there is also a high prevalence of overuse injuries, which have been reported to account for 66% of all cheerleading-related injuries (14). ...
Full-text available
IntroductionLittle is known about the demands of competitive cheerleading. Therefore, the objective of this study was to assess fatigue and recovery during preparation for world championships.Methods Fifteen participants from the German senior “All-Girl” and “Coed” national teams (nine males and six women) were recruited. Data were collected during the final preparation (T1 -T7) and competition days (C1 -C2). Heart rate variability (HRV) and resting heart rate (HR) were measured every morning. Data on training load, recovery, and stress (Short Scale for Recovery and Stress) were surveyed after training. Countermovement jump height (CMJ), sit-and-reach, and exercise-induced muscle damage (EMID) scores were taken in the afternoon.ResultsThere was a practically relevant decrease in CMJ (T2, T6). A trend for HR to increase (T5–C2) and HRV to decrease (T4, T6–C2) was evident. Through training, recovery decreased and recovered as C1 approached (mental performance: T2–T4 p = 0.004; T2–C1 p = 0.029; T3–T4 p = 0.029; emotional balance: T3–T4 p = 0.023; T3–C1 p = 0.014; general recovery status T1–T3 p = 0.008; T3–T4 p = 0.024; T3–C1 p = 0.041), whereas stress increased during the first days and returned to normal before C1 (emotional dysbalance: T2–T4 p = 0.014; T2–C1 p = 0.009; T3–T4 p = 0.023; T3–C1 p = 0.014). EMID scores increased for the upper and lower body between T3, T5–T7 (p ≤ 0.036) and T3, T6–T7 (p ≤ 0.047), respectively.DiscussionPre-competition training led to substantial fatigue, and most markers indicate that athletes do not compete fully recovered. This could possibly be avoided by optimizing the training load or implementing recovery strategies.
Full-text available
ENGLISH BELOW>O cheerleading vem crescendo significativamente ao redor do planeta. Não por acaso, recebeu em 2021, diretamente do Comitê Olímpico Internacional (COI), o reconhecimento mais alto concedido à uma modalidade esportiva, o primeiro passo oficial para um esporte participar dos Jogos Olímpicos. No Brasil, a modalidade está fortemente presente em universidades, assim como o número de ginásios especializados em cheerleading aumentam exponencialmente. A partir do status concedido pelo COI e dado o progressivo crescimento do cheerleading no país, este projeto visa, portanto, à luz da teoria em gestão do esporte, discutir quais são as perspectivas de desenvolvimento do cheerleading no curto, médio e longo prazo no Brasil. Para isso, enquanto procedimento metodológico, a pesquisa qualitativa foi escolhida e aplicada através de um roteiro de entrevista semiestruturada realizada com coaches de cheerleading, como são conhecidos os treinadores e treinadores da modalidade, que atuam na cidade de São Paulo e região e que possuem relevância nacional, de forma a compreender o perfil daqueles que atuam como gestores da modalidade no país, bem como identificar os principais desafios em prol de seu desenvolvimento no cenário nacional, destacando aqui a gestão esportiva da modalidade e a promoção da saúde do cheerleader. Como principais resultados, observamos que o cheerleading cresceu de forma amadora, porém, no momento, está inserido em um processo de regularização, vide a recém-criada Confederação Brasileira de Cheerleading e Dança. Em segundo lugar, verificamos os principais desafios vividos pelos gestores no curto e médio prazo: a dificuldade em obter patrocínio e a necessidade de regularização da modalidade no país. No longo prazo, questões acerca da profissionalização da gestão, a exigência da formação em Educação Física e a ampliação do cheerleading para as categorias de base foram mencionadas. Incentivar a promoção da saúde do praticante também foi amplamente debatido nesta pesquisa, visto que a modalidade envolve um altíssimo risco devido aos arremessos e elevações característicos. Espera-se que os dados obtidos através desta pesquisa embasem futuras produções acadêmicas sobre o cheerleading no país, visto que a modalidade vem se expandido expressivamente, e que, justamente, é digna de maior aprofundamento científico. Cheerleading has been growing significantly around the planet. Not by chance, in 2021, directly from the International Olympic Committee (IOC), received the highest recognition given to a sport, the first official step for a sport to participate in the Olympic Games. In Brazil, the modality is strongly present in universities, and the number of gyms specializing in cheerleading has increased exponentially. Based on the status granted by the IOC and given the progressive growth of cheerleading in the country, this project aims, therefore, in the light of sport management theory, to discuss what are the prospects for the development of cheerleading in the short, medium, and long term in Brazil. For this, as a methodological procedure, the qualitative research was chosen and applied through a semi-structured interview script carried out with cheerleading coaches from the city of São Paulo and regions that have national relevance to understanding the profile of those who act as managers of the modality in the country, as well as identifying the main challenges for its development on the national scene, highlighting here the sport management of the modality and the promotion of cheerleader health. As the main results, we observed that cheerleading grew in an amateur way; however, at the moment, it is inserted in the process of regularization, see the recently created Brazilian Confederation of Cheerleading and Dance. Second, we verified the main challenges faced by managers in the short and medium term: the difficulty in obtaining sponsorship and the need to regularize the sport in the country. In the long term, the coaches mentioned questions about the professionalization of management, the requirement of training in Physical Education, and the expansion of cheerleading to the basic categories. Encouraging the health promotion of the practitioner was also widely discussed in this research since the modality involves a very high risk due to the characteristic throws and elevations. We expect that the data obtained through this research will support future academic productions on cheerleading in the country since the modality has expanded significantly, which is worthy of further scientific investigation.
Full-text available
Background Little is known about the epidemiology of clavicle fractures in United States (US) high school athletes. Sports participation among high school students has increased steadily, placing increased numbers at risk of sports-related injury. Purpose To describe the epidemiology of clavicle fractures among high school athletes, including injury rates by sex, sport, and type of play and trends in operative versus nonoperative treatment. Study Design Descriptive epidemiology study. Methods The study data set included all athlete-exposure (AE) and clavicle fracture data collected from 2008-2009 through 2016-2017 from a large sample of US high schools as part of the National High School Sports-Related Injury Surveillance Study for students participating in boys’ football, boys’/girls’ soccer, boys’/girls’ basketball, boys’/girls’ volleyball, boys’ wrestling, boys’ baseball, girls’ softball, girls’ field hockey, boys’ ice hockey, boys’/girls’ lacrosse, boys’/girls’ swimming and diving, boys’/girls’ track and field, girls’ gymnastics, girls’ cheerleading, boys’/girls’ tennis, and boys’/girls’ cross-country. Results Overall, 567 clavicle fractures were reported during 31,520,765 AEs, an injury rate of 1.80 per 100,000 AEs. Injury rates varied by sport, with the highest rates in the boys’ full-contact sports of ice hockey (5.27), lacrosse (5.26), football (4.98), and wrestling (2.21). Among girls’ sports, the highest rates were in soccer (0.92), lacrosse (0.26), and basketball (0.25). In sex-comparable sports, injury rates were still significantly higher among boys (1.03) than girls (0.35) (rate ratio, 2.91; 95% CI, 1.97-4.30). Injury rates were significantly higher in competition (4.58) as compared with practice (0.87) (rate ratio, 5.27; 95% CI, 4.44-6.26). Most injuries were treated conservatively (82.7%) rather than operatively (17.3%). Time to return to sports varied, with a greater proportion of medical disqualifications among those treated operatively (40.0%) as compared with those treated conservatively (22.6%) (injury proportion ratio, 1.77; 95% CI, 1.31-2.39). Conclusion Although clavicle fracture rates are relatively low, they vary by sport, sex, and activity. Understanding such differences should drive more effective, targeted injury prevention efforts. Increased time loss from sports with surgical versus conservative treatment may have been influenced by factors including injury severity and its timing relative to the season’s progress.
Full-text available
Visits for pediatric minor blunt head trauma continue to increase. Variability exists in clinician evaluation and management of this generally low-risk population. Clinical decision rules identify very low-risk children who can forgo neuroimaging. Observation before imaging decreases neuroimaging rates. Outcome data can be used to risk stratify children into more discrete categories. Decision aids improves knowledge and accuracy of risk perception and facilitates identification of caregiver preferences, allowing for shared decision making. For children in whom imaging is performed and is normal or shows isolated linear skull fractures, deterioration and neurosurgical intervention are rare and hospital admission can be avoided.
Full-text available
Objective: This study was designed to determine concussion incidence, risk, and relative risk among middle and high school athletes participating in various sports. Method: Data were retrospectively obtained from 10,334 athletes of 12 different sports in Hawaii. In addition to determining the overall concussion incidence, comparisons of incidence, risk, and relative risk were made according to age, sex, concussion history, sport, and football position. Results: The overall incidence of concussion among youth athletes was 1,250 (12.1%). The relative risk for a concussion was almost two times greater in 18-year olds than in 13-year-old athletes. In comparable sports, girls had a 1.5 times higher concussion risk than boys. Athletes with a prior concussion had 3-5 times greater risk to sustain a concussion than those with no history of a concussion. Among varied sports, wrestling and martial arts had the highest relative risk of a concussion, followed by cheerleading, football, and track and field. No differences in concussion risks were found among the football players in different positions. Conclusions: Older youths, females, those with a history of concussion, and those participating in high contact sports were found to have higher risks of sustaining a concussion. The findings increase awareness of concussion patterns in young athletes and raise concerns regarding protective strategies and concussion management in youth sports.
Full-text available
Objective: To describe recent epidemiological trends in concussion diagnosis within the United States (U.S) population. Methods: We conducted a retrospective review of PearlDiver, a private-payor insurance database. Our search included International Classification of Disease, Ninth Revision codes for sports-related concussions spanning 2010 through 2014. Overall study population included patients aged 5 to 39 with subgroup analysis performed on Cohort A (Youth), children and adolescents aged 5 to 19, and Cohort B (Adults), adults aged 20 to 39. Incidence was defined as the number of individuals diagnosed normalized to the number of patients in the database for each demographic. Results: Our search returned 1,599 patients diagnosed during the study period. The average (±SD) annual rate was 4.14 ± 1.42 per 100,000 patients for the overall population. Youth patients were diagnosed at a mean annual rate of 3.78 ± 1.30 versus 0.36 ± 0.16 per 100,000 in Adults. Concussion normalized incidence significantly increased from 2.47 to 3.87 per 100,000 patients (57%) in the Youth cohort (p=0.048). In Adults, rate grew from 0.34 to 0.44 per 100,000 patients (29%) but was not statistically significant (p=0.077). Four-year compound annual growth rates for Youth and Adults were 26.3% and 20.4%, respectively. Youth patients comprised 1,422/1,599 (90.18%) of all concussion diagnoses and were predominantly male (75%). Adults also constituted 138/1,599 (8.63%) of the sample and were also largely male (80%). Midwestern states had highest diagnostic rates (Cohort A:19 per 100,000 and Cohort B:1.8 per 100,000). Both cohorts had the most total diagnoses made in the fourth quarter followed by the second quarter. Conclusion: Sports-related concussion diagnostic rates have grown significantly in the youth population. Quarterly, regional and gender distributions appear consistent with participation in concussion-prone sports. Utilization of individualized and multifaceted approaches are recommended to advance diagnosis, assessment and management of concussions in the U.S. population.
Background: Ongoing monitoring of concussion rates and distributions is important in assessing temporal patterns. Examinations of high school sport-related concussions need to be updated. This study describes the epidemiology of concussions in 20 high school sports during the 2013-2014 to 2017-2018 school years. Methods: In this descriptive epidemiology study, a convenience sample of high school athletic trainers provided injury and athlete exposure (AE) data to the National High School Sports-Related Injury Surveillance Study (High School Reporting Information Online). Concussion rates per 10 000 AEs with 95% confidence intervals (CIs) and distributions were calculated. Injury rate ratios and injury proportion ratios examined sex differences in sex-comparable sports (soccer, basketball, baseball and softball, cross country, track, and swimming). We also assessed temporal trends across the study period. Results: Overall, 9542 concussions were reported for an overall rate of 4.17 per 10 000 AEs (95% CI: 4.09 to 4.26). Football had the highest concussion rate (10.40 per 10 000 AEs). Across the study period, football competition-related concussion rates increased (33.19 to 39.07 per 10 000 AEs); practice-related concussion rates decreased (5.47 to 4.44 per 10 000 AEs). In all sports, recurrent concussion rates decreased (0.47 to 0.28 per 10 000 AEs). Among sex-comparable sports, concussion rates were higher in girls than in boys (3.35 vs 1.51 per 10 000 AEs; injury rate ratio = 2.22; 95% CI: 2.07 to 2.39). Also, among sex-comparable sports, girls had larger proportions of concussions that were recurrent than boys did (9.3% vs 6.4%; injury proportion ratio = 1.44; 95% CI: 1.11 to 1.88). Conclusions: Rates of football practice-related concussions and recurrent concussions across all sports decreased. Changes in concussion rates may be associated with changes in concussion incidence, diagnosis, and management. Future research should continue to monitor trends and examine the effect of prevention strategies.
Background:: Cheerleading is a specialized athletic activity that can lead to catastrophic injuries. Cheerleading rules are in place to maximize safety of participants. The purpose of this study was to describe catastrophic cheerleading injuries among high school and collegiate-level participants in the United States and to explore whether the 2006-2007 basket toss rule change was effective at reducing the number of catastrophic injuries. Hypothesis:: The 2006-2007 basket toss rule change contributed to a reduction in the number of catastrophic injuries among high school and collegiate cheerleaders. Study design:: Case series. Level of evidence:: Level 4. Methods:: Data on catastrophic cheerleading injuries were collected by the National Center for Catastrophic Sport Injury Research from July 2002 to June 2017. Information collected included cheerleader, event, and injury characteristics. The impact of the 2006-2007 rule change banning the basket toss on any hard surfaces was assessed by comparing injury rates and 95% CIs before and after the rule change. Results:: There were 54 catastrophic cheerleading injuries, or 3.6 injuries per year. From July 2002 through June 2017, the injury rate was 2.12 per 1,000,000 cheerleaders (95% CI, 1.56-2.69). Most cheerleaders sustained serious injuries (n = 27; 50%) during practice (n = 37; 69%) to the head (n = 28; 52%) and cervical spine (n = 17; 32%). From July 2002 through June 2017, basket tosses were the stunt that accounted for the highest proportion of injuries (n = 19; 35%). The basket toss injury rate decreased from 1.55 to 0.40 per 1,000,000 cheerleaders among both high school and collegiate cheerleaders after the rule change. Conclusion:: Catastrophic injury rates in cheerleading decreased dramatically after the 2006-2007 rule change banning basket tosses from being performed on any hard surfaces. In particular, there was a nearly 4-fold reduction in the rate of catastrophic basket toss injuries.
Objective: The incidence of boxing-related upper-extremity (UE) injuries in the United States has not been well characterized. Recent rule changes have been made to make participation safer for athletes, although the consequences of such rule changes on injury rates is unclear. Therefore, we sought to determine the incidence, characteristics and trends of boxing-related UE injuries. Methods: The National Electronic Injury Surveillance System (NEISS) was queried for the years 2012-2016. All UE injuries related to boxing from 2012-2016 that occurred during organized boxing participation were selected. Examined variables included injured body party, injury diagnosis, patient age, and sex. Annual injury incidence rates by body part and diagnosis were calculated. Results: The mean incidence of boxing-related UE injuries from 2012-2016 was 673 injuries (95% CI 537-809) per 100,000 person-years, with hand fractures being the most common injury (132 (95% CI 130-135) per 100,000 person-years). The incidence of UE injury significantly declined from 865 (95% CI 846-884) per 100,000 person-years in 2012 to 656 (95% CI 642-671) per 100,000 person-years in 2016 (p<0.01). Injuries to the hand exhibited the largest decrease, decling by 33%. The majority of boxers sustaining UE injuries were male (84.4%) and between the ages of 20-39 (59.9%). Conclusions: Injuries to the UE due to participation in boxing accounted for thousands of emergency department visits in the United States annually, with males younger than 20 years of age, most susceptible to injury. Injuries to the hand, wrist and shoulder occurred at the highest rate. Finally, following rule changes made by sanctioning organizations in 2013, a significant decline in boxing-related UE injuries were observed.
Objectives: This study investigates morbidity and mortality suffered by divers in the USA and Canada. Study design: Prospectively recruited probability-weighted sample for estimating the national burden of injury and a weighted retrospective survey for estimating exposure. Methods: The National Electronic Surveillance System and Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) were searched for scuba diving injuries. The Divers Alert Network diving fatality database was searched for deaths, and Sports and Fitness Industry Association estimates for diving were obtained from annual surveys. Results: In the USA, there were an estimated 1394 emergency department (ED) presentations annually for scuba-related injuries. The majority (80%) were treated and/or released. There were an estimated 306 million dives made by the US residents 2006-2015 and concurrently 563 recreational diving deaths, a fatality rate of 0.18 per 105 dives and 1.8 per 105 diver-years. There were 658 diving deaths in the US 2006-2015 and 13,943 ED presentations for scuba injuries, giving a ratio of 47 diving deaths in the USA for every 1000 ED presentations. There were 98 cases of scuba-related injuries identified in the CHIRPP data. The prevalence of scuba-related injuries for patients aged 3-17 years was 1.5 per 105 cases, and the prevalence of scuba-related injuries to patients 18-62 years was 16.5 per 105 cases. Discussion: In Canada and the USA, only one out of every 10,000 ED presentations is due to a scuba-related injury. That there are 47 deaths for every 1000 ED presentations for scuba injuries speaks to the relatively unforgiving environment in which scuba diving takes place. For 1.8 deaths per million recreational dives, mortality in scuba diving is nonetheless relatively low.
Background: Approximately 300,000 U.S. adolescents sustain concussions annually while participating in organized athletics. This study aimed to track sex and sport-specific trends among high school sports-related concussions over time, to identify whether a particular sport predisposes athletes to a higher risk, and to assess whether traumatic brain injury law enactments have been successful in improving recognition. Methods: Injury data for academic years 2005 to 2014 were collected from annual reports generated by High School RIO (Reporting Information Online). The relative proportions of total estimated concussions to total estimated injuries were compared using an injury proportion ratio. The concussion rate was defined as the number of concussions per 10,000 athlete exposures (1 athlete participating in 1 practice or competition), with rates compared using a rate ratio. To evaluate the impact of legislation on sports-related concussions in this population, trends in concussion rates and proportions were analyzed before enactment (academic years 2005-2009) and after enactment (academic years 2010-2014). Results: Between 2005-2006 and 2014-2015, a significant increase (p < 0.0001) in the overall number of concussions for all sports combined, the overall concussion rate (rate ratio, 2.30 [95% confidence interval, 2.04 to 2.59]), and the overall proportion of concussions (injury proportion ratio, 2.68 [95% confidence interval, 2.66 to 2.70]) was seen. Based on the injury proportion ratio, during the 2014-2015 academic year, concussions were more common in girls' soccer than in any other sport (p < 0.0001). Conclusions: Because of potentially devastating consequences, concussion prevention and recognition measures continue to be emphasized in high school contact sports. The data in our study suggest that significant increases in the overall rate and proportion of reported concussions during the past decade could have been affected by traumatic brain injury legislation. To our knowledge, this is the first study to show that girls' soccer players may have an even greater risk of sustaining a concussion than all other sports. Clinical relevance: Sports-related concussions in adolescent athletes can have devastating consequences, and we now know that female athletes, especially girls' soccer players, may be at an even greater risk for sustaining this injury than all other athletes. Knowledge of the trends identified by this study may help lead to policy and prevention measures that can accommodate each sport effectively and potentially halt these trends.