Safety in Cheerleading: Epidemiology and Recommendations: Policy Statement

This is a revision of the policy statement “Cheerleading Injuries: Epidemiology and Recommendations for Prevention” published in 2012. The authors encourage referencing the Appendix for cheer-specific terminology used throughout this policy statement.

Cheerleading originated in the late 1800s as a way to lead crowds cheering on sports teams using chant/fight song leaders, megaphones, pompoms, and basic jumps. Now, it includes fast-paced floor routines requiring significant athleticism and participants perform dances, jumps, tumbling, and complex stunts involving pyramid building and toss athletes into the air. With the increasing physical demands, year-round participation, and competitive nature, pediatricians need to be prepared for performing focused preparticipation evaluations, managing associated injuries, and advocating for injury prevention.

Cheerleading started as a primarily scholastic discipline, but now it can be broadly categorized as either scholastic or nonscholastic (see Table 1). Scholastic cheer is a traditional student-based activity involving game day support, although now it often involves “competitive spirit” and teams competing against other schools. Nonscholastic cheer includes “club/all-star cheer,” which has teams from private gyms competing against one another in a specific format, or recreational cheer (youth community organizations), which provides game day support to non-school-based athletic teams. The newest subcategory of both scholastic and nonscholastic cheer is STUNT, which has teams competing head-to-head against one another in a series of short routines for “4 quarters of play”— partner stunts, pyramids and tosses, jumps and tumbling, and a team routine (STUNT the Sport - USA Cheer). Every category of cheerleading shares many similarities, but their focus (game day support versus competition) and setting (schools, private gyms, community organizations) are what makes each unique.

As cheerleading has evolved, participation has grown tremendously. According to the 2022 Sports & Fitness Industry Association’s annual report, cheer had 3.5 million annual participants in the United States ages 6 years or older. The overwhelming majority of participants were 6 to 17 years old, with a significant decline after 18 years of age. The 2022 estimates were a decline from the peak of 4 million participants in 2016, but it remains to be seen whether this was pandemic-related or will be sustained.¹ 

Thirty-one states have organizations overseeing scholastic cheerleading or “competitive spirit” where the primary purpose is to compete against other schools. The data from these 31 states are reported to the National Federation of State High School Associations (NFHS). In 2018–2019, the participation survey revealed 161 358 female participants from 7214 schools. Only 21 states reported data on male participants, revealing 3938 participants from 870 schools.² 

The sport of cheerleading in the United States is not subject to enforcement by the US Department of Education’s Office for Civil Rights as part of compliance standards for Title IX, which prohibits discrimination based on sex in education programs and activities receiving federal financial assistance. This debate around cheer and Title IX has played out in the courts, where a 2008 ruling did not recognize cheer as a sport.³  The issue led USA Cheer to publish a position paper discussing Title IX and cheer compliance. They feel “traditional cheerleading” should be governed as a student activity with the focus on school spirit rather than competition, and thus, not subject to Title IX compliance. They also specifically designed the discipline of STUNT team cheer to eliminate the crowd-leading components and focus exclusively on athletic competition. This means STUNT is the only cheer discipline that meets the definition of a Title IX sport.⁴  In January 2023, STUNT cheer was elevated to join the National Collegiate Athletics Association (NCAA) Emerging Sports for Women Program at the Division II level. Consideration for expansion of STUNT to NCAA Division 1 and 3 may occur in the future.

Cheerleading is largely a North American sport, and USA Cheer is the governing body in the United States. In 2023, the US Olympic and Paralympic Committee welcomed USA Cheer as an Affiliate Sports Organization, which is a council for increasing interest and national programming around sports not currently in the Olympic Games.⁵  Internationally, the governing body for cheer since 2004 has been the International Cheer Union (ICU). In 2021, the ICU was granted full recognition status by the International Olympic Committee,⁶  which means the ICU can petition to be included in the Olympic Games. These recognitions by the US Olympic and Paralympic Committee and the International Olympic Committee ensure greater support and funding for cheer development in the United States and many countries around the world.

Gathering data on cheer injuries is a challenge because of the lack of a centralized surveillance system. For many sports and activities, the NFHS and NCAA collect comprehensive injury data. Because only about half of the state high school associations recognize cheer as a sport/activity and because the NCAA has yet to approve cheer as a sport, these organizations do not have a systematic method of compiling information on cheer injuries.

The US Consumer Product Safety Commission operates a public database, the National Electronic Injury Surveillance System (NEISS), which compiles reports of injuries presenting to US emergency departments (EDs). One recent study found a national estimate of 350 000 patients aged 5 to 25 years were treated for cheerleading injuries in EDs from 2010–2019. This number translates to ∼35 000 patients per year, with the vast majority 12 to 18 years old. When comparing injury data from the years 2010–2019, the proportion of injured patients 12 to 18 years old decreased significantly, but this means there was an increase in the proportion of injured patients younger than age 12.⁷  A study from Canada also found 5- to 11-year-olds were more than twice as likely to have moderate to severe injuries when compared with their older peers.⁸ 

The NEISS database revealed 98% of patients presenting to EDs with cheer injuries were female, but the proportion of male patients increased significantly from 1.4% to 3.4% over the study time frame. The setting for most injuries was a recreational/sports club/private gym (52%), followed by schools (31%) and, finally, homes (1.1%). Ninety-seven percent were released from the ED, and only 2.3% were admitted, kept for observation, or transferred. Of those admitted or transferred, most had either a head/neck/spine injury or an upper extremity fracture.⁷ 

Another study used the High School Reporting Information Online (RIO) database, which has a representative sample of US high schools with athletic trainers (ATs) reporting injury data. They reviewed injury data from academic years 2009–2010 through 2013–2014. They found an injury rate much lower than most other high school sports, with an overall injury rate of 0.71 per 1000 athletic exposures (AEs). AEs are defined as 1 athlete participating in 1 practice, competition, or performance. This injury rate remained relatively constant throughout the study, demonstrating that injury rates for cheerleading are among the lowest when comparing all high school sports (see Table 2).

Other interesting patterns also emerged from the RIO database. Injury rates during practices (0.76/1000 AEs) and competitions (0.85/1000 AEs) were much higher than those seen during a performance (0.49/1000 AEs). Competition is when cheerleaders compete in a judged event with a coach or school supervisor present, and performances are cheering at halftime or on the sidelines in support of another event. Female athletes accounted for 97% of the injuries, but the male injury rate was significantly higher (1.33 vs 0.69/1000 AEs). Despite the relatively low overall injury rate in cheerleading, injuries tended to be more severe, resulting in more time loss from sport.⁹ 

Over the past decade, data from both the NEISS and RIO databases have provided insight into the types of injuries associated with cheerleading, but some limitations in this data are worth acknowledging. The NEISS electronic database relies on coding in the ED, which means injuries must be accurately entered as cheerleading rather than tumbling or gymnastics. The RIO database utilizes high schools with ATs, so it only captures information for scholastic cheer and leaves gaps in our knowledge about injury risk associated with nonscholastic cheer.

Concussions account for 31% of all cheerleading injuries reported by ATs in the RIO data. This statistic is striking when compared with the 4% to 6% previously reported from 2006–2009.^10,11  For comparison, concussion rates rose in all sports during this period, although to a lesser degree. This dramatic increase has been partially attributed to improved awareness and reporting, but there may also be some risk inherent to the sport. Concussion rates (2.21/10 000 AEs) were still lower than in all other girls’ sports (2.70/10 000 AEs) and lower than in boys’ and girls’ sports combined (3.78/10 000 AEs).

The RIO data also offer some cheer-specific findings. Stunting accounted for 69% of all cheer-related concussions, followed by pyramids (16%) and tumbling (9%). The most common mechanisms were contact with another athlete (59%) and contact with the playing surface (38%). Concussions in bases and back spotters typically resulted from contact with another athlete, whereas in flyers, the cause was typically contact with the playing surface. Of the concussions reported, 206 occurred during practice, 21 during performances, and 18 during competition. Despite the overall low concussion rates in cheer, the rate of 2.51 concussions/10 000 AEs in practice ranks third behind only boys’ football (4.78) and boys’ wrestling (3.02).

Concussion is a major contributor toward the severity of cheer injuries and time loss from sport attributable to injury. Most cheer-related concussions resulted in a time loss of 1 to 3 weeks, but concussion was the leading cause of cheer injuries resulting in time loss of 3 weeks or more.⁹ 

NEISS data from 2012–2019 indicated concussion and closed head injuries were responsible for 16% of all cheer-related ED visits and were the leading cause of cheer-related hospital admissions (22%).⁷  Despite the increases in reported concussions, the rate of hospital admissions from cheer-related ED visits has not risen significantly from previously published reports.¹² 

The most common mechanism for injuries in cheer is a fall which may result in collision/contact with another athlete or may lead to unexpected contact with the playing surface. Stunting is the leading cause of injury (53%) followed by tumbling (21%). Shoulder-level stunts account for 15% of stunt injuries, and above-the-shoulder level stunts account for 37%. When stunting, the dismount appears to be most risky, and specifically when dismounting to a cradle (64%) versus dismounting to the floor (36%). Bases account for 46% of all injuries, flyers for 36%, and spotters 10%.

Injury data show the most injured body sites are the head and neck (43%), ankle (12%), hand/wrist (9%), and trunk (8%). Ligament sprains, muscle strains, and bony fractures are common types of acute musculoskeletal injuries seen during cheer (see Table 3). Once again, injury rates during performances were lower than those seen in competition or practice.⁹  Overuse injuries are also common and account for more than 65% of cheer-related clinic visits in one study.¹³ 

Even with injury rates for cheer being rather low, the time lost and severity of injuries are significant. Thirty-four percent of athletes return to cheer in less than 1 week following an injury, and 41% take between 1 and 3 weeks. However, 11% percent are out longer than 3 weeks, and 5% are medically disqualified for the season. The injuries most likely to take 3 or more weeks to return are concussion (35%), fracture (31%), and ligament sprains (16%). The biggest drivers behind medical disqualifications for the season are fractures (29%) and dislocations (16%).⁹ 

Catastrophic sports injuries are defined as any severe injury incurred during participation in a school/college-sponsored sport. Catastrophic injuries are divided into 3 categories: (1) fatal, (2) nonfatal but with permanent, severe disability, and (3) severe injury without permanent functional disability.

Catastrophic sports injuries can be further classified as either (1) direct (traumatic), or (2) indirect (exertional/medical). The direct injuries relate to trauma (eg, closed-head injury, skull fractures, and cervical spine injuries) from participating in the skills of a sport. The indirect injuries relate to a failure of body systems attributable to exertion with sports participation (eg, cardiac collapse, heat stroke) or a complication secondary to a nonfatal injury.

The latest report from the National Center for Catastrophic Sport Injury Research published in 2023 covers the time frame of fall 1982 to spring 2022. During this 40-year period, the authors discovered 89 reports of catastrophic injuries in high school cheerleading (see Table 4). Of these injuries, the vast majority were in female athletes (n = 87) and classified as direct/traumatic (n = 77). There were 9 reported fatalities, with 1 classified as direct and 8 as indirect. The direct/traumatic catastrophic injury rate per 100 000 female high school participants was 0.03 for fatal injuries, 0.82 for nonfatal injuries, and 1.50 for serious injuries. The indirect/medical catastrophic injury rate per 100 000 female high school participants was 0.27 for fatal injuries, 0 (none reported) for nonfatal injuries, and 0.14 for serious injuries (see Table 5).

The data reported for collegiate cheer during the same time period revealed 33 reports of direct/traumatic catastrophic injuries, including 28 in females and 5 in males. These included 1 classified as fatal, 15 classified as nonfatal, and 16 classified as serious. There was 1 injury classified as unknown. Injury rates could not be calculated because of lack of data on the number of participants.¹⁴ 

In the 2006–2007 academic year, the NFHS and the American Association of Cheerleading Coaches and Administrators implemented rule changes for cheerleading to maximize safety for participants. The most notable rule change was eliminating the basket toss on hard surfaces such as basketball courts and limiting this specific stunt to mats, grass, and rubberized track surfaces. The basket toss is a stunt in which a flyer is tossed into the air by multiple bases whose hands are interlocked (see Appendix). Previous studies had shown the basket toss was responsible for 21% of catastrophic cheerleading injuries.¹⁵  Implementation of this safety rule led to a 74% reduction in catastrophic basket toss injuries over the course of a decade.¹⁶ 

Cheerleaders should regularly have a preparticipation physical evaluation (PPE) in their medical home utilizing the latest PPE monograph (https://www.aap.org/en/patient-care/preparticipation-physical-evaluation/), which includes a medical history, physical evaluation, and a medical eligibility form. Given that cheerleading is a sport that has historically emphasized a slim, lean body aesthetic, participants are at risk for body image dissatisfaction, inadequate caloric intake for sport, and accompanying risk of bone stress injuries. Participants, parents, and coaches can ameliorate these risks by avoiding language that suggests participants should conform to a specific body morphology, and choosing uniforms that are inclusive for all body shapes and sizes and that do not expose the midriff.¹⁷  The American Academy of Pediatrics clinical report “Identification and Management of Eating Disorders in Children and Adolescents” (https://doi.org/10.1542/peds.2020-040279) can be helpful, and the PPE questions relating to weight, body image, and menses are important. Pediatricians can use the PPE as an opportunity to educate patients on appropriate nutrition, maximizing bone health, and tracking menstrual cycles as a vital sign of overall health.

• Advocate for scholastic cheerleading to be overseen by state associations and school athletic departments in all 50 states. This oversight would lead toward ensuring cheerleaders have access to certified/qualified coaches, proper facilities including strength and conditioning programs, practice/competition oversight, organized injury surveillance, and health care professionals including ATs and physicians.

• Cheerleaders need supervision by qualified coaches trained and certified in proper spotting for partner stunts, safety measures, and basic injury management. The rules of execution for technical skills are set forth in the most recent version of the NFHS Spirit Rules Book (https://www.nfhs.org/activities-sports/spirit/) and the USA Cheer Safety and Risk Management Course (https://usacheer.org/safety/usa-cheer-safety-risk-management).

• Encourage cheerleaders to be trained in proper techniques and demonstrate adequate strength, balance, and skill progression to protect one another before attempting stunts/skills. Skills (pyramids, mounts, tosses, and tumbling) should only be performed on safe surfaces without obstructions. Pyramids should not exceed the height of 2 people, and spotters are recommended for all pyramids. No cheer stunts, skills, or events should take place on concrete, asphalt, dirt, vinyl floors, or surfaces that are wet or uneven.

• Safety guidelines need to especially consider the physical and developmental stages of younger athletes so they can participate safely.

• Every school, gym, coach, and cheerleader needs access to a written emergency action plan. Emergency action plans are best when practiced with all participants on a regular basis. Resources and templates are readily available from the NFHS, National Athletic Trainer’s Association (https://www.nata.org/sites/default/files/emergencyplanninginathletics.pdf), and USA Cheer (https://usacheer.org/safety/resources/cheerleading-emergency-action-plan).

• A PPE provides an excellent opportunity to promote safe cheer participation and counsel on specific risks associated with cheerleading.

• Encourage events to be held in venues that are compliant with safety guidelines and rules established by USA Cheer, the NFHS, or the US All Star Federation.

• Cheerleaders, coaches, officials, and parents should be educated on the signs, symptoms, and proper management of concussion. Any cheerleader suspected of having a concussion needs immediate removal from participation and should not be allowed to return without documented clearance.

• Continued surveillance of cheerleading-related injuries is crucial to improving safety, measuring the efficacy of previous rule changes, and guiding new recommendations. Report all catastrophic injuries to the National Center for Catastrophic Sport Injury Research at https://nccsir.unc.edu or https://www.sportinjuryreport.org.

• Cheer needs to be committed to a safe and positive environment free from abuse and misconduct. Training and policies consistent with the US Center for SafeSport (https://uscenterforsafesport.org/) are important to prevent sexual abuse, physical abuse, emotional abuse, bullying, harassment, and hazing. A process for anonymous reporting of any suspected abuse or misconduct is essential to athlete safety and should be emphasized throughout the cheer community. Free online courses are available through US Center for SafeSport, the NFHS, and USA Cheer.

• Encourage the inclusion of all participants in cheer. Patients with disabilities interested in cheer can be directed to organizations such as ParaCheer International (https://www.paracheer.org/) and others highlighted by USA Cheer (https://usacheer.org/inclusion-opportunities-in-cheer).

Greg Canty, MD, FAAP

Jennifer King, DO, FAAP

Margaret Alison Brooks, MD, FAAP, Chairperson

Rebecca L. Carl, MD, MS, FAAP, Chairperson-elect

Susannah M. Briskin, MD, FAAP

Steven Cuff, MD, FAAP

Nicholas M. Edwards, MD, MPH, FAAP

Sarah Kinsella, MD, FAAP

Pamela J. Lang, MD, FAAP

Christina Lin Master, MD, FAAP

Shane Michael Miller, MD, FAAP

Francisco Jose Silva, MD, MPH, FAAP

Kevin D. Walter, MD, FAAP

Avery Faigenbaum, EdD, FACSM, FNSCA

Alex Diamond, DO, MPH, FAAP – National Federation of State High School Associations

Patrice C. Elder, MAEd, ATC – National Athletic Trainers Association

Andrew Peterson, MD, FAAP – American Medical Society for Sports Medicine

Anjie Emanuel, MPH

AE

athletic exposure

AT

athletic trainer

ED

emergency department

ICU

International Cheer Union

NCAA

National Collegiate Athletics Association

NEISS

National Electronic Injury Surveillance System

NFHS

National Federation of State High School Associations

PPE

preparticipation physical evaluation

RIO

High School Reporting Information Online