Cheerleading Injuries: Patterns, Prevention, Case Reports

Mark R. Hutchinson, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 25 - NO. 9 - SEPTEMBER 97

In Brief: Compared with other sports, cheerleading carries a relatively low risk of injury, but the injuries that do occur tend to be relatively severe in terms of time lost. The most common injury site is the ankle, with head and neck injuries less common but more severe. Two case reports illustrate overuse and acute injuries typical of the sport. Cheerleading injuries have been attributed to lack of experience, inadequate conditioning, insufficient supervision, difficult stunts, and inappropriate surfaces and equipment. Prevention recommendations are included.

Cheerleading began at the turn of the century when a University of Minnesota football fan stood in his seat and led the crowd in a verse in support of their team. From that humble beginning has blossomed a competitive athletic activity that includes nearly a million participants at the elementary, high school, college, and professional levels (1). Cheerleading competitions are held at regional and national levels, and training is a year-round activity. Cheerleading routines can include gymnastic elements, tumbling runs, partner stunts, pyramid formations, and dance routines. Each of these components is associated with injury risks unique to the sport. As it is used here, the term "injury" means any cheerleading injury that forces the person to miss at least 1 day of participation.

Risk of Injury

An injury surveillance system created in 1982 by the National Collegiate Athletic Association (NCAA) (2) permits easy and valid comparison of risks from sport to sport. The system compares risks of various sports relative to the number of athletic exposures (AEs). Although the NCAA survey does not include cheerleading, it provides data for comparison with findings from cheerleading studies. Mueller (3), who has reported the most extensive studies of cheerleading injuries, found an injury rate of 0.31 injuries per 100 participants among 53,738 cheerleaders who participated in the Universal Cheerleading Association's summer camps. Assuming each camp session lasts 6 days, and with morning and afternoon sessions each qualifying as an AE, the injury rate would translate to 0.26 injuries per 1,000 AEs.

In a separate study (3), Mueller noted that injury rates in 1 school year were 13.3 per 100 collegiate cheerleaders and 3.3 per 100 high school cheerleaders. Assuming 200 AEs per year, this translates to 0.67 injuries per 1,000 AEs in college athletes and 0.17 injuries per 1,000 AEs in high school athletes.

As compared with other major collegiate sports, the injury risk in cheerleading appears to be relatively low (table 1: not shown). Variations in definitions of injury, methods of data gathering, and assumptions about the number of athletic exposures may affect the validity of comparisons of cheerleading with other sports.

Severity of Injury

Little literature is available comparing the severity of injuries from cheerleading with that of other athletic activities. Much of what has been written is anecdotal and focuses on isolated case reports (4-9). Some studies that have analyzed cheerleading did not compare it with other sports (10-14). In one of the few studies that have compared cheerleading with other sports, Axe et al (15) reported on 619 athletes from 23 sports, and found that more days were lost per injury in cheerleading (28.8) than in any other sport (table 2: not shown).

Additionally, in 1993, we surveyed 7 high school teams in central Kentucky regarding the past year's injury patterns, types of injuries, risk factors, and time lost from the sport (unpublished data). Seventy-four high school cheerleaders (aged 14 to 18; average age 15) recorded 737 complaints. Eleven of the complaints were injuries with time loss. The average days lost per injury (35.0), confirmed the findings of Axe et al (15).

The reason for the high degree of injury severity as defined by time lost from sport is unclear, but it may be associated with the demands of cheerleading: The sport requires that all extremities be completely functional for stunts and tumbling runs. Football players can play in hand casts, and throwing and racket sport athletes can still perform if their nondominant arm is mildly injured. Cheerleaders, however, must often lift a partner, perform a tumbling run, do a dance routine, and balance atop a pyramid—all within the span of a few minutes.

Injury Sites and Types

Ankle injuries are the most common injuries in cheerleading, followed by knee injuries (table 3). At the collegiate level, an increase in upper-extremity injuries (3) is probably related to the increase in partner stunts and catches required.

Table 3. Distribution of High School and Collegiate Cheerleading Injuries by Injury Site
Injury Site	Injury Distribution (%)
Ankle	22
Knee	15
Hand	13
Back	12
Shoulder	8
Wrist	8
Head and neck	7
Elbow	5
Abdomen	2
Foot	2
Groin	2
Hip	2
Leg	2
Thigh	0
From Hutchinson MR, unpublished data.

Head and neck injuries make up only 7% of all cheerleading injuries but can be the most severe. A report from Mueller and Cantu (12,13) of the National Center for Catastrophic Sports Injury Research showed that 20 head and neck injuries occurred in cheerleading between 1982 and 1992, and 10 occurred during pyramid stunts. Eight of the injuries were permanently disabling; 2 were fatal.

The most common types of cheerleading injuries are ligament sprains and muscle strains (figure 1), and a majority of the injuries are related to overuse. Cheerleading differs from many other sports because it is a year-round activity—cheerleaders are asked to perform through three seasons, then peak for national competitions in the spring. This constant "in season" state does not allow appropriate time for recuperation or conditioning, which in turn magnifies the risk of overuse injuries.

Causes of Injury

The sport of cheerleading requires the athlete to participate in a variety of activities, including dances, chants and yells, gymnastic tumbling runs, and partner stunts. Partner stunts include human pyramids, lifts and catches, and human tosses (basket tosses).

Dancing. The dance component of cheerleading is associated with injuries common in modern dance and ballet. These include overuse injuries of the legs such as plantar fasciitis, tendinitis, ligament sprains of the foot and ankle, stress fractures, patellofemoral syndrome, hip strains, and inflammation along the iliotibial band.

Cheer and chant routines. While chants and yells may lead to little more than a sore throat, they may be combined with routines that involve injury risk. We have seen at least one young cheerleader suffer an anterior cruciate ligament injury by colliding with a teammate while performing a split leap during a simple chant.

Gymnastics and partner stunts. Most injuries in cheerleading occur during gymnastics maneuvers and partner stunts (see "Cheerleading Injury Case Reports," below)—and partner stunts have been associated with the most catastrophic types of injuries. Our 1993 retrospective survey showed that gymnastic maneuvers were the leading cause of injuries (67%), followed by falls from mounts and partner stunts (16%). In contrast, Mueller's surveillance studies (3) showed a predominance of injuries related to partner stunts (figure 2). The contrasting findings may be due to Mueller's inclusion of collegiate and summer camp athletes, who participate in more frequent and more difficult stunts and pyramids.

Injuries in the gymnastics component of cheerleading mimic injury patterns for gymnasts. Overuse injuries of the shoulders, wrists, and elbows are common because of the use of the arm for weight bearing. Ankle and knee ligament injuries can occur in the landing and impact phase of tumbling runs. Low-back injuries may occur because of repeated hyperextension.

Injury patterns in partner stunts can be subdivided in relation to the task of the athlete in the stunt. Athletes at the base of pyramids or partner lifts require significant upper-body strength. Musculoskeletal failure or injury can occur in any link of the kinetic chain in these stunts, but seems to be more frequent in the arm and shoulder. Shoulder and dorsal wrist impingement and shoulder instability are not uncommon. In athletes who serve as bases in partner stunts, the greater incidence of arm injuries in women as compared with those in men may be associated with women's reduced upper-body strength. Because of the risk of falls from mounts, athletes at the tops of pyramids and lifts run the greatest risk of catastrophic injury, fractures, and dislocations.

Contributing factors. Other factors that may contribute to injuries in cheerleading include lack of experience, inadequate conditioning, poor supervision, noncushioned playing surfaces, poor nutrition, and poor shoes.

Experience may be a factor in the frequency, type, and severity of injuries. Experienced cheerleaders are apt to attempt stunts that pose increased risks. Less experienced cheerleaders have more frequent but less severe injuries, possibly because of poor conditioning, inadequate supervision, or attempting difficult maneuvers prematurely.

Prevention of Injury

Limiting stunts. Safety guidelines for cheerleaders vary tremendously from state to state, school to school, and organization to organization. After the death of a cheerleader in a pyramid stunt, the North Dakota and Minnesota legislatures banned pyramids at the high school and college levels (13). Illinois banned the use of basket tosses at the high school level after a similar catastrophic event.

Decisions to abolish certain stunts have been controversial. Some politicians, administrators, and others view certain stunts as unduly risky. Advocates, fans, and many athletes, however, view the prohibition of stunts as unfair to participants in the affected areas: Without experience in certain stunts, the argument goes, athletes cannot compete for college scholarships or expect to win national events. My view is that decisions about which stunts are allowed should be based on epidemiologic data and not necessarily on isolated events. In any case, following safety guidelines can reduce the risk of injuries (table 4), and athletes should know and follow all guidelines in effect in their region.

Table 4. Practical Tips for Preventing Cheerleading Injuries Supervision Coaches or supervisors should: Enforce adherence to local and state rules Ensure use of proper techniques Require proper spotting for all mounts Require proper spotting for all at-risk gymnastics maneuvers Have an emergency plan in place Teach gradual progression to difficult skills Equipment Participants should: Practice on mats or pads Wear well-fitted shoes with good cushioning and a stable base General Health Physicians or coaches should: Recognize possible nutritional disorders Identify untreated injuries with preseason physicals Identify and treat injuries early Participants should: Increase flexibility in extremities symmetrically Increase motor strength in extremities symmetrically Progress gradually in practice intensity Strengthen shoulder and rotator cuff ("base" athletes) Strengthen lower back and abdomen (all athletes)

Environment and equipment. Optimizing the environment and equipment is important. Too often, the cheerleaders' practice area is the last unused space in the gym, or even the hallway. Practicing on hard floors without mats leads to overuse injuries, and to more severe injuries when falls occur. If mats are unavailable, practicing outdoors on the grass or using well-cushioned shoes can reduce impact.

Shoes should be well-fitted and comfortable (see "How to Steer Patients Toward the Right Sport Shoe."). For female athletes, shoes designed for women rather than downsized men's shoes are preferred. Broad soles may reduce the risk of ankle sprains. Cross-trainers or running shoes are excellent choices. Shoes should be chosen for function, not solely for aesthetics.

Supervision. Talented supervision is necessary, and coaches must understand the risks of each maneuver. Safe performance and spotting techniques should be emphasized. Riskier maneuvers must be approached gradually and sequentially, with emphasis on mastery of the preceding skill. Educating athletes about safe practice patterns will reduce injuries.

Screening. The preparticipation physical examination will identify chronic injuries that should be treated or conditioning deficiencies that should be remedied. Poor conditioning leads to the overuse injuries common in cheerleaders. A conditioning program prior to participation and a gradual progression in intensity early in training can prevent many of these injuries.

The preparticipation exam is also the ideal time to address nonmusculoskeletal health issues. A general health history should be obtained to screen for cardiac arrhythmias, dizziness, or seizures. The presence of any of these should preclude taking part in stunts and pyramids, and an aggressive workup should be done before participation is allowed.

In addition, women participating in aesthetic sports such as dance, gymnastics, and cheerleading are at increased risk of eating disorders. The health history should include careful evaluation of daily eating patterns and menstrual irregularities. Any athlete with a new stress fracture or overuse injury should also undergo this screening. Abnormalities should be addressed immediately with education or referral.

Preparation for emergencies. Finally, emergency procedures and plans should be carefully outlined prior to any practice and performance. Coaches and supervisors should know first aid and the location of the nearest telephone, and emergency transportation should be available.

References

1. George GS (ed): American Association of Cheerleading Coaches and Advisors: Cheerleading Safety Manual. Memphis, UCA Publications Dept, 1990
2. National Collegiate Athletic Association (NCAA): NCAA Injury Surveillance System. Overland Park, KS, NCAA, 1993
3. Mueller FO: Cheerleading Injury Research. Memphis, UCA Publications Dept, 1993
4. Shields RW Jr, Jacobs IB: Median palmar digital neuropathy in a cheerleader. Arch Phys Med Rehabil 1986;67(11):824-826
5. Tehranzadeh J, Labosky DA, Gabriele OF: Ganglion cysts and tear of triangular fibrocartilages of both wrists in a cheerleader. Am J Sports Med 1983;11(5):357-359
6. Lockey MW: The sport of cheerleading. J Miss State Med Assoc 1991;32(10):375
7. Ross T: Cheerleading and club sports. Law and Sports Conference Proceedings. Winston-Salem, NC, Sports and the Courts Inc, 1986, pp 100-106
8. Murphy P: Cheerleading not as safe as it once was. Phys Sportsmed 1985;13(11):39-40
9. Hage P: Cheerleading: new problems in a changing sport. Phys Sportsmed 1981;9(2):140-145
10. DeBenedette V: Are cheerleaders athletes? Phys Sportsmed 1987;15(9):214-220
11. Hage P: Cheerleaders suffer few serious injuries. Phys Sportsmed 1983;11(1):25-26
12. Mueller FO, Cantu RC: National Center for Cata-strophic Sports Injury Research: Tenth Annual Report. Chapel Hill, NC, University of North Carolina, 1993
13. Cantu RC, Mueller FO: Cheerleading. Clin J Sports Med 1994;4(2):75-76
14. Whiteside JA, Fleagle SB, Kalenak A: Fractures and refractures in intercollegiate athletes: an eleven-year experience. Am J Sports Med 1981;9(6):369-377
15. Axe MJ, Newcomb WA, Warner D: Sports injuries and adolescent athletes. Del Med J 1991;63(6):359-363

Cheerleading Injury Case Reports

Shoulder Instability

Case history. A 15-year-old female high school cheerleader presented with bilateral shoulder pain that was exacerbated by her continued participation in pyramids, partner stunts, and gymnastic tumbling runs. She served as the base for pyramid and partner stunts. The onset of complaints was gradual with no well-defined traumatic event. She also noted that her arm felt "dead" at times.

Physical examination showed generalized ligamentous laxity with hyperextension of her fingers, elbows, and knees. Her shoulders had increased laxity to anterior-posterior translation, a positive sulcus sign, and positive apprehension for anterior instability. Isolated rotator cuff testing showed her cuff to be intact, but weak. Scapular stabilizing muscles were weak, and she held her shoulders in a drooped, protracted position. Radiographs were normal.

The diagnosis was bilateral, multidirectional shoulder instability. Treatment involved a 6-week rest from gymnastic tumbling runs (which demand weight-bearing on the arms), lifting of teammates, and serving as a base. During that time she underwent rehabilitation guided by an athletic trainer. Rehabilitation emphasized rotator cuff strengthening, scapular stabilizer strengthening, and proper lifting technique. When she was asymptomatic, she was allowed to gradually add skills that loaded her shoulders. She continued her maintenance rehabilitation program and was able to perform with no further complaints.

Discussion. This patient had a classic case of shoulder instability. The instability is commonly bilateral, and associated with generalized ligamentous laxity in other areas of the body. Although the patient had slight rotator cuff weakness, rotator cuff disease was not the primary diagnosis. In young athletes, instability is a much more likely cause of rotator cuff complaints.

Like gymnastics, cheerleading demands flexibility. However, without proper conditioning of associated muscle stabilizers, normal ligamentous laxity and flexibility may lead to pathologic laxity. This athlete's role as the base for pyramid and partner stunts placed increased distraction loads across her shoulders, which exacerbated her complaints.

Traumatic Ankle Injury

Case history. A 19-year-old female cheerleader fell to the ground and injured her left ankle when her male partner slipped and they both lost their balance. At the time they were performing a "liberty"—a partner stunt in which the base, with arms vertically extended, holds the partner overhead while the partner poses on one foot on the extended hand. When the patient fell from the 8-foot height, the spotter was unable to ease her fall and she rolled her ankle, sustaining an open fracture-dislocation of her ankle.

The patient was taken urgently to surgery where the open wound was irrigated. The dislocation was reduced, and the fracture was fixed with plates and screws. The medial ligamentous attachment onto the medial malleolus, which had been completely avulsed, was primarily repaired. Fortunately, after a period of cast immobilization, her course was uneventful with no infection and excellent fracture healing.

Discussion. This case illustrates the risk of traumatic injury in cheerleading. Both the coach and a spotter were present, but the spotter was unable to catch his falling comrade. The injury occurred during a game, so mats were not in use. The athlete was an NCAA Division I collegiate gymnast who had rehearsed the stunt with her partner multiple times, so it does not appear that too-aggressive skill development was a factor. Her shoes were appropriate and not a factor in the injury. In general, it appears that the injury was unpreventable. Cheerleading carries some unavoidable risk. Nonetheless, safety precautions can reduce the severity and frequency of injuries.

Dr Hutchinson is director of sports medicine services and attending orthopedic surgeon in the department of orthopedics at the University of Illinois at Chicago (UIC). He serves as team physician for the UIC Flames and the USA Rhythmic Gymnastics national team. Address correspondence to Mark R. Hutchinson, MD, College of Medicine, Dept of Orthopaedics (MC 844), 209 Medical Sciences South, 901 S Wolcott Ave, Chicago, IL 60612-7342; e-mail to mhutch@uic.edu.

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