March 2020 Issue

Focus on Fitness: Cheerleading Injuries and Safety
By Jennifer Van Pelt, MA
Today’s Dietitian
Vol. 22, No. 3, P. 48

March is designated as National Cheerleading Safety Month. Since its origin in the late 1800s, cheerleading has evolved from simple sideline cheering for sports teams into a competitive athletic activity with complex physical stunts. In its early years and through the 1960s, cheerleading mostly involved pompom shaking and chanting, with some simple jumps and gymnastics movements, such as splits. In the early 1970s, the Dallas Cowboys debuted the first professional cheerleading team in the National Football League. Title IX, the legislation that opened the door for competitive sports for women, was passed the same year, and cheerleading rapidly evolved into a competitive activity.

 Cheerleading began incorporating gymnastics tumbling, fast-paced dance movements, and complicated multiperson stunts, such as pyramids, lifts, and “tossing” of team members. In 1990, 600,000 American children aged 6 and older participated in cheerleading; by 2003, that number had increased to almost 3.6 million.1

Despite its increasing athleticism and number of competitive events, the National Collegiate Athletic Association (NCAA) doesn’t consider competitive cheerleading as a sport (although 29 state high school athletic associations do recognize it as a sport). The American Academy of Pediatrics (AAP) notes the lack of recognition by the NCAA as a problem because injuries aren’t consistently tracked and safety regulations and surveillance at the national level are lacking.1 However, sports medicine researchers and other athletic safety organizations, including some dedicated to cheerleading, recently published epidemiologic studies on cheerleading injuries.

Epidemiology of Injuries
According to the AAP and the US Consumer Product Safety Commission, the number of injuries associated with cheerleading increased more than 400% from 1980 to 2007. From 1990 to 2012, cheerleading injuries in those aged 5 to 18 increased at a rate of 189% per year. From 2001 to 2012, the annual rate of concussions and other closed-head injuries increased by 290%.1-3

According to the AAP, the most common types of injuries include the following:

• sprains and strains (53%);
• abrasions, hematomas, and contusions (13% to 18%);
• fractures and dislocations (10% to 16%);
• lacerations and punctures (4%); and
• concussions and head injuries (3.5% to 4%).

The lower extremities comprise the most commonly injured anatomic area, followed by the upper extremities, head/neck, and trunk. Tumbling and falls from heights are responsible for approximately 15% to 25%, respectively, of cheerleading injuries. Stunts (eg, lifting, flying/tossing, building pyramids) are responsible for approximately 40% to 60% of all cheerleading injuries and 96% of concussions and other head injuries. Approximately 50% to 66% of head/neck injuries occur during pyramid stunts.1,3

While the overall injury rate for cheerleading is low compared with other sports, the injuries are more severe.1,3 Organizations that track sports-related injuries in high school have reported that cheerleading is associated with a high rate of direct catastrophic injuries, defined as injuries resulting directly from participation in the fundamental activities of the sport. Direct catastrophic injuries include serious injuries requiring medical care and weeks of recovery (eg, fractured neck vertebrae, concussion), temporary paralysis, injuries resulting in permanent disability, and death. Direct catastrophic injuries that have been reported as a result of cheerleading include cervical fractures, spinal cord injuries, paralysis, severe head injuries (including permanent brain injury), skull fractures, and joint dislocations.3 In a 2018 report from the National Center for Catastrophic Sport Injury Research (NCCSIR), researchers wrote that cheerleading was second only to football for the highest number of direct traumatic, catastrophic injuries. And, cheerleading, along with gymnastics, football, and ice hockey, had the highest rates of catastrophic injuries per 100,000 participants.4 Other NCCSIR reports have noted that cheerleading was responsible for 65% of all catastrophic injuries in high school–aged female athletes and 71% of catastrophic injuries in female college athletes from the early 1990s to 2008.3

Safety Efforts
Although some of the increases in injury rates can be attributed to expanded surveillance and reporting capabilities and growing numbers of cheerleading participants, most are due to the increased complexity of cheerleading skills and movements and the rapid evolution to a competitive, year-round sport. In response to these injury rates, the AAP published a professional policy statement on preventing cheerleading injuries, recommending the following1:

• designating cheerleading as a sport at the national level by the NCAA so it’s subject to rules and regulations by sports governing bodies and school athletic departments;
• requiring all cheerleaders to have a physical examination before beginning any cheerleading activity;
• ensuring that cheerleaders have access to appropriate strength and conditioning programs;
• requiring all cheerleading teams to be supervised by qualified coaches with training and certification in spotting for gymnastics and stunts, safety, and injury management;
• avoiding performance of stunts on hard, wet, uneven, vinyl, or dirt surfaces;
• requiring coaches to follow rules for technical skill execution established by cheerleading safety organizations;
• establishing a written emergency plan for coaches, parents, and athletes to follow in conjunction with a team physician and/or certified athletic trainer;
• ensuring a physician or certified athletic trainer is present at practices and competitions;
• removal from practice and competition any cheerleader with signs of a head injury and requiring medical clearance before being allowed to return to participation; and
• continued surveillance and reporting of all catastrophic injuries to the NCCSIR.

Cheerleading safety advocates were responsible for rule changes in the mid-2000s that banned one stunt—the basket toss—from being performed on any hard surfaces. After the rule change, catastrophic injuries associated with the basket toss decreased almost four-fold.5 Other rule changes for safety have included height restrictions on pyramids and limitations on tossing and flying stunts.3

Since the 1970s’ evolutionary surge in competitive cheerleading, national safety advocacy organizations have emerged, despite the lack of sport designation and governance by the NCAA. In 1987, the American Association of Cheerleading Coaches and Administrators (AACCA) was established to develop coaching, risk management, and safety guidelines for cheerleading. In 2007, the USA Federation for Sport Cheering (USA Cheer) was established to serve as the National Governing Body for Sport Cheering; one of its mission statements is to promote safety and safety education for cheerleading in the United States. In 2018, the AACCA merged with USA Cheer ( to sponsor CheerSafe (, a coalition of national, regional, and state cheerleading organizations that have collaborated to improve cheerleading safety. CheerSafe’s mission is to educate parents, cheerleaders, and school administrators about cheerleading safety at every level and to promote and improve cheerleading safety. Both CheerSafe and USA Cheer offer numerous resources for cheerleading safety on their websites.

— Jennifer Van Pelt, MA, is a certified group fitness instructor and health care researcher in the Lancaster, Pennsylvania, area.


1. LaBella CR, Mjaanes J; Council on Sports Medicine and Fitness. Cheerleading injuries: epidemiology and recommendations for prevention. Pediatrics. 2012;130(5):966-971.

2. 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.

3. Jones G, Khazzam M; American Orthopaedic Society for Sports Medicine. Cheerleading injuries. Published Fall 2017.

4. Kucera KL, Cantu RC; The University of North Carolina at Chapel Hill, National Center for Catastrophic Sport Injury Research. Catastrophic sports injury research thirty-sixth annual report, fall 1982 - spring 2018. Published October 3, 2019.

5. Yau RK, Dennis SG, Boden BP, Cantu RC, Lord JA, Kucera KL. 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):32-39.