Cheerleading-related injuries in the United States: a prospective surveillance study

Assessment of fatigue and recovery in elite cheerleaders prior to and during the ICU World Championships

Introduction

Little 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.

Results

There 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.

Discussion

Pre-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.

Evaluation of differences across age groups in the incidence, severity, and recovery of concussion in adolescent student-athletes from 2009 to 2019

OBJECTIVE

Concussion incidence is known to be highest in children and adolescents; however, there is conflicting evidence about the effect of age on concussion risk and recovery within the adolescent age range. The heterogeneity of results may be partially due to the use of age groupings based on convenience, making comparisons across studies difficult. This study evaluated the independent effect of age on concussion incidence, severity, and recovery in student-athletes aged 12-18 years using cluster analysis to define groupings.

METHODS

Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) scores of 11,403 baseline tests and 4922 postinjury tests were used to calculate the incidence rates for adolescent student-athletes grouped into 3 age bands (12-13, 14-15, and 16-18 years of age) on the basis of clustering analysis. The recently created Severity Index was used to compare concussion severity between groups. Follow-up tests for subjects who sustained a concussion were used to evaluate recovery time. The chi-square test and 1-way ANOVA were used to compare differences in demographic characteristics and concussion incidence, severity, and recovery. Multivariable logistic and linear regressions were used to evaluate the independent effects of age on concussion incidence and severity, respectively. Multivariable Cox hazard regression was used to evaluate differences in recovery time. Further analyses were conducted to directly compare findings across studies on the basis of the age groupings used in prior studies.

RESULTS

Multivariable regression analyses demonstrated that the 14- to 15-year-old age group had a significantly higher concussion incidence than both the 12- to 13-year-old (14- to 15-year-old group vs 12- to 13-year-old group, OR 1.57, 95% CI 1.16-2.17, p = 0.005) and 16- to 18-year-old (16- to 18-year-old group vs 14- to 15-year-old group, OR 0.79, 95% CI 0.69-0.91, p = 0.0008) age groups. There was no difference in incidence between the 12- to 13-year-old and 16- to 18-year-old groups (16- to 18-year group vs 12- to 13-year group, OR 1.26, 95% CI 0.93-1.72, p = 0.15). There were also no differences in concussion severity or recovery between any groups.

CONCLUSIONS

This study found that concussion incidence was higher during mid-adolescence than early and late adolescence, suggesting a U-shaped relationship between age and concussion risk over the course of adolescence. Age had no independent effect on concussion severity or recovery in the 12- to 13-, 14- to 15-, and 16- to 18-year-old groups. Further analysis of the various age groups revealed that results may vary significantly with minor changes to groupings, which may explain the divergent results in the current literature on this topic. Thus, caution should be taken when interpreting the results of this and all similar studies, especially when groupings are based on convenience.

Understanding the Cheerleader as an Orthopaedic Patient: An Evidence-Based Review of the Literature

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.

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

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.

Pediatric Cheerleading Injuries Treated in Emergency Departments in the United States

This study investigates the epidemiology of cheerleading injuries to children in the United States. Data were analyzed from the National Electronic Injury Surveillance System for children 5 through 18 years of age treated in US emergency departments for cheerleading injuries from 1990 through 2012. An estimated 497 095 children ages 5 to 18 years were treated in US emergency departments for a cheerleading injury during the 23-year study period, averaging 21 613 injured children per year. From 1990 to 2012, the annual cheerleading injury rate increased significantly by 189.1%; and from 2001 to 2012, the annual rate of cheerleading-related concussion/closed head injury increased significantly by 290.9%. Falls were the most common mechanism of injury (29.4%) and were more likely to lead to hospitalization (relative risk = 2.47; 95% confidence interval = 1.67-3.68) compared with other injury mechanisms. The rising number and rate of pediatric cheerleading injuries underscore the need for increased efforts to prevent these injuries.

A Qualitative Investigation of Need Fulfillment and Motivational Profiles in Collegiate Cheerleading

PURPOSE

Cheerleading is one of the fastest-growing sports in the United States. Members of spirit squads play an undeniable role in developing a university's athletic image, and participation in cheer has the potential to affect adolescents and young adults in a positive manner. Yet, cheerleaders also encounter stereotypes, constant trivialization, and a relative lack of external rewards. Given this complex contextual and situational environment, the current investigation was designed to better understand why people are motivated to participate in collegiate cheerleading. More specifically, guided by the premises of self-determination theory (SDT), this study explored motivational profiles and basic psychological need satisfaction (i.e., competence, autonomy, and relatedness) across different contexts and situations that comprise the collegiate cheerleading environment.

METHOD

Consistent with established guidelines for qualitative inquiry, 12 collegiate cheerleaders were interviewed at 3 separate time points during the course of 1 academic semester.

RESULTS

Deductive and inductive qualitative analyses yielded 3 higher-order themes, including: (a) context specificity of basic psychological need satisfaction, (b) contribution of performance to motivation, and (c) occurrences of intrinsic motivation.

CONCLUSIONS

These results highlighted the complex nature of motivation and basic psychological need fulfillment, including a potential synergism between relatedness and competence fulfillment as well as an influence of academics on sport motivation. These nuances add to the theoretical understanding of SDT and offer valuable insight for coaches and sport psychology professionals working with collegiate spirit squads.

Cheerleading Injuries in United States High Schools

BACKGROUND AND OBJECTIVES

Approximately 400 000 students participate in US high school cheerleading annually, including 123,386 involved in competitive spirit squads. The degree of athleticism and the difficulty of cheerleading skills have increased in recent decades, renewing safety concerns. This study describes the epidemiology of high school cheerleading injuries and compares cheerleading injury rates and patterns relative to other sports.

METHODS

Data collected by the longitudinal, National High School Sports-Related Injury Surveillance Study from 2009/2010 through 2013/2014 were analyzed.

RESULTS

Injury rates in cheerleading ranked 18th of 22 sports, with an overall injury rate of 0.71 per 1000 athlete-exposures (AEs). Competition (0.85) and practice (0.76) injury rates were similar, whereas performance rates were lower (0.49). Although 96.8% of injured cheerleaders were girls, the overall injury rate was higher in boys (1.33 vs 0.69, rate ratio [RR]: 1.93, 95% confidence interval [CI]: 1.30-2.88). Although concussions were the most common cheerleading injury (31.1% of injuries), concussion rates were significantly lower in cheerleading (2.21 per 10,000 athlete-exposures) than all other sports combined (3.78; RR: 0.58, 95% CI: 0.51-0.66) and all other girls' sports (2.70; RR: 0.82, 95% CI: 0.72-0.93). Over half of all injuries occurred during stunts (53.2%).

CONCLUSIONS

Although safety remains a concern among cheerleaders, overall injury rates are lower than most other high school sports. Although overall injury rates are relatively low, cheerleading injuries may be more severe when they do occur. A detailed knowledge of cheerleading injury patterns relative to other sports is needed to drive targeted, evidence-based prevention efforts.

Factors Influencing Risk and Recovery from Sport-Related Concussion: Reviewing the Evidence

Identifying factors that influence the risk and recovery from sport-related concussion (SRC) has become an important part of the clinical management of the injury. Consensus statements and clinical anecdotes have suggested several factors (i.e., history of migraine headaches) that may increase risk or lead to a protracted recovery from SRC. In the current paper, we will present evidence supporting primary and secondary risk factors listed in current consensus statements and relevant literature on emerging factors proposed to influence SRC risk and recovery.

What goes up must come down! A primary care approach to preventing injuries amongst highflying cheerleaders

PURPOSE

This article provides information regarding the most common nonlife-threatening and catastrophic injuries that occur during cheerleading, and describes the role of the nurse practitioner (NP) in managing patients who participate in cheerleading.

DATA SOURCES

Literature review of evidence-based research articles, epidemiological reports, and current guidelines.

CONCLUSIONS

Cheerleading is one of the most popular sports among adolescent females, and participation has increased rapidly in recent years. Rates of injury have also increased as the difficulty of this activity reaches new heights. Several factors such as body changes during puberty, societal pressures affecting nutrition, and lack of safety regulations place cheerleaders at risk for injury. Sprains/strains are the most common injury, and concussions are the most common traumatic injury. Injuries occur as a result of tumbling, stunting, falling, spotting, and unsafe practice surfaces.

IMPLICATIONS FOR PRACTICE

The role of the NP in injury prevention is to identify risk factors during preparticipation physicals, initiate conditioning and strength training routines, and implement safety measures during practices and competitions. The NP should also provide education and guidance to cheerleaders, parents, and coaches.

Cheerleading injuries: epidemiology and recommendations for prevention

Over the last 30 years, cheerleading has increased dramatically in popularity and has evolved from leading the crowd in cheers at sporting events into a competitive, year-round sport involving complex acrobatic stunts and tumbling. Consequently, cheerleading injuries have steadily increased over the years in both number and severity. Sprains and strains to the lower extremities are the most common injuries. Although the overall injury rate remains relatively low, cheerleading has accounted for approximately 66% of all catastrophic injuries in high school girl athletes over the past 25 years. Risk factors for injuries in cheerleading include higher BMI, previous injury, cheering on harder surfaces, performing stunts, and supervision by a coach with low level of training and experience. This policy statement describes the epidemiology of cheerleading injuries and provides recommendations for injury prevention.

Epidemiology of United States high school sports-related fractures, 2008-09 to 2010-11

BACKGROUND

High school athletes sustain millions of injuries annually, many of which are fractures. Fractures can severely affect athletes physically, emotionally, and financially and should be targeted with focused prevention methods.

HYPOTHESIS

Patterns and primary mechanisms of fractures differ by sport and gender.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

High school sports-related injury data were collected from academic years 2008-09 to 2010-11 for 18 sports and from 2009-10 to 2010-11 for 2 additional sports. We used linear regression to describe annual fracture rate trends and calculated fractures rates, rate ratios (RRs), and injury proportion ratios (IPRs).

RESULTS

From 2008-09 to 2010-11, certified athletic trainers reported a total of 21,251 injuries during 11,544,455 athlete exposures (AEs), of which 2103 (9.9%) were fractures, with an overall rate of 1.82 fractures per 10,000 AEs. Fracture rates were highest in football (4.37 per 10,000 AE), boys' ice hockey (3.08), and boys' lacrosse (2.59). Boys sustained 79.1% of all fractures, and the overall rates of fractures were greater in boys' sports than in girls' sports for competition (RR, 2.82; 95% CI, 2.45-3.24) and practice (RR, 2.43; 95% CI, 2.07-2.86). The most commonly fractured body sites were the hand/finger (32.1%), lower leg (10.1%), and wrist (9.5%). Overall, 17.2% of fractures required surgery, which was higher than for all other injuries combined (IPR, 3.14; 95% CI, 2.81-3.52). The most common mechanism of fracture involved contact with another player (45.5%). Using linear regression, we found the proportion of all injuries that were fractures was inversely correlated with the athlete's age (P = .02) but was not correlated with the athletes' age- and gender-adjusted body mass index.

CONCLUSION

Fractures are a significant problem for high school athletes. Targeted preventive interventions should be implemented to reduce the burdens these injuries cause the athletes.

The epidemiology of sport-related concussion

Concussions and head injuries may never be completely eliminated from sports. However, with better data comes an improved understanding of the types of actions and activities that typically result in concussions. With this knowledge can come improved techniques and rule changes to minimize the rate and severity of concussions in sports. This article identifies the factors that affect concussion rate.

Epidemiology of strain/sprain injuries among cheerleaders in the United States

OBJECTIVE

The aim of this study is to describe the epidemiology of cheerleading-related strain/sprain injuries by type of cheerleading team and type of event.

METHODS

Athlete exposure (AE) and injury data were collected from 412 United States cheerleading teams via the Cheerleading Reporting Information Online surveillance tool, and injury rates were calculated.

RESULTS

Strains/Sprains were the most common injury (53%; 0.5 injuries per 1000 AEs) sustained by cheerleaders during our 1-year study. The lower extremities (42%), particularly the ankles (28%), were injured most often. Most injuries occurred during practice (82%); however, the rate of injury was higher during competition (0.8 injuries per 1000 AEs; 95% confidence interval [CI], 0.6-1.0) than during practice (0.6 injuries per 1000 AEs; 95% CI, 0.5-0.6) for all team types. Injuries were sustained most frequently by high school cheerleaders (51%), although college cheerleaders had the highest injury rate (1.2 injuries per 1000 AEs). Strains/Sprains occurred most frequently while attempting a stunt (34%) or while tumbling (32%). Spotting/Basing other cheerleaders (19%) was the most common mechanism of injury and was more likely to result in a lower back strain/sprain than other mechanisms of injury (odds ratio, 3.38; 95% CI, 1.41-8.09; P < .01).

CONCLUSIONS

Cheerleaders should increase their focus on conditioning and strength-building training, which may help to prevent strain/sprain injuries. Spotters and bases should additionally focus on proper lifting technique to help avoid back injury. Guidelines may need to be developed for return-to-play after cheerleading-related strain/sprain injuries.

Epidemiology of cheerleading stunt-related injuries in the United States

CONTEXT

Cheerleading-related injuries are on the rise. To date, no epidemiologic studies of cheerleading stunt-related injuries have been published.

OBJECTIVE

To describe and compare cheerleading stunt-related injuries by type of cheerleading team (All Star, college, high school, middle school, or recreation league) and event (practice, pep rally, athletic event, or cheerleading competition).

DESIGN

Prospective injury surveillance study.

SETTING

Participant exposure and injury data were collected from US cheerleading teams via the Cheerleading RIO (Reporting Information Online) surveillance tool.

PATIENTS OR OTHER PARTICIPANTS

Athletes from enrolled cheerleading teams who participated in official, organized cheerleading practices, pep rallies, athletic events, or cheerleading competitions.

MAIN OUTCOME MEASURE(S)

The numbers, types, and rates of cheerleading stunt-related injuries during a 1-year period (2006-2007) are reported.

RESULTS

Stunt-related injuries accounted for 60% (338/567) of the injuries sustained by US cheerleaders who participated in the study and 96% (22/23) of the concussions and closed head injuries (CHIs) reported during the study. Collegiate cheerleaders were more likely to sustain a concussion or CHI than were cheerleaders on other types of teams (P = .02, odds ratio = 3.10, 95% confidence interval = 1.20, 8.06). Most injuries occurred while the cheerleader was spotting or basing another cheerleader (34%, 115/338), and these injuries comprised 32% (51/161) of all stunt-related strains and sprains. Four cheerleaders (1.2%, 4/335) were admitted to the hospital, and 9 cheerleaders (2.7%, 9/335) required surgery.

CONCLUSIONS

Cheerleading stunts pose an increased risk for injury, especially in terms of sustaining a concussion or CHI. Spotters and bases were most likely to be injured during the performance of cheerleading stunts and were at risk for sustaining strain and sprain injuries. The ankle, lower back, and wrist were the sites most likely to be reinjured while performing cheerleading stunts.

Epidemiology of cheerleading fall-related injuries in the United States

CONTEXT

Over the past several decades, cheerleaders have been performing fewer basic maneuvers and more gymnastic tumbling runs and stunts. As the difficulty of these maneuvers has increased, cheerleading injuries have also increased.

OBJECTIVE

To describe the epidemiology of cheerleading fall-related injuries by type of cheerleading team and event.

DESIGN

Prospective injury surveillance study.

SETTING

Participant exposure and injury data were collected from US cheerleading teams via the Cheerleading RIO (Reporting Information Online) surveillance tool.

PATIENTS OR OTHER PARTICIPANTS

Athletes from 412 enrolled cheerleading teams who participated in official, organized cheerleading practices, pep rallies, athletic events, or cheerleading competitions.

MAIN OUTCOME MEASURE(S)

The numbers and rates of cheerleading fall-related injuries during a 1-year period (2006-2007) are reported.

RESULTS

A total of 79 fall-related injuries were reported during the 1-year period. Most occurred during practice (85%, 67/79) and were sustained by high school cheerleaders (51%, 40/79). A stunt or pyramid was being attempted in 89% (70/79) of cases. Fall heights ranged from 1 to 11 ft (0.30-3.35 m) (mean = 4.7 + or - 2.0 ft [1.43 + or - 0.61 m]). Strains and sprains were the most common injuries (54%, 43/79), and 6% (5/79) of the injuries were concussions or closed head injuries. Of the 15 most serious injuries (concussions or closed head injuries, dislocations, fractures, and anterior cruciate ligament tears), 87% (13/15) were sustained while the cheerleader was performing on artificial turf, grass, a traditional foam floor, or a wood floor. The fall height ranged from 4 to 11 ft (1.22-1.52 m) for 87% of these cases (13/15).

CONCLUSIONS

Cheerleading-related falls may result in severe injuries and even death, although we report no deaths in the present study. The risk for serious injury increases as fall height increases or as the impact-absorbing capacity of the surfacing material decreases (or both).